UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Benefits and complications associated with kidney-pancreas transplantation in diabetes mellitus

Authors
Christina L Klein, MD
Tarek Alhamad, MD, MS, FACP, FASN
Section Editors
Daniel C Brennan, MD, FACP
David M Nathan, MD
Deputy Editor
Albert Q Lam, MD

INTRODUCTION

Combined kidney-pancreas transplantation is an established treatment for selected diabetic patients with end-stage diabetic nephropathy. More than two-thirds of pancreas transplants are performed as simultaneous pancreas-kidney (SPK) transplants, with the remainder performed as sequential pancreas after kidney (PAK) transplant or pancreas transplant alone (PTA) [1].

While SPK transplantation usually employs grafts procured from a single deceased donor, PAK typically involves transplantation of a deceased-donor pancreas graft into a recipient with a functioning living- or deceased-donor kidney allograft. Selected patients without substantial renal disease may be candidates for PTA.

The benefits and nonimmunologic complications associated with combined or sequential kidney-pancreas transplantation in patients with diabetes mellitus are presented here. Patient selection for and the clinical approach to these procedures are discussed separately. (See "Patient selection for and immunologic issues relating to kidney-pancreas transplantation in diabetes mellitus".)

BENEFITS

Overview — The major benefits of combined kidney-pancreas transplantation are decreased mortality and improved quality of life. The decreased mortality is due in part to the well-established survival benefit conferred by kidney transplantation (ie, even without pancreas transplantation) compared with dialysis [2]. (See "Patient survival after renal transplantation", section on 'Survival compared with dialysis'.)

The improved quality of life is due to freedom from frequent blood sugar monitoring, insulin therapy, hypoglycemia, and dialysis [3-6].

