Simultaneous Pancreas-Kidney Transplants in Type I and Type II Diabetic Patients With End-Stage Renal Disease: Similar 10-Year Outcomes

doi:10.1016/j.transproceed.2004.12.215

Transplantation Proceedings

Volume 37, Issue 2, March 2005, Pages 1283-1284

https://doi.org/10.1016/j.transproceed.2004.12.215 Get rights and content

Abstract

Introduction

Herein we report 10- to 15-year results of simultaneous pancreas-kidney (SPK) transplants in 135 type I and type II insulin-dependent diabetes mellitus (IDDM) patients.

Methods

Diabetes type was defined by the absence (type I) or presence (type II) of C-peptide. The freedom from dialysis and need for insulin defined graft survival. Patient survival was verified by record review and the Social Security Death Registry. The mean follow-up exceeded 100 months.

Results

Type II IDDM present in 28% of the 135 cohort, predominately among African-Americans (AA). The type II group was two-thirds AA (43% of the total AA patients) and 17% of the non–African-American (nAA) group. The difference between the two groups by C-peptide level was significant (P = .001). Type II patients had a higher body mass index, were slightly older at the onset of DM, but had similar duration of IDDM before ESRD. At 5 and 10 years, pancreas survival for type 1 DM was 71% and 49%; for type II DM it was 67% and 56% (P = .52). Kidney survival for type I DM was 77% and 50%; for type II it was 72% and 56% (P = .65). Patient survival for type I DM was 85% and 63%; for type II DM it was 73% and 70% (P = .98).

Conclusions

We conclude that the outcomes of SPK transplants are equivalent regardless of diabetes type. Accordingly, the decision whether to perform pancreas transplants in diabetic recipients of kidney allografts should be based on general acceptance criteria not diabetes type.

Section snippets

Methods

Type I IDDM is defined by the absence of detectable C-peptide (<0.8 ng/mL); type II IDDM is defined by its presence (C-peptide > 0.8 ng/mL). Graft survival was defined as the freedom from dialysis (kidney) and/or the need for insulin (pancreas). Patient survival was verified by medical record review augmented by the Social Security Death Registry. Statistical analyses were performed as indicated in the results section. The mean follow-up period for the SPK recipients exceeded 100 months.

Results

Type II IDDM was present in 28% of the 135 SPK recipients cohort, occurring predominately among the African-American recipients. Two-thirds of the total type II IDDM group were African-American (43% of all African-Americans in the 135 SPK recipients cohort). In opposition, only 17% of the non–African-Americans in the cohort were type II IDDM. The difference between the two racial groups by C-peptide level was highly significant (Pearson chi-square, 1 df, P = .001). Characteristics of the total

Discussion

We reaffirm our 1998 conclusion. The patient, kidney, and pancreas outcomes are equivalent regardless of the recipients' pretransplant type of diabetes. Accordingly, the decision whether or not to perform SPK transplants in diabetic recipients should be based on a transplant center's general acceptance criteria not on the potential recipient's C-peptide status.

References (2)

T.M. Sasaki et al.
Successful long-term kidney-pancreas transplants in diabetic patients with high C-peptide levels
Transplantation
(1998)
J.A. Light et al.
Successful long-term kidney-pancreas transplants regardless of C-peptide status or race
Transplantation
(2001)

Cited by (50)

