Evolution of diabetic nephropathy in kidney grafts. Evidence that a simultaneously transplanted pancreas exerts a protective effect

First World Consensus Conference on pancreas transplantation: Part II - recommendations

The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.

Long-term Outcomes in Simultaneous Pancreas-Kidney Transplant Recipients: Single-center Experience From Poland

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal disease (ESRD) due to type 1 diabetes mellitus (DM1). Since the 1980s, pancreas transplantation has become the most effective strategy to restore normoglycemia in patients with DM1. The aim of this study was to present long-term outcomes data for SPKT.

METHODS

We performed a retrospective analysis of 73 SPKT recipients followed in our outpatient center who underwent transplantation between 1988 and 2015.

RESULTS

A total of 50.7% of the patients were male. At the time of surgery, patients' mean age was 37.38 ± 7.44 years. Patients were diagnosed with DM1 at an average of 25 ± 6.08 years before SPKT. For 21.9% of patients, the transplant was done preemptively. Most (91.8%) had enteric drainage. All patients received induction of immunosuppression (either polyclonal immunoglobulins anti-thymocyte globulin or thymoglobulin [64.4%] or monoclonal globulins daclizumab or basiliximab [35.6%]). Patient survival at 1, 5, 10, 15 years was 99%, 97%, 89%, and 75%; kidney survival was 99%, 96%, 84%, and 67%; and pancreas survival was 95%, 92%, 84%, and 64%, respectively. There was a notable tendency toward increased creatinine level (from 1.18 at 1 year to 1.78 at 15 years) and decreased hemoglobin level (from 13.84 at 1 year to 12.65 at 15 years).

CONCLUSION

Diabetic patients with ESRD have a poor prognosis without transplantation. SPKT provides marked prolongation of the patient's life and freedom from insulin injections. Enteric drainage is currently the surgical technique of choice. SPKT should remain as the treatment of choice in this patient population.

Simultaneous Pancreas-Kidney Transplantation Versus Living Donor Kidney Transplantation Alone: an Outcome-Driven Choice?

PURPOSE OF REVIEW

The choice of optimum transplant in a patient with type 1 diabetes mellitus (T1DM) and chronic kidney disease stage V (CKD V) is not clear. The purpose of this review was to investigate this in more detail-in particular the choice between a simultaneous pancreas-kidney transplantation (SPKT) and living donor kidney transplantation (LDKT), including recent evidence, to aid clinicians and their patients in making an informed choice in their care.

RECENT FINDINGS

Analyses of large databases have recently shown SPKT to have better survival rates than a LDKT in the long-term, despite an early increase in morbidity and mortality in SPKT recipients. This survival advantage has only been shown in those SPKT recipients with a functioning pancreas and not those who had early pancreas graft loss. The choice of SPKT or LDKT should not be based on patient and graft survival outcomes alone. Individual patient circumstances, preferences, and comorbidities, among other factors should form an important part of the decision-making process. In general, an SPKT should be considered in those patients not on dialysis and LDKT in those nearing or already on dialysis.

Long-term diabetes complications after pancreas transplantation

PURPOSE OF REVIEW

The intention of this study is to summarize present knowledge about adverse effects of hyperglycemia in diabetes, and in this context review more recent data concerning the effects of pancreas transplantation on a wide range of diabetic complications.

RECENT FINDINGS

Effective blood glucose control by insulin delays progression of microvascular complications and probably improves survival in type 1 diabetes. A successful pancreas transplantation combined with a kidney graft has recently been found to prevent diabetic kidney lesions, and registry data support improved long-term patient survival. Cardiovascular mortality was reduced in one study, even though coronary heart disease was not significantly altered. Advanced coronary lesions may be too advanced in these patients at baseline. However, with a successful single pancreas transplant, which is generally performed in patients with near-normal kidney function, pancreas transplantation may improve left ventricular function. Development of retinopathy and neuropathy is delayed with functioning pancreas grafts, and both quality of life and certain skin lesions may improve after pancreas transplantation.

SUMMARY

In patients with type 1 diabetes, pancreas transplantation may improve cardiac outcomes and ameliorate diabetic lesions in the kidney transplant. Also quality of life, neuropathy, retinopathy, and healing of certain skin lesions may be improved.

An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK Transplant Registry study

Transplant options for patients with type 1 diabetes and end-stage renal disease (ESRD) include deceased donor kidney, live donor kidney (LDK) and simultaneous pancreas-kidney (SPK) transplantation. The aim of this study was to compare outcomes between LDK and SPK for patients with type 1 diabetes and ESRD in the UK. Data on all SPK (n = 1739) and LDK (n = 385) transplants performed between January 2001 and December 2014 were obtained from the UK Transplant Registry. Unadjusted patient and kidney graft survival were calculated using the Kaplan-Meier method. Multivariate analysis of kidney graft and patient survival was performed using Cox proportional hazards regression. There was no significant difference in patient (P = 0.435) or kidney graft survival (P = 0.204) on univariate analysis. On multivariate analysis there was no association between LDK/SPK and patient survival [HR 0.71 (0.47-1.06), P = 0.095]. However, LDK was associated with an overall lower risk for kidney graft failure [HR 0.60 (0.38-0.94), P = 0.025]. SPK recipients with a functioning pancreas graft had significantly better kidney graft and patient survival than LDK recipients or those with a failed pancreas graft. SPK transplantation does not confer an overall survival advantage compared to LDK. However, those SPK recipients with a functioning pancreas have significantly better outcomes.

Simultaneous pancreas-kidney transplantation: lessons learned from the initial experience of a single center in Korea

Purpose

The purpose of this study is to report the results of simultaneous pancreas-kidney (SPK) transplantations and describe the lessons learned from the early experiences of a single center.

