As of October 10, 2002, nearly 19,000 pancreas transplants had been reported to the IPTR, approximately 14,000 in the US and approximately 5,000 outside the US. An era analysis of US cases from 1987-2002 showed a progressive improvement in outcome (p < 0.04), with pancreas transplant graft survival rates (GSRs) going from 75% at one year for 1988-89 to 85% for 2000-2001 SPK cases, from 53% to 77% for PAK cases, and from 48% to 73% for PTA cases. The improvements were due both to decreases in technical failure (TF) rates (from 16% to 8% in SPK, 16% to 9% in PAK, and 19% to 13% in PTA) and immunological failure rates (going from 5% to 2% for SPK, from 27% to 6% for PAK, and from 37% to 9% for PTA cases). The proportion of recipients > 45 years old increased from 9-11% for 1987-92 to 25-30% for 1999-2002 cases, and the improved outcomes encompassed the older patients as well. Contemporary pancreas transplant outcomes were calculated separately for 1996-2002 US and non-US cases. The results of the US analysis are summarized first. US patient survival rates at one year were > or = 94% in each recipient category, with one-year primary pancreas GSRs of 84% for SPK (n = 5.784), 76% for PAK (n = 1,033), and 77% for PTA (n = 470) (p < 0.0001). The immunological graft failure rates for 1996-2002 technically successful SPK, PAK and PTA cases were 2% (n = 5,231), 7% (n = 907), and 8% (n = 404) at one year (p = 0.0001). There was a progressive increase in the use of ED as opposed to BD) for duct management. For 1996-2002 US primary pancreas transplants, ED was used in 65% of SPK, 50% of PAK and 46% for PTA cases. Of the ED transplants, venous drainage via the portal system was used for 23% or SPK, 27% of PAK and 43% of PTA cases. Pancreas GSRs were not significantly different for 1996-2002 ED (n = 3,708) and BD (n = 1,942) SPK transplants (84% and 85%, respectively, at one year), nor was there a difference in pancreas GSRs for systemic (n = 2,859) versus portal (n = 842) venous drained ED SPK transplants (84% vs. 85% at one year). Kidney GSRs were slightly higher for ED versus BD SPK cases, 92% versus 90% at one year (p < 0.003). Pancreas GSRs for PAK transplants were 80% at one year for BD (n = 495; all systemic venous drainage) versus 72% for ED with systemic (n = 357) versus 71% for ED with portal (n = 134) venous drainage (p = 0.004 overall, but p = ns for ED portal vs. systemic). For PTA cases, one-year GSRs were 78% with BD (n = 240; all systemic venous drainage) versus 70% for ED with systemic (n = 115) versus 81% for ED with portal (n = 88) venous drainage (p = 0.2 overall, and 0.09 for ED portal vs. ED systemic). BD transplants were associated with a 12% conversion rate to ED by 2 years posttransplant in all 3 recipient categories. The age of US pancreas transplant recipients made little difference for outcome in the SPK category, with one-year pancreas GSRs ranging from 82% to 85% for patients grouped by age in decades from 10-19 to 60-69 years. In the PAK category, one-year GSRs progressively increased with each decade of age, going from 69% for those 20-29 to 83% for those 60-69 years old. Likewise, in the PTA category one-year GSRs increased with each decade of age, going from 41% for the 10-19 to 65% for the 20-29 to 76% for the 30-39 to 83% for the 40-49 to 85% for the 60-69 year old recipients. Pancreas GSRs were identical (84% at one year) for 1996-2002 US SPK recipients reported to have Type 1 (n = 5,356) or Type 2 (n = 288) diabetes (5% classified as Type 2). TAC+MMF was the dominant maintenance immunosuppressant for 1996-2002 US cases (approximately 60%), and with this regimen one-year GSRs were > or = 80% in all 3 recipient categories. An analysis of GSRs according to type of anti-T-cell antibody agents (depleting vs. non-depleting vs. none) for induction therapy in TAC+MMF treated recipients did not detect significant differences in any of the categories. The absolute numbers and the proportions of US pancreas grafts that were retransplants in the SPK and PTA categories (1% and 10% respectively) were relatively small, while a large number of the PAK grafts were retransplants (n = 346; 32% of the total). The majority of the latter were done after isolated failure of a pancreas graft in SPK recipients. In the SPK (n = 78) and PTA (n = 53) categories, the retransplant GSRs were significantly (p --> 0.06) lower than those for primary transplants. In the PAK category, however, GSRs were not significantly different (p = 0.14) for retransplant versus primary cases (72% and 76%, respectively, at one year). Known causes of death in 1996-2002 US pancreas recipients were tabulated for each category. Most were from cardio-cerebro-vascular accidents (1.3-2.6% incidence) or from infections (1.2-1.4% incidence), while death from malignancy or PTLD was reported in < or = 0.6% of recipients. In regard to non-US pancreas transplants, the overwhelming majority were in the SPK category (n = 2,163 for 1996-2002), with one-year patient, kidney and pancreas survival rates of 96%, 91% and 85% as good or better than the outcomes for US cases. In summary, with modern immunosuppression (TAC + MMF for maintenance) 1996-2002 pancreas transplant graft survival rates were > or = 80% at one year in all categories of recipients (SPK, PAK, PTA). The solitary pancreas transplant outcomes continue to improve as more are done.