Beneficial effects of posttransplant dipeptidyl peptidase-4 inhibitor administration after pancreas transplantation to improve β cell function

Exploring the Impact of Diabetes on Kidney Transplant: Patient Outcomes and Management Strategies

Diabetic kidney disease (DKD) is a serious consequence of diabetes mellitus (DM). If not managed effectively, DKD often develops into end-stage renal disease (ESRD). The most successful treatment for ESRD is kidney transplantation, offering improved quality of life and survival rates. For insulin-dependent diabetic patients with ESRD, simultaneous pancreas-kidney transplantation (SPKT) offers a treatment alternative that treats both kidney failure and the underlying diabetes. However, SPKT involves more complicated surgery, prolonged operative time, and a higher risk of complications. This review aims to highlight the impact of DM on kidney transplant recipients (KTRs) regarding post-transplant complications, graft survival, mortality rates, and the role of glucose-lowering medications and immunosuppressants. The incidence of urinary tract infections, cardiovascular complications, and diabetic foot disease was higher among KTRs. A decrease in graft survival rate at five years was observed among diabetics compared to non-diabetics, with similar graft survival rates among type 1 and type 2 DM. The mortality rate was notably higher among diabetic patients, with cardiovascular complications being the leading cause. The emergence of new-onset diabetes mellitus post-transplantation (NODAT) is a significant cause of concern. Certain risk factors, including a family history of DM, age >45 years, obesity, male gender, and immunosuppressive medications, have been linked to this phenomenon. Immunosuppression is a substantial challenge among diabetics as certain medications such as tacrolimus have shown to be considerably diabetogenic compared to cyclosporine and belatacept, and it is also postulated that corticosteroids can lead to hyperglycemia. Some studies proved that glucose-lowering medications, including insulin degludec, glucagon-like peptide-1 receptor agonists, thiazolidinediones, and sodium-glucose cotransporter 2 inhibitors, are safe and effective among KTRs. However, these studies are debatable and of low confidence. Hence, it is imperative to conduct large clinical trials and establish definitive guidelines to manage pre-existing diabetes and NODAT among KTRs with multidisciplinary care to help clinicians improve patient outcomes.

Management of Failing Kidney and Pancreas Transplantations

Survival rates for allografts have improved over the last 2 decades, yet failing allografts remains a challenge in the field of transplant. The risks of mortality and morbidity associated with failed allografts are compounded by infectious complications and metabolic abnormalities, emphasizing the need for a standardized approach to management. Management of failing allografts lacks consensus, highlighting the need for unified protocols to guide treatment protocols and minimize risks with postdialysis initiation. The decision to wean off immunosuppression depends on various factors, including living donor availability and infectious risks, necessitating improved coordination of care and a standard guideline. Treatment of failed pancreas focuses on glycemic control, with insulin as the mainstay, while considering surgical interventions such as graft pancreatectomy in advanced symptomatic cases. Navigating the complexities of failed allograft management demands a multidisciplinary approach and standardized stepwise protocol. Addressing the gaps in management plans for failing allografts and employing a systematic approach to transplant decisions will enhance patient outcomes and facilitate informed decision-making.

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.