Renal transplantation in diabetic nephropathy
- Garry S Tobin, MD
Garry S Tobin, MD
- Associate Professor of Medicine
- Washington University School of Medicine
- Christina L Klein, MD
Christina L Klein, MD
- Transplant Nephrologist
- Piedmont Transplant Institute
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Medical Director and Co-Director of the Comprehensive Transplant Center, Department of Internal Medicine, Division of Nephrology
- Johns Hopkins Medical School
- Section Editors
- Barbara Murphy, MB, BAO, BCh, FRCPI
Barbara Murphy, MB, BAO, BCh, FRCPI
- Section Editor — Renal Transplantation
- Professor of Medicine
- Mount Sinai School of Medicine
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
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 .
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 .
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".)
BENEFITS OF TRANSPLANTATION
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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- BENEFITS OF TRANSPLANTATION
- Transplantation versus dialysis
- Pre-emptive transplantation and living-donor versus deceased kidneys
- Expanded-criteria kidneys
- PRETRANSPLANT EVALUATION
- Timing of referral
- Cardiac evaluation
- - Prevalence of cardiovascular disease
- - Approach to evaluation
- - Intervention following positive screening test
- Evaluation of peripheral vascular disease
- POSTTRANSPLANTION CARE
- Allograft rejection
- Viral infection
- Urinary tract infection
- Recurrent diabetic nephropathy
- Glycemic control
- SUMMARY AND RECOMMENDATIONS