Pancreas-Kidney transplantation: Impact of dialysis modality on the outcome

Effect of pretransplant dialysis modalities on pancreas-kidney transplant outcomes: a systematic review and meta-analysis

BACKGROUND

The impact of different pretransplant dialysis modalities on post-transplant outcomes for pancreas-kidney transplantation is currently unclear. This study aims to assess the association between pretransplant dialysis modalities [hemodialysis (HD) and peritoneal dialysis] and outcomes following pancreas-kidney transplantation.

METHODS

The authors searched PubMed, EMBASE, and the Cochrane Library for relevant studies published from inception until 1 December 2023. The authors included studies that examined the relationship between pretransplant dialysis modalities and clinical outcomes for pancreas-kidney transplantation. The primary outcomes considered were patient, pancreas and kidney graft survival, and intra-abdominal infection.

RESULTS

A total of 13 studies involving 1503 pancreas-kidney transplant recipients were included. Pretransplant HD was associated with improved pancreas graft survival (hazard ratio = 0.71, 95% confidence interval: 0.51-0.99, I ²=12%) and a decreased risk of intra-abdominal infection [odds ratio (OR)=0.69, 95% CI: 0.51-0.93, I ²=5%). However, no significant association was found between the dialysis modalities and patient or kidney graft survival. Furthermore, pretransplant HD was linked to a reduced risk of anastomotic leak (OR=0.32, 95% CI: 0.161-0.68, I ²=0%) and graft thrombosis (OR=0.56, 95% CI: 0.33-0.96, I ²=20%).

CONCLUSION

Pretransplant HD is the preferred dialysis modality while awaiting pancreas-kidney transplantation, although well-designed prospective studies are needed to confirm these findings.

Factores de riesgo para el desarrollo de complicaciones de la herida quirúrgica en el trasplante renal

Introducción: Las complicaciones quirúrgicas suponen un riesgo para el paciente tras el trasplante renal, siendo diversos los posibles factores de riesgo implicados.Objetivo: Determinar qué factores de riesgo contribuyen a la aparición de complicaciones de la herida quirúrgica en pacientes sometidos a un trasplante renal.Material y Método: Estudio de cohorte retrospectivo en pacientes trasplantados renales desde enero 2018 a diciembre 2021. Se recogieron datos sociodemográficos y clínicos del donante y del receptor. Se analizó la incidencia de infección y dehiscencia de la herida quirúrgica y sus factores de riesgo.Resultados: Presentaron infección el 13,5% de los pacientes y dehiscencia el 15,9% de la muestra, siendo pacientes con más edad (61,71±9,81 años frente a 56,56±11,88 años; p=0,030), con mayor tasa de sobrepeso según su IMC (42,9% frente 19,6%; p=0,046) y una mayor comorbilidad asociada (3,07±1,54 frente a 2,23±1,38 puntos; p=0,003). De los pacientes con infección, el 53,6% presentó, además, dehiscencia superficial de la herida. El exudado apareció en el 90,9% de los casos que desarrollaron una dehiscencia frente al 12,1% de los pacientes que no sufrieron dicha complicación (p<0,001).Conclusiones: La infección y la dehiscencia son complicaciones frecuentes tras el TR. La edad, el sobrepeso, comorbilidad alta y el exudado son factores de riesgo para desarrollar complicaciones de la herida quirúrgica tras el trasplante renal.

Impact of the Type of Dialysis on Time to Transplantation: Is It Just a Matter of Immunity?

