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Are Diabetics Candidates For Kidney Transplants

Renal Transplantation In Diabetic Nephropathy

Renal Transplantation In Diabetic Nephropathy

INTRODUCTION Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) in Western societies and accounts for approximately 40 to 45 percent of cases of ESRD in the United States. Diabetic nephropathy was the etiology of ESRD in approximately 23 percent of kidney transplant recipients transplanted in the United States in 2008 [1]. Diabetes presents particular challenges both in the pretransplant evaluation and after transplantation. These challenges are related to the high incidence of cardiovascular disease among diabetic patients and the increased risk of bacterial and fungal infections compared with nondiabetic transplant recipients. In addition, glycemic control is often more difficult after transplantation. This is because immunosuppressive regimens used after transplantation have detrimental effects on pancreatic beta-cell function and peripheral insulin action, which make it difficult to achieve target glucose levels and prevent the recurrence of the diabetic lesions in the transplanted kidney [2]. The major issues related to renal transplantation in diabetic patients with ESRD are discussed in this topic review. The role of combined kidney-pancreas transplantation is discussed separately. New-onset diabetes that occurs after renal transplantation is also discussed separately. (See "Benefits and complications associated with kidney-pancreas transplantation in diabetes mellitus" and "Patient selection for and immunologic issues relating to kidney-pancreas transplantation in diabetes mellitus" and "New-onset diabetes after transplant (NODAT) in renal transplant recipients".) BENEFITS OF TRANSPLANTATION Kidney transplantation is the preferred renal replacement therapy for diabetic patients with end-stage renal disease (ESRD) since it generally r Continue reading >>

Kidney Transplantation

Kidney Transplantation

The surgical implantation of a kidney from one donor to a non-identical human recipient (allograft). Kidney transplantation that occurs between identical twins referred to as isograft. Simultaneous pancreas and kidney (SPK) transplantation has been a successful therapy for patients with end-stage kidney disease secondary to type 1 diabetes mellitus. Other options include pancreas or islet cell transplantation before or after kidney transplantation. Most patients with kidney transplantation (and all with pancreas transplantation) are allograft recipients and require lifetime immunosuppression to prevent immune-mediated graft rejection. Diabetes, in the context of kidney transplantation, includes both patients who have diagnosed diabetes prior to transplantation and patients who develop post-transplantation diabetes mellitus (PTDM). Diabetes accounts for ~45% of new cases of chronic kidney disease diagnosed each year. In 2007, among newly-listed adults for kidney transplantation, about 40% had diabetes. This incidence can be as high as 65% in Native Americans. Additionally, about 5 to 25% of non-diabetic kidney transplant recipients will develop post-transplant diabetes mellitus (PTDM) per year. A higher incidence of new onset diabetes after transplant (NODAT ) among recipients receiving tacrolimus compared with cyclosporine has been noted. The incidence of new onset diabetes mellitus after transplant (NODAT) is variable, ranging between 10 and 46% depending on the study design and the definition of NODAT. More specifically, NODAT has been reported to occur in 4–25% of renal transplant recipients, 2.5–25% of liver transplant recipients, 4– 40% of heart transplant recipients, and 30–35% of lung transplant recipients. PTDM is a strong, independent predictor of allog Continue reading >>

Curing Diabetes With Kidney/pancreas Transplant

Curing Diabetes With Kidney/pancreas Transplant

Patients with Severe Disease Not Managed by Medication are Now Diabetes and Dialysis Free (Washington, D.C.) – Jeffrey Edwards of Washington, D.C. can hardly believe that his 17 year battle with diabetes is over. His debilitating three-times-a-week dialysis sessions are finished. “I’m no longer doing finger sticks to check my blood sugar, I can eat what I want, when I want and I feel great. It’s almost as if the diabetes never existed,” said Edwards, age 53. Edwards, a letter carrier for the U.S. Postal Service of 31 years, is one of an increasing number of patients at the MedStar Georgetown Transplant Institute to receive a life-changing kidney/pancreas transplant as a treatment for severe diabetes. “Because the regulation of insulin is performed by the pancreas, transplanting the pancreas in someone with severe diabetes cures them of their disease,” said Peter Abrams, M.D., a kidney and pancreas transplant surgeon at the MGTI. “When we transplant the kidney at the same time, then the patient is no longer ruled by dialysis. And the new pancreas protects the new kidney from further damage due to the diabetes. We call that a kidney/pancreas transplant. Mr. Edwards is doing great. He has no diabetes. He functions as a normal non-diabetic human being now.” The pancreas is a gland about five to six inches long that sits behind the stomach and extends horizontally between the spleen and the duodenum. Pancreatic enzymes aid with digestion. It also produces insulin for the essential regulation of the use of blood sugar throughout the body. Diabetes occurs when the pancreas fails to correctly produce insulin. Jeffrey Edwards had suffered through the many ravages of diabetes. A two week diabetic coma in 1999 almost ended his life. Congestive heart failure due t Continue reading >>

