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Yu M, King KL, Maclay LM, Husain SA, Schold JD, Mohan S. Incomplete reporting of clinically significant acute rejection episodes in the national kidney transplant registry. Am J Transplant 2024:S1600-6135(24)00277-6. [PMID: 38636806 DOI: 10.1016/j.ajt.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Administrative claims data could provide a unique opportunity to identify acute rejection (AR) events using specific antirejection medications and to validate rejected data reported to the Organ Procurement and Transplantation Network. This retrospective cohort study examined differences in registry-reported events and those identified using claims data among adult kidney transplant recipients from 2012 to 2017 using Standard Analysis Files from the US Renal Data System. Rejection rates, survival estimates, and center-level differences were assessed using each approach. Among 45 880 first-time kidney transplant recipients, we identified 3841 AR events within 12 months of transplant reported by centers in the registry; claims data yielded 2945 events. Of all events occurring within 12 months of transplant, 48.5% were reported using registry only, 32.9% were identified using claims only, and 18.6% were identified using both approaches. A 3-year death-censored graft survival probability was 90.0%, 88.4%, and 81.2% (P < .001) for ARs identified using registry only, claims data only, and both approaches, respectively. The large discordance between registry-reported and claims-based events suggests incomplete and potentially inaccurate reporting of events in the Organ Procurement Transplant Network registry. These findings have important implications for analyses that use AR data and underscore the need for improved capture of clinically meaningful events.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Lindsey M Maclay
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
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2
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Mori T, Nyumura I, Hanai K, Shinozaki T, Babazono T. Effects of simultaneous pancreas and kidney transplantation in Japanese individuals with type 1 diabetes and end-stage kidney disease. Diabetol Int 2024; 15:278-289. [PMID: 38524933 PMCID: PMC10959910 DOI: 10.1007/s13340-024-00691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/08/2024] [Indexed: 03/26/2024]
Abstract
This single-center observational cohort study aimed to assess the potential benefits of simultaneous pancreas and kidney transplantation (SPK) in terms of mortality and kidney graft outcomes in Japanese individuals with type 1 diabetes (T1D) and end-stage kidney disease (ESKD). We first compared all-cause mortality rates between 78 SPK recipients and 108 non-transplanted individuals with T1D and ESKD. To mitigate the bias stemming from immortal time before receiving SPK, we utilized Cox regression models treating SPK as a time-dependent covariate. Next, we compared all-cause mortality rates and kidney graft loss rates between 65 SPK recipients and 58 kidney transplantation alone (KTA) recipients. Multivariate Cox hazard models and Fine and Gray competing-risk models were employed. SPK recipients experienced significantly lower all-cause mortality rates than non-transplanted individuals, even after accounting for immortal time bias (p = 0.015 by log-rank test, hazard ratio [HR] = 0.334, p = 0.025). When comparing SPK and KTA recipients, no statistically significant difference was observed in mortality rates (HR = 0.627, p = 0.588 by Cox model; HR = 0.385, p = 0.412 by Fine and Gray model) or kidney graft loss rates (HR = 0.612, p = 0.436 by Cox model; HR = 0.639, p = 0.376 by Fine and Gray model). Dysglycemia-associated mortality were observed in non-transplanted individuals and KTA recipients, but not in SPK recipients. These findings highlight the potential life-saving impact of SPK compared with intensive insulin therapy and dialysis. Additionally, this study suggests that both SPK and KTA may offer comparable outcomes. These findings have significant implications for clinical decision-making in the context of organ transplantation for individuals with T1D and ESKD.
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Affiliation(s)
- Tomomi Mori
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Izumi Nyumura
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Ko Hanai
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Tetsuya Babazono
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
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3
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Alfaro Villanueva LA, Junior RM, Rangel ÉB, Modelli LG, Viana LA, Cristelli MP, Requião-Moura L, Foresto RD, Tedesco-Silva H, Pestana JM. Assessing the influence of graft loss on 4-year patient survival after simultaneous pancreas-kidney transplantation: Kaplan-Meier versus Competing Risk Analysis model. Clin Transplant 2024; 38:e15298. [PMID: 38545918 DOI: 10.1111/ctr.15298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Graft loss increases the risk of patient death after simultaneous pancreas-kidney (SPK) transplantation. The relative risk of each graft failure is complex due to the influence of several competing events. METHODS This retrospective, single-center study compared 4-year patient survival according to the graft status using Kaplan-Meier (KM) and Competing Risk Analysis (CRA). Patient survival was also assessed according to five eras (Era 1: 2001-2003; Era 2: 2004-2006; Era 3: 2007-2009; Era 4: 2010-2012; Era 5: 2012-2015). RESULTS Between 2000 and 2015, 432 SPK transplants were performed. Using KM, patient survival was 86.5% for patients without graft loss (n = 333), 93.4% for patients with pancreas graft loss (n = 46), 43.7% for patients with kidney graft loss (n = 16), and 25.4% for patients with pancreas and kidney graft loss (n = 37). Patient survival was underestimated using KM versus CRA methods in patients with pancreas and kidney graft losses (25.4% vs. 36.2%), respectively. Induction with lymphocyte depleting antibodies was associated with 81% reduced risk (HR.19, 95% CI.38-.98, p = .0048), while delayed kidney function (HR 2.94, 95% CI 1.09-7.95, p = .033) and surgical complications (HR 2.94, 95% CI 1.22-7.08, p = .016) were associated with higher risk of death. Four-year patient survival increased from Era 1 to Era 5 (79% vs. 87.9%, p = .047). CONCLUSION In this cohort of patients, kidney graft loss, with or without pancreas graft loss, was associated with higher mortality after SPK transplantation. Compared to CRA, the KM model underestimated survival only among patients with pancreas and kidney graft losses. Patient survival increased over time.
