0041-1337/99/6706-915/0 TRANSPLANTATION Vol. 67, 915–934, No. 6, March 27, 1999 Copyright © 1999 by Lippincott Williams & Wilkins, Inc. Printed in U.S.A. Transplantation  BRIEF COMMUNICATIONS SUCCESSFUL LIVING RELATED SIMULTANEOUS PANCREAS- KIDNEY TRANSPLANT BETWEEN IDENTICAL TWINS ENRICO BENEDETTI, 1,2 TY DUNN, 1 MALEK G. MASSAD, 1 VANDAD RAOFI, 1 AMELIA BARTHOLOMEW, 1 RAINER W. G. GRUESSNER, 3 AND CAROLYN BRECKLIN 4 Departments of Surgery and Medicine, University of Illinois at Chicago, Chicago, Illinois, and Department of Surgery, University of Zurich, Zurich, Switzerland Simultaneous pancreas-kidney transplant from liv- ing donors has been recently proposed as an effective therapeutic option in selected uremic patients with type I diabetes. We report the first simultaneous pan- creas-kidney transplant performed between identical twins. Posttransplant, the recipient has been main- tained on low dose cyclosporine to avoid recurrent auto-immune insulitis. At the 1-year follow-up, both donor and recipient are well with normal renal func- tion and excellent glucose control. Simultaneous pan- creas-kidney transplant between identical twins can be performed successfully using cyclosporine to pre- vent recurrent auto-immune insulitis. The first successful kidney transplant, performed by Mur- ray in 1954, was a living related renal transplant between identical twins (ITs*) (1). Since this landmark case, different organs and tissues have been successfully transplanted be- tween ITs, including bowel (2), pancreas (3), bone marrow (4), and parathyroid (5). We report the first case of simultaneous pancreas-kidney transplant (SPK) between ITs, performed to cure end-stage renal failure caused by type I diabetes. CASE REPORT The patient is a 38-year-old African American female with history of insulin-dependent diabetes mellitus who was ini- tially recognized to have renal failure when she presented with menorrhagia in July 1996. At that time, her serum creatinine was 2.5 mg/dl and she was noted to have protein- uria. She had already been diagnosed with diabetic retinop- athy and had undergone laser photocoagulation to her right eye. Her serum creatinine was noted to rise progressively, and she was referred to our nephrology service by her pri- mary care physician. Her past medical history was signifi- cant for insulin-dependent diabetes mellitus since age 19, when she presented with symptomatic hyperglycemia during her freshman year of college. Her surgical history included appendectomy, total abdominal hysterectomy, and left vitrec- tomy. She had no family history of diabetes. At the time of evaluation, she was taking the following medications: nifed- ipine, captopril, furosemide, iron, and insulin. Physical ex- amination was significant for a blood pressure of 144/94 mmHg, normal cardiovascular exam, and marked bilateral pitting edema of the lower extremities. There was evidence of early peripheral neuropathy. Urinalysis was significant for trace blood and proteinuria; urine sediment showed oval fat bodies and maltese crosses. Serum creatinine was 3.3 mg/dl and 24 hr urine protein was 4.4 g. The hemoglobin was 7.8 g/dl with mean corpuscular volume of 90 m 3 and a white blood count of 4,800/mm 3 . Serum albumin was 3.5 g/dl, cal- cium 8.8 mg/dl, and phosphate 4.0 mg/dl. She was negative for anti-islet and anti-insulin antibodies, and her C-peptide levels were undetectable. A renal ultrasound demonstrated normal size kidneys with normal echotexture. Despite good blood pressure and glucose control, her renal disease pro- gressed; she was therefore referred for transplantation. Stan- dard pretransplant evaluation confirmed that she was an excellent candidate for SPK. Because she had a nondiabetic IT as a potential donor, a living related kidney and pancreas transplant was considered. Standard HLA typing confirmed that the donor and recipient had identical HLA phenotype (A 3,30 ;B 35,49 ;C w4,w7 ;DR 4,18 ;DQ 3,4 ). Mixed lymphocyte culture between the donor and the recipient was mutually nonreac- tive. Donor work-up included negative anti-islet antibody and anti-insulin antibody assays. Furthermore, baseline fasting insulin levels and oral glucose tolerance test were normal. A preoperative abdominal spiral computed tomo- graphic scan of the donor defined the presence of normal anatomy of the left kidney (single artery and vein). After extensive discussion with both the donor and the recipient, the decision was made to proceed with a preemp- tive SPK. Inasmuch as the recipient’s creatinine had risen to 10 mg/dl, the procedure was carried out without further delay. Donor operation. Through a midline incision, the left kid- ney was initially procured in the standard fashion and im- mediately transported to the recipient operating room for transplantation. Then, the tail and body of the donor pan- creas were surgically exposed and dissected free (Fig. 1). The 1 Department of Surgery, University of Illinois at Chicago. 2 Address correspondence to: Enrico Benedetti, M.D., Department of Surgery, Division of Transplantation, 840 South Wood Street, M/C 958, Chicago, IL 60612. 3 Department of Surgery, University of Zurich. 4 Department of Medicine, University of Illinois at Chicago. * Abbreviations: IT, identical twin; SPK, simultaneous pancreas- kidney transplant. 915