Transplantation of the type 1 diabetic patient: the long-term benefit of a functioning pancreas allograft

Assessing the influence of graft loss on 4-year patient survival after simultaneous pancreas-kidney transplantation: Kaplan-Meier versus Competing Risk Analysis model

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.

Comparison of Outcomes and Survival of Two Cohorts of Patients with Simultaneous Pancreas-Kidney Transplantation: A Retrospective Cohort Study in a Latin American Hospital

Background

Simultaneous pancreas-kidney transplantation (SPKT) is a complex and demanding procedure with a considerable risk of morbidity and mortality. Advances in surgical techniques and organ preservation have introduced changes in care protocols. Two cohorts of patients receiving SPKT with two different protocols were compared to determine overall survival and pancreatic and renal graft failure-free survival.

Methods

This retrospective observational study was conducted in two cohorts of SPKT recipient patients that underwent surgery between 2001 and 2021. Outcomes were compared in transplant patients between 2001 and 2011 (cohort 1; initial protocol) and 2012-2021 (cohort 2; improved protocol). In addition to the temporality, the cohorts were defined by a protocolization of technical aspects and medical management in cohort 2 (improved protocol), compared to a wide variability in the procedures carried out in cohort 1 (initial protocol). Overall survival and pancreatic and renal graft failure-free survival were the primary outcomes. These outcomes were determined using Kaplan-Meier survival analysis and the log-rank test.

Results

Fifty-five SPKT were performed during the study period: 32 in cohort 1 and 23 in cohort 2. In the survival analysis, an average of 2546 days (95% CI: 1902-3190) was found in cohort 1, while in cohort 2, it was 2540 days (95% CI: 2100-3204) (p > 0.05). Pancreatic graft failure-free survival had an average of 1705 days (95% CI: 1037-2373) in cohort 1, lower than the average in cohort 2 (2337 days; 95% CI: 1887-2788) (p = 0.016). Similarly, renal graft failure-free survival had an average of 2167 days (95% CI: 1485-2849) in cohort 1, lower than the average in cohort 2 (2583 days; 95% CI: 2159-3006) (p = 0.017).

Conclusions

This analysis indicates that pancreatic and renal graft failure-free survival associated with SPKT decreased significantly in cohort 2, with results related to improvements in the treatment protocol implemented in that cohort.

An Initial Analysis of the Baseline Levels of Dd-cfDNA After Pancreas Transplantation: A Prospective Study From High-volume Centers in the United States

Pancreas transplantation offers patients with diabetes an opportunity for glucose homeostasis. Current blood tests to surveil for rejection have poor sensitivity and specificity for identifying rejection, and pancreas biopsies are challenging and associated with morbidity and graft loss. Donor-derived cell-free DNA (dd-cfDNA) is shed from transplanted organs and detectable in peripheral blood. Thus, a potential dd-cfDNA blood test assessing rejection would be clinically advantageous.

Methods

One hundred eighty-one dd-cfDNA samples (n) were collected from 77 patients (N) up to 132 mo posttransplant.

Results

The median dd-cfDNA level among all subjects was 0.28% (0.13%, 0.71%). In simultaneous pancreas-kidney (SPK) transplant recipients, the median dd-cfDNA level was 0.29% (0.13%, 0.71%), and it was 0.23% (0.08%, 0.71%) in pancreas transplant alone (PTA) recipients. When isolating for when without infection or rejection, the median dd-cfDNA level was 0.28% (0.13%, 0.64%) for SPK and 0.20% (0.00%, 0.32%) for PTA. Both transplant types approached 1.0% ≤1 mo posttransplant followed by a decrease in median dd-cfDNA. During episodes of rejection or infection, median dd-cfDNA levels were greater among all transplant types.

Conclusions

The mean dd-cfDNA level for all pancreas transplant recipients is <1.0%, consistent with the published kidney transplant rejection threshold (>1.0%), regardless of SPK or PTA. Early posttransplant dd-cfDNA levels are transiently higher than later measurements. Dd-cfDNA elevation also correlates with rejection and infection and thus is a promising biomarker for surveilling pancreas transplant dysfunction.

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

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

Cardiovascular outcomes after simultaneous pancreas kidney transplantation compared to kidney transplantation alone: a propensity score matching analysis

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.