Methods

Between January 2002 and June 2013, a total of 8 patients underwent SPK transplantation. Clinical and radiologic data were reviewed retrospectively.

Results

Seven patients were diagnosed with type I diabetes mellitus and one patient became insulin-dependent after undergoing a total pancreatectomy because of trauma. Pancreas exocrine drainage was performed by enteric drainage in 4 patients and bladder drainage in 4 patients. Three patients required conversion from initial bladder drainage to enteric drainage due to urinary symptoms and duodenal leakage. Four patients required a relaparotomy due to hemorrhage, ureteral stricture, duodenal leakage, and venous thrombosis. There was no kidney graft loss, and 2 patients had pancreas graft loss because of venous thrombosis and new onset of type II diabetes mellitus. With a median follow-up of 76 months (range, 2-147 months), the death-censored graft survival rates for the pancreas were 85.7% at 1, 3, and 5 years and 42.9% at 10 years. The patient survival rate was 87.5% at 1, 3, 5, and 10 years.

Conclusion

The long-term grafts and patient survival in the current series are comparable to previous studies. A successful pancreas transplant program can be established in a single small-volume institute. A meticulous surgical technique and early anticoagulation therapy are required for further improvement in the outcomes.

In patients with type 1 diabetes simultaneous pancreas and kidney transplantation preserves long-term kidney graft ultrastructure and function better than transplantation of kidney alone

AIMS/HYPOTHESIS

In patients with type 1 diabetes and end-stage renal disease (ESRD) we aimed to determine whether long-term normoglycaemia, as achieved by successful simultaneous pancreas and kidney (SPK) transplantation, would preserve kidney graft structure and function better than live donor kidney (LDK) transplantation alone.

METHODS

Estimated GFR (eGFR) was calculated in SPK (n = 25) and LDK (n = 17) recipients in a stable phase 3 months after transplantation and annually during follow-up. Kidney graft biopsies were obtained at follow-up for measurement of glomerular volume (light microscopy), glomerular basement membrane (GBM) and podocyte foot process widths and mesangial volume fraction (electron microscopy).

RESULTS

SPK and LDK recipients were similar in age and diabetes duration at engraftment. Donor age was higher in the LDK group. Median follow-up time was 10.1 years. Mean HbA1c levels during follow-up were 5.5 ± 0.4% (37 ± 5 mmol/mol) and 8.3 ± 1.5% (68 ± 16 mmol/mol) in the SPK and LDK group, respectively (p < 0.001). Compared with SPK recipients, LDK recipients had wider GBM (369 ± 109 nm vs 281 ± 57 nm; p = 0.008) and increased mesangial volume fraction (median 0.23 [range 0.13-0.59] vs 0.16 [0.10-0.41]; p = 0.007) at follow-up. Absolute eGFR change from baseline was -11 ± 21 and -23 ± 15 ml min(-1) 1.73 m(-2) (p = 0.060), whereas eGFR slope was -1.1 (95% CI -1.7, -0.5) and -2.6 (95% CI -3.1, -2.1) ml min(-1) 1.73 m(-2) per year in the SPK and LDK group, respectively (p = 0.001).

CONCLUSIONS/INTERPRETATION

In patients with type 1 diabetes and long-term normoglycaemia after successful SPK transplantation, kidney graft ultrastructure and function were better preserved compared with LDK transplantation alone.

Long-term outcomes after organ transplantation in diabetic end-stage renal disease

Patients with type 1 diabetic end-stage renal disease (ESRD) may be offered single kidney transplantation from a live donor (LDK) or a deceased donor (DDK) to replace the lost kidney function. In the latter setting the patient may also receive a simultaneous pancreas together with a kidney from the same donor (SPK). Also in some cases a pancreas after kidney may be offered to those who have previously received a kidney alone (PAK). The obvious benefit of a successful SPK transplantation is that the patients not only recover from uremia but also obtain normal blood glucose control without use of insulin or other hypoglycemic agents. Accordingly, this combined procedure has become an established treatment for type 1 diabetic patients with ESRD. Adequate long-term blood glucose control may theoretically lead to reduced progression or even reversal of microvascular complications. Another potential beneficial effect may be improvement of patient and kidney graft survival. Development of diabetic complications usually takes a decade to develop and accordingly any potential benefits of a pancreas transplant will not easily be disclosed during the first decade after transplantation. The purpose of the review is to assess the present literature of outcomes after kidney transplantation in patients with diabetic ESRD, with our without a concomitant pancreas transplantation. The points of interest given in this review are microvascular complications, graft outcomes, cardiovascular outcomes and mortality.

Outcomes of de novo allograft diabetic nephropathy in renal allograft recipients

OBJECTIVES

Despite increased use of diabetogenic immunosuppressive drugs and increased incidence of new-onset diabetes after transplant in renal allograft recipients, there are few case studies on the subject of de novo allograft diabetic nephropathy and interstitial fibrosis/tubular atrophy without specific glomerular changes. We sought to study the outcomes of allograft diabetic nephropathy and interstitial fibrosis/tubular atrophy without specific glomerular changes in patients with new-onset diabetes after transplant.

MATERIALS AND METHODS

We reviewed the case records of all new-onset diabetes after transplant patients who underwent graft biopsy for graft dysfunction from 1992 to 2010. We analyzed the clinical characteristics and outcomes of new-onset diabetes after transplant patients with de novo allograft diabetic nephropathy and interstitial fibrosis/tubular atrophy without specific glomerular changes.