              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Oct 22 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Clinical Transplants 2002, Cecka JM, Terasaki PI (Eds), UCLA Immunogenetics Center, Los Angeles 2003.
  2. Venstrom JM, McBride MA, Rother KI, et al. Survival after pancreas transplantation in patients with diabetes and preserved kidney function. JAMA 2003; 290:2817.
  3. Nathan DM, Fogel H, Norman D, et al. Long-term metabolic and quality of life results with pancreatic/renal transplantation in insulin-dependent diabetes mellitus. Transplantation 1991; 52:85.
  4. Becker BN, Odorico JS, Becker YT, et al. Simultaneous pancreas-kidney and pancreas transplantation. J Am Soc Nephrol 2001; 12:2517.
  5. Kendall DM, Rooney DP, Smets YF, et al. Pancreas transplantation restores epinephrine response and symptom recognition during hypoglycemia in patients with long-standing type I diabetes and autonomic neuropathy. Diabetes 1997; 46:249.
  6. Cottrell DA, Henry ML, O'Dorisio TM, et al. Hypoglycemia after successful pancreas transplantation in type I diabetic patients. Diabetes Care 1991; 14:1111.
  7. Fioretto P, Steffes MW, Sutherland DE, et al. Reversal of lesions of diabetic nephropathy after pancreas transplantation. N Engl J Med 1998; 339:69.
  8. Navarro X, Sutherland DE, Kennedy WR. Long-term effects of pancreatic transplantation on diabetic neuropathy. Ann Neurol 1997; 42:727.
  9. Jukema JW, Smets YF, van der Pijl JW, et al. Impact of simultaneous pancreas and kidney transplantation on progression of coronary atherosclerosis in patients with end-stage renal failure due to type 1 diabetes. Diabetes Care 2002; 25:906.
  10. Koznarová R, Saudek F, Sosna T, et al. Beneficial effect of pancreas and kidney transplantation on advanced diabetic retinopathy. Cell Transplant 2000; 9:903.
  11. Sampaio MS, Kuo HT, Bunnapradist S. Outcomes of simultaneous pancreas-kidney transplantation in type 2 diabetic recipients. Clin J Am Soc Nephrol 2011; 6:1198.
  12. La Rocca E, Fiorina P, di Carlo V, et al. Cardiovascular outcomes after kidney-pancreas and kidney-alone transplantation. Kidney Int 2001; 60:1964.
  13. Witczak BJ, Jenssen T, Endresen K, et al. Risk factors for mortality in diabetic nephropathy patients accepted for transplantation. Transplantation 2007; 84:356.
  14. Cohen DJ, St Martin L, Christensen LL, et al. Kidney and pancreas transplantation in the United States, 1995-2004. Am J Transplant 2006; 6:1153.
  15. Mai ML, Ahsan N, Gonwa T. The long-term management of pancreas transplantation. Transplantation 2006; 82:991.
  16. Smets YF, Westendorp RG, van der Pijl JW, et al. Effect of simultaneous pancreas-kidney transplantation on mortality of patients with type-1 diabetes mellitus and end-stage renal failure. Lancet 1999; 353:1915.
  17. Becker BN, Brazy PC, Becker YT, et al. Simultaneous pancreas-kidney transplantation reduces excess mortality in type 1 diabetic patients with end-stage renal disease. Kidney Int 2000; 57:2129.
  18. Reddy KS, Stablein D, Taranto S, et al. Long-term survival following simultaneous kidney-pancreas transplantation versus kidney transplantation alone in patients with type 1 diabetes mellitus and renal failure. Am J Kidney Dis 2003; 41:464.
  19. Drognitz O, Benz S, Pfeffer F, et al. Long-term follow-up of 78 simultaneous pancreas-kidney transplants at a single-center institution in Europe. Transplantation 2004; 78:1802.
  20. Tydén G, Bolinder J, Solders G, et al. Improved survival in patients with insulin-dependent diabetes mellitus and end-stage diabetic nephropathy 10 years after combined pancreas and kidney transplantation. Transplantation 1999; 67:645.
  21. Rayhill SC, D'Alessandro AM, Odorico JS, et al. Simultaneous pancreas-kidney transplantation and living related donor renal transplantation in patients with diabetes: is there a difference in survival? Ann Surg 2000; 231:417.
  22. Bunnapradist S, Cho YW, Cecka JM, et al. Kidney allograft and patient survival in type I diabetic recipients of cadaveric kidney alone versus simultaneous pancreas kidney transplants: a multivariate analysis of the UNOS database. J Am Soc Nephrol 2003; 14:208.
  23. Young BY, Gill J, Huang E, et al. Living donor kidney versus simultaneous pancreas-kidney transplant in type I diabetics: an analysis of the OPTN/UNOS database. Clin J Am Soc Nephrol 2009; 4:845.
  24. Weiss AS, Smits G, Wiseman AC. Twelve-month pancreas graft function significantly influences survival following simultaneous pancreas-kidney transplantation. Clin J Am Soc Nephrol 2009; 4:988.
  25. Gruessner RW, Sutherland DE, Gruessner AC. Mortality assessment for pancreas transplants. Am J Transplant 2004; 4:2018.
  26. Sampaio MS, Poommipanit N, Cho YW, et al. Transplantation with pancreas after living donor kidney vs. living donor kidney alone in type 1 diabetes mellitus recipients. Clin Transplant 2010; 24:812.