Retrospective Analysis of Pancreas Transplants in Poland in Years 1998-2015
2020, Transplantation Proceedings
Transplantation of the pancreas is an established method for the treatment of complicated diabetes mellitus. As the numbers of diabetic patients increase so does the need for efficient treatment methods. Despite significant perioperative risk and complications related to immunosuppression, pancreas transplant remains the best therapeutic option for selected patients.
The analysis was based on the comparison of characteristics of all organ donors and recipients in years 1998 to 2015. The collected data were divided into 2 periods to facilitate identification of populational changes.
The total number of pancreas transplants in Poland was 139 in years 1998 to 2006 and 268 in years 2007 to 2015. The largest differences revealed by the comparison of donor-related variables in both periods were those related to the doses of pressor amines, duration of circulatory arrest, and duration of stay at the intensive care unit. The critical finding consisted in the improvement of short-term survival of recipients and organs being observed in contrast to the surprising lack of improvement in long-term survival. Reduced likelihood of transplantation success was observed already in overweight patients (body mass index 25-29.99 kg/m²).
No significant changes were observed with regard to pancreas transplant outcomes over the period of many years. Transplantation success is determined by 1-year survival of the organ, and the therapeutic success is measured by long-term disease-free survival of the patient. In the era of rapid advances in numerous areas of medicine, the lack of significant extension of patient survival times warrants a closer look of our knowledge on pancreas transplants.
Three-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation in type 2 diabetes patients
2020, American Journal of Transplantation
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%LCLaHR_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 _1.532.20_3.17; LD-KA: aHR _1.291.87_2.71) and death (DD-KA: aHR _2.123.25_5.00; LD-KA: aHR _1.542.35_3.59). SPK,P- recipients had significantly higher risk of death (aHR _1.683.30_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.
Pancreas and kidney transplantation for diabetic nephropathy
2019, Kidney Transplantation - Principles and Practice
Pancreas Transplantation at a Single Latin-American Center; Overall Results with Type 1 and Type 2 Diabetes Mellitus
2018, Transplantation Proceedings
Citation Excerpt :
As has been reported worldwide, the procedure itself has significant clinical and surgical complications that reflect the severity of the disease at the time of the transplantation, but the overall experience brought us to a significant reduction not only in the numbers of complications observed but also in the length of hospital stay (from 29.6 to 12.2 days over the past 2 years). All of the clinical and biochemical parameters used for post-transplantation follow-up showed no significant differences between groups, as has been reported by others [19]. At the end of the present study period, 95.5% of the survivors were on tacrolimus, mofetil mycophenolate, and steroids as maintenance immunosuppressive regimen.
Simultaneous pancreas-kidney transplantation (SPK) has become the treatment of choice for type 1 diabetes mellitus (T1DM) patients with chronic renal failure. Type 2 diabetes mellitus (T2DM), was once considered to be a contraindication for pancreas transplantation; however, it has been accepted as a new indication, under strict criteria. Although favorable results have increase the indication for T2DM in developed countries, there have been no reports of long-term results for this indication from Latin American centers.
From April 2008 to March 2016, patients receiving SPK or pancreas transplant alone (PTA) for T2DM were included and compared with T1DM recipients. Variables were compared between groups with the use of χ² and t tests; Kaplan-Meier with log rank was used for patient and graft survivals; P < .05 was considered to be significant.
A total of 45 SPK and 1 PTA were performed, 35 (76.1%) for T1DM and 11 (24.5%) for T2DM. Mean pre-transplantation C-peptide was significantly higher in the T2DM group (P = .01); HbA_1c was higher in the T1DM group (P = .03). No differences were found in weight, body mass index, and pre-transplantation glycemia. Patient survivals for T1DM recipients were 88.2% and 84.8% at 1 and 5 years, respetively, versus 100% and 74.1% for T2DM recipients (P = .87).
Our initial prospective experience in a single Latin American center showed that medium- and long-term outcomes for T1DM and T2DM individuals receiving pancreas transplants are similar, under strict selection criteria.
Multiorgan transplantation
2016, Transplantation Reviews
Kidney transplantation has proven to be the gold standard therapy for severe chronic kidney disease (CKD) due to multiple etiologies in individuals deemed eligible from a surgical standpoint. While kidney transplantation is traditionally considered in conditions of native kidney disease such as diabetes and immunological or inherited causes of kidney disease, an increasing indication for kidney transplantation is kidney dysfunction in the setting of other severe organ dysfunction that requires transplant, such as severe liver or heart disease. In these settings, multiorgan transplantation is now commonly performed, with controversy regarding the appropriate utilization of kidneys transplanted both from a physiological perspective (distinguishing those who require a kidney transplant) and also from an ethical perspective (allocation of a scarce resource to a more morbid population). These issues persist in the setting of simultaneous pancreas–kidney transplant (SPK), in which utilization for patients with type 1 diabetes has been historically accepted. Questions of physiological benefit persist, and utilization is waning despite broader allocation policies that encourage SPK, including consideration for patients with type 2 diabetes. The purpose of this review will be to summarize the physiological data regarding multiorgan transplantation and place these into context while reviewing current allocation policy in the United States.
Pancreas transplantation in C-peptide positive patients: Does "type" of diabetes really matter?
2015, Journal of the American College of Surgeons
In the past, type 2 (C-peptide positive) diabetes mellitus (DM) was a contraindication for simultaneous pancreas-kidney transplantation (SPKT).
We retrospectively analyzed outcomes in SPKT recipients according to pretransplantation C-peptide levels ≥2.0 ng/mL or < 2.0 ng/mL.
From November 2001 to March 2013, we performed 162 SPKTs including 30 (18.5%) in patients with C-peptide levels ≥2.0 ng/mL pretransplantation (C-peptide positive group, range 2.1 to 12.4 ng/mL) and 132 in patients with absent or low C-peptide levels (<2.0 ng/mL, C-peptide “negative”). C-peptide positive patients were older at SPKT, had a later age of onset and shorter duration of pretransplantation DM, and more were African-American (all p < 0.05) compared with C-peptide negative patients. With a mean follow-up of 5.6 years, patient (80% vs 82.6%), kidney graft (63.3% vs 68.9%), and pancreas graft survivals (50% vs 62.1%, all p = NS) rates were comparable in C-peptide positive and negative patients, respectively. At latest follow-up, there were no differences in acute rejection episodes, surgical complications, major infections, readmissions, hemoglobin A1c levels, serum creatinine, and estimated glomerular filtration rate levels between the 2 groups. C-peptide levels were higher (mean 5.0 vs 2.6 ng/mL, p < 0.05) and post-transplant weight gain (≥5 kg) was more common (57% vs 33%, p = 0.004) in the C-peptide positive group. Survival outcomes in C-peptide positive (n = 14) vs C-peptide negative (n = 22) African-American patients were similar, as were outcomes in C-peptide positive patients with a body mass index < or ≥ 28 kg/m².
Patients with higher pretransplantion C-peptide levels appear to have a type 2 DM phenotype compared to insulinopenic patients undergoing SPKT. However, survival and functional outcomes were similar, suggesting that pretransplantation C-peptide levels should not be used exclusively to determine candidacy for SPKT.

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Simultaneous Pancreas-Kidney Transplants in Type I and Type II Diabetic Patients With End-Stage Renal Disease: Similar 10-Year Outcomes

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Successful long-term kidney-pancreas transplants in diabetic patients with high C-peptide levels

Transplantation

Successful long-term kidney-pancreas transplants regardless of C-peptide status or race

Transplantation