Long-term survival after kidney and kidney-pancreas transplantation in diabetic patients

Patient and kidney transplant survival in type 1 diabetics after kidney transplant alone compared to simultaneous pancreas-kidney transplant

Background

Donor and other differences mean understanding drivers of transplant survival for type 1 diabetics is challenging. We aimed to compare outcomes of simultaneous pancreas‐kidney transplant over kidney transplant alone for people with end‐stage kidney disease (ESKD) and type 1 diabetes.

Methods

We performed a population‐based cohort study comparing outcomes from kidney alone and kidney‐pancreas transplants using registry data. Our study population was people in Australia and New Zealand with type 1 diabetes and ESKD who received a kidney transplant in 1984–2016. Primary outcomes were time to kidney transplant failure and all‐cause death. Secondary outcomes were time to cardiovascular and non‐cardiovascular death. We compared adjusted survival using Cox regression (hazard ratio HR and 95% confidence intervals CI).

Results

Of 1295 type 1 diabetics receiving a transplant, 430 (33%) received deceased donor kidney, 172 (13%) received living donor kidney, and 693 (54%) received pancreas‐kidney transplant. Compared to deceased donor kidney, pancreas‐kidney recipients had 40% lower rate of kidney transplant failure (adjusted HR 0.60; 95% CI 0.45–0.81; p = 0.001) and 34% lower mortality (adjusted HR 0.66; 95% CI 0.53–0.83; p < 0.001), driven by 49% reduction in cardiovascular mortality (adjusted HR 0.51; 95% CI 0.36–0.72; p < 0.001). Pancreas‐kidney recipients had similar reductions in transplant failure and mortality compared to living kidney recipients, after adjusting for transplant timing.

Conclusions

For people with type 1 diabetes, pancreas‐kidney transplant provides improved transplant and overall survival compared to deceased donor kidney alone. Living donor kidneys may perform just as well as pancreas‐kidney transplant if waiting times are short.

Joint modelling for organ transplantation outcomes for patients with diabetes and the end-stage renal disease

This article is motivated by jointly modelling longitudinal and time-to-event clinical data of patients with diabetes and end-stage renal disease. All patients are on the waiting list for the pancreas transplant after kidney transplant, and some of them have a pancreas transplant before kidney transplant failure or death. Scant literature has studied the dynamical joint relationship of the estimated glomerular filtration rates trajectory, the effect of pancreas transplant, and time-to-event outcomes, although it remains an important clinical question. In an attempt to describe the association in the multiple outcomes, we propose a new joint model with a longitudinal submodel and an accelerated failure time submodel, which are linked by some latent variables. The accelerated failure time submodel is used to determine the relationship of the time-to-event outcome with all predictors. In addition, the piecewise linear function in the survival submodel is used to calculate the dynamic hazard ratio curve of a time-dependent side event, because the effect of the side event on the time-to-event outcome is non-proportional. The model parameters are estimated with a Monte Carlo EM algorithm. The finite sample performance of the proposed method is investigated in simulation studies. Our method is demonstrated by fitting the joint model for the clinical data of 13,635 patients with diabetes and the end-stage renal disease.

Influencing factors of new-onset diabetes after a renal transplant and their effects on complications and survival rate

OBJECTIVE

To discuss the onset of and relevant risk factors for new-onset diabetes after a transplant (NODAT) in patients who survive more than 1 year after undergoing a renal transplant and the influence of these risk factors on complications and long-term survival.

METHOD

A total of 428 patients who underwent a renal transplant between January 1993 and December 2008 and were not diabetic before surgery were studied. The prevalence rate of and relevant risk factors for postoperative NODAT were analyzed on the basis of fasting plasma glucose (FPG) levels, and differences in postoperative complications and survival rates between patients with and without NODAT were compared.

RESULTS

The patients in this study were followed up for a mean of 5.65 ± 3.68 years. In total, 87 patients (20.3%) developed NODAT. Patients who converted from treatment with CSA to FK506 had increased prevalence rates of NODAT (P <0.05). Multi-factor analysis indicated that preoperative FPG level (odds ratio [OR]  =  1.48), age (OR  =  1.10), body mass index (OR  =  1.05), hepatitis C virus infection (OR  =  2.72), and cadaveric donor kidney (OR  =  1.18) were independent risk factors for NODAT (All P <0.05). Compared with the N-NODAT group, the NODAT group had higher prevalence rates (P < 0.05) of postoperative infection, hypertension, and dyslipidemia; in addition, the survival rate and survival time of the 2 groups did not significantly differ.

CONCLUSION

Among the patients who survived more than 1 year after a renal transplant, the prevalence rate of NODAT was 20.32%. Preoperative FPG level, age, body mass index, hepatitis C virus infection, and cadaveric donor kidney were independent risk factors for NODAT. Patients who converted from treatment with CSA to FK506 after a renal transplant had aggravated impairments in glycometabolism. Patients with NODAT were also more vulnerable to postoperative complications such as infection, hypertension, and hyperlipidemia.

Preconditioning of pancreatic graft with isoproterenol reduces posttransplant ischemia/reperfusion injury in rats

AIM: To determine the protective effects of isoproterenol preconditioning (IPC) against ischemia/reperfusion injury in rats after pancreas transplantation and to explore mechanisms involved.