Beneficial Effect of Successful Simultaneous Pancreas-Kidney Transplantation on Plasma Profile of Metalloproteinases in Type 1 Diabetes Mellitus Patients

It is not fully elucidated whether the restoring of normal glucose metabolism after successful simultaneous pancreas-kidney transplantation (SPK) improves vascular wall morphology and function in type 1 diabetic (T1D) patients. Therefore, we compared arterial stiffness, assessed by pulse wave velocity (PWV), carotid intima-media thickness (IMT), and biomarkers of arterial wall calcification in T1D patients after SPK or kidney transplantation alone (KTA). In 39 SPK and 39 KTA adult patients of similar age, PWV, IMT, circulating matrix metalloproteinases (MMPs) and calcification biomarkers were assessed at median 83 months post transplantation. Additionally, carotid plaques were visualized and semi-qualitatively classified. Although PWV and IMT values were similar, the occurrence of atherosclerotic plaques (51.3 vs. 70.3%, p < 0.01) and calcified lesions (35.9 vs. 64.9%, p < 0.05) was lower in SPK patients. There were significantly lower concentrations of MMP-1, MMP-2, MMP-3, and osteocalcin in SPK subjects. Among the analyzed biomarkers, only logMMP-1, logMMP-2, and logMMP-3 concentrations were associated with log HbA_1c. Multivariate stepwise backward regression analysis revealed that MMP-1 and MMP-3 variability were explained only by log HbA_1c. Normal glucose metabolism achieved by SPK is followed by the favorable profile of circulating matrix metalloproteinases, which may reflect the vasoprotective effect of pancreas transplantation.

Impact of Simultaneous Pancreas-kidney Transplantation on Cardiovascular Risk in Patients With Diabetes

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.

Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate?

OBJECTIVES

Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention.

MATERIALS AND METHODS

A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains.

RESULTS

We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group.

CONCLUSIONS

Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.

Three-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation in type 2 diabetes patients

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 aHR_95%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 2.20_3.17 ; LD-KA: aHR _1.29 1.87_2.71 ) and death (DD-KA: aHR _2.12 3.25_5.00 ; LD-KA: aHR _1.54 2.35_3.59 ). SPK,P- recipients had significantly higher risk of death (aHR _1.68 3.30_6.50 ). 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.

Impact of donor cardiopulmonary resuscitation on the outcome of simultaneous pancreas-kidney transplantation-a retrospective study

Previous cardiac arrest in brain-dead donors has been discussed as a potential risk factor in pancreas transplantation (PT), leading to a higher rate of organ refusal. This study aimed to assess the impact of cardiopulmonary resuscitation (CPR) in brain-dead donors on pancreas transplant outcome. A total of 518 type 1 diabetics underwent primary simultaneous pancreas-kidney (SPK) transplantation at our center between 1994 and 2018. Patients were divided into groups, depending on whether their donor had been resuscitated or not. A total of 91 (17.6%) post-CPR donors had been accepted for transplantation (mean duration of cardiac arrest, 19.4 ± 15.6 min). Those donors were younger (P < 0.001), had lower pancreas donor risk index (PDRI, P = 0.003), and had higher serum creatinine levels (P = 0.021). With a median follow-up of 167 months (IQR 82-229), both groups demonstrated comparable short- and long-term patient and graft survival. The resuscitation time (<20 min vs. ≥20 min) also showed no impact, with similar survival rates for both groups. A multivariable Cox regression analysis suggested no statistically significant association between donor CPR and patient or graft survival. Our results indicate that post-CPR brain-dead donors are suitable for PT without increasing the risk of complications.

Assessing Pancreas Transplant Candidate Cardiac Disease: Preoperative Protocol Development at a Rapidly Growing Transplant Program