RESULTS

Of the 1989 recipients, 421 patients developed new-onset diabetes after transplant and 26 underwent graft biopsy. Of the 26 patients, 9 had histopathologic evidence of de novo allograft diabetic nephropathy, and 17 had interstitial fibrosis/tubular atrophy without specific glomerular changes. The mean duration from transplant to developing novo allograft diabetic nephropathy was 115.2 months (range, 33-192 mo), and from developing new-onset diabetes after transplant to allograft diabetic nephropathy, was 109.66 months (range, 27-188.4 mo). Of the 9 patients with de novo allograft diabetic nephropathy, 3 died (33.3%), 2 reached end-stage renal disease (22.2%), and 4 remained stable (44.4%). Of the 17 with interstitial fibrosis/tubular atrophy, 2 died (11.7%), 5 developed end-stage renal disease (29.4%), and 10 remained stable on triple immunosuppression and insulin therapy during follow-up (58.8%).

CONCLUSIONS

De novo allograft diabetic nephropathy is a significant cause of graft and patient loss in renal allograft recipients who develop new-onset diabetes after transplant.

Microvascular damage in type 1 diabetic patients is reversed in the first year after simultaneous pancreas-kidney transplantation

Simultaneous pancreas-kidney transplantation (SPK) is an advanced treatment option for type 1 diabetes mellitus (DM) patients with microvascular disease including nephropathy. Sidestreamdarkfield (SDF) imaging has emerged as a noninvasive tool to visualize the human microcirculation. This study assessed the effect of SPK in diabetic nephropathy (DN) patients on microvascular alterations using SDF and correlated this with markers for endothelial dysfunction. Microvascular morphology was visualized using SDF of the oral mucosa in DN (n = 26) and SPK patients (n = 38), healthy controls (n = 20), DM1 patients (n = 15, DM ≥ 40 mL/min) and DN patients with a kidney transplant (KTx, n = 15). Furthermore, 21 DN patients were studied longitudinally up to 12 months after SPK. Circulating levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2) and soluble thrombomodulin (sTM) were measured using ELISA. Capillary tortuosity in the DN (1.83 ± 0.42) and DM ≥ 40 mL/min (1.55 ± 0.1) group was increased and showed reversal after SPK (1.31 ± 0.3, p < 0.001), but not after KTx (1.64 ± 0.1). sTM levels were increased in DN patients and reduced in SPK and KTx recipients (p < 0.05), while the Ang-2/Ang-1 ratio was normalized after SPK and not after KTx alone (from 0.16 ± 0.04 to 0.08 ± 0.02, p < 0.05). Interestingly, in the longitudinal study, reversal of capillary tortuosity and decrease in Ang-2/Ang-1 ratio and sTM was observed within 12 months after SPK. SPK is effective in reversing the systemic microvascular structural abnormalities in DN patients in the first year after transplantation.

Early histologic lesions and risk factors for recurrence of diabetic kidney disease after kidney transplantation

BACKGROUND

Recurrence of diabetic kidney disease (DKD) after diabetic kidney transplantation has been reported. The aim of this study was to determine the early histologic lesions, focusing especially on abnormal glomerular angiogenesis, and clinical risk factors of recurrent DKD after kidney transplantation.

METHODS

The authors studied 34 renal transplant recipients with diabetes and 30 without diabetes. All patients had undergone both baseline and posttransplant follow-up biopsies. Glomerular morphometric analyses of the mesangial area, the capillary number, and the capillary area were performed with a computer-assisted image analyzer, and glomerular basement membrane (GBM) thickness was evaluated by electron microscopy. The incidence of polar vasculosis as an angiogenic phenomenon was also evaluated. Clinical data including hemoglobin (Hb)A1c, blood pressure, urinary albumin excretion, and serum lipid profiles were compared with histologic parameters.

RESULTS

Together with the increased glomerular mesangial area and GBM thickness, the glomerular capillary number and area and the incidence of polar vasculosis were significantly higher in patients with diabetes. Most of these alterations were significantly associated with the mean posttransplant HbA1c levels but not with blood pressure or lipid profiles. In the multiple regression analysis, HbA1c level remained significantly associated with these histologic parameters.

CONCLUSIONS

Similar to mesangial expansion and GBM thickening, glomerular neovascularization represented by increased capillary number and area and glomerular polar vasculosis can occur as an early diabetic lesion in recurrent DKD. Posttransplant hyperglycemia is a significant risk factor predictive of the progression of recurrent DKD in kidney allografts.

Transplantation of the pancreas

Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.

Early pancreas graft failure is associated with inferior late clinical outcomes after simultaneous kidney-pancreas transplantation

BACKGROUND

Early pancreas graft failure after simultaneous pancreas and kidney (SPK) transplantation is common. We studied the impact of early pancreas graft failure on long-term kidney and patient survival.

METHODS

We included all primary SPK transplants performed in the United States between January 1, 2000, and December 31, 2007, who had maintained kidney graft function at 90 days posttransplantation. Kaplan-Meier and Cox multivariate analyses were performed. The causes of death between the two cohorts were compared.

RESULTS

A total of 6282 SPK recipients were included in the analyses. Of those, 470 had lost pancreas graft within the first 90 days largely related to pancreas graft thrombosis. Early pancreas graft failure was associated with lower subsequent kidney graft and patient survival (log-rank, P=0.02 and P<0.001, respectively). Multivariate regression analyses demonstrated a 70% higher risk of kidney graft failure after 3 years (adjusted hazard ratio 1.69; 95% CI 1.08, 2.66; P=0.022) and more than doubled the risk for death (adjusted hazard ratio 2.18; 95% CI 1.67, 2.85; P<0.001) among SPK recipients with early pancreas graft failure. The causes of death were similar between the two cohorts.

