For people with diabetes and end stage renal disease, kidney transplantation improves long-term outcomes compared with dialysis. - For people with type 1 diabetes and end stage renal disease, simultaneous pancreas-kidney transplantation can improve kidney graft survival and result in prolonged insulin independence. - For people with type 1 diabetes, pancreas or islet allotransplantation improves glycemic control, prevents severe hypoglycemia even in the absence of complete insulin independence, but with the risks of longterm immunosuppression. - In people undergoing total pancreatectomy for benign pancreatic disease, islet autotransplantation can prevent or ameliorate labile diabetes. - Post-transplant diabetes is common after solid organ transplantation and is associated with increased risk for mortality, cardiovascular disease and graft loss.- Diabetes sometimes damages kidneys so badly that they no longer work. When kidneys fail, one option is a kidney transplant. - For certain people with type 1 diabetes, pancreas or islet transplants may help stabilize blood glucose levels. - Your diabetes health-care team can discuss the benefits and risks of these procedures with you.# Introduction
Restoring endogenous insulin secretion by whole pancreas or islet transplantation has been established as an alternative to insulin injection therapy in select individuals with type 1 diabetes (1,2). Both pancreas and islet transplantation can result in insulin independence and glucose stability, especially in the setting of glucose lability or frequent, severe hypoglycemia. Unfortunately, the absence of prospective randomized controlled trials makes it challenging to draw firm conclusions about the overall efficacy and safety of these therapies compared with exogenous insulin treatment. Also, the limited number of specialized islet and pancreas transplantation centres and the relatively small number of donor pancreases limit the availability of these treatments.
More broadly, diabetes is an important clinical issue in solid organ transplantation. Diabetes is the leading indication for kidney transplants (3) and is a common comorbidity in people listed for other solid organ transplants. New cases of diabetes developing after solid organ transplantation-post-transplant diabetes mellitus (PTDM)-are common and associated with reduced patient and graft survival. There is uncertainty about many aspects of PTDM, including diagnostic criteria, screening, glycemic targets and which glucoselowering therapies are safest and most effective after transplant (4). Nevertheless, some general recommendations regarding the role of pancreas and islet transplantation, and the diagnosis and management of PTDM, may be made based on a growing body of data and/or current clinical experience.

# Pancreas Transplantation
Pancreas transplantation can result in complete independence from exogenous insulin in the majority of cases (5). As shown in Table 1, worldwide, non-controlled 1-, 5-and 10-year mean pancreas graft and patient survival rates differ slightly among the 3 major types of transplantations (6). Long-term pancreas graft survival declines with time, with a median graft survival of 9 years and <10% survival at 21 years (7). Chronic graft failure is the most common reason for transplant loss (8). Glycemic control and glycated hemoglobin (A1C) are markedly improved after successful pancreas transplantation, with most recipients achieving normal glucose tolerance, albeit with hyperinsulinemia (9,10). Improvements in the histological changes of diabetic nephropathy have been reported 5 to 10 years post-transplantation (11,12).
Long-term patient and kidney graft survival improves with simultaneous pancreas kidney (SPK) transplant (13)(14)(15). Improvement and/or stabilization of diabetic retinopathy has been demonstrated