Diabetic retinopathy after combined kidney–pancreas transplantation

Abstract

Diabetic retinopathy (DR) is amenable to good diabetic control; however, only successful pancreas transplantation can achieve sustained normoglycaemia. The aim of this long-term study was to examine the course of DR in insulin-dependent diabetic recipients of a simultaneous kidney and pancreas transplant (SPK). Successful SPK recipients (n = 46) and failed pancreas transplant with a functioning kidney transplant (n = 8) were assessed by baseline and regular post-transplant ophthalmic examinations (n = 432) for up to 10 yr after SPK. At the time of SPK (n = 108 eyes), the mean duration of diabetes was 25 +/- 7 yr, ten eyes were blind, and 79% of eyes had advanced DR that had panretinal laser (panretinal photocoagulation, PRP. Successful SPK recipients had normal glucose control with a mean HBA1C of 5.2 +/- 0.6%. DR remained stable in 75% of both the study and control groups, with no difference between groups. The DR mostly evolved towards inactive proliferative DR. After SPK, 14% of non-blind eyes showed improvement of DR, 76% remained stable and 10% progressed. Early vitreous haemorrhage occurred in 6.1% of eyes, and was related to established DR. Cataract of all types increased after transplantation (p < 0.01), which reduced visual acuity (VA) in affected eyes. The mean overall VA remained unchanged for the study duration. In summary, uremic patients from diabetic nephropathy had a high prevalence of severe proliferative DR and blindness at the time of presentation for SPK. This was subsequently stabilised to inactive proliferative DR by appropriate laser therapy followed by metabolic control achieved by SPK.

Pancreas transplant alone has beneficial effects on retinopathy in type 1 diabetic patients

“…However, many patients still progress to more severe lesions despite improvements in glucose control [4]. After blood glucose normalisation subsequent to simultaneous pancreas-kidney transplantation, a few groups (but not all) observed amelioration of diabetes ocular complications [6][7][8][9][10][11][12][13][14], but it cannot be ruled out that the attendant cure of uraemia might have played an important role [25]. Therefore, studying normoglycaemic pancreas-alone recipients is possibly a better way to assess the effects of normoglycaemia on diabetes complications.…”

“…Lately, the effects of combined pancreas-kidney transplantation on diabetic retinopathy have been described, and conflicting results reported [6][7][8][9][10][11][12][13][14]. Some work showed no significant change or even progression in retinal complications following combined pancreas-kidney transplantation [6][7][8][9].…”

“…In addition, an increased prevalence of posttransplant cataract has also been observed [15]. Other authors, however, reported more consistent improvements, including slower progression of established retinopathy and less need for laser therapy [10][11][12][13][14]. Little information is available with regard to the effects of pancreas transplant alone (PTA) on diabetic retinopathy.…”

Simultaneous pancreas-kidney transplantation: The role in the treatment of type 1 diabetes and end-stage renal disease

“…31 Following SPK transplantation, 14% of non-blind eyes showed improvement, 76% remained stable and only 10% progressed further. 32 A separate study reported an improvement in post-transplant visual acuity in 32% of the eyes and frequency/severity of vitreous hemorrhages in 46% of eyes. 31 It may take up to 4 years before noticeable functional improvement in retinopathy and acuity may be observed.…”

Pancreas and islet cell transplantation

“…33 Amelioration of diabetes-associated morbidity-Numerous studies have shown that a successful pancreas transplant can slow micro-vascular complications, including nephropathy, retinopathy and neuropathy. [34][35][36][37] Disappointingly, however, clear evidence has not emerged showing that pancreas transplantation can reverse pre-existing lesions or completely prevent the progression of new ones that are diabetes-related. This could be the result of factors that are independent of glycaemic control.…”