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Affiliation(s)
| | | | - Érika Bevilaqua Rangel
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Gustavo Modelli
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | | | | | - Lúcio Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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4
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Favorable Outcomes in Older Recipients Receiving Simultaneous Pancreas Kidney Transplantation. Transplant Direct 2022; 8:e1413. [PMCID: PMC9671747 DOI: 10.1097/txd.0000000000001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/19/2022] Open
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5
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Ji M, Wang M, Hu W, Ibrahim M, Lentine KL, Merzkani M, Murad H, Al-Hosni Y, Parsons R, Wellen J, Chang SH, Alhamad T. Survival After Simultaneous Pancreas‐Kidney Transplantation in Type 1 Diabetes: The Critical Role of Early Pancreas Allograft Function. Transpl Int 2022; 35:10618. [PMID: 36171743 PMCID: PMC9510367 DOI: 10.3389/ti.2022.10618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Mengmeng Ji
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Mei Wang
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Wenjun Hu
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Mohamed Ibrahim
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Krista L. Lentine
- Division of Nephrology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Massini Merzkani
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Haris Murad
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Yazen Al-Hosni
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Ronald Parsons
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Jason Wellen
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Su-Hsin Chang
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Tarek Alhamad
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- *Correspondence: Tarek Alhamad,
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6
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Nicholl DDM, Whitelaw JP, Weir RV, Bissonnette MLZ, Gill JS, Landsberg DN. Case Report: Absence of Clinically Significant Recurrent Diabetic Kidney Disease on Postmortem Biopsy 32 Years After Kidney Transplantation for Type 1 Diabetes. Transplant Direct 2021; 7:e790. [PMID: 34805492 PMCID: PMC8601317 DOI: 10.1097/txd.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/17/2021] [Accepted: 09/01/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- David D. M. Nicholl
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - John P. Whitelaw
- Department of Pathology (Retired), Nanaimo Regional General Hospital, Nanaimo, BC, Canada
| | - Rene V. Weir
- Division of Nephrology, Department of Medicine, Royal Jubilee Hospital, Victoria, BC, Canada
| | - Mei Lin Z. Bissonnette
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - John S. Gill
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David N. Landsberg
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
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Lange UG, Rademacher S, Zirnstein B, Sucher R, Semmling K, Bobbert P, Lederer AA, Buchloh D, Seidemann L, Seehofer D, Jahn N, Hau HM. Cardiovascular outcomes after simultaneous pancreas kidney transplantation compared to kidney transplantation alone: a propensity score matching analysis. BMC Nephrol 2021; 22:347. [PMID: 34674648 PMCID: PMC8529792 DOI: 10.1186/s12882-021-02522-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Coronary heart disease due to arteriosclerosis is the leading cause of death in type 1 diabetic patients with end-stage renal disease (ESRD). The aim of this study was to evaluate the effect of simultaneous pancreas kidney transplantation (SPKT) compared to kidney transplantation alone (KTA) on survival, cardiovascular function and metabolic outcomes. Methods A cohort of 127 insulin-dependent diabetes mellitus (IDDM) patients with ESRD who underwent either SPKT (n = 100) or KTA (n = 27) between 1998 and 2019 at the University Hospital of Leipzig were retrospectively evaluated with regard to cardiovascular and metabolic function/outcomes as well as survival rates. An additional focus was placed on the echocardiographic assessment of systolic and diastolic cardiac function pretransplant and during follow-up. To avoid selection bias, a 2:1 propensity score matching analysis (PSM) was performed. Results After PSM, a total of 63 patients were identified; 42 patients underwent SPKT, and 21 patients received KTA. Compared with the KTA group, SPKT recipients received organs from younger donors (p < 0.05) and donor BMI was higher (p = 0.09). The risk factor-adjusted hazard ratio for mortality in SPKT recipients compared to KTA recipients was 0.63 (CI: 0.49–0.89; P < 0.05). The incidence of pretransplant cardiovascular events was higher in the KTA group (KTA: n = 10, 47% versus SPKT: n = 10, 23%; p = 0.06), but this difference was not significant. However, the occurrence of cardiovascular events in the SPKT group (n = 3, 7%) was significantly diminished after transplantation compared to that in the KTA recipients (n = 6, 28%; p = 0.02). The cardiovascular death rate was higher in KTA recipients (19%) than in SPK recipients with functioning grafts (3.3%) and comparable to that in patients with failed SPKT (16.7%) (p = 0.16). In line with pretransplant values, SPKT recipients showed significant improvements in Hb1ac values (p = 0.001), blood pressure control (p = < 0.005) and low-density lipoprotein/high-density lipoprotein (LDL/HDL) ratio (p = < 0.005) 5 years after transplantation. With regard to echocardiographic assessment, SPKT recipients showed significant improvements in left ventricular systolic parameters during follow-up. Conclusions Normoglycaemia and improvement of lipid metabolism and blood pressure control achieved by successful SPKT are associated with beneficial effects on survival, cardiovascular outcomes and systolic left ventricular cardiac function. Future studies with larger samples are needed to make predictions regarding cardiovascular events and graft survival. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02522-8.
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Affiliation(s)
- U G Lange
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - S Rademacher
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - B Zirnstein
- Sana Hospital Borna, Clinic of Anaesthesia, Intensive Care and Palliative Medicine, Rudolf-Virchow-Strasse 2, 04552, Borna, Saxony, Germany
| | - R Sucher
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - K Semmling
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - P Bobbert
- Ev. Hubertus Hospital Berlin, Clinic of Internal Medicine and Angiology, Spanische Allee 10-14, 14129, Berlin, Berlin, Germany
| | - A A Lederer
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - D Buchloh
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - L Seidemann
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - D Seehofer
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany
| | - N Jahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - H-M Hau
- University Hospital Leipzig, Clinic of Visceral, Transplant, Thoracic and Vascular Surgery, Liebigstrasse 20, 04103, Leipzig, Saxony, Germany. .,Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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8
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Schwarzenbach M, Bernhard FE, Czerlau C, Sidler D. Chances and risks of sodium-glucose cotransporter 2 inhibitors in solid organ transplantation: A review of literatures. World J Transplant 2021; 11:254-262. [PMID: 34316450 PMCID: PMC8290999 DOI: 10.5500/wjt.v11.i7.254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Marlene Schwarzenbach
- Department of Nephrology and Hypertension, University Hospital Insel Bern, Bern 3010, Switzerland
| | - Flavia Elena Bernhard
- Department of Nephrology and Hypertension, University Hospital Insel Bern, Bern 3010, Switzerland
| | - Cecilia Czerlau
- Department of Nephrology and Hypertension, University Hospital Insel Bern, Bern 3010, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, University Hospital Insel Bern, Bern 3010, Switzerland
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9
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Impact of Simultaneous Pancreas-kidney Transplantation on Cardiovascular Risk in Patients With Diabetes. Transplantation 2021; 106:158-166. [PMID: 33660656 DOI: 10.1097/tp.0000000000003710] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND cardiovascular disease is the major cause of death in patients with type 1 Diabetes. Of the available risk predictors for this population, the Steno Type 1 Risk Engine (STENO T1) is the only one which includes kidney function as a risk factor, which is a well described independent risk factor for cardiovascular disease. METHODS we explore how SPKT modifies the predicted cardiovascular risk by the STENO T1 through a retrospective study including recipients of a first SPKT between 2000 and 2016. RESULTS 268 SPKT recipients with a mean age of 40 years old and a median follow-up of 10 years were included. Prior to transplantation, the expected incidence of Cardiovascular Events (CVE) at 5 and 10 years according to STENO T1 would have been 31% and 50%, respectively, contrasting with an actual incidence of 9.3% and 16% for the same timepoints, respectively (P < 0.05). These differences were attenuated when STENO T1 was recalculated assuming 12th month glomerular filtration rate (at 5 and 10 years predicted CVE incidence was of 10.5% and 19.4%, respectively). Early pancreas graft failure (HR 3.00 [95% CI 1.14 - 7.88]; P = 0.02) was an independent risk factor for post-SPKT CVE, alongside with kidney graft failure (HR 2.90 [95% CI 1.53 - 5.48]; P = 0.001), and diabetes duration (HR 1.04 [95% CI 1.00-1.09], P = 0.04). CONCLUSIONS SPKT decreases in more two-thirds the predicted cardiovascular risk by the STENO T1. A functioning pancreas graft further reduces CVE risk, independently of kidney graft function.