CONCLUSION

Early pancreas graft failure in SPK transplant recipients is associated with an increased risk for subsequent kidney failure and death. Optimization of therapeutic interventions after early pancreas graft failure is needed.

Evolution of β-Cell Replacement Therapy in Diabetes Mellitus: Pancreas Transplantation

Diabetes mellitus remains one of the leading causes of morbidity and mortality worldwide. According to the Centers for Disease Control and Prevention, approximately 23.6 million people in the United States are affected. Of these individuals, 5-10% have been diagnosed with type 1 diabetes mellitus (TIDM), an autoimmune disease. Although it often appears in childhood, T1DM may manifest at any age. The effects of T1DM can be devastating, as the disease often leads to significant secondary complications, morbidity, and decreased quality of life. Since the late 1960s, surgical treatment for diabetes mellitus has continued to evolve and has become a viable alternative to chronic insulin administration. In this review, the historical evolution, current status, graft efficacy, benefits, and complications of pancreas transplantation are explored.

Impact of glucose metabolism abnormalities on histopathological changes in kidney transplant protocol biopsies

The impact of post-transplant diabetes (PTDM) on kidney transplant histopathology has been poorly described. We examined the association of glucose metabolism abnormalities on the progression of histopathological changes in serial protocol biopsies. Helsinki University Hospital kidney transplant recipients during 2004-2006 were followed up. Patients with pre-existing diabetes or 2-h oral glucose tolerance test (OGTT) performed at 3 months, and protocol biopsies taken at 0 and 12 months were analyzed (n = 76). Diabetes was defined according to WHO/ADA. Histology was analyzed with chronic allograft damage index (CADI). Altogether 32 patients had pre-existing diabetes. In OGTT at 3 months, four showed PTDM, eight impaired glucose tolerance (IGT), two impaired fasting glucose, and 30 normal glucose tolerance. Patients with impaired glucose metabolism were older (P = 0.005), received grafts from older donors (P = 0.04), and had reduced renal function at 12 months (P = 0.003). In patients with IGT or PTDM, 2-h postload glucose values in OGTT correlated with CADI at 12 months (R = 0.84, P = 0.001) and with the change in CADI score between 0 and 12 months (R = 0.67, P = 0.025). Graft survival was reduced in patients with pre-existing diabetes (P = 0.01). Glucose abnormalities were associated with the progression of histopathological changes, especially in patients with already compromised kidneys, supporting the harmful role of PTDM to the kidney allograft.

Twelve-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation

BACKGROUND AND OBJECTIVES

Simultaneous pancreas-kidney transplantation (SPK) is regarded as the treatment of choice for type 1 diabetes (T1DM) and kidney dysfunction, despite the morbidity associated with pancreas transplantation. These morbidities often influence selection of SPK versus living-donor kidney alone (LD KA) transplant. This study quantifies the impact of pancreas graft function on outcomes following SPK.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the SRTR database, SPK wait-listed patients transplanted from 1997 to 2005 were evaluated and segregated as: (1) SPK recipients with functioning pancreas graft 12 mo posttransplant (SPK, P+); (2) SPK recipients with loss of pancreas graft function within 12 mo posttransplant (SPK, P-); (3) recipients of deceased donor (DD) KA; (4) recipients of LD KA. The study compared patient and kidney graft survival to 84 mo posttransplant.

RESULTS

Patient survival for SPK, P+ was significantly better than the LD KA; SPK, P-; and DD KA cohorts (88.6% versus 80.0%, 73.9% and 64.8%, respectively [P < 0.001]), a finding confirmed by multivariate analysis and not influenced by pancreas-after-kidney transplantation (PAK) rates and outcomes. Unadjusted graft survival was also highest in the SPK, P+ cohort (72.0% versus 63.6%, 59.8%, 49.7%, P = 0.015 versus LD KA).

CONCLUSIONS

SPK recipients with functioning pancreas grafts have superior survival compared with LD KA and DD KA, including in the setting of PAK. Early pancreas graft failure results in kidney and patient survival rates similar to KA. These data help further clarify the decision-making of SPK versus KA transplant options for patients and providers.

Pancreatico-renal composite transplant: a new technique designed to decrease pancreatic graft thrombosis

Pancreas graft thrombosis continues to be a major cause of graft loss. The removal of the donor spleen is accompanied by a significant reduction in pancreas graft blood flow. It is likely that reduced blood flow contributes to thrombosis in concert with other factors. We present a case of simultaneous pancreas and dual kidney transplantation wherein one donor kidney was anastomosed to the splenic vessels of the pancreas graft. The portal venous drainage of the pancreas graft was into the vena cava and duodenal segment was drained into the recipient's jejunum. Intraoperative blood flow determinations using an ultrasonic flow probe around the graft portal vein showed that the placement of the renal graft in the position of the donor spleen improved flow by approximately one-third (e.g. at 15 min after transplantation, 800 cc/min vs. 550 cc/min with the composite vascular pedicle clamped). The perfusion phase of a radionuclide scan on postoperative day 3 showed both transplanted kidneys had brisk and comparable visualization. The patient had an uneventful recovery and was discharged on the seventh postoperative day with normal blood glucose values and a serum creatinine of 1.2 mg/mL. A pancreatico-renal composite graft may decrease the incidence of thrombosis by improving pancreatic graft blood flow.