Pancreas transplant rates, despite improving outcomes, have decreased over the past two decades. This is due, in part, to ageing, increasingly co-morbid pancreas transplant candidates. There is a paucity of published data regarding coronary artery disease (CAD) in this population. To inform peri-operative management strategies, we sought to understand the frequency of CAD among recipients of pancreas transplants at our center. Informed by these data, we sought to develop a standard protocol for evaluation. A retrospective review of pancreas transplants (solitary pancreas and simultaneous pancreas-kidney) was undertaken at the University of Maryland. Transplant outcomes and frequency of cardiac disease were analyzed. Current data were compared with historic controls. Over the study period, 59 patients underwent pancreas transplantation. Coronary architecture was assessed in 38 patients (64.4%). Discrete evidence of CAD was present in 28 of 39 patients (71.7%). All pancreas candidates (n = 21) who underwent left heart catheterization (LHC) demonstrated CAD (100%). No patients experienced myocardial infarction (MI) and no deaths resulted from cardiac disease in the early post-transplant period. Pancreas transplant candidates are at high risk for CAD. At a center in which pancreas transplant rates are increasing, a rigorous cardiac work up revealed that 71.7% of assessed recipients had CAD. Although asymptomatic, 6.8% required coronary artery bypass graft (CABG). Despite increasing age and co-morbid status, pancreas transplant recipients can enjoy excellent results if protocolized preoperative testing is used.

Diabetic kidney disease: A systematic review on the role of epigenetics as diagnostic and prognostic marker

Diabetic kidney disease is one of the most serious microvascular complications and among the leading causes of end stage renal disease. Persistently increasing albuminuria has been considered to be the central hallmark of nephropathy. However, albuminuria can indicate kidney damage for clinicians; it is not a specific biomarker for prediction of diabetic kidney disease prior to the onset of this devastating complication, and in fact all individuals with microalbuminuria do not progress to overt nephropathy. Controlled glycemia is unable to prevent nephropathy in all diabetic individuals indicating the role of other factors in progression of diabetic kidney disease. There are numerous cellular and molecular defects persisting prior to appearance of clinical symptoms. So, there is an urgent need to look for easy, novel, and accurate way to detect diabetic kidney disease prior to its beginning or at the infancy stage so that its progression can be slowed or arrested. It is now accepted that initiation and progression of diabetic kidney disease are a result of complex interactions between genetic and environmental factors. Environmental signals can alter the intracellular pathways by chromatin modifiers and regulate gene expression patterns leading to diabetes and its complications. In the present review, we have discussed a possible link between aberrant DNA methylation and altered gene expression in diabetic kidney disease. Drugs targeting to reverse epigenetic alteration can retard or stop the development of this devastating disease, just by breaking the chain of events occurring prior to the development of this microvascular complication in patients with diabetes.

Solid pancreas transplant: Pushing forward

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Long-term diabetes complications after pancreas transplantation

PURPOSE OF REVIEW

The intention of this study is to summarize present knowledge about adverse effects of hyperglycemia in diabetes, and in this context review more recent data concerning the effects of pancreas transplantation on a wide range of diabetic complications.

RECENT FINDINGS

Effective blood glucose control by insulin delays progression of microvascular complications and probably improves survival in type 1 diabetes. A successful pancreas transplantation combined with a kidney graft has recently been found to prevent diabetic kidney lesions, and registry data support improved long-term patient survival. Cardiovascular mortality was reduced in one study, even though coronary heart disease was not significantly altered. Advanced coronary lesions may be too advanced in these patients at baseline. However, with a successful single pancreas transplant, which is generally performed in patients with near-normal kidney function, pancreas transplantation may improve left ventricular function. Development of retinopathy and neuropathy is delayed with functioning pancreas grafts, and both quality of life and certain skin lesions may improve after pancreas transplantation.

SUMMARY

In patients with type 1 diabetes, pancreas transplantation may improve cardiac outcomes and ameliorate diabetic lesions in the kidney transplant. Also quality of life, neuropathy, retinopathy, and healing of certain skin lesions may be improved.

Successful pancreas transplantation alone is associated with excellent self-identified health score and glucose control: A retrospective study from a high-volume center in the United States

BACKGROUND

The benefits of pancreas transplantation are often difficult to measure. Here, we sought to determine the difference in quality of life for diabetic patients with and without a functional pancreas transplant alone (PTA).

METHODS

Pancreas transplant alone cases from 1993 to 2015 were considered. An IRB-approved survey inclusive of 15 questions spanning four domains was employed. Chi-square, Fisher's exact, and the T test were used where appropriate.