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10
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Impact of Functional Status on Outcomes of Simultaneous Pancreas-kidney Transplantation: Risks and Opportunities for Patient Benefit. Transplant Direct 2020; 6:e599. [PMID: 32903964 PMCID: PMC7447442 DOI: 10.1097/txd.0000000000001043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/27/2020] [Indexed: 01/16/2023] Open
Abstract
Background. The impact of functional status on survival among simultaneous pancreas-kidney transplant (SPKT) candidates and recipients is not well described. Methods. We examined national Scientific Registry of Transplant Recipients (SRTR) data for patients listed for SPKT in the United States (2006–2019). Functional status was categorized by center-reported Karnofsky Performance Score (KPS). We used Cox regression to quantify associations of KPS at listing and transplant with subsequent patient survival, adjusted for baseline patient and transplant factors (adjusted hazard ratio, 95% LCLaHR95%UCL). We also explored time-dependent associations of SPKT with survival risk after listing compared with continued waiting in each functional status group. Results. KPS distributions among candidates (N = 16 822) and recipients (N = 10 316), respectively, were normal (KPS 80–100), 62.0% and 57.8%; capable of self-care (KPS 70), 23.5% and 24.7%; requires assistance (KPS 50–60), 12.4% and 14.2%; and disabled (KPS 10–40), 2.1% and 3.3%. There was a graded increase in mortality after listing and after transplant with lower functional levels. Compared with normal functioning, mortality after SPKT rose progressively for patients capable of self-care (aHR, 1.001.181.41), requiring assistance (aHR, 1.061.311.60), and disabled (aHR, 1.101.552.19). In time-dependent regression, compared with waiting, SPKT was associated with 2-fold mortality risk within 30 days of transplant. However, beyond 30 days, SPKT was associated with reduced mortality, from 52% for disabled patients (aHR, 0.260.480.88) to 70% for patients with normal functioning (aHR, 0.260.300.34). Conclusions. While lower functional status is associated with increased mortality risk among SPKT candidates and recipients, SPKT can provide long-term survival benefit across functional status levels in those selected for transplant.
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11
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Shingde R, Calisa V, Craig JC, Chapman JR, Webster AC, Pleass H, O’Connell PJ, Allen R, Robertson P, Yuen L, Kable K, Nankivell B, Rogers NM, Wong G. Relative survival and quality of life benefits of pancreas–kidney transplantation, deceased kidney transplantation and dialysis in type 1 diabetes mellitus—a probabilistic simulation model. Transpl Int 2020; 33:1393-1404. [DOI: 10.1111/tri.13679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/27/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Rashmi Shingde
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Vaishnavi Calisa
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health Flinders University Adelaide SA Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Angela C. Webster
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
| | - Henry Pleass
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Philip J. O’Connell
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Richard Allen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Paul Robertson
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Lawrence Yuen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Kathy Kable
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Brian Nankivell
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Natasha M. Rogers
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Germaine Wong
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- College of Medicine and Public Health Flinders University Adelaide SA Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
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12
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Xie WY, McAlister VC, Fiorini K, Sener A, Luke PP. Elevated C-peptide Levels Are Associated With Acute Rejection in Kidney Pancreas Transplantation. Transplant Proc 2020; 52:987-991. [PMID: 32143871 DOI: 10.1016/j.transproceed.2020.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/10/2019] [Accepted: 01/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We assessed whether allograft rejection or failure can be predicted by an acute increase in C-peptide production from the transplanted pancreas. METHODS Patients with a minimum of 5 years of follow-up post simultaneous pancreas-kidney transplant were identified. C-peptide levels were obtained during clinic visits routinely. Graft failure was defined as return to dependence on insulin therapy or return to dialysis for pancreas and kidney grafts, respectively. Protocol kidney allograft biopsies were performed at 3 and 12 months. For-cause biopsies were also performed. RESULTS Acute rejections were detected in 11 patients on biopsy results of the renal allograft. C-peptide levels drawn prior to documented rejections were significantly higher in patients with acute rejection than patients with borderline or no rejection (P = .006). Receiver operating characteristics curves for C-peptide indicated greater accuracy in predicting rejection than simultaneously drawn serum creatinine or lipase. CONCLUSIONS Higher C-peptide levels in simultaneous pancreas-kidney recipients is associated with acute rejection vs nonrejection.
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Affiliation(s)
- Wen Y Xie
- Department of Urology, London Health Sciences Center, London, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Vivian C McAlister
- University of Western Ontario, London, Ontario, Canada; Department of General Surgery, London Health Sciences Center, London, Ontario, Canada
| | - Kyle Fiorini
- Department of Urology, London Health Sciences Center, London, Ontario, Canada
| | - Alp Sener
- Department of Urology, London Health Sciences Center, London, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Patrick P Luke
- Department of Urology, London Health Sciences Center, London, Ontario, Canada; University of Western Ontario, London, Ontario, Canada.
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13
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Alhamad T, Kunjal R, Wellen J, Brennan DC, Wiseman A, Ruano K, Hicks V, Wang M, Schnitzler MA, Chang SH, Lentine KL. Three-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation in type 2 diabetes patients. Am J Transplant 2020; 20:788-796. [PMID: 31553823 DOI: 10.1111/ajt.15615] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/01/2019] [Accepted: 08/29/2019] [Indexed: 01/25/2023]
Abstract
Successful simultaneous pancreas-kidney transplantation (SPK) improves quality-of-life and prolongs kidney allograft and patient survival in type-1 diabetic (T1DM) patients. However, the use of SPK in type-2 diabetic (T2DM) patients remains limited. We examined a national transplant registry for 35 849 T2DM kidney disease patients who received transplant between 2000 and 2016 and survived the first 3 months with a functioning kidney, and categorized as: deceased-donor kidney transplant alone (DD-KA, 68%), living-donor kidney transplant alone (LD-KA, 30%), or SPK (2%). Among SPK recipients, 6% had pancreas allograft failure within 3 months (SPK,P-) and 94% had a functional pancreas (SPK,P+). Associations of transplant type with kidney allograft failure and death (multivariable-adjusted hazard ratio, 95%LCL aHR95%UCL ), over follow-up through December 2018, were quantified by multivariable inverse probability of treatment weighted survival analyses. SPK recipients had better kidney graft and patient survival than LD-KA or DD-KA recipients. Compared to SPK,P+, DD-KA, or LD-KA recipients had significantly higher risk of kidney allograft failure (DD-KA: aHR 1.53 2.203.17 ; LD-KA: aHR 1.29 1.872.71 ) and death (DD-KA: aHR 2.12 3.255.00 ; LD-KA: aHR 1.54 2.353.59 ). SPK,P- recipients had significantly higher risk of death (aHR 1.68 3.306.50 ). Similar to T1DM, T2DM patients with SPK have a survival benefit compared to those with kidney transplant alone, but this benefit depends upon successful early pancreas function.
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Affiliation(s)
- Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA.,Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ryan Kunjal
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jason Wellen
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel C Brennan
- Comprehensive Transplant Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander Wiseman
- Division of Nephrology, University of Colorado, Denver, Colorado, USA
| | - Kricia Ruano
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Veronica Hicks
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mei Wang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mark A Schnitzler
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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14
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Esmeijer K, Hoogeveen EK, van den Boog PJM, Konijn C, Mallat MJK, Baranski AG, Dekkers OM, de Fijter JW. Superior Long-term Survival for Simultaneous Pancreas-Kidney Transplantation as Renal Replacement Therapy: 30-Year Follow-up of a Nationwide Cohort. Diabetes Care 2020; 43:321-328. [PMID: 31801788 DOI: 10.2337/dc19-1580] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/03/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In patients with type 1 diabetes and end-stage renal disease, it is controversial whether a simultaneous pancreas-kidney (SPK) transplantation improves survival compared with kidney transplantation alone. We compared long-term survival in SPK and living- or deceased-donor kidney transplant recipients. RESEARCH DESIGN AND METHODS We included all 2,796 patients with type 1 diabetes in the Netherlands who started renal replacement therapy between 1986 and 2016. We used multivariable Cox regression analyses adjusted for recipient age and sex, dialysis modality and vintage, transplantation era, and donor age to compare all-cause mortality between deceased- or living-donor kidney and SPK transplant recipients. Separately, we analyzed mortality between regions where SPK transplant was the preferred intervention (80% SPK) versus regions where a kidney transplant alone was favored (30% SPK). RESULTS Of 996 transplanted patients, 42%, 16%, and 42% received a deceased- or living-donor kidney or SPK transplant, respectively. Mean (SD) age at transplantation was 50 (11), 48 (11), and 42 (8) years, respectively. Median (95% CI) survival time was 7.3 (6.2; 8.3), 10.5 (7.2; 13.7), and 16.5 (15.1; 17.9) years, respectively. SPK recipients with a functioning pancreas graft at 1 year (91%) had the highest survival (median 17.4 years). Compared with deceased-donor kidney transplant recipients, adjusted hazard ratios (95% CI) for 10- and 20-year all-cause mortality were 0.79 (0.49; 1.29) and 0.98 (0.69; 1.39) for living-donor kidney and 0.67 (0.46; 0.98) and 0.79 (0.60; 1.05) for SPK recipients, respectively. A treatment strategy favoring SPK over kidney transplantation alone showed 10- and 20-year mortality hazard ratios of 0.56 (0.40; 0.78) and 0.69 (0.52; 0.90), respectively. CONCLUSIONS Compared with living- or deceased-donor kidney transplantation, SPK transplant was associated with improved patient survival, especially in recipients with a long-term functioning pancreatic graft, and resulted in an almost twofold lower 10-year mortality rate.