Pancreas transplantation: indications and consequences

Pancreas transplantation continues to evolve as a strategy in the management of diabetes mellitus. The first combined pancreas-kidney transplant was reported in 1967, but pancreas transplant now represents a number of procedures, each with different indications, risks, benefits, and outcomes. This review will summarize these procedures, including their risks and outcomes in comparison to kidney transplantation alone, and how or if they affect the consequences of diabetes: hyperglycemia, hypoglycemia, and microvascular and macrovascular complications. In addition, the new risks introduced by immunosuppression will be reviewed, including infections, cancer, osteoporosis, reproductive function, and the impact of immunosuppression medications on blood pressure, lipids, and glucose tolerance. It is imperative that an endocrinologist remain involved in the care of the pancreas transplant recipient, even when glucose is normal, because of the myriad of issues encountered post transplant, including ongoing management of diabetic complications, prevention of bone loss, and screening for failure of the pancreas graft with reinstitution of treatment when indicated. Although long-term patient and graft survival have improved greatly after pancreas transplant, a multidisciplinary team is needed to maximize long-term quality, as well as quantity, of life for the pancreas transplant recipient.

Allograft diabetic nephropathy may progress to end-stage renal disease

Mesangial expansion and glomerular basement membrane thickening characteristic of diabetic nephropathy recur in diabetic recipients of renal allografts from non-diabetic donors but progression to renal failure is minimally documented. Three female renal allograft recipients (aged 40, 62 and 73 yr), who developed end-stage renal disease (ESRD) due to recurrent diabetic nephropathy (two patients) and de novo diabetes (one patient) are reported. Onset of proteinuria, uncontrolled hypertension, azotemia, renal allograft pathologic findings and the need for hemodialysis were analyzed. None of the kidney donors (one cadaver, two living related) had known diabetes or perturbed glucose metabolism pre-transplantation. The three patients presented had different varieties of diabetes; type 1, type 2 and new onset diabetes after transplantation (NODAT). In each subject, proteinuria was detected by dipstick at a mean of 8.3 yr (range 8-9) post-transplantation and increased to the nephrotic range (3.7-4.8 g/day) inducing hypoalbuminemia and azotemia. A histopathologic diagnosis of allograft diabetic nephropathy was made in a mean of 11.7 yr (range 10-14), based on glomerular basement membrane thickening, nodular and diffuse intercapillary glomerulosclerosis, arteriolosclerosis, and tubular atrophy with marked tubular basement membrane thickening characteristic of advanced diabetic nephropathy. All three patients manifested uremia and resumed hemodialysis. Two patients died from sepsis within 2 months and one patient died 2.5 yr later after resumption of maintenance hemodialysis. We infer that recurrent or de novo diabetic nephropathy in renal allografts follows a clinical decade-long course irrespective of diabetes. Reports of ESRD due to allograft diabetic nephropathy (ADN) have been limited because of shorter survival of diabetic transplant recipients and few kidney biopsies performed in patients with chronic allograft dysfunction. The occurrence of allograft diabetic nephropathy in some, but not all patients, however, suggests that individual genetic variability modulates disease expression.

[Pancreatic transplantation: 1. Indications and results]

In the face of a rising incidence of diabetes, pancreatic transplantation seems to be the only treatment capable of normalizing glycosylated hemoglobin and stabilizing or improving the complications of diabetes. To date, more than 19,000 pancreatic transplantations have been done worldwide. Surgical indications must take into account the constraints and risks specific to the diabetic illness, the risks of a complex surgical procedure, and the absolute necessity for long term immunosuppression. Combined kidney/pancreas transplantation is the most common procedure (90% of cases) and is the most effective treatment for renal insufficiency due to diabetes. Results have improved significantly over the last ten Years due to improvements in the surgical technique and to improvement of immunosuppressive regimens. Results are at least as good and perhaps better than those achieved in the transplantation of other solid organs; patient survival, renal graft survival, and pancreatic graft survival are respectively 95%, 92%, and 85% at one Year. Results of pancreatic transplantation alone have improved and now seem equal to those of combined organ transplantation. Transplantation seems to be cost-effective in the overall care of advanced diabetes, particularly in those patients on chronic dialysis or having degenerative complications.

Effect of ethnicity on outcome of simultaneous pancreas and kidney transplantation

The influence of ethnicity on outcome of simultaneous pancreas-kidney transplantation (SPK) is poorly defined. After excluding technical failures, we retrospectively reviewed 96 consecutive SPKs (63 Caucasians [C], 33 African-Americans [AA]). All patients received antibody induction, tacrolimus, mycophenolate mofetil, and steroids. One-, 3-, and 5-year actuarial patient survival was similar between C (98%, 95%, 87%) and AA (90%, 90%, 81%), p=NS. One-, 3-, and 5-year kidney graft survival was similar between C (98%, 86%, 81%) and AA (85%, 85%, 78%), p =NS. One-, 3-, and 5-year pancreas graft survival was significantly worse in AA (71%, 68%, 46%) than in C (90%, 85%, 81%), p = 0.008. The cumulative incidence of kidney and pancreas acute rejection (AR) was higher in AA compared with C. Distribution of kidney and pancreas rejection grade was similar between C and AA. AA experienced more pancreas graft losses from early death with functioning graft, AR, and late chronic rejection. The higher incidence of AR and resistance to currently employed induction, maintenance, and antirejection immunosuppression therapies in AA may account for their inferior pancreas graft survival. More aggressive immunosuppression strategies may improve pancreas graft survival in AA but may be associated with increased morbidity and mortality. Further study is warranted.

