Long-term effects of pancreas transplant alone on nephropathy in type 1 diabetic patients with optimal renal function

Abstract

BackgroundLimited data are available regarding optimal selection criteria for pancreas transplant alone (PTA) to minimize aggravation of diabetic nephropathy.MethodsA total of 87 type 1 diabetic patients were evaluated before and after PTA at a single center from January, 1999 to December, 2015, together with 87 matched non-transplanted type 1 diabetic subjects who were candidates for PTA to compare deterioration of native kidney function. A total of 163 patients (79 in the transplanted group and 84 in the nontransplanted group) were finally enrolled after excluding nine patients with estimated glomerular filtration rate less than 60 mL/min/1.73 m2 and two patients with moderate proteinuria (≥ 1.5 g/day).ResultsA total of seven recipients (8.9%) had end-stage renal disease post-transplant whereas only one patient (1.2%) developed end-stage renal disease in the nontransplanted group during their follow-up period (median 12.0, range 6–96 months) (p = 0.03). Furthermore, a composite of severe renal dysfunction and end-stage renal disease (31.6% vs 2.4%) was significantly higher in the transplanted group (p < 0.001). Multivariate Cox regression analysis revealed that a higher level of tacrolimus at six months post-transplant (HR = 1.648, CI = 1.140–2.385, p = 0.008) was the only significant factor associated with end-stage renal disease.ConclusionsThere is a considerable risk for deterioration of renal function in PTA recipients post-transplant compared with non-transplant diabetic patients. With rather strict selection criteria such as preoperative proteinuria and estimated glomerular filtration rate, PTA should be considered in diabetic patients to minimize post-transplant aggravation of diabetic nephropathy.

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

“…Despite few studies have addressed this issue, this recipient population does not seem to be exposed to an undue risk of renal failure after PTA. 161 , 162 , 163 , 164 The same recommendation was released for patients with the same level of renal function and nephrotic syndrome. However, this recommendation could not be graded as it was supported only by anecdotal cases.…”

“…In patients with normal (eGFR ≥ 90 ml/min/1.73 m 2 ) or mildly decreased (eGFR 60–89 ml/min/1.73 m 2 ) renal function and proteinuria (without nephrotic syndrome), experts recommended that the benefits of insulin independence should be balanced against the potential risk of worsening of nephropathy. Despite few studies have addressed this issue, this recipient population does not seem to be exposed to an undue risk of renal failure after PTA 161–164 . The same recommendation was released for patients with the same level of renal function and nephrotic syndrome.…”

Pancreas Retransplant After Pancreas Graft Failure in Simultaneous Pancreas-kidney Transplants Is Associated With Better Kidney Graft Survival

“…15-17 In addition, there are several studies showing that the progressive deterioration of renal function in pancreas transplant alone recipients is mainly related to immunosuppressive medications. 18-21 Although SPK is a very favorable option for diabetic end-stage renal disease patients, pancreas after kidney transplants are also an attractive option for type 1 diabetic patients who have previously undergone kidney transplantation. 1,22 Kidney graft survival is higher in pancreas after kidney transplant recipients compared with diabetic recipients of kidney transplants alone, as measured from the time of the kidney as well as the pancreas transplants.…”

Progression of diabetic nephropathy after successful pancreas transplantation alone: a case report

“…Successful pancreas transplantation without any complications, such as transplant rejection, helps to control glucose levels, and has a mostly positive effect on diabetic complications [ 1 ]. Nevertheless, the effect of pancreas transplantation on diabetic nephropathy remains controversial because immunosuppressants, such as calcineurin inhibitors, show nephrotoxicity [ 5 , 6 ]. Hence, pancreas transplantation alone is recommended when the glomerular filtration rate (GFR) is good (≥70–80 mL/min) and proteinuria is mild (within 1 g/day) [ 4 ].…”