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Affiliation(s)
- Kevin Esmeijer
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellen K Hoogeveen
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Cynthia Konijn
- Netherlands Organ Transplantation Registry, Leiden, the Netherlands
| | - Marko J K Mallat
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andre G Baranski
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
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15
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Parajuli S, Arunachalam A, Swanson KJ, Aziz F, Garg N, Redfield RR, Kaufman D, Djamali A, Odorico J, Mandelbrot DA. Outcomes after simultaneous kidney‐pancreas versus pancreas after kidney transplantation in the current era. Clin Transplant 2019; 33:e13732. [PMID: 31628870 DOI: 10.1111/ctr.13732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/28/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Annamalai Arunachalam
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Kurtis J. Swanson
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Fahad Aziz
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Robert R. Redfield
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Dixon Kaufman
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Arjang Djamali
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Jon Odorico
- Division of Transplant Surgery University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Didier A. Mandelbrot
- Division of Nephrology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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16
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Giorgakis E, Mathur AK, Chakkera HA, Reddy KS, Moss AA, Singer AL. Solid pancreas transplant: Pushing forward. World J Transplant 2018; 8:237-251. [PMID: 30596031 PMCID: PMC6304337 DOI: 10.5500/wjt.v8.i7.237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/10/2018] [Accepted: 11/15/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreas transplant has evolved significantly in recent years. It has now become a viable treatment option on type 1 diabetic patients with poorly controlled diabetes on conventional treatment, insulin intolerance, hypoglycaemia unawareness, brittle diabetes and/ or end-stage kidney disease. The purpose of this review is to provide an overview of pancreas transplant historical origins and current barriers to broader utilization of pancreata for transplant, with a focus on areas for future improvement to better pancreas transplant care. Donor pancreata remain underutilized; pancreatic allograft discard rates remain close to 30% in the United States. Donations after cardiac death (DCD) pancreata are seldom procured. Study groups from Europe and the United Kingdom showed that procurement professionalization and standardization of technique, as well as development of independent regional procurement teams might increase organ procurement efficiency, decrease discards and increase pancreatic allograft utilization. Pancreas transplant programs should consider exploring pancreas procurement opportunities on DCD and obese donors. Selected type 2 diabetics should be considered for pancreas transplant. Longer follow-up studies need to be performed in order to ascertain the long-term cardiovascular and quality of life benefits following pancreas transplant; the outcomes of which might eventually spearhead advocacy towards broader application of pancreas transplant among diabetics.
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Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
- Department of Transplant, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Amit K Mathur
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Harini A Chakkera
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Kunam S Reddy
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Adyr A Moss
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
| | - Andrew L Singer
- Division of Transplant, Department of Surgery, Mayo Clinic, Phoenix, AZ 85054, United States
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17
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Venkatanarasimhamoorthy VS, Barlow AD. Simultaneous Pancreas-Kidney Transplantation Versus Living Donor Kidney Transplantation Alone: an Outcome-Driven Choice? Curr Diab Rep 2018; 18:67. [PMID: 30030637 PMCID: PMC6061188 DOI: 10.1007/s11892-018-1039-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The choice of optimum transplant in a patient with type 1 diabetes mellitus (T1DM) and chronic kidney disease stage V (CKD V) is not clear. The purpose of this review was to investigate this in more detail-in particular the choice between a simultaneous pancreas-kidney transplantation (SPKT) and living donor kidney transplantation (LDKT), including recent evidence, to aid clinicians and their patients in making an informed choice in their care. RECENT FINDINGS Analyses of large databases have recently shown SPKT to have better survival rates than a LDKT in the long-term, despite an early increase in morbidity and mortality in SPKT recipients. This survival advantage has only been shown in those SPKT recipients with a functioning pancreas and not those who had early pancreas graft loss. The choice of SPKT or LDKT should not be based on patient and graft survival outcomes alone. Individual patient circumstances, preferences, and comorbidities, among other factors should form an important part of the decision-making process. In general, an SPKT should be considered in those patients not on dialysis and LDKT in those nearing or already on dialysis.
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Affiliation(s)
| | - Adam D Barlow
- Consultant Transplant Surgeon, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
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18
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Defining kidney allograft benefit from successful pancreas transplant: separating fact from fiction. Curr Opin Organ Transplant 2018; 23:448-453. [PMID: 29878910 DOI: 10.1097/mot.0000000000000547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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19
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Ziaja J, Kowalik AP, Kolonko A, Kamińska D, Owczarek AJ, Kujawa-Szewieczek A, Kusztal MA, Badura J, Bożek-Pająk D, Choręza P, Zakrzewska A, Król R, Chłopicki S, Klinger M, Więcek A, Chudek J, Cierpka L. Type 1 diabetic patients have better endothelial function after simultaneous pancreas-kidney transplantation than after kidney transplantation with continued insulin therapy. Diab Vasc Dis Res 2018; 15:122-130. [PMID: 29233018 DOI: 10.1177/1479164117744423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Jacek Ziaja
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Adrian P Kowalik
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Aureliusz Kolonko
- 2 Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Dorota Kamińska
- 3 Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Aleksander J Owczarek
- 4 Department of Statistics, Department of Instrumental Analysis, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Agata Kujawa-Szewieczek
- 2 Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Mariusz A Kusztal
- 3 Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Joanna Badura
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Dominika Bożek-Pająk
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Piotr Choręza
- 4 Department of Statistics, Department of Instrumental Analysis, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Zakrzewska
- 5 Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Kraków, Poland
| | - Robert Król
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Stefan Chłopicki
- 5 Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Kraków, Poland
- 6 Chair of Pharmacology, Jagiellonian University Medical College, Kraków, Poland
| | - Marian Klinger
- 3 Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wrocław, Poland
| | - Andrzej Więcek
- 2 Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Jerzy Chudek
- 7 Department of Pathophysiology, Medical University of Silesia, Katowice, Poland
- 8 Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia, Katowice, Poland
| | - Lech Cierpka
- 1 Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
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20
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Cardiac Assessment of Patients With Type 1 Diabetes Median 10 Years After Successful Simultaneous Pancreas and Kidney Transplantation Compared With Living Donor Kidney Transplantation. Transplantation 2017; 101:1261-1267. [PMID: 27467687 DOI: 10.1097/tp.0000000000001274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In recipients with type 1 diabetes, we aimed to determine whether long-term normoglycemia achieved by successful simultaneous pancreas and kidney (SPK) transplantation could beneficially affect progression of coronary artery disease (CAD) when compared with transplantation of a kidney-alone from a living donor (LDK). METHODS In 42 kidney transplant recipients with functioning grafts who had received either SPK (n = 25) or LDK (n = 17), we studied angiographic progression of CAD between baseline (pretransplant) and follow-up at 7 years or older. In addition, computed tomography scans for measures of coronary artery calcification and echocardiographic assessment of left ventricular systolic function were addressed at follow-up. RESULTS During a median follow-up time of 10.1 years (interquartile range [IQR], 9.1-11.5) progression of CAD occurred at similar rates (10 of 21 cases in the SPK and 5 of 14 cases in the LDK group; P = 0.49). Median coronary artery calcification scores were high in both groups (1767 [IQR, 321-4035] for SPK and 1045 [IQR, 807-2643] for LDK patients; P = 0.59). Left ventricular systolic function did not differ between the 2 groups. The SPK and LDK recipients were similar in age (41.2 ± 6.9 years vs 40.5 ± 10.3 years; P = 0.80) and diabetes duration at engraftment but with significant different mean HbA1c levels of 5.5 ± 0.4% for SPK and 8.3 ± 1.5% for LDK patients (P < 0.001) during follow-up. CONCLUSIONS In patients with both type 1 diabetes and end-stage renal disease, SPK recipients had similar progression of CAD long-term compared with LDK recipients. Calcification of coronary arteries is a prominent feature in both groups long-term posttransplant.
