Pancreas-Kidney Transplant Tied to Better Survival Than Kidney Transplant Alone in Type 1 Diabetes

By Marilynn Larkin

January 11, 2020

NEW YORK (Reuters Health) - Compared with kidney transplantation alone, simultaneous pancreas-kidney (SPK) transplantation was associated with an almost twofold lower 10-year mortality among type 1 diabetics, in a retrospective study.

"Patients with type 1 diabetes and end-stage renal failure experience inferior survival while on dialysis," Dr. Johan W. de Fijter of Leiden University Medical Center in the Netherlands told Reuters Health by email. "These patients benefit most from a pre-emptive (i.e., before initiation of dialysis) kidney transplantation, in essence requiring availability of a suitable living donor."

"The results of this (Netherlands) nationwide evaluation provides evidence that additional restoration of endogenous insulin secretion resulted in significantly better overall patient survival beyond (that seen in) recipients of a living kidney transplant alone," he said.

The study included all 2,796 patients with type 1 diabetes in the Netherlands who started renal replacement therapy or received a first kidney transplant between 1986 and 2016.

As reported in Diabetes Care, of the 996 who received new kidneys, 42% received a deceased-donor kidney; 16%, a living-donor kidney; and 42%, an SPK transplant. The mean ages at transplantation were 50, 48, and 42 years, respectively.

Mean age at start of dialysis was 59 years for patients who stayed on chronic maintenance dialysis and 44 years for transplant recipients.

Crude survival was highest in SPK recipients and lowest in recipients of a deceased-donor kidney. Median survival time was 7.3 years for deceased-donor kidney recipients; 10.5 years for living-donor kidney recipients; and 16.5 years for SPK recipients.

SPK recipients with a functioning pancreas graft at one year (91%) had the highest survival (median 17.4 years).

Compared with deceased-donor kidney transplant recipients, adjusted hazard ratios for 10- and 20-year all-cause mortality for living-donor kidney recipients were 0.79 and 0.98, and for SPK recipients, 0.67 and 0.79.

Further, a treatment strategy favoring SPK over kidney transplantation alone showed 10- and 20-year mortality hazard ratios of 0.56 and 0.69, respectively.

Summing up, the authors state, "Compared with living- or deceased-donor kidney transplantation, SPK transplant was associated with improved patient survival, especially in recipients with a long-term functioning pancreatic graft, and resulted in an almost twofold lower 10-year mortality rate."

Dr. de Fijter said, "These results support the mandatory exchange of combined pancreas-kidney transplants in case donors with a suitable pancreas are identified. A second key issue is early referral of type 1 diabetics for timely pre-transplant work-up and placement on the active SPK waiting list (eGFR <20 ml/min/1.73m2), well before the need of a vascular access and initiation of dialysis. In the current cohort, over 30% of patients received a preemptive SPK transplant."

Availability of SPK compared with kidney transplant alone, "is a relevant consideration in view of the scarcity of organs available for transplantation, especially from deceased donors," he added. "Currently, the main restriction is the donor age, which is generally kept under 56 years," and the age limit is the same for recipients.

Dr. Ron Shapiro, surgical director of the Kidney and Pancreas Transplant Program at Mount Sinai's Recanati/Miller Transplantation Institute in New York City, commented in an email to Reuters Health, "The superior survival with SPK has been well described in the literature, and this...analysis confirms previous studies."

"The concern has always been that there is a selection bias, in that younger and healthier patients get the combined procedure, and older and less healthy patients get just the kidney," he noted. "In the U.S., approximately 1,000 pancreases are transplanted annually, compared to 19,000 kidneys. Younger, better-risk diabetic patients are already routinely listed for SPK (or living donor kidney transplant with pancreas after kidney transplant)."

"There are only enough pancreases to take care of 0.1% of diabetics, so we are dealing with a very small number of organs," he added.

SOURCE: Diabetes Care, online December 4, 2019.