Cardiovascular benefits of simultaneous pancreas-kidney transplant versus kidney alone transplant in diabetic patients

Survival After Simultaneous Pancreas‐Kidney Transplantation in Type 1 Diabetes: The Critical Role of Early Pancreas Allograft Function

Simultaneous pancreas-kidney transplantation (SPK) carries about a 7%–22% risk of technical failure, but the impact of early pancreas allograft loss on subsequent kidney graft and patient survival is not well-defined. We examined national transplant registry data for type 1 diabetic patients who received SPK between 2000 and 2021. Associations of transplant type (i.e., SPK, deceased‐donor kidney transplant [DDKA], living‐donor kidney transplant [LDKA]) with kidney graft failure and patient survival were estimated by multivariable inverse probability of treatment-weighted accelerated failure-time models. Compared to SPK recipients with a functioning pancreas graft 3 months posttransplant (SPK,P+), LDKA had 18% (Time Ratio [TR] 0.82, 95%CI: 0.70–0.95) less graft survival time and 18% (TR 0.82, 95%CI: 0.68–0.97) less patient survival time, DDKA had 23% (TR 0.77, 95%CI: 0.68–0.87) less graft survival time and 29% (TR 0.71, 95%CI: 0.62–0.81) less patient survival time, and SPK with early pancreas graft loss had 34% (TR 0.66, 95%CI: 0.56–0.78) less graft survival time and 34% (TR 0.66, 95%CI: 0.55–0.79) less patient survival time. In conclusion, SPK,P+ recipients have better kidney allograft and patient survival compared with LDKA and DDKA. Early pancreas graft failure results in inferior kidney and patient survival time compared to kidney transplant alone.

Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review

The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).

Chances and risks of sodium-glucose cotransporter 2 inhibitors in solid organ transplantation: A review of literatures

Solid organ transplantation offers life-saving treatment for patients with end-organ dysfunction. Patient survival and quality of life have improved over the past few decades as a result of pharmacological development, expansion of the donor pool, technological advances and standardization of practices related to transplantation. Still, transplantation is associated with cardiovascular complications, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from traditional risk factors seen in patients with type 2 diabetes mellitus, but also from specific post-transplant risk factors such as metabolic side effects of immunosuppressive drugs, post-transplant viral infections and hypomagnesemia. Oral hypoglycaemic agents are the first choice for the treatment of type 2 diabetes mellitus in non-transplanted patients. However, the evidence on the safety and efficacy of oral hypoglycaemic agents in transplant recipients is limited. The favourable risk/benefit ratio, which is suggested by large-scale and long-term studies on new glucose-lowering drug classes such as glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, makes studies warranted to assess the potential role of these agents in the management of PTDM.

[Transplantation strategy in type 1 diabetic patients]

Beta cell replacement by pancreas or Langerhans islets transplantation is the only way to restore glucose homeostasis in type 1 diabetic patients. The counterpart is the need for long-term immunosuppression. These transplantations are therefore mainly indicated for patients candidates for kidney transplantation and for patients with poor quality of life due to unstable diabetes with life-threatening hypoglycemic events. Both beta cell replacement techniques have different benefits and risks and should be adapted to each type 1 diabetic patient. The transplant strategy must be personalized according to parameters assessed in the pre-transplant period, validated by a multidisciplinary team and reassessed regularly until transplantation.

Outcomes of dialysis and the transplantation options for patients with diabetic end-stage renal disease in Korea

BACKGROUND

The best therapeutic option for diabetic end-stage renal disease (DMESRD) has not been established among living donor kidney transplantation (LDKT), deceased donor kidney transplantation (DDKT), simultaneous pancreas and kidney transplantation (SPK), and dialysis.

METHODS

We retrospectively analyzed the outcomes of DMESRD patients at two Korean centers from February 2000 to December 2011.

RESULTS

Among 674 patients, 295 underwent kidney transplantation (LDKT, 175; DDKT, 72; and SPK, 48), while 379 were still on dialysis. The dialysis group had a higher mortality rate than the transplantation group. From the time after dialysis initiation, LDKT group had a better patient survival rate than DDKT registration group and SPK registration group. From the time after transplantation, LDKT had a better patient survival rate than DDKT; however, there was no significant difference between LDKT and SPK. In SPK, patient survival and kidney or pancreas graft survival rates were not different between types 1 and 2 DMESRD.

CONCLUSION

LDKT is better than waiting for SPK/DDKT in DMESRD patients, if a living donor is available, and this conclusion may be unique to Korea where waiting time for SPK is long. SPK can be used in non-obese Asians with type 2 as well as type 1 DMESRD.

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.

Impact of Medicare coverage on disparities in access to simultaneous pancreas and kidney transplantation

In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18-55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16-1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09-1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87-1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78-1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66-0.79 and 0.59-0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure.