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21
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Abstract
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.
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22
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Barlow AD, Saeb-Parsy K, Watson CJE. An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK Transplant Registry study. Transpl Int 2017; 30:884-892. [PMID: 28319322 DOI: 10.1111/tri.12957] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/18/2016] [Accepted: 03/15/2017] [Indexed: 11/30/2022]
Abstract
Transplant options for patients with type 1 diabetes and end-stage renal disease (ESRD) include deceased donor kidney, live donor kidney (LDK) and simultaneous pancreas-kidney (SPK) transplantation. The aim of this study was to compare outcomes between LDK and SPK for patients with type 1 diabetes and ESRD in the UK. Data on all SPK (n = 1739) and LDK (n = 385) transplants performed between January 2001 and December 2014 were obtained from the UK Transplant Registry. Unadjusted patient and kidney graft survival were calculated using the Kaplan-Meier method. Multivariate analysis of kidney graft and patient survival was performed using Cox proportional hazards regression. There was no significant difference in patient (P = 0.435) or kidney graft survival (P = 0.204) on univariate analysis. On multivariate analysis there was no association between LDK/SPK and patient survival [HR 0.71 (0.47-1.06), P = 0.095]. However, LDK was associated with an overall lower risk for kidney graft failure [HR 0.60 (0.38-0.94), P = 0.025]. SPK recipients with a functioning pancreas graft had significantly better kidney graft and patient survival than LDK recipients or those with a failed pancreas graft. SPK transplantation does not confer an overall survival advantage compared to LDK. However, those SPK recipients with a functioning pancreas have significantly better outcomes.
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Affiliation(s)
- Adam D Barlow
- Leeds Transplant Centre, St. James's University Hospital, Leeds, UK
| | - Kourosh Saeb-Parsy
- Department of Surgery and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Cambridge, UK
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23
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Long-Term Outcomes of Kidney and Simultaneous Pancreas-Kidney Transplantation in Recipients With Type 1 Diabetes Mellitus: Silesian Experience. Transplant Proc 2017; 48:1681-6. [PMID: 27496471 DOI: 10.1016/j.transproceed.2016.01.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/21/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Kidney transplantation (KTx) markedly reduces mortality in patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM). The outstanding issue is whether transplantation should be limited only to KTx, with further insulinotherapy, or combined with pancreas transplantation in patients with ESKD/T1DM. The goal of this study was to compare the results of simultaneous pancreas-kidney transplantation (SPKTx) and deceased donor KTx and to identify factors affecting patient and kidney graft survival in patients with ESKD/T1DM. METHODS Eighty-seven deceased donor KTx and 66 SPKTx operated on in the Silesia region of Poland between 1998 and 2013 were included in the retrospective analysis. RESULTS During the mean 6.7 ± 3.6 years of follow-up, fewer cardiovascular episodes were observed in SPKTx recipients than in KTx recipients (1.5% vs 12.6%; P < .05). Five-year patient survival (80.7% in SPKTx vs 77.5% in KTx) and kidney graft survival (66.1% in SPKTx vs 70.4% in KTx) did not differ between study groups. There were no differences in patient survival (log-rank test, P = .99) or kidney graft survival (P = .99) based on Kaplan-Meier curves. Multivariable Cox proportional hazard analysis failed to identify factors explaining patient and kidney graft survival. Five-year pancreas graft survival was 58.9%. SPKTx recipients had significantly higher estimated glomerular filtration rates during the 7-year posttransplant period and less frequently developed proteinuria (6.1% vs 23%; P < .01). CONCLUSIONS Pancreas transplantation reduced cardiovascular risk and prevented the development of proteinuria but did not improve patient and kidney graft survival in recipients with T1DM in the 7-year follow-up period.
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Stites E, Wiseman AC. Multiorgan transplantation. Transplant Rev (Orlando) 2016; 30:253-60. [PMID: 27515042 DOI: 10.1016/j.trre.2016.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/04/2016] [Indexed: 01/24/2023]
Abstract
Kidney transplantation has proven to be the gold standard therapy for severe chronic kidney disease (CKD) due to multiple etiologies in individuals deemed eligible from a surgical standpoint. While kidney transplantation is traditionally considered in conditions of native kidney disease such as diabetes and immunological or inherited causes of kidney disease, an increasing indication for kidney transplantation is kidney dysfunction in the setting of other severe organ dysfunction that requires transplant, such as severe liver or heart disease. In these settings, multiorgan transplantation is now commonly performed, with controversy regarding the appropriate utilization of kidneys transplanted both from a physiological perspective (distinguishing those who require a kidney transplant) and also from an ethical perspective (allocation of a scarce resource to a more morbid population). These issues persist in the setting of simultaneous pancreas-kidney transplant (SPK), in which utilization for patients with type 1 diabetes has been historically accepted. Questions of physiological benefit persist, and utilization is waning despite broader allocation policies that encourage SPK, including consideration for patients with type 2 diabetes. The purpose of this review will be to summarize the physiological data regarding multiorgan transplantation and place these into context while reviewing current allocation policy in the United States.
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Affiliation(s)
- Erik Stites
- Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Denver, Aurora, CO, USA
| | - Alexander C Wiseman
- Division of Renal Diseases and Hypertension, Transplant Center, University of Colorado Denver, Aurora, CO, USA.
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Lindahl JP, Hartmann A, Aakhus S, Endresen K, Midtvedt K, Holdaas H, Leivestad T, Horneland R, Øyen O, Jenssen T. Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation. Diabetologia 2016; 59:844-52. [PMID: 26713324 DOI: 10.1007/s00125-015-3853-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/14/2015] [Indexed: 01/30/2023]
Abstract
AIMS/HYPOTHESIS Mortality due to cardiovascular disease (CVD), particularly coronary artery disease (CAD), is high in type 1 diabetic patients with end-stage renal disease (ESRD). We aimed to determine whether normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, could improve long-term outcomes compared with living donor kidney-alone (LDK) transplantation. METHODS We studied 486 type 1 diabetic patients with ESRD who underwent a first SPK (n = 256) or LDK (n = 230) transplant between 1983 and 2012 and were followed to the end of 2014. Data were retrieved from the Norwegian Renal Registry and hospital records. Kaplan-Meier plots and multivariate Cox regression, with correction for recipient, donor and transplant factors, were used to examine potential associations between transplant type and all-cause and CVD- and CAD-related mortality. RESULTS Median follow-up time was 7.9 years (interquartile range 4.3, 12.9). The adjusted HR for CVD-related deaths in SPK recipients compared with LDK recipients was 0.63 (95% CI 0.40, 0.99; p = 0.047), while the HRs for all-cause and CAD-related mortality were 0.81 (95% CI 0.57, 1.16; p = 0.25) and 0.63 (95% CI 0.36, 1.12; p = 0.12), respectively. Compared with the LDK group, SPK recipients were younger and received grafts from younger donors. Cardiovascular mortality was higher in patients transplanted between 1983 and 1999 compared with those who received their grafts in subsequent years. CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes and ESRD, SPK transplantation was associated with reduced long-term cardiovascular mortality compared with LDK transplantation.