Reversibility of established diabetic glomerulopathy by anti-TGF-beta antibodies in db/db mice

Treatment with a neutralizing anti-transforming growth factor-beta (TGF-beta) antibody can prevent the development of diabetic nephropathy in the db/db mouse, a model of type 2 diabetes. However, it is unknown whether anti-TGF-beta therapy can reverse the histological lesions of diabetic glomerulopathy once they are established. Diabetic db/db mice and their non-diabetic db/m littermates were allowed to grow until 16 weeks of age, by which time the db/db mice had developed glomerular basement membrane (GBM) thickening and mesangial matrix expansion. The mice were then treated with an irrelevant control IgG or a panselective, neutralizing anti-TGF-beta antibody for eight more weeks. Compared with control db/m mice, the db/db mice treated with IgG had developed increased GBM width (16.64+/-0.80 nm vs. 21.55+/-0.78 nm, P<0.05) and increased mesangial matrix fraction (4.01+/-0.81% of total glomerular area vs. 9.55+/-1.04%, P<0.05). However, the db/db mice treated with anti-TGF-beta antibody showed amelioration of GBM thickening (18.40+/-0.72 nm, P<0.05 vs. db/db-IgG) and mesangial matrix accumulation (6.32+/-1.79%, P<0.05 vs. db/db-IgG). Our results demonstrate that inhibiting renal TGF-beta activity can partially reverse the GBM thickening and mesangial matrix expansion in this mouse model of type 2 diabetes. Anti-TGF-beta regimens would be useful in the treatment of diabetic nephropathy.

Pancreas and kidney transplantation

Kidney transplantation is preferred over dialysis for management of end-stage renal disease complicating type I or type 2 diabetes, for those who are eligible. Simultaneous pancreas-kidney (SPK) or pancreas after kidney transplantation (PAK) is an important alternative to kidney transplantation alone for type I diabetes patients if the patient is able to withstand the additional risks of these procedures, because of the benefits of glucose control on other diabetic complications. Pancreas transplantation alone (PTA) is most useful for the treatment of debilitating, frequent hypoglycemia complicating type I diabetes, if renal function is adequate. One-year pancreas graft survival is best after SPK (82%) but has significantly improved after both PAK (74%) and PTA (76%). The I-year kidney graft and patient survival rates after SPK are similar to kidney transplantation alone. Pancreas transplantation normalizes glucose beyond what can be achieved with insulin therapy and has been shown to decrease progression of or improve most, if not all, diabetic end-organ complications using current immunosuppression regimens. However, the diabetologist and endocrinologist should remain involved in the care of the pancreas or kidney transplant recipient for treatment of vascular disease risk factors such as dyslipidemia, surveillance of other diabetic complications including foot ulcers, surveillance and treatment of bone loss, and management of hyperglycemia if it recurs.

Trends and perspectives in pancreas and simultaneous pancreas and kidney transplantation

Pancreas transplantation is still the best option to achieve normoglycaemia and insulin independence in patients with type I diabetes. As a result of improvements in surgical techniques, immunosuppression and patient selection, one year survival rates of 95, 83, and 88% for patient, pancreas, and kidney survival, respectively, are reported for patients with simultaneous pancreas and kidney transplantation. The main goals for the future are to reduce postoperative morbidity, to identify the relevant indications for single pancreas transplantation, to adopt the best surgical technique for individual patients' needs (bladder versus enteric drainage with or without portal venous delivery of insulin), and to develop immunosuppressive strategies with low nephrotoxic and diabetogenic potential.

Hospital charges following simultaneous kidney--pancreas transplantation: enteric drainage versus bladder drainage

BACKGROUND

Enteric drainage (ED) is associated with reduced morbidity compared with bladder drainage (BD) after simultaneous kidney-pancreas transplantation (SKPT) and is becoming increasingly common (more than 50% of SKPTs done in the US in 1998 were performed with enteric drainage). Although several studies have reported the morbidity and graft survival of ED compared with BD previously, there are limited data available comparing the length of stay and hospital charges between these two drainage procedures.

METHODS

Fourteen SKPTs were performed during the period January 1995 May 1998 using BD and 20 during June 1998-August 1999 using ED. Hospital charges analyzed included the following categories: pharmacy, inpatient room, laboratory, operating room, medical surgical supply, radiology/nuclear medicine, and miscellaneous. Organ acquisition charges and professional fees were not included in this analysis.

RESULTS

The mean hospital stay for patients with ED was 7.8+/-2.2 d (range 5-12 d; median 7.5 d) compared with 15.9+/-7 d (range 8-38 d; median 15 d) for patients with BD (p = 0.002). The mean hospital charges during initial hospitalization for the ED group were $36 582+/-11 424 compared with $64 555+/-29 054 for the BD group (p = 0.005). There was a significant decrease in the charges relating to pharmacy, inpatient room, laboratory, radiology/nuclear medicine, and miscellaneous category in the ED group compared with the BD group, while the charges relating to operating room and medical-surgical supply were no different between the two groups. One-year actuarial kidney and pancreas graft survival rates were 83% and 93%, respectively, for the BD group and 90% and 80%, respectively, for the ED group (p = NS).

CONCLUSIONS

SKPT patients with ED had a 43% reduction in hospital charges and equivalent pancreas and kidney graft survival rates compared with SKPT patients with BD. A shorter hospital stay and a reduction in pharmacy, radiology/nuclear medicine, and laboratory charges contributed to the decreased hospital charges in SKPT patients with ED.

Simultaneous pancreas-kidney transplantation and living related donor renal transplantation in patients with diabetes: is there a difference in survival?

OBJECTIVE

To compare the outcome of simultaneous pancreas-kidney transplantation (SPK) and living related donor renal transplantation (LRD) in patients with diabetes.

SUMMARY BACKGROUND DATA

It remains unanswered whether diabetic patients with end-stage renal failure are better served by LRD or SPK.

