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Options For Diabetic Dialysis Patients

by William Bry, M.D., Surgical Director, Kidney Transplant Program, California Pacific Medical Center and Laura Miyashita

Diabetic patients with kidney failure have several options for kidney replacement therapy. “Transplantation is considered the best choice for many patients but each type of transplant—living donor or deceased donor, and kidney alone or combined kidney-pancreas transplant—presents risks and benefits that one should weigh given their situation,” says William Bry, M.D., surgical director of California Pacific’s Kidney Transplant Program.

Kidney-Pancreas Transplant Candidates

In general, candidates for kidney-pancreas transplant include:

1. Juvenile onset (type l) diabetic patients under age 60 who are insulin-dependent with kidney failure.


2. Selected non-obese mature onset (type 2) diabetic patients under age 60 who are insulin-dependent with kidney failure.

“Although nationwide about 6% of kidney-pancreas transplants are performed for selected adult-onset [type 2] diabetics, most of these individuals are best served with kidney transplantation alone, either from a living or deceased donor,” says Bry. “We evaluate each candidate thoroughly because sometimes, due to cardiac disease, weight or other medical conditions, the risk of a combined kidney-pancreas transplant outweighs the benefit gained.”

Pancreas Transplant Volumes at California Pacific Medical Center

2010 data represents transplants from 1/1/10-9/15/10

2006	2007	2008	2009	2010
22	18	19	14	11

Advantages of a Living Donor

By having a family or friend who can serve as a living donor, a diabetic patient with renal failure maybe able to avoid dialysis altogether. “Unfortunately, diabetic patients who are considered to be good transplant candidates do not do well with dialysis and multiple studies have shown that any type of transplant will improve their quality and length of life compared to chronic dialysis,” explains Bry. He adds, “Studies show that the greatest benefit to diabetic patients facing dialysis is to receive an early kidney transplant, regardless of whether one receives a pancreas as well.”

Individuals who receive a kidney transplant from a living donor have the option of receiving a pancreas from a deceased donor after recovering from the initial kidney transplant. “The disadvantage of this approach is that the success rate of the pancreas is not quite as high with this type of ‘pancreas after kidney’ transplant compared with receiving a combined kidney-pancreas transplant from a deceased donor in one surgery,” says Bry.

Kidney-Pancreas Allocation

If a living donor is not available, a patient would choose between receiving a kidney alone or a kidney and pancreas from a deceased donor.

Kidneys and pancreases from deceased donors are allocated differently in the U.S. depending on geography and the guidelines of the local organ procurement organization (OPO). In most parts of the country—including Northern California—a patient’s name is placed on the pancreas transplant waiting list. Once a pancreas donor becomes available, the patient then receives both the pancreas and kidney from that donor. In other areas, a patient must wait on the longer kidney transplant waiting list and then when he/she reaches the top of the list for a kidney, he/she can receive a pancreas from the same donor.

“These two options present a great difference in one’s waiting time for a transplant and favor those in a geography that goes by the pancreas transplant waiting list versus the kidney list,” explains Bry. Accordingly, the Pancreas Transplant Committee of the United Network for Organ Sharing (UNOS) is working on a uniform system for kidney-pancreas allocation that will favor the system that entails a shorter wait to transplantation. “This means that all pancreas transplant candidates will wait on one national list and will receive both a pancreas and kidney in a shorter length of time,” says Bry.

Pancreas Transplant Outcomes at California Pacific Medical Center

1-year data represents patients receiving their transplant between 1/01/2007 and 6/30/2009
Further information is available on the Scientific Registry of Transplant Recipients Web site (www.ustransplant.org) including more details about how the above numbers are calculated.

Type	Observed	Expected	How does center’s survival compare to what is expected for similar patients?
Adult kidney graft survival	93.02	93.10	Not Significantly Different
Adult pancreas graft survival	88.19	85.75	Not Significantly Different
Adult patient survival	93.02	95.90	Not Significantly Different

article from Fall Winter 2010 Kidney Review newsletter