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Affiliation(s)
- Jørn P Lindahl
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway.
| | - Anders Hartmann
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Hallvard Holdaas
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Torbjørn Leivestad
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Rune Horneland
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Ole Øyen
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Trond Jenssen
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
- Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
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Jeon HJ, Koo TY, Han M, Kim HJ, Jeong JC, Park H, Ha J, Kim SJ, Ahn C, Park JB, Yang J. Outcomes of dialysis and the transplantation options for patients with diabetic end-stage renal disease in Korea. Clin Transplant 2016; 30:534-44. [PMID: 26914661 DOI: 10.1111/ctr.12719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Hee Jung Jeon
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tai Yeon Koo
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ha Jin Kim
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong Cheol Jeong
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyojun Park
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung Joo Kim
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Curie Ahn
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Berm Park
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Transplantation Center, Seoul National University Hospital, Seoul, Republic of Korea
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Redfield RR, Rickels MR, Naji A, Odorico JS. Pancreas Transplantation in the Modern Era. Gastroenterol Clin North Am 2016; 45:145-66. [PMID: 26895686 DOI: 10.1016/j.gtc.2015.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA.
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, 2-134 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Ali Naji
- Division of Transplantation, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA
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Bartlett ST, Markmann JF, Johnson P, Korsgren O, Hering BJ, Scharp D, Kay TWH, Bromberg J, Odorico JS, Weir GC, Bridges N, Kandaswamy R, Stock P, Friend P, Gotoh M, Cooper DKC, Park CG, O'Connell P, Stabler C, Matsumoto S, Ludwig B, Choudhary P, Kovatchev B, Rickels MR, Sykes M, Wood K, Kraemer K, Hwa A, Stanley E, Ricordi C, Zimmerman M, Greenstein J, Montanya E, Otonkoski T. Report from IPITA-TTS Opinion Leaders Meeting on the Future of β-Cell Replacement. Transplantation 2016; 100 Suppl 2:S1-44. [PMID: 26840096 PMCID: PMC4741413 DOI: 10.1097/tp.0000000000001055] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/07/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Stephen T. Bartlett
- Department of Surgery, University of Maryland School of Medicine, Baltimore MD
| | - James F. Markmann
- Division of Transplantation, Massachusetts General Hospital, Boston MA
| | - Paul Johnson
- Nuffield Department of Surgical Sciences and Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Olle Korsgren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Bernhard J. Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - David Scharp
- Prodo Laboratories, LLC, Irvine, CA
- The Scharp-Lacy Research Institute, Irvine, CA
| | - Thomas W. H. Kay
- Department of Medicine, St. Vincent’s Hospital, St. Vincent's Institute of Medical Research and The University of Melbourne Victoria, Australia
| | - Jonathan Bromberg
- Division of Transplantation, Massachusetts General Hospital, Boston MA
| | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Gordon C. Weir
- Joslin Diabetes Center and Harvard Medical School, Boston, MA
| | - Nancy Bridges
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Raja Kandaswamy
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Peter Stock
- Division of Transplantation, University of San Francisco Medical Center, San Francisco, CA
| | - Peter Friend
- Nuffield Department of Surgical Sciences and Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Mitsukazu Gotoh
- Department of Surgery, Fukushima Medical University, Fukushima, Japan
| | - David K. C. Cooper
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Chung-Gyu Park
- Xenotransplantation Research Center, Department of Microbiology and Immunology, Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Phillip O'Connell
- The Center for Transplant and Renal Research, Westmead Millennium Institute, University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Cherie Stabler
- Diabetes Research Institute, School of Medicine, University of Miami, Coral Gables, FL
| | - Shinichi Matsumoto
- National Center for Global Health and Medicine, Tokyo, Japan
- Otsuka Pharmaceutical Factory inc, Naruto Japan
| | - Barbara Ludwig
- Department of Medicine III, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden of Helmholtz Centre Munich at University Clinic Carl Gustav Carus of TU Dresden and DZD-German Centre for Diabetes Research, Dresden, Germany
| | - Pratik Choudhary
- Diabetes Research Group, King's College London, Weston Education Centre, London, United Kingdom
| | - Boris Kovatchev
- University of Virginia, Center for Diabetes Technology, Charlottesville, VA
| | - Michael R. Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Megan Sykes
- Columbia Center for Translational Immunology, Coulmbia University Medical Center, New York, NY
| | - Kathryn Wood
- Nuffield Department of Surgical Sciences and Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Kristy Kraemer
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Albert Hwa
- Juvenile Diabetes Research Foundation, New York, NY
| | - Edward Stanley
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Camillo Ricordi
- Diabetes Research Institute, School of Medicine, University of Miami, Coral Gables, FL
| | - Mark Zimmerman
- BetaLogics, a business unit in Janssen Research and Development LLC, Raritan, NJ
| | - Julia Greenstein
- Discovery Research, Juvenile Diabetes Research Foundation New York, NY
| | - Eduard Montanya
- Bellvitge Biomedical Research Institute (IDIBELL), Hospital Universitari Bellvitge, CIBER of Diabetes and Metabolic Diseases (CIBERDEM), University of Barcelona, Barcelona, Spain
| | - Timo Otonkoski
- Children's Hospital and Biomedicum Stem Cell Center, University of Helsinki, Helsinki, Finland
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Powell F, Harper S, Callaghan C, Shaw A, Godfrey E, Bradley J, Watson C, Pettigrew G. Postoperative CT in pancreas transplantation. Clin Radiol 2015. [DOI: 10.1016/j.crad.2015.06.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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The current challenges for pancreas transplantation for diabetes mellitus. Pharmacol Res 2015; 98:45-51. [DOI: 10.1016/j.phrs.2015.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 01/26/2015] [Accepted: 01/27/2015] [Indexed: 12/27/2022]
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Abstract
Diabetes mellitus is one of the most important causes of chronic kidney disease (CKD). In patients with advanced diabetic kidney disease, kidney transplantation (KT) with or without a pancreas transplant is the treatment of choice. We aimed to review current data regarding kidney and pancreas transplant options in patients with both type 1 and 2 diabetes and the outcomes of different treatment modalities. In general, pancreas transplantation is associated with long-term survival advantages despite an increased short-term morbidity and mortality risk. This applies to simultaneous pancreas kidney transplantation or pancreas after KT compared to KT alone (either living donor or deceased). Other factors as living donor availability, comorbidities, and expected waiting time have to be considered whens electing one transplant modality, rather than a clear benefit in survival of one strategy vs. others. In selected type 2 diabetic patients, data support cautious utilization of simultaneous pancreas kidney transplantation when a living kidney donor is not an option. Pancreas and kidney transplantation seems to be the treatment of choice for most type 1 diabetic and selected type 2 diabetic patients.