METHODS

Using a longitudinal database, data from all diabetic patients receiving LRD or cadaveric renal transplants or SPKs from January 1986 through January 1996 were analyzed. Patient and graft survival, early graft function, and the cause of patient and graft loss were compared for 43 HLA-identical LRDs, 87 haplotype-identical LRDs, 379 SPKs, and 296 cadaveric renal transplants.

RESULTS

The demographic composition of the SPK and LRD groups were similar, but because of less strict selection criteria in the cadaveric transplant group, patients were 10 years older, more patients received dialysis, and patients had been receiving dialysis longer before transplantation. Patient survival was similar for the SPK and LRD groups but was significantly lower for the cadaveric renal transplant group. Similarly, there was no difference in graft survival between SPK and LRD recipients, but it was significantly lower for recipients in the cadaveric renal transplant group. Delayed graft function was significantly more common in the cadaveric renal transplant group. Discharge creatinine, the strongest predictor of patient and graft survival, was highest in the SPK group and lowest in the HLA-identical LRD group. The rate of rejection within the first year was greatest in SPK patients (77%), intermediate in the haplotype-identical LRD and cadaveric transplant groups (57% and 48%, respectively), and lowest (16%) in the HLA-identical LRD group. Cardiovascular disease was the primary cause of death for all groups. Acute rejection, chronic rejection, and death with a functioning graft were the predominant causes of graft loss.

CONCLUSIONS

This study demonstrates that there was no difference in patient or graft survival in diabetic patients receiving LRD or SPK transplants. However, graft and patient survival rates in diabetic recipients of cadaveric renal transplants were significantly lower than in the other groups.

Surgical complications after pancreas transplantation with portal-enteric drainage

BACKGROUND

Despite recent advances, surgical complications remain an important source of morbidity after pancreas transplantation (PTX). Several previous studies have delineated the surgical complications after PTX with systemic-bladder (S-B) drainage, but data are limited regarding the incidence and outcomes of surgical complications after PTX with portal-enteric (P-E) drainage.

STUDY DESIGN

We retrospectively studied surgical complications after 83 vascularized PTXs with P-E drainage in 79 patients (65 simultaneous kidney-PTXs [SKPT] and 18 solitary PTXs [SPT], 8 pancreas alone and 10 pancreas after kidney transplantation). Twelve (15%) were retransplants. A surgical complication was defined as the need for repeat laparotomy within the first 3 months after PTX.

RESULTS

A total of 53 surgical complications requiring repeat laparotomy occurred in 31 patients (37%). The incidence of surgical complications in SKPT and SPT was 38% and 33%, respectively. The most common indications for repeat laparotomy were: vascular thrombosis in 13% (SKPT 14% and SPT 11%), intraabdominal infection in 10% (SKPT 12% and SPT 0%), intraabdominal bleeding in 8% (SKPT 8% and SPT 11%), and duodenal allograft leak in 4% (SKPT 3% and SPT 6%). Patient survival rates at 1 and 3 years with versus without surgical complications were 84% and 80% versus 94% and 86%, respectively (p = NS). Pancreas graft survival rates at 1 and 3 years with versus without surgical complications were 48% and 44% versus 89% and 76%, respectively (p < 0.0001). The incidence of surgical complications was 45% in the first 42 P-E transplantations performed between 1990 and 1995, compared with 29% in the next 41 transplantations performed during 1996 and 1997 (p = NS). The mean number of repeat laparotomies per patient decreased from 1.2 in the former group to 0.5 in the latter group (p = NS). The incidence rates of vascular thrombosis, intraabdominal infection, and duodenal leak in the former and latter groups were 17% versus 10%, 12% versus 7%, and 2% versus 5%, respectively.

CONCLUSIONS

Surgical complications after PTX are common, and their incidence and outcomes with P-E drainage are similar to those with S-B drainage. The complication rate does not vary according to the type of transplant (SKPT versus SPT). Increasing experience with P-E drainage results in a decreased incidence of surgical complications.

Successful obstetric outcome after simultaneous pancreas and kidney transplantation

A 34-year-old woman became pregnant two years after having a simultaneous pancreas and kidney (SPK) transplantation, necessitated by type 1 diabetes and end-stage renal disease. The pregnancy was uneventful until 30 weeks' gestation, when she developed pancreatitis and a worsening of mild hypertension. A healthy 1700 g boy was delivered by caesarean section at 34 weeks' gestation. This is the first report of a successful pregnancy after SPK transplantation in Australia.

Strategies to expand the donor pool for pancreas transplantation

BACKGROUND

Our organ procurement organization has been forced to liberalize the donor criteria in order to expand the donor pool for pancreas transplantation. In this report, we describe our experience using whole organ pancreatic grafts from "marginal" donors, which include grafts obtained from donors over 45 years of age and from donors who were identified to be hemodynamically unstable at the time of organ retrieval.

METHODS

A prospective study was performed between July 1994 and March 1998, during which time 137 pancreas transplants were performed at our center using organs procured by our own surgeons (organs sent by other teams were excluded). The rapid en bloc technique was used exclusively. The use of pancreatic grafts from marginal donors was analyzed for short-term and overall graft survival, and for delayed graft function and complications.

RESULTS

Overall pancreas graft survival for our series was 83%, with a mean follow-up of 23 months. There were 22 pancreas grafts from donors over 45 years of age, 13 of whom were greater than 50 years of age. The actual graft survival rate of the over-45 donor group was 86%. Fifty-one grafts were removed from hemodynamically unstable donors on high-dose vasopressors. The actual graft survival in this group was 86%. There was no significant difference found in graft survival between recipients of pancreatic grafts from marginal and nonmarginal donors. Delayed graft function was exhibited by more recipients of grafts from donors on high-dose vasopressors (P<0.05), but this had no effect on long-term graft survival and endocrine function. Recipients of marginal donor grafts did not have higher rates of complication compared to recipients of nonmarginal grafts.