RESULTS

A total of 137 PTAs were performed during the study period. Of those reached (n = 32), 94% responded to the survey. Self-reported health scores were better (2.1 vs 3.0) for those with functioning pancreata (n = 18) vs those with a non-functional pancreas (n = 14), respectively (P = .036). Those with a functional pancreas had a HgbA1c of 5.3, vs 7.7 for a non-functional pancreas (P = .016). Significant hypoglycemia was reported in two of 18 with a functional transplant vs nine of 14 patients with a failed transplant (P = .003). Daily frustration with blood sugar affecting quality of life was significantly higher for patients with non-functional pancreas grafts (P < .001).

CONCLUSIONS

Pancreas transplantation alone is associated with better glucose control than insulin. In addition, recipients of functional PTAs have improved quality of life and better overall health scores than those with failed grafts.

Cardiac Assessment of Patients With Type 1 Diabetes Median 10 Years After Successful Simultaneous Pancreas and Kidney Transplantation Compared With Living Donor Kidney Transplantation

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

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.

Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation

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.

Pancreas Transplantation in the Modern Era

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

Kidney Transplantation in the Diabetic Patient

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.

Pancreas transplantation in type II diabetes mellitus

Although the diagnosis of type 2 diabetes mellitus was once considered a contraindication to simultaneous pancreas-kidney transplantation, a growing body of evidence has revealed that similar graft and patient survival can be achieved when compared to type 1 diabetes mellitus recipients. A cautious strategy regarding candidate selection may limit appropriate candidates from additional benefits in terms of quality of life and potential amelioration of secondary side effects of the disease process. Although our current understanding of the disease has changed, uniform listing characteristics to better define and study this population have limited available data and must be established.

Long-term outcomes after organ transplantation in diabetic end-stage renal disease

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.

Pretransplantation GAD-autoantibody status to guide prophylactic antibody induction therapy in simultaneous pancreas and kidney transplantation

BACKGROUND

Daclizumab and antithymocyte globulin (ATG) have been shown to reduce allograft rejection. We assessed the safety and efficacy of daclizumab or ATG prophylaxis in combination with triple immunotherapy in simultaneous pancreas-kidney transplant (SPKT) recipients.

METHODS

Thirty-nine type 1 diabetic patients scheduled for primary SPKT were randomized to receive prophylactic therapy with either daclizumab or ATG. A group of 27 patients without prophylactic antibodies was used for retrospective comparison. All patients received cyclosporine and mycophenolate mofetil and gradually tapered prednisone. Autoantibodies and cellular autoreactivity were measured to assess recurrent autoreactive responses.

RESULTS

Baseline and transplant characteristics were comparable among groups. Both daclizumab and ATG therapy resulted in a significant reduction in acute rejection episodes. The incidence of rejection episodes was significantly higher in pretransplantation GAD autoantibody-positive daclizumab-treated recipients compared with GAD autoantibody-negative or ATG-treated recipients. IA-2 islet autoantibodies showed no association with rejection. There were no significant differences between the groups for in vitro autoreactivity, clinical outcome, or functional parameters.

CONCLUSIONS

Daclizumab or ATG combined with a maintenance immunosuppressive regime consisting of cyclosporine, mycophenolate mofetil, and prednisolone were well tolerated and equally effective in reducing the incidence of acute rejection episodes in SPKT recipients. Up to 3 years, no adverse sequelae of the immunoprophylaxis or clinical and ex vivo recurrent autoimmunity were observed. We propose that the pretransplantation existence of GAD65 autoantibodies serves as a marker guiding the choice for prophylactic therapy in pancreas transplantation.

Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease

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.

Follow-up of secondary diabetic complications after pancreas transplantation

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Pancreatic transplant in diabetes

Whole organ pancreas transplantation is increasingly being performed for the treatment of diabetes mellitus. To date, over 32,000 pancreas transplants have been performed worldwide. The procedure is associated with significant mortality and morbidity in early transplant period. However, the successful pancreas transplantation has the potential to render patients insulin-independent and halt the progression of complications of diabetes, thereby improving both quality of life and patient survival.