Background: Renal transplantation represents the therapeutic gold standard in patients with end stage renal disease (ESRD). Still the role of pre-transplant dialysis in affecting time to transplantation has yet to be determined. We wanted to verify whether the type of renal replacement therapy (hemodialysis vs. peritoneal dialysis) affects time to transplantation and to identify clinical features related to the longer time to transplantation. Methods: We performed a retrospective single-center observational study on patients who had received a transplant in the Bologna Transplant Unit from 1991 to 2019, described through the analysis of digital transplant list documents for sex, age, body mass index (BMI), blood group, comorbidities, underlying disease, serology, type of dialysis, time to transplantation, Panel Reactive Antibodies (PRA) max, number of preformed anti Human Leukocyte Antigens (HLA) antibodies. A p-value < 0.05 was considered statistically significant. Results: In the 1619 patients analyzed, we observed a significant difference in time to transplant, PRA max and Preformed Antibodies Number between patients who received Hemodialysis (HD) and Peritoneal dialysis (PD). Then we performed a multiple regression analysis with all the considered factors in order to identify features that support these differences. The clinical variables that independently and directly correlate with longer time to transplantation are PRA max (p < 0.0001), Antibodies number (p < 0.0001) and HD (p < 0.0001); though AB blood group (p < 0.0001), age (p < 0.003) and PD (p < 0.0001) inversely correlate with time to transplantation. Conclusions: In our work, PD population received renal transplants in a shorter period of time compared to HD and turned out to be less immunized. Considering immunization, the type of dialysis impacts both on PRA max and on anti HLA antibodies.

Risk Factors for Early Pancreatic Allograft Thrombosis Following Simultaneous Pancreas-Kidney Transplantation: A Systematic Review

Simultaneous pancreas-kidney (SPK) transplantation remains the most effective treatment for providing consistent and long-term euglycemia in patients having type 1 diabetes with renal failure. Thrombosis of the pancreatic vasculature continues to contribute significantly to early graft failure and loss. We compared the rate of thrombosis to graft loss and systematically reviewed risk factors impacting early thrombosis of the pancreas allograft following SPK transplantation. We searched the MEDLINE, EMBASE, The Cochrane Library, and PREMEDLINE databases for studies reporting thrombosis following pancreas transplantation. Identified publications were screened for inclusion and synthesized into a data extraction sheet. Sixty-three studies satisfied eligibility criteria: 39 cohort studies, 22 conference abstracts, and 2 meta-analyses. Newcastle-Ottawa Scale appraisal of included studies demonstrated cohort studies of low bias risk; 1127 thrombi were identified in 15 936 deceased donor, whole pancreas transplants, conferring a 7.07% overall thrombosis rate. Thrombosis resulted in pancreatic allograft loss in 83.3% of reported cases. This review has established significant associations between donor and recipient characteristics, procurement and preservation methodology, transplantation technique, postoperative management, and increased risk of early thrombosis in the pancreas allograft. Further studies examining the type of organ preservation fluid, prophylactic heparin protocol, and exocrine drainage method and early thrombosis should also be performed.

Influence of dialysis duration on outcomes of simultaneous pancreas-kidney transplant

OBJECTIVE

The objective of this study was to assess how pre-transplant dialysis duration affects transplant outcomes after simultaneous pancreas-kidney transplant (SPK) in patients with type 1 diabetes mellitus (T1DM).

METHODS

Data of 6887 T1DM patients who underwent SPK transplantation between 2008 and 2018 were obtained from the Scientific Registry of Transplant Recipients database. According to pre-transplant dialysis duration, the patients were divided into the preemptive SPK, 0-2 years, 2-5 years, and >5 years dialysis groups. Kaplan-Meier survival analysis was performed to compare patient and graft survival among the groups. Univariate and multivariate Cox regression analyses were used to identify predictors of transplant outcomes.

RESULTS

The mean follow-up period was 56.7 ± 34.7 months. Compared with no dialysis or preemptive SPK, dialysis for 0-2 years was not significantly associated with patient or kidney graft survival, while long-term dialysis of 2-5 years and >5 years was significantly associated with increased risk of death and kidney graft failure. However, the duration of dialysis was not associated with pancreas graft survival.

CONCLUSION

Long-term dialysis duration before SPK transplant is an independent predictor of patient death and kidney graft failure in T1DM patients.

