Trends in immunosuppression after pancreas transplantation: What is in the pipeline?

PURPOSE OF REVIEW: To provide an overview of currently available immunosuppressive strategies and novel therapeutic developments in pancreas transplantation. RECENT FINDINGS: From 1966 through 2012 more than 30 000 pancreas transplantations have been performed around the world with excellent patient and graft survival. However, drug-related side effects and toxicities remain to negatively affect long-term outcomes. At present, more than 90% of pancreas transplant recipients receive induction therapy with depleting or nondepleting antibodies. The most widely used maintenance protocols are based on tacrolimus and mycophenolate mofetil with early or delayed corticosteroid withdrawal. In case of documented side effects related to this standard protocol, several regimens are actively pursued to switch to mammalian target of rapamycin inhibitors as well as to attempt initial calcineurin inhibitor avoidance and immunosuppression minimization. In addition, the recent documented negative impact of donor-specific antibodies on pancreas transplantation outcome has resulted in new treatment protocols for antibody-mediated rejection including intravenous immunoglobulins, anti-CD20 antibodies and protease inhibitors. SUMMARY: Implementation of novel therapeutic strategies and combination protocols to reduce or avoid drug toxicities and immune-related complications that are evaluated in prospective and randomized trials is requested to improve outcomes after pancreas transplantation.