Background:Patients with type 1 diabetes associated with end stage renal failure are indicated for simultaneous pancreas and kidney transplantation (SPK), but if the living donor is available, can transplant surgeons recommend that preceding solo-kidney transplantation prior to pancreatic transplantation be carried out?
Methods: To study of effectiveness of preceding solo-kidney transplantation for type1 Diabetes with end stage renal failure, comparative retrospective analysis was performed between SPK (n=232) and pancreas transplantation after kidney (PAK) (n=39) which have been performed until December 2016.
Results
1. Is the waiting period prolonged for pancreas transplantation if kidney transplantation is preceded?
We compared the waiting periods of 232 cases of SPK and 39 cases of PAK that were carried out in Japan until December 2016. The median waiting period was SPK: 1127 (11-4974) days and PAK: 710 (58-4453) days, showing no statistically significant difference (p=0.078) but having a shorter tendency in PAK.
2. After PAK, does renal function deteriorate?
Among 35 cases of PAK who had undergone surgery one year prior, s-Cre values before surgery and one year after surgery were compared. It was found that s-Cre one year after surgery had statistically significantly increased (p=0.022). However, the median sCre had slightly increased from 1.18 mg/dl before surgery to 1.21 mg/dl one year after surgery, which is not considered clinically problematic.
3.Is pancreatic graft survival the same with SPK?
1, 3 and 5-year pancreatic graft survival after SPK was 87.5%, 86.4%, 82.8%, respectively, and 87.1%, 65.0%, 49.1% after PAK, indicating no difference in 1-year survival. Upon examining the causes of pancreatic graft loss, graft loss occurred due to rejection among 8/37 cases (21.6%) after SPK; whereas after PAK it occurred for the same reason among 10/16 cases (62.5%), indicating significantly higher occurrence of pancreatic graft loss due to rejection (p=0.01). However, in PAK using rATG for induction, rejection occurred as a complication among 2/15 cases (12.3%), indicating a lower tendency compared to that occurring among cases in which rATG was not used (10/24 cases, 41.7%). Moreover, while 5-year pancreatic graft survival was 37.6% after PAK not using rATG, it was revealed that survival of 78.8% could be maintained in cases of rATG induction.
4.Can the prognosis be improved by a preceding kidney transplantation?
The life prognosis of patients waiting for SPK and PAK was compared.1, 3, and 5-year survival of patients waiting for SPK was 98.4%, 92.1%, and 88.0%, respectively, while that of patients waiting for PAK was 100%, 96.6%, and 96.6%, with the life prognosis of patients waiting for PAK significantly better than those waiting for SPK (p=0.029).
Conclusion: According to considering patient survival, preceding solo-kidney transplantation for type1 Diabetes with end stage renal failure should be performed if donor is available.