Transplantation in type 1 diabetes

Abstract

Simultaneous pancreas-kidney transplantation is now a routine procedure in transplantation. Surgical complication rates are low, and with potent immunosuppressive medication, long-term allograft and patient survival are excellent. From data that were also derived from pancreas transplantation alone, we know that longstanding normoglycaemia can halt or even reverse diabetic lesions in various organs, i.e. heart or kidney. However, data on long-term allograft and patient survival in type 1 diabetics who received a combined transplant in contrast to patients who received a kidney transplant alone (either from a living or a deceased donor) are still scarce. Recent evidence suggests that simultaneous pancreas-kidney transplantation is highly superior to kidney transplantation alone from a deceased donor with respect to allograft and patient survival, and this survival benefit is already visible after only 5 years of follow-up [13]. After 10 years of posttransplant follow-up, patient survival in simultaneous pancreas-kidney transplantation is even superior to that in type 1 diabetic patientswho received a kidney transplant (alone) from a living donor. These data clearly argue in favour of simultaneous pancreas-kidney transplantation in type 1 diabetic patients with kidney failure. Therefore, every type 1 diabetic patient with chronic kidney disease stage 4 or 5 should be evaluated for a combined transplant, and this procedure should ideally be performed in a pre-emptive fashion before the patient goes to dialysis. One might speculate that intensified glycaemic control, i.e. targeting a glycosylated haemoglobin value below 6.5% by the use of insulin, might have comparable positive effects in patients who received a kidney transplant alone in type 1 diabetes and this may also apply to patients with type 2 diabetes or posttransplantation diabetes mellitus after kidney transplantation. However, it is often difficult to reach those target levels and adverse events such as hypoglycaemia and even an increased rate of deaths have been reported [14,15].