Dialysis, Kidney Transplantation, or Pancreas Transplantation for Patients with Diabetes Mellitus and Renal Failure

Abstract

Abstract. Patients with type 1 diabetes mellitus and end-stage renal disease may remain on dialysis or undergo cadaveric kidney transplantation, living kidney transplantation, sequential pancreas after living kidney transplantation, or simultaneous pancreas-kidney transplantation. It is unclear which of these options is most effective. The objective of this study was to determine the optimal treatment strategy for type 1 diabetic patients with renal failure using a decision analytic Markov model. Input data were obtained from the published medical literature, the United Network for Organ Sharing registry, and patient interviews. The outcome measures were life expectancy (in life-years [LY]) and qualityadjusted life expectancy (in quality-adjusted life-years [QALY] The results were sensitive to the value of several key variables. Simultaneous pancreas-kidney transplantation had the greatest life expectancy and quality-adjusted life expectancy when living kidney transplantation was excluded from the analysis. These data indicate that living kidney transplantation is associated with the greatest life expectancy and quality-adjusted life expectancy for type 1 diabetic patients with renal failure. Treatment strategies involving pancreas transplantation should be considered for patients with frequent metabolic complications of diabetes and for those patients who favor kidney-pancreas transplantation over kidney transplantation alone. For patients without a living donor, simultaneous pancreas-kidney transplantation is associated with the greatest life expectancy.

Improved patient survival with simultaneous pancreas and kidney transplantation in recipients with diabetic end-stage renal disease

“…It is not a novel discovery that SPK recipients have improved survival compared with DDK recipients [4,[11][12][13][14][15][16][17]. There has, however, been a selection bias towards healthier and younger recipients receiving an SPK transplant rather than a DDK transplant alone.…”

“…Thus, the selection bias between SPK and LDK recipients may be less pronounced than in most other published studies, and the metabolic effects of a functioning pancreatic transplant may therefore more accurately reflect the differences in long-term outcomes. Several previous studies have compared patient and graft survival in diabetic patients receiving an SPK or kidney transplant alone (KTA), with somewhat conflicting results [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. However, two recent major publications have presented long-term results in favour of better outcomes with SPK transplantation [16,22].…”

Which Renal Transplant Candidates Should Accept Marginal Kidneys in Exchange for a Shorter Waiting Time on Dialysis?

“…These estimates incorporated the applicable death rate on dialysis and posttransplantation as a function of the donor type. We also examined the impact of organ quality and waiting time in patient subsets of patients with diabetes and black patients, who have significant variations in prognosis on dialysis (19,20). We constructed a multivariate logistic model for the response variable of listing for expanded donors as indicated in the database.…”

Pancreas Versus Islets After a Successful Kidney Transplant

“…SPK transplantation provides a logical and practical solution that resolves both renal failure and diabetes in a single combined operation, improving renal transplant half-life, reducing mortality, improving overall quality of life and significantly reducing healthcare costs [83,84].…”