Comparison of glycemic control after pancreas transplantation for Type 1 and Type 2 diabetic recipients at a high volume center

Abstract

Introduction:The number of pancreas transplants (PTX) in patients with Type 2 diabetes (T2DM) has increased in response to excellent outcomes in appropriately selected patients.Not all pancreas transplant centers share an enthusiasm for performing PTX for T2DM out of concern for increased complication rates. This study aims to clarify the characteristics of T2DM recipients with successful outcomes to clarify which candidates are more suitable for PTX as means of maximizing access to this highly effective therapy for Type 2 patients. Methods & Results: At MedStar Georgetown Transplant Institute, 50 patients underwent pancreas transplant between 2013 and 2016. Based on patient characteristics, 38(78%) were categorized as T1DM, and 11 (22%) were considered T2DM. One case was excluded due to early graft loss. The estimated age of diabetes onset was significantly different between T1DM and T2DM cohorts (13 years vs. 29 years, P < .001). T2DM patients had significantly higher preoperative C-peptide levels (4.11 vs. 0.05, P < .001).Preoperative HbA1c, preoperative Body Mass Index (BMI), number of diabetic complications, and hemodialysis status were similar between both groups. At 2-year follow-up, there was no statistical difference in glycemic control between the two groups (T1DM vs. T2DM). Infectious complications and readmission rates were similar. Other trends that did not meet statistical significance included T1DM group with a slightly higher mortality and re-intervention rate. The T2DM group demonstrated higher BMI, higher rejection rates, and higher short-term postoperative insulin requirements. Graft survival was 95% and 82% for T1 and T2DM at 2 years post-transplant, respectively.Conclusion: Successful PTX in T1DM and T2DM recipient groups resulted in comparable glycemic control at 2-year post-transplant follow-up. T2DM group had a trend toward higher BMI as well as higher rates of rejection, temporary insulin requirement and graft failure, although none of these trends reached statistical significance.These results suggest that strict classification of T1 and T2DM by itself may not be relevant to achieving excellent outcomes in pancreas transplantation and, therefore, patient selection for PTX should not be based primarily on this classification.

Single center results of simultaneous pancreas-kidney transplantation in patients with type 2 diabetes

“…Our study also suggests that posttransplant glycemic control, in terms of fasting glucose and HbA1c, was comparable between T1D and T2D patients. However, consistent with Andacoglu et al, 21 at the end of 3 years, we found that BMI was significantly higher in T2D compared to T1D recipients. Our study was consistent with Hau et al 16 in finding a higher fasting C‐peptide in T2D compared to T1D recipients, though the differences did not reach statistical significance.…”

“…Consistent with other studies, 16,20,21,35 our study showed that pancreas transplantation was able to sustain normal blood glucose and HbA1c for at least 3 years in T2D recipients. Our study also suggests that posttransplant glycemic control, in terms of fasting glucose and HbA1c, was comparable between T1D and T2D patients.…”

“…Comparing results of pancreas transplantation between selected patients with T1D and T2D, most subsequent studies found similar outcomes 13,15‐20 . This cluster of studies evaluated varied endpoints such as risk of death, 13 kidney graft survival and pancreas graft survival, 15‐19 posttransplant glycemia and BMI control, 18,21 insulin resistance or β‐cell function, 20 and patient survival 10,16,22 finding comparable results regardless of whether the patient was categorized as T1D or T2D. In the majority of these studies, only clinical impression was used to categorize patients into one group or another.…”

Preoperative C-Peptide Predicts Weight Gain After Pancreas Transplantation

“…The presence of elevated C-peptide alone should not preclude the consideration for pancreas transplant, as these recipients have been shown to have equivalent outcomes when appropriate selection criteria are applied. 8,10,11,30 Pretransplant obesity has been shown to predict higher rates of patient and graft survival regardless of diabetic type. 10,22,23,30 Patients who develop obesity after transplant are likely susceptible to these risks and thus every effort should be made to mitigate weight gain.…”

“…In these carefully selected recipients, pancreas graft and patient survival approaches requisite benchmarks. 4,5,8,9 Analysis of the Organ Procurment Transplant Network/ United Network for Organ Sharging (OPTN/UNOS) database comparing pancreas transplants in insulinopenic or type 2 diabetic recipients demonstrated no difference in patient or graft survival in carefully selected patients. 2,10,11 Furthermore, the Scientific Registry of Transplant Recipients database analysis showed that combined pancreas and kidney transplantation afforded better survival compared to kidney transplant alone in type 2 diabetes, but univariate analysis identify donor and recipient age (and not the pancreas graft) as imparting survival advantage.…”