Pancreas after living donor kidney transplants in diabetic patients: impact on long-term kidney graft function

In this single-institution study, we compared outcomes in diabetic recipients of living donor (LD) kidney transplants that did vs. did not undergo a subsequent pancreas transplant. Of 307 diabetic recipients who underwent LD kidney transplants from January 1, 1995, through December 31, 2003, a total of 175 underwent a subsequent pancreas after kidney (PAK) transplant; 75 were deemed eligible (E) for, but did not receive (for personal or financial reasons), a PAK, and thus had a kidney transplant alone (KTA); and 57 deemed ineligible (I) for a PAK because of comorbidity also had just a KTA. We analyzed the three groups (PAK, KTA-E, KTA-I) for differences in patient characteristics, glycemic control, renal function, patient and kidney graft survival rates, and causes of death. Kidney graft survival rates (actuarial) were similar in the PAK vs. KTA-E groups at one, five, and 10 yr post-transplant: 98%, 82%, and 67% (PAK) vs. 100%, 84%, and 62% (KTA-E) (p = 0.9). The long-term (greater than four yr post-transplant) estimated glomerular filtration rate (GFR) was higher in the PAK than in the KTA-E group: 53 +/- 20 mL/min (PAK) vs. 43 +/- 16 mL/min (KTA-E) (p = 0.016). The patient survival rates were also similar for the PAK and KTA-E groups. We conclude that the subsequent transplant of a pancreas after an LD kidney transplant does not adversely affect patient or kidney graft survival rates; in fact, it is associated with better long-term kidney graft function.

Living donor kidney versus simultaneous pancreas-kidney transplant in type I diabetics: an analysis of the OPTN/UNOS database

BACKGROUND AND OBJECTIVES

Transplant options for type I diabetics with end-stage renal disease include simultaneous pancreas-kidney (SPKT), living donor kidney (LDKT), and deceased donor kidney transplant (DDKT). It is unclear whether SPKT offers a survival benefit over LDKT in the current era of transplantation. The authors compared outcomes of kidney transplant recipients with type I diabetes using data from the Organ Procurement and Transplant Network/United Network for Organ Sharing.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Adult (age 20 to 59) type I diabetics who received a solitary first-time kidney transplant between 2000 and 2007 were studied. Outcomes included overall kidney graft and patient survival. Multivariate analysis was performed using a stepwise Cox proportional hazards model.

RESULTS

Kidney graft survival was better for recipients of LDKT compared with SPKT (P = 0.008), although patient survival was similar (P = 0.346). On multivariate analysis, LDKT was associated with lower adjusted risks over 72 mo follow-up of kidney graft failure (HR 0.71; 95% CI 0.61 to 0.83) and patient death (HR 0.78; 95% CI 0.65 to 0.94) versus SPKT. Compared with DDKT, SPKT had superior unadjusted kidney graft and patient survival, partly due to favorable SPKT donor and recipient factors.

CONCLUSIONS

Despite more transplants from older donors and among older recipients, LDKT was associated with superior outcomes compared with SPKT and was coupled with the least wait time and dialysis exposure. LDKT utilization should be considered in all type I diabetics with an available living donor, particularly given the challenges of ongoing organ shortage.

Outcome of pancreas transplantation in recipients older than 50 years: a single-centre experience

BACKGROUND

Pancreas transplantation (PT) remains the only treatment that can restore insulin independence among insulin-dependent diabetics. An ageing population in developed countries has led to an increasing number of older patients who may be suitable for PT. Some investigators argue that PT in recipients older than 50 years has an inferior outcome compared with the younger group.

METHODS

The object of this study was to compare the outcomes of 31 PT in patients aged 50 and above 105 PT in recipients below 50 years performed between June 2001 and December 2007.

RESULTS

The incidence of general posttransplant complications were similar in both; 60% in less than 50 vs. 58% in more than or equal to 50, P=0.539. So, as the incidence of other surgical complication in the more than or equal to 50 group compared with less than 50 (graft thrombosis 13% vs. 11.5%; bleeding 19% vs. 6.7%; abdominal abscess 23% vs. 19%; pancreatic leak 13% vs. 9.6%). There was no significant difference in the incidence of urinary tract infection and early rejection in either group. However, the incidence of respiratory tract infection was significantly higher in more than or equal to 50 (38.7% in >or=50 vs. 9.6% in <50, P=0.003). One-year patient survival was 88% in more than or equal to 50 vs. 92% in less than 50 group, P=0.399; and pancreas graft survival rate was similar (79% in the >or=50 and 74% in <50, P=0.399).

CONCLUSION

This study demonstrates that it is feasible to safely transplant potential PT recipients aged 50 and above. However, good medical assessment and careful patient selection is strongly recommended.