Simultaneous pancreas-kidney transplant versus kidney transplant alone in diabetic patients

Abstract

The decision for simultaneous pancreas-kidney (SPK) versus kidney transplant alone (KTA) in diabetic patients with renal failure depends on the potential risks and benefits for each procedure. The purpose of this study was to compare the morbidity, mortality, and renal allograft survival in diabetic patients who underwent SPK versus KTA, and to discern the added risks associated with pancreas transplantation. Between 7/1/86 and 9/30/90, 69 primary cadaver SPK and 59 primary cadaver KTA were performed in type I diabetic patients with chronic renal failure. Antilymphocyte globulin or OKT3 was used for induction therapy, followed by standard triple therapy (prednisone, azathioprine, and cyclosporine). Patient and graft survivals were retrospectively analyzed. In addition, a detailed comparison of morbidity in those patients treated after 7/1/87 was performed (53 SPK, 49 KTA). For those <45 years of age (65 SPK, 42 KTA), there were no significant differences (P > 0.6) in the actuarial patient survival at one year (SPK 92%, KTA 95%), or two years (SPK 89%, KTA 92%), or actuarial renal allograft survival at one year (SPK 82%, KTA 83%) or two years (SPK 77%, KTA 83%). However, for those >45 years old, actuarial renal allograft survival was significantly higher (P < 0.03) in the KTA group. The mean serum creatinine levels were similar at one year (SPK 1.8. KTA 1.9 mg/d). Thirty-nine percent of KTA patients had at least one rejection episode versus 72% for SPK (P < 0.02). The SPK recipients were hospitalized longer during the initial admission (SPK 23.3 ± 24 day, KTA 13.5 ± 1.3 day, P < 0.001) and had a higher number of readmissions (SPK 2.8 ± 0.3, KTA 1.7 ± 0.E. P < 0.02). Complications were more common in the SPK group in the following categories: wound problems (SPK 23%, KTA 0%, P < 0.0002), urologic problems (SPK 25%, KTA 8%, P < 0.06), bacterial infections (SPK 36%, KTA 12%, P < 0.02), fungal infections (SPK 45%, KTA 18%, P < 0.006) and urinary tract infections (UTI) (SPK 62%, KTA 27%, P < 0.0006). Gram positive bacteria and Candida were the prevalent pathogens in the UTIs in the SPK group. The incidence of pyelonephritis, peripheral vascular disease, viral infections (including CMV), vascular, GI, respiratory, cardiac, neurologic, or ophthalmologic problems were not statistically different in the two groups. These data suggest that SPK can be performed with patient and renal allograft survival rates equivalent to KTA in uremic diabetic patients < 45 years old, with a pancreas survival rate of 73% at one and 67% at two years. However, patients >45 are at increased risk and may have poorer renal allograft survival. The increased early morbidity and hospital time should be considered along with the benefits of improved quality of life with a functioning pancreas when offering or selecting patients for SPK transplants.