Elsevier

Transplantation Reviews

Volume 27, Issue 4, October 2013, Pages 112-116
Transplantation Reviews

Kidney transplant options for the diabetic patient

https://doi.org/10.1016/j.trre.2013.07.002Get rights and content

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.

Introduction

While kidney transplantation has been consistently associated with improved survival when compared to dialysis from the 1990s to the present, pancreas transplantation has become increasingly successful in recent years due to advances in surgical outcomes and immunosuppression [1], [2], [3] With kidney transplant survival in diabetics approaching 88% for deceased donors and 96% for living donors at 1 year, one-year pancreas graft survival is now nearly 85% when performed as a simultaneous pancreas kidney transplant, (SPK), and 77% when performed as a pancreas after kidney transplant, (PAK) [4], [5]. Questions of the relative advantages of SPK transplant over living donor kidney transplant alone (LDKA) with or without subsequent pancreas transplant (pancreas after kidney, PAK) have been addressed in large database analyses, but specific patient and transplant center attributes may have an impact on the specific modality recommendations given to an individual patient. This review will summarize these reports and provide commentary when applying these data to the care of the individual.

Section snippets

The benefit of the added pancreas transplant in kidney transplant recipients

For the patient with T1DM and chronic kidney disease, initial transplant options include kidney transplant alone (from a deceased or living donor, DDKA, LDKA) or simultaneous pancreas kidney transplant (SPK). Under most circumstances, the benefit of LDKA versus DDKA is well understood in terms of graft survival as well as patient survival [5], [6]. The potential for pancreas transplant to provide benefits beyond kidney transplant alone can be assessed not only by patient and graft survival data

Timing of pancreas transplantation: Pancreas simultaneously with kidney, or after kidney transplant?

While the benefits and risks of SPK transplant can provide a framework for understanding the potential benefit of pancreas transplantation in general, a common clinical scenario is one in which external factors such as waiting time for an SPK preclude this option, and encourage LDKA with a later consideration for pancreas after kidney transplant (PAK). When examining registry data, long-term pancreas graft function is inferior when performed as a PAK than as an SPK. For patients transplanted in

Individual comorbidities and circumstances that impact transplant modality choice

It must be acknowledged that the above data is derived either from retrospective database analyses or large single center reports, with the data under these conditions subject to differing levels of bias. The findings are consistent in the association of superior survival with the added pancreas provided that pancreatic function is achieved even for a short period. However, since the differences appear relatively late in the course of a transplant it is very appropriate to consider all options

Pancreas transplantation for type 2 diabetes?

Until recently, there was no clear distinction for the type of diabetes that was considered appropriate for pancreas transplantation, primarily due to the difficulties in appropriately classifying patients based upon simple and often inaccurate indicators such as insulin utilization, c-peptide levels, and age of onset of disease. A small subset of patients reported as type 2 diabetes have received SPK transplants over the last decade [52]; patients with type 2 diabetes now comprise 8% of

Summary

Given the narrow but consistent advantages of an added pancreas transplant either as an SPK or PAK over kidney transplant alone, the decision-making for a specific individual regarding transplant options will most likely focus upon the individual’s morbidity and perceived quality of life associated with ongoing diabetes care, the waiting time in which a patient must wait for an SPK rather than undergo a kidney transplant (typically via a living donor), and the characteristics and allocation

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