Glycemic Control in Simultaneous Islet-Kidney Versus Pancreas-Kidney Transplantation in Type 1 Diabetes: A Prospective 13-Year Follow-up

Abstract

OBJECTIVEIn patients with type 1 diabetes and end-stage renal disease, combined transplantation of a kidney together with a pancreas or isolated pancreatic islets are options to improve glycemic control. The aim of this study was to compare their long-term outcome with regard to metabolic control and surgical complication rate, as well as function of the transplanted kidney. RESEARCH DESIGN AND METHODSWe conducted a prospective cohort study in consecutive patients receiving either a pancreas or islet transplant simultaneously with or after kidney transplantation (simultaneous pancreas-kidney [SPK]/pancreas-after-kidney [PAK] or simultaneous islet-kidney [SIK]/islet-after-kidney [IAK] transplantation). RESULTSNinety-four patients who had undergone SPK/PAK transplantation were compared with 38 patients who had undergone SIK/IAK transplantation over a period of up to 13 years. HbA 1c levels declined from 7.8 6 1.3% (62 6 14 mmol/mol) to 5.9 6 1.1% (41 6 12 mmol/mol), and from 8.0 6 1.3% (64 6 14 mmol/mol) to 6.5 6 1.1% (48 6 12 mmol/mol), respectively, in the SPK/PAK and SIK/IAK groups (P < 0.001 for both) and remained stable during follow-up, despite a reduction in the rate of severe hypoglycemia by >90%. The 5-year insulin independence rate was higher in the SPK/PAK group (73.6 vs. 9.3% in the SIK/IAK group), as was the rate of relaparotomy after transplantation (41.5 vs. 10.5% in the SIK/IAK group). There was no difference in the rate of kidney function decline. CONCLUSIONSDuring a long-term follow-up, SPK/PAK transplantation as well as SIK/IAK transplantation resulted in a sustained improvement of glycemic control with a slightly higher glycated hemoglobin level in the SIK/IAK group. While insulin independence is more common in whole-organ pancreas recipients, islet transplantation can be conducted with a much lower surgical complication rate and no difference in kidney function decline.

Pancreas transplantation in the treatment of diabetes mellitus type 1: modern aspects

“…Однако пациенты, получившие помимо почки трансплантат подже-лудочной железы или трансплантат островковых клеток поджелудочной железы, имеют схожие ре-зультаты по сохранности почечной функции через 5 и 10 лет после операции. И хотя во второй группе пациентов реже бывают хирургические осложне-ния, но значительно меньше вероятность сохране-ния эугликемии и инсулинонезависимости через 5 лет [27].…”

“…При не-возможности адекватной коррекции возможно вы-полнение отсроченной конверсии анастомоза с фор-мированием дуоденоэнтероанастомоза [27,64,68].…”

Pankreastransplantation

“…DasSterblichkeitsrisikobeiei- ner PAK-Transplantation im Vergleich zu Patienten, welche eine Nierentransplantation erhalten haben und auf der Warteliste für eine Bauchspeicheldrüse stehen, wird kontrovers diskutiert. Jedoch zeigen kontrollierte Blutzuckerwerte nach einer Pankreastransplantation ein länge-res Transplantatüberleben der Niere [18].…”

“…Gemessen an der Insulinunabhängigkeitals Maßstabfürdas Transplantatüberleben erwiesen sich nach 1 Jahr 89 % und nach 5 Jahren > 70 % der Transplantate noch als funktionstüchtig [3,18]. Das ERA-EDTA-Register (ERA: "European Renal Association", EDTA: "European Dialysis and Transplant Association") zeigt ein Patientenüberleben bei dialysepflichtigen Patienten mit Diabetes von 87,8 % nach 1 Jahr und 50,6 % nach 5 Jahren [20].…”

Continuous subcutaneous insulin pump treatment associated with absence of recurrent kidney allograft diabetic nephropathy

“…However, kidney-pancreas transplantation is associated with significant morbidity, and donor organ shortage limits its widespread application [8]. Islet after kidney transplantation can also potentially reduce long-term diabetic complications; however, the rate of insulin independence after islet transplantation remains significantly lower as compared to full pancreas transplantation [9].…”