Transplant Options for Patients With Diabetes and Advanced Kidney Disease: A Review

Abstract

Optimal glycemic control in kidney transplant recipients with diabetes is associated with improved morbidity and better patient and allograft survival. Transplant options for patients with diabetes requiring insulin therapy and chronic kidney disease who are suitable candidates for kidney transplantation should include consideration of β-cell replacement therapy: pancreas or islet transplantation. International variation related to national regulatory policies exists in offering one or both options to suitable candidates and is further affected by pancreas/islet allocation policies and transplant waiting list dynamics. The selection of appropriate candidates depends on patient age, coexistent morbidities, the timing of referral to the transplant center (predialysis versus on dialysis) and availability of living kidney donors. Therefore, early referral (estimated glomerular filtration rate < 30 mL/min/1.73 m²) is of the utmost importance to ensure adequate time for informed decision making and thorough pretransplant evaluation. Obesity, cardiovascular disease, peripheral vascular disease, smoking, and frailty are some of the conditions that need to be addressed before acceptance on the transplant list, and ideally before dialysis becoming imminent. This review offers insights into selection of pancreas/islet transplant candidates by transplant centers and an update on posttransplant outcomes, which may have practice implications for referring nephrologists.

Keywords: chronic kidney disease (CKD); diabetes mellitus; hypoglycemia unawareness; kidney transplantation; pancreas after kidney transplantation (PAK); review; simultaneous islet-kidney transplantation (SIK); simultaneous pancreas-kidney transplantation (SPK); β-cell replacement therapy.

Figure 1 –

Diagram of clinical β-cell replacement treatment alternatives, highlighting major advantages and disadvantages of each procedure. * Data from observational retrospective single center non-randomized or registries studies. $ Data from randomized clinical trials ¥ Compared to Kidney Transplant Alone # Compared to islet transplantation & Compared to Pancreas Transplantation BMI – Body Mass Index; CVD – Cardiovascular disease; IAH – Impaired hypoglycemia awareness; KTA – Kidney Transplant Alone ; MACE – Major Adverse Cardiovascular Events; QoL – Quality of Life

Figure 2 –

Practical decision making algorithm for β-cell replacement in patients with insulin-dependent diabetes and advanced kidney disease. CVD – Cardiovascular Disease; DDKT – Deceased Donor Kidney Transplant; eGFR – estimated Glomerular Filtration Rate; IAK – Islet-After-Kidney; LDKT – Living Donor Kidney Transplant; PAK – Pancreas-After-Kidney; SIK – Simultaneous Islet-Kidney; SPK – Simultaneous Pancreas-Kidney; PVD – Peripheral Vascular Disease.