Simultaneous pancreas kidney transplant versus other kidney transplant options in patients with type 2 diabetes

BACKGROUND AND OBJECTIVES

Current organ allocation policy prioritizes placement of kidneys (with pancreas) to patients listed for simultaneous pancreas-kidney transplantation (SPK). Patients with type 2 diabetes mellitus (T2DM) may undergo SPK, but it is unknown whether these patients enjoy a survival advantage with SPK versus deceased-donor kidney transplantation alone (DDKA) or living-donor kidney transplantation alone (LDKA).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the Scientific Registry of Transplant Recipients database, patients with T2DM, age 18-59 years, body mass index 18-30 kg/m(2), who underwent SPK, DDKA, or LDKA from 2000 through 2008 were identified. Five-year patient and kidney graft survival rates were compared, and multivariable analysis was performed to determine donor, recipient, and transplant factors influencing these outcomes.

RESULTS

Of 6416 patients identified, 4005, 1987, and 424 underwent DDKA, LDKA, and SPK, respectively. On unadjusted analysis, patient and kidney graft survival rates were superior for LDKA versus SPK, whereas patient but not graft survival was higher for SPK versus DDKA. On multivariable analysis, survival advantage for SPK versus DDKA was related not to pancreas transplantation but younger donor and recipient ages in the SPK cohort.

CONCLUSIONS

Good outcomes can occur with SPK in selected patients with T2DM, but no patient or graft survival advantage is provided by added pancreas transplantation compared with DDKA; outcomes were superior with LDKA. These results support cautious use of SPK in T2DM when LDKA is not an option, with close oversight of the effect of kidney (with pancreas) allocation priority over other transplant candidates.

Outcomes of preemptive kidney with or without subsequent pancreas transplant compared with preemptive simultaneous pancreas/kidney transplantation

BACKGROUND

Prior studies have indicated that type 1 diabetic (T1DM) recipients of a simultaneous pancreas-kidney (SPK) transplant have greater short-term mortality compared with living donor kidney (LDK) transplantation. Whether this association remains and how outcomes compare to deceased donor kidney (DDK) transplantation in the preemptive setting are unknown.

METHODS

Using data on recipients transplanted between 2000 and 2010 from the Organ Procurement and Transplantation Network/United Network of Organ Sharing, patient and graft survival (calculated from the time of kidney transplant) of pancreas after preemptive LDK (PALK, n=389), preemptive LDK not receiving a pancreas transplant (LDK/noP, n=289), preemptive DDK (n=112), and preemptive SPK transplantations (n=1402) were compared.

RESULTS

At 6 years, patient survival was excellent (PALK=89.4%, LDK/noP=84.9%, DDK=81.2%, and SPK=91.1%) and not different between PALK, LDK/noP, and SPK (P value vs. PALK: LDK/noP=0.08; SPK=0.85) but was lower with preemptive DDK versus preemptive PALK (P=0.03). When both LDK groups were considered together, there was higher mortality in the first 180 days after transplant with preemptive DDK (3.7% vs. 1.1%; P=0.03) and similar mortality with preemptive SPK (2.3%; P=0.07). After multivariate adjustment, there was a trend toward increased risk of death with preemptive DDK compared with preemptive PALK (hazard ratio: 1.91; 95% confidence interval: 0.95-3.84).

CONCLUSIONS

Patient survival associated with preemptive transplantation among T1DM recipients was excellent at 6 years, with the greatest survival favoring PALK, LDK/noP, and SPK rather than DDK. In contrast with prior studies reporting greater short-term mortality with SPK among the general T1DM population, short-term mortality after preemptive transplant is similar between LDK and SPK.

Intensivtherapie nach Transplantation solider Organe

Der Intensivmedizin kommt eine zentrale Bedeutung in Rahmen der Transplantationsmedizin zu. Aufgrund ihrer marginalen Organfunktion benötigen die Patienten nicht selten bereits im Vorfeld der Transplantation eine intensivmedizinische Versorgung, zu der dann auch die Evaluation und Listung sowie die Koordination des zeitkritischen Transplantationsablaufs gehören können. Die direkte postoperative Betreuung nach komplexen Organtransplantationen bedarf fast ausschließlich der Versorgung im Rahmen von Überwachungsstationen, in denen sowohl direkt transplantationsassoziierte Komplikationen als auch Nebenerkrankungen eine intensivmedizinische Behandlungen notwendig machen. Sie zielt auf die Stabilisierung der Organfunktion, Behandlung begleitender Organdysfunktionen, adäquate Induktion der Immunsuppression und die möglichst frühe Wiedererlangung der Eigenständigkeit des Transplantierten ab.

The role of kidney-pancreas transplantation in diabetic kidney disease

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