CONCLUSIONS

Based on our results, we currently employ a graft selection strategy not limited by donor age or hemodynamic stability. Our selection of pancreas organs for transplantation is based on careful inspection of the pancreas and determination of the adequacy of the ex vivo flush. Our results suggest that the current pancreas donor pool may be expanded substantially.

Contribution of native kidney function to total glomerular filtration rate after combined kidney-pancreas transplantation

BACKGROUND

Combined kidney-pancreas transplantation (CKPT) with its associated euglycemia has been shown to prevent or reduce recurrent diabetic nephropathy in the renal allograft. There has been no evaluation of residual native kidney function after CKPT. The purpose of this study was to determine whether native kidney function may be present in diabetic recipients years after CKPT.

METHODS

Between 1986 and 1992, 37 patients with type 1 insulin-dependent diabetes mellitus with renal failure underwent CKPT. In each case, a single native nephrectomy was performed. We studied 16 patients who had continuing renal and pancreas function more than 4 years after CKPT. Fourteen diabetics with a functioning renal allograft but no pancreas function were used as a control group. Simultaneous renal scans (technetium-99m diethylenetriamine pentaacetic acid) of the native and transplanted kidneys were obtained with a dual-head scintillation camera. Total glomerular filtration rate (GFR) was determined from the rate of clearance of the tracer from the extracellular space measured for 2 hr with an ambulatory renal monitor.

RESULTS

The study groups had similar pretransplant characteristics. At the time of the study, the mean serum creatinine level was not significantly different in the CKPT and control groups (1.7+/-0.7 vs. 1.5+/-0.3 mg/dl, respectively). In the CKPT and control groups, total GFRs were 70.1+/-33 vs. 72.1+/-16.5 ml/min (NS), allograft GFRs were 63+/-34.2 vs. 70.4+/-16 ml/min (NS), and native kidney GFRs were 7.1+/-7.2 vs. 1.7+/-1.9 ml/min (P < 0.05), respectively. In both groups, there was a significant correlation between total GFR and allograft GFR (P < 0.001), but not between total GFR and native kidney GFR. Significant single native kidney GFR (more than 8 ml/min) was found in 7/16 (44%) patients in the CKPT group, but in none of the controls.

CONCLUSIONS

These results suggest that residual native kidney function can be present and contribute moderately to total GFR after CKPT. Euglycemia after CKPT may have a protective role in native kidneys.

Long-term effects of pancreatic transplantation on diabetic neuropathy

Restoration of a long-lasting euglycemic state by a functioning pancreatic transplantation (PTx) is the most logical treatment for insulin-dependent diabetes mellitus and for amelioration of secondary complications, including neuropathy. We evaluated neurological function by clinical examination, nerve conduction studies, and autonomic function tests in 115 patients with a functioning PTx and in 92 control patients treated with insulin, at baseline and 1, 2, 3.5, 5, 7, and 10 years later. In control patients, neuropathy progressively worsened during follow-up. The clinical examination score and composite indices of abnormality of motor and sensory nerve conduction decreased significantly at all intervals tested. Autonomic function indices also decreased, but significantly only after 1 year. In patients who received a successful PTx the neuropathy improved. The motor and sensory nerve conduction indices increased significantly at all intervals after transplantation, whereas the clinical examination and autonomic tests improved only slightly. Patients who received either a PTx alone, a PTx after a kidney graft, or simultaneous pancreatic and kidney transplantations improved similarly over the follow-up. These results indicate that a functioning PTx halts the progression and improves the signs of diabetic polyneuropathy by restoration of a normoglycemic state.

Long-term duct-occluded segmental pancreatic autografts: absence of microvascular diabetic complications

BACKGROUND

Current insulin therapies for control of glucose metabolism in patients with type I diabetes mellitus prevent major metabolic consequences of insulin deficiency, but none prevents or arrests long-term complications. In experimental models of canine diabetes, retinopathy, neuropathy, and nephropathy have been shown to develop within 5 years. The aim of this study was to determine in a canine model whether glucose control provided by segmental duct-occluded pancreas autografts could prevent the long-term complications of diabetes.

METHODS

Thirty-five outbred mongrel dogs underwent segmental pancreas autotransplantation with residual pancreatectomy. Follow-up over 5 years included endocrine, retinal fundus photography, fluorescein angiography, and nerve conduction studies. At endpoint, analysis of organ specific changes was undertaken.

RESULTS

Long-term survival was achieved in 14 dogs for 4 to 5 years and in 3 dogs for 3 to 5 years. Glycosylated hemoglobin levels remained within normal limits, although response to glucose challenge was suboptimal. Fundus photography and fluorescein angiography demonstrated the absence of retinal vascular aneurisms, capillary leakage, and obliteration. Retinal digest showed no vascular changes and normal endothelial/pericyte ratios. Nerve conduction was normal, and histology of nerves revealed normal density of myelinated fibers and absence of intrafascicular vessels and glycogen deposits, with no change in spectrum of fiber diameters and ovoids. Renal histology revealed no evidence of nephropathy with normal glomerular basement membranes.

CONCLUSIONS

We have demonstrated that duct-occluded segmental pancreatic autografts are capable of providing satisfactory metabolic control for up to 5 years, thereby preventing development of the long-term microvascular complications of diabetes.