Abstract
Recent progress in surgery and immunosuppression has expanded the “transplant menu” for patients with diabetic nephropathy which is now including: Kidney Transplantation from a Deceased Donor (DDKT) or a Living Donor (LDKT), Simultaneous Pancreas Kidney (SPK), Pancreas Transplantation Alone (PTA), Pancreas after Kidney (PAK) and Islet transplantation. As pre-emptive transplantation presents a clear survival advantage over dialysis, all diabetic patients with chronic kidney disease (CKD) should be referred for early evaluation by a transplant center. For type 1 diabetes mellitus (T1DM) patients, LDKT and SPK transplantation offer superior and approximately equivalent long-term patient and allograft survival. PAK transplant rates tend to decline due to surgical and immunological complications, but it may still be considered for well selected candidates with preserved kidney allograft function. For type 2 diabetes mellitus (T2DM) patients, not only LDKT, but even DDKT are superior to dialysis. SPK transplantation should be offered only in selected cases with special metabolic characteristics similar to T1DM. PTA should be considered only for selected cases of T1DM with well preserved renal function (eGFR>80 ml/min/1.73 m2 and minimal proteinuria), as it may a cause of rapid deterioration of renal function. Islet transplantation should still be considered as an experimental procedure for T1DM, and has no place in patients with advanced CKD, but it may be applied in already immunosuppressed patients following KT. However, the best transplant option for patients with diabetic nephropathy therapy should always be individualized, taking under consideration the patients’ preferences and expectations, their overall medical condition and the transplant center’s experience with all these procedures.
Highlights
Diabetes Mellitus (DM) is a worldwide epidemic and the leading cause of Chronic Kidney Disease (CKD), blindness, stroke, heart attack and amputations [1,2]
For type 2 diabetes mellitus (T2DM) patients, LDKT, but even DDKT are superior to dialysis
Islet transplantation should still be considered as an experimental procedure for type 1 diabetes mellitus (T1DM), and has no place in patients with advanced CKD, but it may be applied in already immunosuppressed patients following Kidney Transplantation (KT)
Summary
Diabetes Mellitus (DM) is a worldwide epidemic and the leading cause of Chronic Kidney Disease (CKD), blindness, stroke, heart attack and amputations [1,2]. The diabetic patient has more options (pancreas transplantation, kidney transplantation, islet transplantation), but has to undergo a major operation (solid organ transplantation) and to be long-life immunosuppressed with all the possible consequences. As pancreas or islets transplantation is not a life-saving procedure and there are no clear indications, the patients with diabetes and the physicians may become confused about optimal solutions for diabetic nephropathy (Table 1). PTA: Pancreas Transplantation Alone; KT: Kidney Transplantation; SPK: Simultaneous Pancreas Kidney; PAK: Pancreas After Kidney; IT: Islet transplantation for patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) (CKD: Chronic Kidney Disease). IT refers to the transplantation of isolated pancreatic islets, which have been harvested from one or more deceased donors It may be combined ( rare) with every type of kidney transplantation. We will try to provide essential information for physicians not involved in transplantation medicine, enlighten the grey zones and review in an unbiased way the contemporary data about transplant options for patients with diabetic nephropathy making clear separations between patients with T1DM and T2DM and patients with early and advanced CKD
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