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Kaku K, Kitada H, Noguchi H, Kurihara K, Kawanami S, Nakamura U, Tanaka M. Living Donor Kidney Transplantation Preceding Pancreas Transplantation Reduces Mortality in Type 1 Diabetics With End-stage Renal Disease. Transplant Proc 2015; 47:733-7. [DOI: 10.1016/j.transproceed.2014.12.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/30/2014] [Indexed: 10/23/2022]
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Simultaneous transplantation of the living donor kidney and deceased donor pancreas and other transplant options for diabetic and uremic patients. Curr Opin Organ Transplant 2015; 20:103-7. [DOI: 10.1097/mot.0000000000000147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The impact of method on kidney graft and patient survival in kidney-pancreas transplantations for type I diabetes mellitus. Int Surg 2015; 100:137-41. [PMID: 25594654 DOI: 10.9738/intsurg-d-13-00050.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Kim SM, Youn WY, Kim DJ, Kim JS, Lee S. Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea. Ann Surg Treat Res 2015; 88:41-7. [PMID: 25553324 PMCID: PMC4279990 DOI: 10.4174/astr.2015.88.1.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/04/2014] [Accepted: 08/07/2014] [Indexed: 01/26/2023] Open
Abstract
Purpose The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center. Methods Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively. Results Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years. Conclusion The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Woo Young Youn
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Doo Jin Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Samuel Lee
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Lindahl JP, Reinholt FP, Eide IA, Hartmann A, Midtvedt K, Holdaas H, Dorg LT, Reine TM, Kolset SO, Horneland R, Øyen O, Brabrand K, Jenssen T. In patients with type 1 diabetes simultaneous pancreas and kidney transplantation preserves long-term kidney graft ultrastructure and function better than transplantation of kidney alone. Diabetologia 2014; 57:2357-65. [PMID: 25145544 DOI: 10.1007/s00125-014-3353-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/23/2014] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS In patients with type 1 diabetes and end-stage renal disease (ESRD) we aimed to determine whether long-term normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, would preserve kidney graft structure and function better than live donor kidney (LDK) transplantation alone. METHODS Estimated GFR (eGFR) was calculated in SPK (n = 25) and LDK (n = 17) recipients in a stable phase 3 months after transplantation and annually during follow-up. Kidney graft biopsies were obtained at follow-up for measurement of glomerular volume (light microscopy), glomerular basement membrane (GBM) and podocyte foot process widths and mesangial volume fraction (electron microscopy). RESULTS SPK and LDK recipients were similar in age and diabetes duration at engraftment. Donor age was higher in the LDK group. Median follow-up time was 10.1 years. Mean HbA1c levels during follow-up were 5.5 ± 0.4% (37 ± 5 mmol/mol) and 8.3 ± 1.5% (68 ± 16 mmol/mol) in the SPK and LDK group, respectively (p < 0.001). Compared with SPK recipients, LDK recipients had wider GBM (369 ± 109 nm vs 281 ± 57 nm; p = 0.008) and increased mesangial volume fraction (median 0.23 [range 0.13-0.59] vs 0.16 [0.10-0.41]; p = 0.007) at follow-up. Absolute eGFR change from baseline was -11 ± 21 and -23 ± 15 ml min(-1) 1.73 m(-2) (p = 0.060), whereas eGFR slope was -1.1 (95% CI -1.7, -0.5) and -2.6 (95% CI -3.1, -2.1) ml min(-1) 1.73 m(-2) per year in the SPK and LDK group, respectively (p = 0.001). CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes and long-term normoglycaemia after successful SPK transplantation, kidney graft ultrastructure and function were better preserved compared with LDK transplantation alone.
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Affiliation(s)
- Jørn P Lindahl
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
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Montero N, Webster AC, Royuela A, Zamora J, Crespo Barrio M, Pascual J. Steroid avoidance or withdrawal for pancreas and pancreas with kidney transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD007669. [PMID: 25220222 PMCID: PMC11129845 DOI: 10.1002/14651858.cd007669.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreas or kidney-pancreas transplantation improves survival and quality of life for people with type 1 diabetes mellitus and kidney failure. Immunosuppression after transplantation is associated with complications. Steroids have adverse effects on cardiovascular risk factors such as hypertension, hyperglycaemia or hyperlipidaemia, increase risk of infection, obesity, cataracts, myopathy, bone metabolism alterations, dermatologic problems and cushingoid appearance. Whether avoiding steroids changes outcomes is unclear. OBJECTIVES We aimed to assess the safety and efficacy of steroid early withdrawal (treatment for less than 14 days after transplantation), late withdrawal (after 14 days after transplantation) or steroid avoidance in patients receiving a pancreas (including a vascularized organ) alone (PTA), simultaneous with a kidney (SPK) or after kidney transplantation (PAK). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register (to 18 June 2014) through contact with the Trials' Search Co-ordinator. We handsearched: reference lists of nephrology textbooks, relevant studies, recent publications and clinical practice guidelines; abstracts from international transplantation society scientific meetings; and sent emails and letters seeking information about unpublished or incomplete studies to known investigators. SELECTION CRITERIA We included randomised controlled trials (RCTs) or cohort studies of steroid avoidance (including early withdrawal) versus steroid maintenance or versus late withdrawal in pancreas or pancreas with kidney transplant recipients. We defined steroid avoidance as complete avoidance of steroid immunosuppression, early steroid withdrawal as steroid treatment for less than 14 days after transplantation and late withdrawal as steroid withdrawal after 14 days after transplantation. DATA COLLECTION AND ANALYSIS Two authors independently assessed the retrieved titles and abstracts, and where necessary the full text reports to determine which studies satisfied the inclusion criteria. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Cohort studies were not meta-analysed, but their findings summarised descriptively. MAIN RESULTS Three RCTs enrolling 144 participants met our inclusion criteria. Two compared steroid avoidance versus late steroid withdrawal and one compared late steroid withdrawal versus steroid maintenance. All studies included SPK and only one also included PTA. All studies had an overall moderate risk of bias and presented only short-term results (six to 12 months). Two studies (89 participants) compared steroid avoidance or early steroid withdrawal versus late steroid withdrawal. There was no clear evidence of an impact on mortality (2 studies, 89 participants: RR 1.64, 95% CI 0.21 to 12.75), risk of kidney loss censored for death (2 studies, 89 participants: RR 0.35, 95% CI 0.04 to 3.09), risk of pancreas loss censored for death (2 studies, 89 participants: RR 1.05, 95% CI 0.36 to 3.04), or acute kidney rejection (1 study, 49 participants: RR 2.08, 95% CI 0.20 to 21.50), however results were uncertain and consistent with no difference or important benefit or harm of steroid avoidance/early steroid withdrawal. The study that compared late steroid withdrawal versus steroid maintenance observed no deaths, no graft loss or acute kidney rejection at six months in either group and reported uncertain effects on acute pancreas rejection (RR 0.88, 95% CI 0.06 to 13.35). Of the possible adverse effects only infection was reported by one study. There were significantly more UTIs reported in the late withdrawal group compared to the steroid avoidance group (1 study, 25 patients: RR 0.41, 95% CI 0.26 to 0.66).We also identified 13 cohort studies and one RCT which randomised tacrolimus versus cyclosporin. These studies in general showed that steroid-sparing and withdrawal strategies had benefits in lowering HbAc1 and risk of infections (BK virus and CMV disease) and improved blood pressure control without increasing the risk of rejection. However, two studies found an increased incidence of acute pancreas rejection (HR 2.8, 95% CI 0.89 to 8.81, P = 0.066 in one study and 43.3% in the steroid withdrawal group versus 9.3% in the steroid maintenance, P < 0.05 at three years in the other) and one study found an increased incidence of acute kidney rejection (18.7% in the steroid withdrawal group versus 2.8% in the steroid maintenance, P < 0.05) at three years. AUTHORS' CONCLUSIONS There is currently insufficient evidence for the benefits and harms of steroid withdrawal in pancreas transplantation in the three RCTs (144 patients) identified. The results showed uncertain results for short-term risk of rejection, mortality, or graft survival in steroid-sparing strategies in a very small number of patients over a short period of follow-up. Overall the data was sparse, so no firm conclusions are possible. Moreover, the 13 observational studies findings generally concur with the evidence found in the RCTs.