  27. Gaston RS, Basadonna G, Cosio FG, et al. Transplantation in the diabetic patient with advanced chronic kidney disease: a task force report. Am J Kidney Dis 2004; 44:529.
  28. Morath C, Zeier M, Döhler B, et al. Transplantation of the type 1 diabetic patient: the long-term benefit of a functioning pancreas allograft. Clin J Am Soc Nephrol 2010; 5:549.
  29. Israni AK, Feldman HI, Propert KJ, et al. Impact of simultaneous kidney-pancreas transplant and timing of transplant on kidney allograft survival. Am J Transplant 2005; 5:374.
  30. Pruijm MT, de Fijter HJ, Doxiadis II, Vandenbroucke JP. Preemptive versus Non-preemptive simultaneous pancreas-kidney transplantation: a single-center, long-term, follow-up study. Transplantation 2006; 81:1119.
  31. Diem P, Abid M, Redmon JB, et al. Systemic venous drainage of pancreas allografts as independent cause of hyperinsulinemia in type I diabetic recipients. Diabetes 1990; 39:534.
  32. Luzi L, Secchi A, Facchini F, et al. Reduction of insulin resistance by combined kidney-pancreas transplantation in type 1 (insulin-dependent) diabetic patients. Diabetologia 1990; 33:549.
  33. Diem P, Redmon JB, Abid M, et al. Glucagon, catecholamine and pancreatic polypeptide secretion in type I diabetic recipients of pancreas allografts. J Clin Invest 1990; 86:2008.
  34. Barrou Z, Seaquist ER, Robertson RP. Pancreas transplantation in diabetic humans normalizes hepatic glucose production during hypoglycemia. Diabetes 1994; 43:661.
  35. Robertson RP. Seminars in medicine of the Beth Israel Hospital, Boston: Pancreatic and islet transplantation for diabetes--cures or curiosities? N Engl J Med 1992; 327:1861.
  36. Robertson RP, Sutherland DE, Kendall DM, et al. Metabolic characterization of long-term successful pancreas transplants in type I diabetes. J Investig Med 1996; 44:549.
  37. Robertson RP. Consequences on beta-cell function and reserve after long-term pancreas transplantation. Diabetes 2004; 53:633.
  38. Larsen JL, Stratta RJ, Ozaki CF, et al. Lipid status after pancreas-kidney transplantation. Diabetes Care 1992; 15:35.
  39. Katz HH, Nguyen TT, Velosa JA, et al. Effects of systemic delivery of insulin on plasma lipids and lipoprotein concentrations in pancreas transplant recipients. Mayo Clin Proc 1994; 69:231.
  40. Bilous RW, Mauer SM, Sutherland DE, et al. The effects of pancreas transplantation on the glomerular structure of renal allografts in patients with insulin-dependent diabetes. N Engl J Med 1989; 321:80.
  41. Fioretto P, Mauer SM, Bilous RW, et al. Effects of pancreas transplantation on glomerular structure in insulin-dependent diabetic patients with their own kidneys. Lancet 1993; 342:1193.
  42. Lindahl JP, Reinholt FP, Eide IA, et al. In patients with type 1 diabetes simultaneous pancreas and kidney transplantation preserves long-term kidney graft ultrastructure and function better than transplantation of kidney alone. Diabetologia 2014; 57:2357.
  43. Coppelli A, Giannarelli R, Vistoli F, et al. The beneficial effects of pancreas transplant alone on diabetic nephropathy. Diabetes Care 2005; 28:1366.
  44. Kennedy WR, Navarro X, Goetz FC, et al. Effects of pancreatic transplantation on diabetic neuropathy. N Engl J Med 1990; 322:1031.
  45. Navarro X, Kennedy WR, Loewenson RB, Sutherland DE. Influence of pancreas transplantation on cardiorespiratory reflexes, nerve conduction, and mortality in diabetes mellitus. Diabetes 1990; 39:802.
  46. Allen RD, Al-Harbi IS, Morris JG, et al. Diabetic neuropathy after pancreas transplantation: determinants of recovery. Transplantation 1997; 63:830.
  47. Aridge D, Reese J, Niehoff M, et al. Effect of successful renal and segmental pancreatic transplantation on peripheral and autonomic neuropathy. Transplant Proc 1991; 23:1670.
  48. Gaber AO, Cardoso S, Pearson S, et al. Improvement in autonomic function following combined pancreas-kidney transplantation. Transplant Proc 1991; 23:1660.
  49. Hossain P, Sachdev A, Malik RA. Early detection of diabetic peripheral neuropathy with corneal confocal microscopy. Lancet 2005; 366:1340.
  50. Tavakoli M, Quattrini C, Abbott C, et al. Corneal confocal microscopy: a novel noninvasive test to diagnose and stratify the severity of human diabetic neuropathy. Diabetes Care 2010; 33:1792.
  51. Porta M, Bandello F. Diabetic retinopathyA clinical update. Diabetologia 2002; 45:1617.
  52. Ciulla TA, Amador AG, Zinman B. Diabetic retinopathy and diabetic macular edema: pathophysiology, screening, and novel therapies. Diabetes Care 2003; 26:2653.
  53. Scheider A, Meyer-Schwickerath E, Nusser J, et al. Diabetic retinopathy and pancreas transplantation: a 3-year follow-up. Diabetologia 1991; 34 Suppl 1:S95.
  54. Ramsay RC, Goetz FC, Sutherland DE, et al. Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus. N Engl J Med 1988; 318:208.
  55. Wang Q, Klein R, Moss SE, et al. The influence of combined kidney-pancreas transplantation on the progression of diabetic retinopathy. A case series. Ophthalmology 1994; 101:1071.
