Transplantation with pancreas after living donor kidney vs. living donor kidney alone in type 1 diabetes mellitus recipients*

Pancreas transplantation from hepatitis C viremic donors to uninfected recipients

Despite utilization of hepatitis C viremic organs for hepatitis C naïve recipients (HCV D+/R-) in other solid organ transplants, HCV viremic pancreata remain an unexplored source of donor organs. This study reports the first series of HCV D+/R- pancreas transplants. HCV D+/R- had shorter waitlist times compared to HCV D-/R-, waiting a mean of 16 days from listing for HCV-positive organs. HCV D+/R- had a lower match allocation sequence than HCV D-/R-, and this correlated with receipt of organs with a lower Pancreas Donor Risk Index (PDRI) score. All HCV D+/R- had excellent graft function with a mean follow-up of 438 days and had undetectable HCV RNA levels by a mean of 23 days after initiation of HCV-directed therapy. The rates of infectious complications, reoperation, readmission, rejection, and length of stay were not impacted by donor HCV status. A national review of potential ideal pancreas donors found that 37% of ideal HCV-negative pancreas allografts were transplanted, compared to only 5% of ideal HCV-positive pancreas allografts. The results of the current study demonstrate the safety of accepting HCV-positive pancreata for HCV-naïve recipients and advocates for increased utilization of ideal HCV-positive pancreas allografts.

Perioperative considerations for kidney and pancreas-kidney transplantation

Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. Nephroprotective strategies include adequate fluid status and goal-directed therapy. The conventional use of diuretics has not demonstrated a real nephroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance. Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.

Pancreas Transplantation: Indications, Techniques, and Outcomes

Pancreas transplantation treats insulin-dependent diabetes with or without concurrent end-stage renal disease. Pancreas transplantation increases survival versus no transplant, increases survival when performed as simultaneous pancreas-kidney versus deceased-donor kidney alone, and improves quality of life. Careful donor and recipient selection are paramount to good outcomes. Several technical variations exist for implantation: portal versus systemic vascular drainage and jejunal versus duodenal versus bladder exocrine drainage. Complications are most frequently technical in the first year and immunologic thereafter. Graft rejection is challenging to diagnose and is treated selectively. Islet cell transplantation currently has inferior outcomes to whole-organ pancreas transplantation.

Ipsilateral versus contralateral placement of the pancreas allograft in pancreas after kidney transplant recipients

BACKGROUND

In a diabetic, uremic kidney transplant recipient that may receive a future pancreas after kidney (PAK) transplant, the kidney is typically implanted on the left side in anticipation of the subsequent pancreas transplant on the right side. In this study, we sought to determine if ipsilateral PAK (iPAK) is as safe as contralateral PAK (cPAK).

METHODS

The 115 PAK transplants (iPAK n = 57, cPAK n = 58) were performed from 1997-2010 and results were compared between the groups.

RESULTS

Kidney graft survival and pancreas graft survival was similar between the two groups. Kidney graft function according to serum creatinine and eGFR was not different between the cPAK and the iPAK groups and there were no episodes of kidney graft thrombosis in either group. Subgroup analyses focusing on donor source also did not show worse outcomes for graft survivals in iPAK group when compared to cPAK group.

CONCLUSIONS

Pancreas and kidney graft survival in PAK transplants is unaffected by the surgical procedure and iPAK is safe.

Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction

PURPOSE OF REVIEW

To define the natural history of kidney allograft loss related to recurrent diabetes following transplant, and to understand the potential benefit of pancreas transplantation upon kidney allograft survival.

RECENT FINDINGS

A postulated benefit of simultaneous pancreas kidney transplant is that, unlike kidney transplant alone, euglycemia from the added pancreas allograft may confer a nephroprotective benefit and prevent recurrent diabetic nephropathy in the renal allograft. Recent large database analyses and long-term histological assessments have been published that assist in quantifying the problem of recurrent diabetic nephropathy and answering the question of the potential benefits of euglycemia. Further data may be extrapolated from larger single-center series that follow the prognosis of early posttransplant diabetes mellitus as another barometer of risk from diabetic nephropathy and graft loss.

SUMMARY

Recurrent diabetic nephropathy following kidney transplant is a relatively rare, late occurrence and its clinical significance is significantly diminished by the competing risks of death and chronic alloimmune injury. Although there are hints of a protective effect upon kidney graft survival with pancreas transplant, these improvements are small and may take decades to appreciate. Clinical decision-making regarding pancreas transplant solely based upon nephroprotective effects of the kidney allograft should be avoided.

