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Renal transplantation in diabetic nephropathy

Garry S Tobin, MD
Christina L Klein, MD
Daniel C Brennan, MD, FACP
Section Editors
Barbara Murphy, MB, BAO, BCh, FRCPI
David M Nathan, MD
Deputy Editor
Albert Q Lam, MD


Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) in Western societies and accounts for approximately 40 to 45 percent of cases of ESRD in the United States. Diabetic nephropathy was the etiology of ESRD in approximately 23 percent of kidney transplant recipients transplanted in the United States in 2008 [1].

Diabetes presents particular challenges both in the pretransplant evaluation and after transplantation. These challenges are related to the high incidence of cardiovascular disease among diabetic patients and the increased risk of bacterial and fungal infections compared with nondiabetic transplant recipients.

In addition, glycemic control is often more difficult after transplantation. This is because immunosuppressive regimens used after transplantation have detrimental effects on pancreatic beta-cell function and peripheral insulin action, which make it difficult to achieve target glucose levels and prevent the recurrence of the diabetic lesions in the transplanted kidney [2].

The major issues related to renal transplantation in diabetic patients with ESRD are discussed in this topic review. The role of combined kidney-pancreas transplantation is discussed separately. New-onset diabetes that occurs after renal transplantation is also discussed separately. (See "Benefits and complications associated with kidney-pancreas transplantation in diabetes mellitus" and "Patient selection for and immunologic issues relating to kidney-pancreas transplantation in diabetes mellitus" and "New-onset diabetes after transplant (NODAT) in renal transplant recipients".)


Kidney transplantation is the preferred renal replacement therapy for diabetic patients with end-stage renal disease (ESRD) since it generally results in better survival and quality of life than dialysis. We recommend that diabetic patients who are eligible receive a kidney transplant rather than continue dialysis. Pre-emptive kidney transplantation rather than initiation of dialysis followed by transplantation is preferred, and, if possible, a living-donor kidney is preferred to a deceased-donor kidney. We also suggest that all waitlisted diabetic patients register on both the standard-donor waitlist and the expanded-criteria-donor (ECD) waitlist. Although ECD kidneys do not meet the criteria for standard-donor kidneys, diabetic patients who receive them are likely to live longer than if they remained on dialysis.