Impact of pre-transplant dialysis modality on the outcome and health-related quality of life of patients after simultaneous pancreas-kidney transplantation

Background

Simultaneous pancreas-kidney transplantation (SPKT) profoundly improves the health-related quality of life (HRQoL) of recipients. However, the influence of the pre-transplant dialysis modality on the success of the SPKT and post-transplant HRQoL remains unknown.

Methods

We analyzed the surgical outcome, long-term survival, as well as HRQoL of 83 SPKTs that were performed in our hospital between 2000 and 2016. Prior to transplant, 64 patients received hemodialysis (HD) and nineteen patients received peritoneal dialysis (PD). Physical and mental quality of life results from eight basic scales and the physical and mental component summaries (PCS and MCS) were measured using the Short Form 36 (SF-36) survey.

Results

Peri- and postoperative complications, as well as patient and graft survival were similar between the two groups. Both groups showed an improvement of HRQoL in all SF-36 domains after transplantation. Compared with patients who received HD before transplantation, PD patients showed significantly better results in four of the eight SF-36 domains: physical functioning (mean difference HD - PD: − 12.4 ± 4.9, P = < 0.01), bodily pain (− 14.2 ± 6.3, P < 0.01), general health (− 6.3 ± 2.8, P = 0.04), vitality (− 6.8 ± 2.6, P = 0.04), and PCS (− 5.2 ± 1.5, P < 0.01) after SPKT. In the overall study population, graft loss was associated with significant worsening of the HRQoL in all physical components (each P < 0.01).

Conclusions

The results of this analysis show that pre-transplant dialysis modality has no influence on the outcome and survival rate after SPKT. Regarding HRQoL, patients receiving PD prior to SPKT seem to have a slight advantage compared with patients with HD before transplantation.

Influence of Peritoneal or Hemodialysis on Results of Simultaneous Pancreas and Kidney Transplant

OBJECTIVES

The influence of peritoneal dialysis on outcomes after simultaneous pancreas and kidney transplant is still vague. In addition, whether peritoneal dialysis leads to a higher risk of infectious complications and higher mortality rates in these transplant patients has not been unambiguously confirmed. In this study, our aim was to verify whether dialysis type determined outcomes on the pancreas graft and whether dialysis type was a risk factor for graftectomy or recipient death.

MATERIALS AND METHODS

Our study group included 44 simultaneous pancreas and kidney transplant patients. Analyzed parameters included type and duration of dialysis treatment, age, sex, long-term pancreas graft survival and patient survival, overall mortality, and number of graftectomies.

RESULTS

Of 44 patients, 3 (7%) required a graftectomy. Mortality rate of the group was 5%. Of 44 patients, 33 had hemodialysis and 11 had peritoneal dialysis. In those who had hemodialysis, the mean duration of renal replacement therapy was 30.5 months, which was significantly longer than duration for those who had peritoneal dialysis (20.4 mo; P < .01). There were 3 graftectomies and 1 death in the hemodialysis group. In the peritoneal dialysis group, there were no graftectomies and 1 death, with no significant differences in the number of graftectomies and mortality rates between the groups. Long-term survival also did not differ between the groups.

CONCLUSIONS

We found that type of dialysis did not affect outcomes in our group of simultaneous pancreas and kidney transplant patients. Before transplant, each patient requires an individual approach to treatment. The type of dialysis performed should not be viewed as a contradiction for transplant.

Effect of Pretransplant Dialysis Modality on Outcomes After Simultaneous Pancreas-Kidney Transplantation

Background

Pretransplant dialysis modality may affect outcome after simultaneous pancreas-kidney transplantation (SPKT), and it has been suspected that peritoneal dialysis (PD) is associated with more postoperative complications compared to hemodialysis (HD). The aim of this study was to evaluate whether pretransplant dialysis modality affects the risk for postoperative complications in SPKT recipients.

