Transplant strategies for diabetic renal patients.

The strict control of glycaemia in the diabetic patient prevents severe long-term complications of diabetes. The most effective physiological method to control glycaemia in the type 1 diabetes patient is pancreas or pancreatic islet transplant. However, these types of transplants require chronic immunosuppressant treatment that leads to short and long term complications and are reserved for type 1 diabetic patients with life threatening complications (frequent unexplained ketoacidosis or hypoglycaemias). With regards to type 1 diabetics with end-stage nephropathy, simultaneous pancreas-kidney transplant has excellent results and makes it possible for the patient to be insulin and dialysis free. If vascular complications, especially coronary disease, make it impossible to perform a simultaneous pancreas-kidney transplant, kidney transplant alone will be indicated and, in the future, the patient may have access to the transplant of pancreatic islets when the technique is perfected. Type 1 diabetic patients who receive a living or cadaver kidney transplant, and later a pancreatic transplant show excellent results. Type 2 diabetics, in whom pancreas transplant is not indicated, as they do not have a total deficit of insulin, can have access to a kidney transplant if they reach end-stage nephropathy in spite of their more advanced age, as long as their vascular disease allows it. Transplant of cadaver islets is beginning to provide good results, thanks to new immunosuppressant protocols. This procedure does not require surgery, the islets being implanted into the liver by infusion through the vena porta. Obtaining islets from embryonic or adult tissue stem cells, although in an experimental phase, could be a reality in the near future.