Interesting concept! And questions well worth debating. The islet cell world have already had that debate and have got their answer. Data suggests that tight control of your sugars not only halts the process of end-organ damage in diabetes but to some extent reverses it with sustained euglycemia. (DCCT and more importantly the EDIC trials). Thus, if this data is to be believed, in most circumstances, a solid organ pancreas transplant that has the advantage of proper glucose control with or without the need for exogenous 'top-up' insulin, without suffering hypoglycemic unawareness might actually be considered a success. 

There is probably a spectrum that ranges from mild graft dysfunction that may necessitate a small amount of insulin at one end all the way through to pre-transplant doses of exogenous insulin. We recently posed this question in the Oxford group and are putting together a clinical research protocol to explore this spectrum with particular interest in C Peptide and HbA1C. 

This is an important question that is currently being addressed by Pratik Choudhary. He has presented his new classification at the Pancreas Advisory Group and we have presented the classification at EPITA. I am sure Pratik will be happy to discuss further.

This question has not been clearly answered.  UNOS has been working on a consensus (see attached file).  Currently pancreas graft failure is defined by UNOS when any of the following occurs:

  A recipient’s transplanted pancreas is removed

  A recipient re-registers for a pancreas

  A recipient registers for an islet transplant after receiving a pancreas transplant

  A recipient’s insulin use is greater than or equal to 0.5 units/kg/day for a consecutive 90 days

  A recipient dies 

Indeed an interesting topic.

As becomes clear from research done at our center, which was presented at EPITA last year in Igls, outcome significantly differs depending on the definition (whether this is reinstitution of exogenous insulin, HbA1c>6.5% or a combination of both), even though one would expect some kind of standardization in treatment of pancreas transplant recipients. The problem with cut-off in any definitions is that they leave no room for nuances.

Further research is being conducted at our center, we hope to be able to (re) initiate the debate on definition of graft failure on a broader level.

All These aspects are substantial an I agree with Dr. Fung that there has to be a Definition at least at a level of expert consensus.

However when we revise the long term patients of our program (start 1993/4, more than 500 transplants over the time) there are two interesting findings:

1. Patients who lost their first pancreas allograft within 4 weeks after surgery will only have 50% one-year survival!

2. Patients who had to get back on Insuline after 3 years survive much  better than expected, probably because there is a minor c- peptide warranting the avoidance of hyperglycemia. Some of these patients may still be in a condition comparable to successful islet transplantation.

Probably there might be 4 grades of pancreas allograft failure:

I back on Insulin, "subnormal" c- Peptide

II back on Insulin, no c- Peptide

III surgical graft loss in Long term

IV surgical graft loss < 4 weeks post transplant.

(please excuse ev. misspellings, there is a correction program underlying adapted to german...)

We agree with the previous remark of a more differentiated definitions of graft failure. In many instances we are victims of our own success. Especially with good graft function we see  weight gain  or due to the burden of  immuno-suppression development of type 2 DM. In those cases more discussion about the definition of graft failure is needed.