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Affiliation(s)
- Nuria Montero
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Ana Royuela
- Hospital Ramon y CajalCIBER Epidemiologia y Salud Publica (CIBERESP)Ctra. Colmenar km, 9.1MadridSpain28047
- Unidad de Bioestadística, Hospital Ramón y CajalMadridSpain
| | - Javier Zamora
- Ramon y Cajal Institute for Health Research (IRYCIS), CIBER Epidemiology and Public Health (CIBERESP) and Cochrane Collaborating CentreClinical Biostatistics UnitCtra. Colmenar km 9,100MadridMadridSpain28034
- CIBER Epidemiologia y Salud Publica (CIBERESP)MadridSpain
| | - Marta Crespo Barrio
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Marítim 25‐29BarcelonaSpain08003
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Massie AB, Kucirka L, Segev DL, Segev DL. Big data in organ transplantation: registries and administrative claims. Am J Transplant 2014; 14:1723-30. [PMID: 25040084 PMCID: PMC4387865 DOI: 10.1111/ajt.12777] [Citation(s) in RCA: 262] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/06/2014] [Accepted: 03/25/2014] [Indexed: 01/25/2023]
Abstract
The field of organ transplantation benefits from large, comprehensive, transplant-specific national data sets available to researchers. In addition to the widely used Organ Procurement and Transplantation Network (OPTN)-based registries (the United Network for Organ Sharing and Scientific Registry of Transplant Recipients data sets) and United States Renal Data System (USRDS) data sets, there are other publicly available national data sets, not specific to transplantation, which have historically been underutilized in the field of transplantation. Of particular interest are the Nationwide Inpatient Sample and State Inpatient Databases, produced by the Agency for Healthcare Research and Quality. The USRDS database provides extensive data relevant to studies of kidney transplantation. Linkage of publicly available data sets to external data sources such as private claims or pharmacy data provides further resources for registry-based research. Although these resources can transcend some limitations of OPTN-based registry data, they come with their own limitations, which must be understood to avoid biased inference. This review discusses different registry-based data sources available in the United States, as well as the proper design and conduct of registry-based research.
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Affiliation(s)
- Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Lauren Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Lindahl JP, Jenssen T, Hartmann A. Long-term outcomes after organ transplantation in diabetic end-stage renal disease. Diabetes Res Clin Pract 2014; 105:14-21. [PMID: 24698407 DOI: 10.1016/j.diabres.2014.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 02/27/2014] [Accepted: 03/06/2014] [Indexed: 01/28/2023]
Abstract
Patients with type 1 diabetic end-stage renal disease (ESRD) may be offered single kidney transplantation from a live donor (LDK) or a deceased donor (DDK) to replace the lost kidney function. In the latter setting the patient may also receive a simultaneous pancreas together with a kidney from the same donor (SPK). Also in some cases a pancreas after kidney may be offered to those who have previously received a kidney alone (PAK). The obvious benefit of a successful SPK transplantation is that the patients not only recover from uremia but also obtain normal blood glucose control without use of insulin or other hypoglycemic agents. Accordingly, this combined procedure has become an established treatment for type 1 diabetic patients with ESRD. Adequate long-term blood glucose control may theoretically lead to reduced progression or even reversal of microvascular complications. Another potential beneficial effect may be improvement of patient and kidney graft survival. Development of diabetic complications usually takes a decade to develop and accordingly any potential benefits of a pancreas transplant will not easily be disclosed during the first decade after transplantation. The purpose of the review is to assess the present literature of outcomes after kidney transplantation in patients with diabetic ESRD, with our without a concomitant pancreas transplantation. The points of interest given in this review are microvascular complications, graft outcomes, cardiovascular outcomes and mortality.
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Affiliation(s)
- Jørn Petter Lindahl
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway.
| | - Trond Jenssen
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Anders Hartmann
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Oslo, Norway
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Greffe de pancréas et d’îlots de Langerhans. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wiseman AC. Kidney transplant options for the diabetic patient. Transplant Rev (Orlando) 2013; 27:112-6. [PMID: 23927899 DOI: 10.1016/j.trre.2013.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Alexander C Wiseman
- Transplant Center, University of Colorado Denver, Mail Stop F749, AOP 7089, 1635 North Aurora Court, Aurora, CO 80045.
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Lindahl JP, Hartmann A, Horneland R, Holdaas H, Reisæter AV, Midtvedt K, Leivestad T, Oyen O, Jenssen T. Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease. Diabetologia 2013; 56:1364-71. [PMID: 23549518 DOI: 10.1007/s00125-013-2888-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/25/2013] [Indexed: 01/20/2023]
Abstract
AIMS/HYPOTHESIS We aimed to determine whether simultaneous pancreas and kidney (SPK) transplantation would improve patient and kidney graft survival in diabetic end-stage renal disease (ESRD) compared with kidney transplantation alone (KTA). METHODS Follow-up data were retrieved for all 630 patients with diabetic ESRD who had received SPK or KTA at our centre from 1983 to the end of 2010. Recipients younger than 55 years of age received either an SPK (n = 222) or, if available, a single live donor kidney (LDK; n = 171). Older recipients and recipients with greater comorbidity received a single deceased donor kidney (DDK; n = 237). Survival was analysed by the Kaplan-Meier method and in multivariate Cox regression analysis adjusting for recipient and donor characteristics. RESULTS Patient survival was superior in SPK compared with both LDK and DDK recipients in univariate analysis. Follow-up time (mean ± SD) after transplantation was 7.1 ± 5.7 years. Median actuarial patient survival was 14.0 years for SPK, 11.5 years for LDK and 6.7 years for DDK recipients. In multivariate analyses including recipient age, sex, treatment modality, time on dialysis and era, SPK transplantation was protective for all-cause mortality compared with both LDK (p = 0.02) and DDK (p = 0.029) transplantation. After the year 2000, overall patient survival improved compared with previous years (HR 0.40, 95% CI 0.30, 0.55; p < 0.001). Pancreas graft survival also improved after 2000, with a 5 year graft survival rate of 78% vs 61% in previous years (1988-1999). CONCLUSIONS/INTERPRETATION Recipients of SPK transplants have superior patient survival compared with both LDK and DDK recipients, with improved results seen over the last decade.
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Affiliation(s)
- J P Lindahl
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway.
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Follow-up of secondary diabetic complications after pancreas transplantation. Curr Opin Organ Transplant 2013; 18:102-10. [PMID: 23283247 DOI: 10.1097/mot.0b013e32835c28c5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Wiseman AC, Huang E, Kamgar M, Bunnapradist S. The impact of pre-transplant dialysis on simultaneous pancreas–kidney versus living donor kidney transplant outcomes. Nephrol Dial Transplant 2013; 28:1047-58. [DOI: 10.1093/ndt/gfs582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Zero-Mismatch Deceased-Donor Kidney Versus Simultaneous Pancreas-Kidney Transplantation. Transplantation 2012; 94:822-9. [DOI: 10.1097/tp.0b013e31826334a6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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