  56. Petersen MR, Vine AK. Progression of diabetic retinopathy after pancreas transplantation. The University of Michigan Pancreas Transplant Evaluation Committee. Ophthalmology 1990; 97:496.
  57. Königsrainer A, Miller K, Steurer W, et al. Does pancreas transplantation influence the course of diabetic retinopathy? Diabetologia 1991; 34 Suppl 1:S86.
  58. Pearce IA, Ilango B, Sells RA, Wong D. Stabilisation of diabetic retinopathy following simultaneous pancreas and kidney transplant. Br J Ophthalmol 2000; 84:736.
  59. Giannarelli R, Coppelli A, Sartini M, et al. Effects of pancreas-kidney transplantation on diabetic retinopathy. Transpl Int 2005; 18:619.
  60. Nikkel LE, Iyer SP, Mohan S, et al. Pancreas-kidney transplantation is associated with reduced fracture risk compared with kidney-alone transplantation in men with type 1 diabetes. Kidney Int 2013; 83:471.
  61. Scialla JJ. Choices in kidney transplantation in type 1 diabetes: are there skeletal benefits of the endocrine pancreas? Kidney Int 2013; 83:356.
  62. Gruessner AC, Sutherland DE. Pancreas transplants for United States (US) and non-US cases as reported to the International Pancreas Transplant Registry (IPTR) and to the United Network for Organ Sharing (UNOS). In: Clinical Transplants 1997, Cecka JM, Terasaki PI (Eds), UCLA Tissue Typing Laboratory, Los Angeles 1998.
  63. Newell KA, Woodle ES, Millis JM, et al. Pancreas transplantation with portal venous drainage and enteric exocrine drainage offers early advantages without compromising safety or allograft function. Transplant Proc 1995; 27:3002.
  64. Monroy-Cuadros M, Salazar A, Yilmaz S, McLaughlin K. Bladder vs enteric drainage in simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2006; 21:483.
  65. Sibley RK, Sutherland DE, Goetz F, Michael AF. Recurrent diabetes mellitus in the pancreas iso- and allograft. A light and electron microscopic and immunohistochemical analysis of four cases. Lab Invest 1985; 53:132.
  66. SRTR/OPTN report data. Unadjusted graft and patient survival at 3 months, 1, 3, 5, and 10 years. http://www.srtr.org/annual_reports/2011/113_dh.pdf (Accessed on June 03, 2015).
  67. Gruessner AC, Sutherland DE. Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of June 2004. Clin Transplant 2005; 19:433.
  68. Finger EB, Radosevich DM, Dunn TB, et al. A composite risk model for predicting technical failure in pancreas transplantation. Am J Transplant 2013; 13:1840.
  69. Ziaja J, Król R, Pawlicki J, et al. Donor-dependent risk factors for early surgical complications after simultaneous pancreas-kidney transplantation. Transplant Proc 2011; 43:3092.
  70. Humar A, Ramcharan T, Kandaswamy R, et al. Technical failures after pancreas transplants: why grafts fail and the risk factors--a multivariate analysis. Transplantation 2004; 78:1188.
  71. Axelrod DA, Sung RS, Meyer KH, et al. Systematic evaluation of pancreas allograft quality, outcomes and geographic variation in utilization. Am J Transplant 2010; 10:837.
  72. Gruessner RW, Dunn DL, Gruessner AC, et al. Recipient risk factors have an impact on technical failure and patient and graft survival rates in bladder-drained pancreas transplants. Transplantation 1994; 57:1598.
  73. www.med.umn.edu/IPTR/annual_reports/2003_annual (Accessed on August 08, 2005).
  74. Siskind E, Maloney C, Akerman M, et al. An analysis of pancreas transplantation outcomes based on age groupings--an update of the UNOS database. Clin Transplant 2014; 28:990.
  75. Sampaio MS, Reddy PN, Kuo HT, et al. Obesity was associated with inferior outcomes in simultaneous pancreas kidney transplant. Transplantation 2010; 89:1117.
  76. Luan FL, Kommareddi M, Cibrik DM, et al. Influence of recipient race on the outcome of simultaneous pancreas and kidney transplantation. Am J Transplant 2010; 10:2074.
  77. Ricart MJ, Malaise J, Moreno A, et al. Cytomegalovirus: occurrence, severity, and effect on graft survival in simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2005; 20 Suppl 2:ii25.
  78. Lipshutz GS, Mahanty H, Feng S, et al. BKV in simultaneous pancreas-kidney transplant recipients: a leading cause of renal graft loss in first 2 years post-transplant. Am J Transplant 2005; 5:366.
  79. Robertson RP. Cyclosporin-induced inhibition of insulin secretion in isolated rat islets and HIT cells. Diabetes 1986; 35:1016.
  80. Nielsen JH, Mandrup-Poulsen T, Nerup J. Direct effects of cyclosporin A on human pancreatic beta-cells. Diabetes 1986; 35:1049.
  81. Robertson RP. Islet transplantation as a treatment for diabetes - a work in progress. N Engl J Med 2004; 350:694.
  82. Tydén G, Reinholt FP, Sundkvist G, Bolinder J. Recurrence of autoimmune diabetes mellitus in recipients of cadaveric pancreatic grafts. N Engl J Med 1996; 335:860.
  83. Guerra G, Indahyung R, Bucci CM, et al. Elevated incidence of posttransplant erythrocytosis after simultaneous pancreas kidney transplantation. Am J Transplant 2010; 10:938.