METHODS: The expression of heat shock protein 70 (HSP70) in the pancreas of rats undergoing IPC was detected at different time points after IPC. A rat model of posttransplant pancreatic ischemia/reperfusion injury was established. The donor rats that showed high expression of HSP70 in the pancreas were used as experiment group, while donor rats that did not undergo IPC were used as control group. The blood and pancreatic samples were taken 6 h after pancreas transplantation. The expression of HSP70 in the pancreas was detected by Western blot and immunohistochemistry. The expression of TNF-α in the pancreas was detected by immunohistochemistry. Serum amylase was determined by iodine colorimetry. The apoptosis rate of pancreatic cells was determined by flow cytometry.

RESULTS: The expression level of HSP70 in the pancreas of donor rats reached the peak at 24 h after IPC, which was significantly higher than those at other time points (0.92 ± 0.25 vs 0.24 ± 0.04, 0.34 ± 0.06, 0.58 ± 0.07, 0.62 ± 0.11 and 0.25 ± 0.09, respectively; all P < 0.05). The expression levels of HSP70 in the experimental group at 6, 12, 24 and 36 h after IPC were significantly higher than those in the control group at corresponding time points (0.34 ± 0.06 vs 0.28 ± 0.07, 0.58 ± 0.07vs 0.25 ± 0.04, 0.92 ± 0.25 vs 0.27 ± 0.05 and 0.62 ± 0.11 vs 0.25 ± 0.06, respectively; all P < 0.05) but returned to normal level at 48 h. No significant differences were noted in the expression levels of HSP70 among each time point in the control group. HSP70 was mainly expressed in pancreatic acinar cells and the vessel wall. The expression level of TNF-α, apoptosis rate, neutrophil count and serum amylase significantly increased in the control group when compared with those in sham-operated group (all P < 0.01). However, the levels of these parameters significantly decreased in the experiment group when compared with those in the control group (11 929 ± 1 220 vs 46 111 ± 3 127, 26.7% ± 4.5% vs 37.4% ± 4.7%, 3 308 ± 531 vs6 668 ± 1 506 and 1 057 IU/L± 148 IU/L vs 1 408 IU/L± 195 IU/L, respectively; all P < 0.05).

CONCLUSION: Isoproterenol preconditioning reduces ischemia/reperfusion injury in rats after pancreas transplantation perhaps by inducing the production of HSP70.

Impact of pancreas transplantation on type 1 diabetes-related complications

PURPOSE OF REVIEW

Type 1 diabetes is a chronic disease that can impact patient survival and quality of life because of acute and chronic complications. Although intensive insulin scheme treatment has been shown to reduce the incidence of diabetes-related complications, only pancreas transplantation has been shown to be able to alter them and in some cases to revert them. In this review, an extensive view of the effect of pancreas transplantation on diabetes-related complication will be described.

RECENT FINDINGS

This review will focus on patients survival, diabetic nephropathy, neuropathy, cardiovascular event, comparing their incidence in type 1 diabetic patients treated with insulin and in type 1 diabetic patients receiving kidney, kidney-pancreas or pancreas alone graft. The review will focus mostly on the papers published in the last decade, with a particular attention to those on new aspects of graft function analysis like spectroscopy. Moreover, a comparison with islet transplantation procedure will be performed.

SUMMARY

This review will give an update on the potential of pancreas transplantation, give a guide for clinical practice and help to consider pancreas transplantation as an alternative to insulin treatment for selected patients.

Influence of pancreas and kidney transplant function on recipient survival

The aim of this study was to evaluate long-term survival after simultaneous pancreas and kidney (SPK) transplantation in relation to function of both grafts. Among 67 recipients who received SPK transplants between 1988 and 2004, 35 had follow-up longer than 18 months, and were divided into: group I (n = 20), recipients with good function of both grafts; group II (n = 7), patients who had lost transplanted pancreas but had still good kidney graft function; group III (n = 8), patients who had lost both grafts. Comparison of survival rates and analysis of the reason of mortality among groups was performed. The cumulative survival rate was significantly higher in group I than in group III (after 3, 5, 10 years: 100%, 100%, 80% vs 75%, 50%, 37%, respectively). Cumulative survival rate for group II after 3, 5, 10 years was 100%, 100%, 33%, respectively. There were no significant differences in survival rates between groups I and II and between groups II and III. In group I deaths for cardiovascular event and for leukemia were noted. In group II deaths due to cardiovascular event and sepsis were observed. In group III all patients died due to cardiovascular events and the mean time from loss of pancreas and kidney graft function to death was: 75 +/- 51 months (range from 19 to 142), and 49 +/- 26 months (range 19 to 99), respectively. Good pancreas and kidney graft functions prevent death due to cardiovascular event.

Closed-loop insulin delivery – what lies between where we are and where we are going?

Closed-loop insulin delivery in individuals with diabetes can potentially lead to near-normal glucose profiles. To this end, existing subcutaneous glucose sensors and external insulin pumps can be linked with an insulin delivery algorithm to create a completely automated closed-loop system. This paper reviews current research into the development of such a system, with particular emphasis on creating a system emulating the physiological properties of the beta-cell. Issues related to using subcutaneous interstitial fluid for glucose sensing and insulin delivery are reviewed. Criteria for optimising the system are discussed using historical data. Existing strategies for open-loop pump therapy are presented with the objective of defining a path to advance from the existing physician/patient determined insulin therapy to a completely automated system.