Simultaneous Pancreas Kidney Transplant versus Other Kidney Transplant Options in Patients with Type 2 Diabetes

Abstract

SummaryBackground 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.

Simultaneous pancreas and kidney transplantation as the standard surgical treatment for diabetes mellitus patients with end-stage renal disease

“…In an early study that compared the outcomes of SPK, DDKA, and LDKA in patients with T2DM, Wiseman and Gralla 38 concluded that both patient and graft survival rates were superior with LDKA transplantation, whereas patient but not graft survival rate was higher in SPK versus DDKA transplantation. After multivariable analysis, the survival advantage of SPK over DDKA was related not so much to the pancreas transplantation but other variables such as younger donor and recipient ages in the SPK cohort (Table 3 38 ).…”

Role of simultaneous pancreas-kidney transplantation in the treatment of diabetes mellitus

“…A 2-es típusú cukorbetegségben és következményes veseelégtelenségben szenvedők szá-mára az élő donorból történő szoliter veseátültetés biztosítja a legjobb eredményt [12]. Célszerűbb tehát a nagyon szűkösen rendelkezésre álló transzplantálható hasnyálmirigyeket az 1-es típusú cukorbetegeknek fenntartani.…”

Kidney, Pancreas and Islet Transplant Options for Patients with Diabetic Nephropathy

“…Regarding T2DM patients eligible for transplantation, the United Network for Organ Sharing (UNOS) has defined the following criteria for SPK: a) insulin therapy and C-peptide level <2 ng/ml or b) insulin therapy with C-peptide level >2 ng/ml and BMI<28 kg/m 2 [42]. The initial concern regarding pancreas transplantation in T2DM patients was insulin resistance that prevails in this type of DM and may result in lower pancreas allograft survival due to β cell exhaustion from the increased insulin demands [43].…”

“…However, in the unadjusted analysis older age and longer dialysis vintage were associated with increased mortality in T2DM compared with T1DM recipients. On the contrary, Wiseman and Gralla have recently reported in a retrospective database analysis of 6416 T2DM patients who underwent transplantation from [2000][2001][2002][2003][2004][2005][2006][2007][2008], that there is no clear patient or graft survival advantage for T2DM patients undergoing SPK compared with DDKT, whereas LDKT provided superior outcomes [42]. These results support a more cautious approach for SPK in T2DM patients eligible for transplantation.…”

“…These patients were mainly males (67%) and presented higher BMI compared with T1DM patients [11]. As data regarding long-term survival after SPK are rather conflicting [42,44], most authorities [42,43,78] suggest that the best option would be to target for LDKT and consider SPK only in well selected cases with a metabolic profile similar to T1DM. In addition, recent data from bariatric surgery implicate a more favorable outcome for T2DM patients with diabetic nephropathy and BMI>32 kg/m 2 before KT [78][79][80].…”