Material/Methods

This was a retrospective longitudinal cohort study of all patients undergoing SPKT from 2010 to 2017, during which 99 simultaneous pancreas-kidney transplantations were performed. Three pre-emptive transplantations were excluded. Patient groups receiving PD (n=59) or HD (n=37) were similar regarding baseline characteristics. All complications occurring during the first 3 months after transplantation, as well as patient and graft survival, were analyzed.

Results

There were no significant differences in postoperative complications between groups, with similar rates of intra-abdominal infections (8% in HD vs. 10% in PD), pancreatitis (16% in HD vs. 17% in PD), gastrointestinal bleedings (22% in HD vs. 10% in PD), and relaparotomies (27% in HD vs. 24% in PD). None of the patients had venous graft thrombosis. Past peritonitis was not associated with increased risk for postoperative complications in PD patients. Patient and graft survival were similar between PD and HD groups.

Conclusions

Peritoneal dialysis is not a risk factor for postoperative complications after SPKT.

Choice of dialysis modality prior to kidney transplantation: Does it matter?

The population of patients with end stage renal disease (ESRD) is increasing, lengthening waiting lists for kidney transplantation. Majority of the patients are not able to receive a kidney transplant in timely manner even though it is well established that patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis. A large number of patients who desire a kidney transplant ultimately end up needing some form of dialysis therapy. Most of incident ESRD patients choose hemodialysis (HD) over peritoneal dialysis (PD) as the modality of choice in the United States, even though studies have favored PD as a better choice of pre-transplant dialysis modality than HD. PD is largely underutilized in the United States due to variety of reasons. As a part of the decision making process, patients are often educated how the choice regarding modality of dialysis would fit into their life but it is not clear and not usually discussed, how it can affect eventual kidney transplantation in the future. In this article we would like to discuss ESRD demographics and outcomes, modality of dialysis and kidney transplant related events. We have summarized the data comparing PD and HD as the modality of dialysis and its impact on allograft and recipient outcomes after kidney transplantation.

Impact of the pretransplant dialysis modality on kidney transplantation outcomes: a nationwide cohort study

OBJECTIVE

Most patients with uraemia must undergo chronic dialysis while awaiting kidney transplantation; however, the role of the pretransplant dialysis modality on the outcomes of kidney transplantation remains obscure. The objective of this study was to clarify the associations between the pretransplant dialysis modality, namely haemodialysis (HD) or peritoneal dialysis (PD), and the development of post-transplant de novo diseases, allograft failure and all-cause mortality for kidney-transplant recipients.

DESIGN

Retrospective nationwide cohort study.

SETTING

Data retrieved from the Taiwan National Health Insurance Research Database.

PARTICIPANTS

The National Health Insurance database was explored for patients who received kidney transplantation in Taiwan during 1998-2011 and underwent dialysis >90 days before transplantation.

OUTCOME MEASURES

The pretransplant characteristics, complications during kidney transplantation and post-transplant outcomes were statistically analysed and compared between the HD and PD groups. Cox regression analysis was used to evaluate the HR of the dialysis modality on graft failure and all-cause mortality. The primary outcomes were long-term post-transplant death-censored allograft failure and all-cause mortality started after 90 days of kidney transplantation until the end of follow-up. The secondary outcomes were events during kidney transplantation and post-transplant de novo diseases adjusted by propensity score in log-binomial model.

RESULTS

There were 1812 patients included in our cohort, among which 1209 (66.7%) and 603 (33.3%) recipients received pretransplant HD and PD, respectively. Recipients with chronic HD were generally older and male, had higher risks of developing post-transplant de novo ischaemic heart disease, tuberculosis and hepatitis C after adjustment. Pretransplant HD contributed to higher graft failure in the multivariate analysis (HR 1.38, p<0.05) after adjustment for the recipient age, sex, duration of dialysis and pretransplant diseases. There was no significant between-group difference in overall survival.

CONCLUSIONS

Pretransplant HD contributed to higher risks of death-censored allograft failure after kidney transplantation when compared with PD.

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients

BACKGROUND

The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up.

METHODS

To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95).

RESULTS

One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis.

CONCLUSION

The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.