Transplantation in the Diabetic Patient with Advanced Chronic Kidney Disease: A Task Force Report

Gaston RS, Basadonna G, Cosio FG, Davis CL, Kasiske BL, Larsen J, Leichtman AB, Delmonico FL. Am J Kidney Dis. 2004;44:529-542.

The incidence of diabetes-related advanced chronic kidney disease has doubled in the last decade. Patients with pre-existing diabetes make up a quarter of kidney transplant recipients, and 15% to 20% of patients who do not have diabetes pretransplantation develop glucose intolerance following transplantation. This report summarizes the discussions and recommendations of a task force of over 60 health professionals on transplantation in patients with diabetes and advanced chronic kidney disease. Four broad issues are addressed: (1) pretransplantation management, (2) therapeutic options in chronic kidney disease, (3) posttransplant diabetes mellitus, and (4) improving posttransplant outcomes.

Patients with chronic kidney disease should be referred as early as possible to a transplant center. This strategy allows for effective implementation of therapeutic options and the opportunity for preemptive transplantation, as preemptive transplantation prior to long-term dialysis is associated with the best outcomes. Complications related to cardiovascular disease are of particular concern in patients with diabetes, and pretransplantation evaluation of patients with diabetes should include cardiovascular evaluation to determine eligibility for transplantation, reduce perioperative morbidity and mortality, and modify future risk.

Therapeutic options for renal replacement therapy in diabetes include peritoneal dialysis, hemodialysis, kidney transplantation from a living or deceased donor, or simultaneous pancreas/kidney (SPK) transplantation. In type 1 diabetes, kidney transplantation from a living donor or SPK transplantation are associated with the best outcomes, with 10-year survival rates of 67% and 65%, respectively. The task force recommended islet transplantation in patients with low insulin requirements and excessive surgical risk. The main objective of posttransplant management is to optimize graft survival in order to minimize rejection. There are numerous factors involved in posttransplantation management, including immunosuppressant therapy, glycemic control, blood pressure control, maintaining renal function, and minimizing the impact of cardiovascular disease.

Posttransplant diabetes mellitus (PTDM) may develop 3 to 6 months following transplantation, although patients remain at risk throughout graft survival. Increased risk is associated with a number of factors, including family history of type 2 diabetes, personal history of glucose intolerance or type 2 diabetes, personal history of gestational glucose intolerance or diabetes, increasing age, ethnicity (ethnic groups at higher risk compared with whites are African Americans, Hispanics, and Native Americans), obesity, dyslipidemia, and hepatitis C. Widely established diagnostic criteria for PTDM do not exist; however, diagnostic criteria have been developed by the American Diabetes Association/World Health Organization.

Effective management of patients prior to kidney transplantation contributes to optimal outcomes following transplantation. Ultimately, optimal care of patients with diabetes and advanced chronic kidney disease entails the involvement of a multidisciplinary team to address all aspects of care before, during, and after transplantation.