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Literature review current through: Sep 2016. | This topic last updated: May 20, 2016.
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  1. http://www.unos.org (Accessed on June 28, 2011).
  2. 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.
  3. Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998; 9:2135.
  4. Port FK, Wolfe RA, Mauger EA, et al. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993; 270:1339.
  5. Ojo AO, Port FK, Wolfe RA, et al. Comparative mortality risks of chronic dialysis and cadaveric transplantation in black end-stage renal disease patients. Am J Kidney Dis 1994; 24:59.
  6. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999; 341:1725.
  7. Rabbat CG, Thorpe KE, Russell JD, Churchill DN. Comparison of mortality risk for dialysis patients and cadaveric first renal transplant recipients in Ontario, Canada. J Am Soc Nephrol 2000; 11:917.
  8. Meier-Kriesche HU, Ojo AO, Port FK, et al. Survival improvement among patients with end-stage renal disease: trends over time for transplant recipients and wait-listed patients. J Am Soc Nephrol 2001; 12:1293.
  9. Oniscu GC, Brown H, Forsythe JL. Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol 2005; 16:1859.
  10. Gill JS, Tonelli M, Johnson N, et al. The impact of waiting time and comorbid conditions on the survival benefit of kidney transplantation. Kidney Int 2005; 68:2345.
  11. Lentine KL, Brennan DC, Schnitzler MA. Incidence and predictors of myocardial infarction after kidney transplantation. J Am Soc Nephrol 2005; 16:496.
  12. Lentine KL, Schnitzler MA, Abbott KC, et al. De novo congestive heart failure after kidney transplantation: a common condition with poor prognostic implications. Am J Kidney Dis 2005; 46:720.
  13. Meier-Kriesche HU, Schold JD, Srinivas TR, et al. Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease. Am J Transplant 2004; 4:1662.
  14. Lentine KL, Rocca Rey LA, Kolli S, et al. Variations in the risk for cerebrovascular events after kidney transplant compared with experience on the waiting list and after graft failure. Clin J Am Soc Nephrol 2008; 3:1090.
  15. Cosio FG, Hickson LJ, Griffin MD, et al. Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 2008; 8:593.
  16. Kasiske BL, Snyder JJ, Matas AJ, et al. Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol 2002; 13:1358.
  17. Meier-Kriesche HU, Port FK, Ojo AO, et al. Effect of waiting time on renal transplant outcome. Kidney Int 2000; 58:1311.
  18. Mange KC, Joffe MM, Feldman HI. Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med 2001; 344:726.
  19. Gill JS, Tonelli M, Johnson N, Pereira BJ. Why do preemptive kidney transplant recipients have an allograft survival advantage? Transplantation 2004; 78:873.
  20. Becker BN, Rush SH, Dykstra DM, et al. Preemptive transplantation for patients with diabetes-related kidney disease. Arch Intern Med 2006; 166:44.
  21. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005; 294:2726.
  22. Schold JD, Meier-Kriesche HU. Which renal transplant candidates should accept marginal kidneys in exchange for a shorter waiting time on dialysis? Clin J Am Soc Nephrol 2006; 1:532.
  23. Snoeijs MG, Schaubel DE, Hené R, et al. Kidneys from donors after cardiac death provide survival benefit. J Am Soc Nephrol 2010; 21:1015.
  24. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.
  25. Witczak BJ, Hartmann A, Jenssen T, et al. Routine coronary angiography in diabetic nephropathy patients before transplantation. Am J Transplant 2006; 6:2403.
  26. Ramanathan V, Goral S, Tanriover B, et al. Screening asymptomatic diabetic patients for coronary artery disease prior to renal transplantation. Transplantation 2005; 79:1453.
  27. Manske CL, Thomas W, Wang Y, Wilson RF. Screening diabetic transplant candidates for coronary artery disease: identification of a low risk subgroup. Kidney Int 1993; 44:617.
  28. Ma IW, Valantine HA, Shibata A, et al. Validation of a screening protocol for identifying low-risk candidates with type 1 diabetes mellitus for kidney with or without pancreas transplantation. Clin Transplant 2006; 20:139.
  29. Krajnc M, Pečovnik-Balon B, Hojs R, Rupreht M. Comparison of coronary artery calcification and some coronary artery calcification risk factors in patients on haemodialysis and in patients with type 2 diabetes. J Int Med Res 2011; 39:1006.
  30. Scandling JD. Kidney transplant candidate evaluation. Semin Dial 2005; 18:487.
  31. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
  32. Elsner D. How to diagnose and treat coronary artery disease in the uraemic patient: an update. Nephrol Dial Transplant 2001; 16:1103.
  33. Schmidt A, Stefenelli T, Schuster E, Mayer G. Informational contribution of noninvasive screening tests for coronary artery disease in patients on chronic renal replacement therapy. Am J Kidney Dis 2001; 37:56.
  34. Sharma R, Pellerin D, Gaze DC, et al. Dobutamine stress echocardiography and the resting but not exercise electrocardiograph predict severe coronary artery disease in renal transplant candidates. Nephrol Dial Transplant 2005; 20:2207.
  35. Rabbat CG, Treleaven DJ, Russell JD, et al. Prognostic value of myocardial perfusion studies in patients with end-stage renal disease assessed for kidney or kidney-pancreas transplantation: a meta-analysis. J Am Soc Nephrol 2003; 14:431.
  36. De Vriese AS, De Bacquer DA, Verbeke FH, et al. Comparison of the prognostic value of dipyridamole and dobutamine myocardial perfusion scintigraphy in hemodialysis patients. Kidney Int 2009; 76:428.
  37. Manske CL, Wang Y, Rector T, et al. Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure. Lancet 1992; 340:998.
  38. Schiel R, Heinrich S, Steiner T, et al. Post-transplant diabetes mellitus: risk factors, frequency of transplant rejections, and long-term prognosis. Clin Exp Nephrol 2005; 9:164.
  39. Schiel R, Heinrich S, Steiner T, et al. Long-term prognosis of patients after kidney transplantation: a comparison of those with or without diabetes mellitus. Nephrol Dial Transplant 2005; 20:611.
  40. Bastos M, Baptista C, Campos MV, et al. Kidney transplantation and diabetes: posttransplantation malignancy. Transplant Proc 2003; 35:1098.
  41. Martinenghi S, Dell'Antonio G, Secchi A, et al. Cancer arising after pancreas and/or kidney transplantation in a series of 99 diabetic patients. Diabetes Care 1997; 20:272.
  42. Valera B, Gentil MA, Cabello V, et al. Epidemiology of urinary infections in renal transplant recipients. Transplant Proc 2006; 38:2414.
  43. Alangaden GJ, Thyagarajan R, Gruber SA, et al. Infectious complications after kidney transplantation: current epidemiology and associated risk factors. Clin Transplant 2006; 20:401.
  44. Owda AK, Abdallah AH, Haleem A, et al. De novo diabetes mellitus in kidney allografts: nodular sclerosis and diffuse glomerulosclerosis leading to graft failure. Nephrol Dial Transplant 1999; 14:2004.
  45. Siddqi N, Hariharan S, Danovitch G. Evaluation and preparation of renal transplant candidates. In: Handbook of Kidney Transplantation, 4th ed., Lippincott Williams & Wilkins, Philadelphia 2005.
  46. Barbosa J, Steffes MW, Sutherland DE, et al. Effect of glycemic control on early diabetic renal lesions. A 5-year randomized controlled clinical trial of insulin-dependent diabetic kidney transplant recipients. JAMA 1994; 272:600.
  47. Lindahl JP, Hartmann A, Aakhus S, et al. Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation. Diabetologia 2016; 59:844.