Simultaneous pancreas-kidney transplant extends life expectancy better than other kidney surgeries for adults with type 1 diabetes
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All-cause mortality risk after a simultaneous pancreas-kidney transplantation is lower than kidney transplantation alone among adults with type 1 diabetes and end-stage renal disease, according to findings published in Diabetes Care.
“We performed the present analyses to aid in the ongoing controversy of whether a simultaneous pancreas-kidney transplant as compared with a kidney transplant alone lowers mortality risk in patients with type 1 diabetes and end-stage renal failure, especially on the long term,” Kevin Esmeijer, MD, MSc, a PhD student in the department of nephrology at Leiden University Medical Center in the Netherlands, and colleagues wrote. “This is the first study that clearly shows that patients with type 1 diabetes, both 10 and 20 years after simultaneous pancreas-kidney transplant, had a substantially higher life expectancy as compared with those who received a living- or deceased-donor kidney transplant alone.”
Esmeijer and colleagues examined all-cause mortality risk in cohorts of adults with type 1 diabetes and ESRD who underwent a simultaneous pancreas-kidney transplant (n = 421; mean age, 42 years; 38% women), a transplant with a kidney from a decreased donor (n = 414; mean age, 50 years; 37% women), a transplant with a kidney from a living donor (n = 161; mean age, 48 years; 42% women) and dialysis (n = 1,800; mean age, 59 years; 47% women). Surgeries were performed and follow-up occurred from 1986 to 2016, and the Netherlands Organ Transplant Registry and Dutch Renal Registry provided patient information.
All-cause mortality risk across 10 years for participants who underwent simultaneous pancreas-kidney transplant was 33% less than the risk observed for participants who underwent a transplant with a kidney from a deceased donor (HR = 0.67; 955 CI, 0.46-0.98). All-cause mortality risk across 20 years for participants who underwent simultaneous pancreas-kidney transplant was 21% less than the risk observed for participants who underwent a transplant with a kidney from a deceased donor (HR = 0.79; 95% CI, 0.6-1.05).
Similarly, the all-cause mortality risk across 10 years for participants who underwent simultaneous pancreas-kidney transplant was 15% less than that for participants who underwent a transplant with a kidney from a living donor (HR = 0.85; 955 CI, 0.53-1.38) while the all-cause mortality risk across 20 years for participants who underwent simultaneous pancreas-kidney transplantation was 19% less than that for participants who underwent a transplant with a kidney from a living donor (HR = 0.81; 95% CI, 0.57-1.16).
If the pancreas graft failed, all-cause mortality risk was increased across 10 years (HR = 2.15; 95% CI, 1.09-4.27) and across 20 years (HR = 1.42; 95% CI, 0.77-2.62) for participants who underwent simultaneous pancreas-kidney transplant vs. if it did not fail.
“The risk of 20-year all-cause mortality for simultaneous pancreas-kidney transplant compared with living-donor kidney recipients was 20% lower, despite the fact that living-donor kidney recipients had better kidney graft survival,” the researchers wrote.
The researchers also found that all-cause mortality risk across 10 years was decreased by 44% for participants who underwent surgery in areas where simultaneous pancreas-kidney transplant was more common vs. areas where it was less common (HR = 0.56; 95% CI, 0.4-0.78). Similarly, all-cause mortality risk across 20 years was decreased by 31% for participants who underwent surgery in areas where simultaneous pancreas-kidney transplant was more common vs. areas where it was less common (HR = 0.69; 95% CI, 0.52-0.9).
“These results encourage care providers and guidelines to adopt simultaneous pancreas-kidney transplantation as the preferred treatment option for patients with type 1 diabetes with or approaching end-stage renal disease,” the researchers wrote. – by Phil Neuffer
Disclosures: The authors report no relevant financial disclosures.
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Janaka Karalliedde, FRCP, PhD
These results provide the first long term mortality data comparisons for kidney only vs. simultaneous pancreas-kidney and add to the growing literature that proposes in type 1 diabetes with end stage renal disease, simultaneous pancreas-kidney should be the preferred modality for transplant when feasible.
Confounding by indication/selection bias needs to be a factor when interpreting such data from registry studies, as those with more severe disease or comorbidities may not be eligible for certain transplants. Regional expertise — in this study the majority of simultaneous pancreas-kidney transplants were done in one center — and availability of donor organs need to be considered as well.
More details on cause of mortality, impact of recent changes in immunosuppression regimes, which have increased graft survival, hospitalizations and impact on burden of microvascular complications over period of follow-up would have been helpful to readers.
Patient reported outcomes, such as quality of life measures, which were not reported in this study, are also important to consider as for many patients, having a simultaneous pancreas-kidney transplant also offers an opportunity to come off insulin treatment and have further benefits by reducing the burden of hypoglycemia.
This important study adds to the growing evidence base that in patients with type 1 diabetes and end stage renal disease, there are clear short-term and longer-term benefits with a strategy of simultaneous pancreas-kidney transplantation. Preemptive transplantation before need for renal replacement therapy is preferred in patients with end stage renal disease; however, the scarcity of donor organs, which remains a major problem worldwide, needs to be urgently addressed.
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