Type 1 diabetic patients have better endothelial function after simultaneous pancreas-kidney transplantation than after kidney transplantation with continued insulin therapy

The purpose of this study was to analyse the influence of simultaneous pancreas-kidney or kidney transplantation on endothelial function and systemic inflammation in type 1 diabetic patients with end-stage renal disease. In 39 simultaneous pancreas-kidney, 39 type 1 diabetic kidney and 52 non-diabetic kidney recipients, flow-mediated dilatation was measured. Additionally, blood glycated haemoglobin, serum creatinine and lipids, plasma nitrites [Formula: see text] and nitrates, asymmetric dimethylarginine, soluble vascular cell adhesion molecule-1, intercellular adhesion molecule-1, and E-selectin, high-sensitivity C-reactive protein, tumour necrosis factor-α, interleukin 1β and interleukin 6 concentrations were assessed. During 58 ± 31 months follow-up period, flow-mediated dilatation and [Formula: see text] were greater in simultaneous pancreas-kidney than in type 1 diabetic kidney recipients [10.4% ± 4.7% vs 7.7% ± 4.2%, p < 0.05 and 0.94 (0.74-1.34) vs 0.24 (0.20-0.43) μmol/L, p < 0.01, respectively]. In type 1 diabetic patients after simultaneous pancreas-kidney or kidney transplantation, [Formula: see text] correlated with flow-mediated dilatation (r = 0.306, p < 0.05) and with blood glycated haemoglobin (r = -0.570, p < 0.001). The difference in [Formula: see text] was linked to blood glycated haemoglobin and estimated glomerular filtration rate, whereas the difference in flow-mediated dilatation was linked to [Formula: see text]. The levels of inflammatory markers (except soluble vascular cell adhesion molecule-1) were similar in simultaneous pancreas-kidney and type 1 diabetic kidney recipients. Improved endothelial function in type 1 diabetic patients with end-stage renal disease after simultaneous pancreas-kidney compared to kidney transplantation is associated with normalisation of glucose metabolism but not with improvement in plasma pro-inflammatory cytokines.

Live donor kidney - PAK versus SPK: how to decide?

PURPOSE OF REVIEW

Patients with type 1 diabetes and end stage renal disease face a complex choice when considering the relative risks and benefits of kidney transplant alone with or without subsequent pancreas after kidney transplant (PAK) or simultaneous kidney pancreas transplant (SPK).

RECENT FINDINGS

SPK is considered the optimal treatment regarding long-term patient survival, but when also faced with the option of living donor kidney transplant with the potential for PAK later, the ideal option is less clear.

SUMMARY

This review summarizes the current literature regarding SPK, living donor kidney transplant alone, and PAK transplant outcomes and examines the relative risks of pre- and posttransplant variables that impact patient and graft survival to help inform this complex treatment decision.

Pancreas Transplantation in the Modern Era

The field of pancreas transplantation has evolved from an experimental procedure in the 1980s to become a routine transplant in the modern era. With short- and long-term outcomes continuing to improve and the significant mortality, quality-of-life, and end-organ disease benefits, pancreas transplantation should be offered to more patients. In this article, we review current indications, patient selection, surgical considerations, complications, and outcomes in the modern era of pancreas transplantation.

The impact of method on kidney graft and patient survival in kidney-pancreas transplantations for type I diabetes mellitus

Patients who develop end-stage renal disease (ESRD) associated with Type I Diabetes Mellitus may receive kidney alone (KA) transplantation, simultaneous pancreas-kidney (SPK) transplantation, or a pancreas after kidney (PAK) transplantation. The goal of this study is to examine the long-term impact of pancreas transplantation on kidney graft and patient survival rates. A total of 85 transplantation cases, consisting of 30 that received living donor KA, 21 that received SPK, and 34 that received PAK, from 2003-2010 at Akdeniz University Organ Transplantation Institute were retrospectively screened. There was a graft loss in 4 cases from the KA group, and in 1 case from each of the SPK and PAK groups. The five-year kidney graft survival rates were 86.7% in KA, 95.2% in SPK, and 97.1% in PAK. There was a single patient loss in both KA and SPK. The kidney survival percentages were higher in SPK and PAK groups compared to the KA group. Therefore, SPK should be the primary preference in these patients; however, for the cases that have a living donor, pancreas transplantation should be considered after kidney transplantation, or the patients can be followed-up on with close blood sugar control.

Kidney transplant options for the diabetic patient

For patients with diabetes and progressive chronic kidney disease, kidney transplantation is the optimal mode of renal replacement therapy, with or without a pancreas transplant. Additional benefits of pancreas transplant have become increasingly apparent due to advances in surgical outcomes and immunosuppression, and may be reasonably considered even in selected patients with type 2 diabetes. In general, pancreas transplantation is associated with long-term survival advantages despite an increased short-term morbidity and mortality risk. This is true with simultaneous pancreas kidney transplantation or pancreas after kidney transplantation compared to kidney transplantation alone, regardless of kidney donor status (living or deceased). Individual patient preferences, comorbidities, and expected waiting time influence selection of transplant modality, rather than a clear survival benefit of one strategy versus the other. In selected patients with type 2 diabetes, recent outcomes data support cautious utilization of simultaneous pancreas kidney transplantation when a living kidney donor transplant is not an option. The purpose of this review is to summarize current data regarding kidney and pancreas transplant treatment options in patients with both type 1 and 2 diabetes and the influence of current organ allocation policies to better understand the advantages and disadvantages of each of these strategies.

