Management of the Failing Pancreas Graft

In this chapter, we discuss graft failure, metabolic reserve, and ways to preserve pancreas function. Management of early technical complications using clinical criteria and duplex ultrasound often provides an opportunity for graft salvage. Similarly, successful treatment of acute rejection via careful follow-up and a tissue diagnosis is critical, as the majority of long-term graft losses are immunologic in nature. Despite normal fasting glucose levels, a minority of recipients will demonstrate impaired glucose control early post-transplantation with a larger percentage showing reduced function after 10 years. Beyond monitoring of glucose and hemoglobin A1c (HbA1c) levels, there is a role for routine oral glucose tolerance testing. In the setting of impaired pancreas function, it is reasonable to consider the use of oral hypoglycemic agents, modification of immunosuppression, and lifestyle changes. We herein provide one approach to optimize impaired pancreas function. For many pancreas recipients, there will eventually be a transition back to the use of insulin. With that decision, comes consideration for the place of transplant pancreatectomy and re-transplantation.