Follow-up of secondary diabetic complications after pancreas transplantation

PURPOSE OF REVIEW

Successful pancreas transplantation restores physiologic glycemic and metabolic control. Its effects on overall patient survival (especially for simultaneous pancreas-kidney transplantation) are clear-cut. We herein review the available literature to define the impact of pancreas transplantation on chronic complications of diabetes mellitus.

RECENT FINDINGS

With longer-term follow-up, wider patient populations, and more accurate investigational tools (clinical and functional tests, noninvasive imaging, histology, and molecular biology), growing data show that successful pancreas transplantation may slow the progression, stabilize, and even favor the regression of secondary complications of diabetes, both microvascular and macrovascular, in a relevant proportion of recipients.

SUMMARY

Patients who are referred for pancreas transplantation usually suffer from advanced chronic complications of diabetes, which have classically been deemed irreversible. A successful pancreas transplantation is often able to slow the progression, stabilize, and even reverse many microvascular and macrovascular complications of diabetes. Growing clinical evidence shows that the expected natural history of long-term diabetic complications can be significantly modified by successful pancreas transplantation.

Does simultaneously transplanted pancreas improve long-term outcome of kidney transplantation in type 1 diabetic recipients?

INTRODUCTION

Simultaneous pancreas-kidney transplantation (SPK) is an alternative to kidney transplantation (KTx) for type 1 diabetic patients with end-stage kidney disease. However, a fair comparison of SPK and KTx is difficult because of significant differences in donor, recipient, and transplantation procedure parameters. The aim of this study was to compare the early and long-term outcomes of SPK versus KTx in southwest Poland.

MATERIAL AND METHODS

Thirty-five diabetic dialysis patients who had SPK and 64 patients who had KTx were included in the analysis.

RESULTS

SPK recipients were younger (38±6 years versus 42±9 years) and received organs from younger donors (25±7 versus 43±12 years) compared to the KTx group. They had shorter kidney cold ischemia time (9±2 hours versus 22±7 hours) but worse HLA class II mismatches (1.4±0.6 versus 1.0±0.5). In the early postoperative period, three patients died from the SPK group and one patient died from the KTx group. Additionally, two SPK patients lost their pancreatic grafts, and five KTx patients lost their kidney grafts. One-year patient survival rates for the SPK and KTx groups were 88% and 98%, respectively, and 5-year, 81% and 93%, respectively. One-year kidney graft survivals rates for the SPK and KTx groups were 100% and 89%, respectively, and 5-years, 89% and 81%, respectively. One-year insulin-free survival among SPK patients was 90% and the 5-year survival rate was 76%. Excretory function of the transplanted kidneys was better among SPK group; however, the difference reached statistical significance only in posttransplant years 2 and 3: 63.5±20.1 versus 50.3±19.7 and 64.9±12.9 versus 51.6±21.8 mL/min/1.73 m2 for SPK and KTx, respectively.

CONCLUSIONS

Normoglycemia in SPK recipients did not improve patient survival at 5 years. The worse HLA compatibility in the SPK group did not lead to impaired kidney graft survival compared to KTx. Better kidney graft function among SPK recipients probably resulted from a more restrictive donor selection.

Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Pancreas Transplantation

Diabetes mellitus remains one of the leading causes of morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention, approximately 23.6 million people in the United States are affected. Of these individuals, 5-10% have been diagnosed with type 1 diabetes mellitus (TIDM), an autoimmune disease. Although it often appears in childhood, T1DM may manifest at any age. The effects of T1DM can be devastating, as the disease often leads to significant secondary complications, morbidity, and decreased quality of life. Since the late 1960s, surgical treatment for diabetes mellitus has continued to evolve and has become a viable alternative to chronic insulin administration. In this review, the historical evolution, current status, graft efficacy, benefits, and complications of pancreas transplantation are explored.

The role of kidney-pancreas transplantation in diabetic kidney disease

For patients with type 1 diabetes, innovations in insulin formulations and delivery have improved the ability to achieve excellent blood glucose control. However, it is uncommon to achieve euglycemia, particularly while avoiding complications arising from hypoglycemia. Pancreas transplantation remains the only broadly applied treatment strategy that can result in normalization of blood glucose, but this must be weighed against the risks of a surgical procedure and subsequent immunosuppression. To improve this risk/benefit ratio, pancreas transplantation is typically performed in patients with kidney failure who are to undergo kidney transplantation and immunosuppression (simultaneous pancreas-kidney transplant) or who have undergone kidney transplant and are obligated to the use of immunosuppressive medications (pancreas after kidney transplant). The purpose of this review is to clarify the benefit of an added pancreas transplant in these clinical settings and formulate an approach to the patient with type 1 diabetes as they approach kidney failure.