Kidney Transplants

Kidney Transplants

Transplant Institute Beth-Israel Deaconess Medical Center Why do people need kidney transplants? Kidney failure happens when your kidneys are not working the way they should. Many different diseases can harm your kidneys and cause poor function. Diabetes and high blood pressure are some of the most common causes of kidney failure in the United States. As your kidneys fail, both usually fail at the same time. You can’t tell that they are failing from the amount of urine you are making, but from blood and urine tests done at your doctor’s office. As your kidneys get worse, however, you may begin to tire easily, have trouble sleeping; feel itchy or sick to your stomach. If you start to accumulate too much fluid from kidney failure, you may feel short of breath with simple activities. People on pills or insulin for diabetes can notice that their blood sugars are lower as their kidneys fail. How is kidney failure treated? Kidney failure can be treated with kidney transplantation or dialysis. Kidney transplantation is a surgical procedure where a kidney comes from either a living donor who donates one of their two kidneys to you, or from a deceased donor (someone dies and the family donates the organs). After receiving a new kidney, you must take medications to prevent your body from attacking (rejecting) the new kidney. These drugs decrease the body’s ability to attack the new kidney by lowering your immune system (immunosuppressants). The drugs also decrease your ability to fight infections and certain kinds of cancer (mainly skin cancers and a rare lymph node cancer). So before a kidney transplant and start of immunosuppressant medications, you must have a complete evaluation at the transplant center. This will make sure you are healthy enough to go through a major o Continue reading >>

Kidney Transplantation In The Diabetic Patient

Kidney Transplantation In The Diabetic Patient

Go to: 1. Introduction In the last few decades, the developed world has experienced a huge impact of chronic kidney disease (CKD) in the diabetic patient. According to a 2014 report (with 2012 data) of the US Renal Data System (USRDS), 44% of total end-stage renal disease (ESRD) causes are diabetic nephropathy [1]. The absolute number is about 50,000 patients in this country. However, the incidence of ESRD in diabetics differs between countries: the percentage ranges between 16% in the Netherlands, 23% in the United Kingdom, and 66% in Singapore [1]. The incidence of diabetics with ESRD in Spain is about 21%, as of 2013 [2]. Despite the alarming data, some progress has been achieved in order to reduce the impact of this entity, in line with the objectives set by the initiative of CKD within the program Healthy People 2020 [3]. The USRDS registry confirms that, while in the 1990s the incidence increased in an exponential way, it remained stable in the following decade [1]. These rates have been stable in recent years among younger individuals, but they have declined in older individuals in most racial groups. Among diabetic patients, an overall reduction in those developing ESRD has also been observed: the rate of new ESRD cases with diabetes listed as the primary cause has declined since 2006 [1]. In addition to the USRDS registry, an important database including 25,000 diabetic patients with ESRD in US was described a few years ago [4]. More than 95% of all diabetics were type 2, while type 1 diabetics represented only 5%, a similar distribution to that described in the general diabetic population. Type 1 diabetics were younger, more frequently Caucasian, with more time on dialysis, more time with a native fistula, and with poor phosphorus and glycemic control [4]. Continue reading >>

Kidney Transplantation In Diabetic Patients Using Cyclosporine: Five-year Follow-up

Kidney Transplantation In Diabetic Patients Using Cyclosporine: Five-year Follow-up

Kidney Transplantation in Diabetic Patients Using Cyclosporine: Five-Year Follow-up From the Division of Organ Transplantation, New England Deaconess Hospital and Harvard Medical School, Boston, Mass. Arch Surg. 1995;130(3):283-288. doi:10.1001/archsurg.1995.01430030053009 Objective: To review our center's experience with kidney transplantation in diabetic recipients; specifically, to compare long-term (5-year) patient and graft survival rates between diabetic and nondiabetic recipients overall and according to donor source using cyclosporine-based immunosuppression. Design: A retrospective review of all kidney transplants performed over the 7-year period from 1987 to 1993. Setting: A large urban tertiary care referral center with a long history of kidney transplantation and care of the diabetic patient. Patients: All patients receiving a kidney transplant, either alone or simultaneously with a pancreas transplant, were reviewed. Main Outcome Measures: Actuarial patient and graft survival, serum creatinine levels, and causes of late graft loss. Results: There was no significant difference in actuarial 5-year patient or kidney graft survival between diabetic and nondiabetic recipients overall or when analyzed by donor source. There was no significant difference in mean serum creatinine levels at 5 years between diabetic and nondiabetic recipients overall or between diabetic and nondiabetic cadaveric recipients. While chronic rejection was the major cause of late graft loss in non-diabetic recipients, death with a functioning graft, principally due to cardiovascular disease, was the major cause of graft loss in diabetic recipients. Conclusions: With cyclosporine-based immunosuppression, diabetic kidney transplant recipients have 5-year patient and graft survival rates an Continue reading >>

Kidney & Pancreas Transplant | Cleveland Clinic

Kidney & Pancreas Transplant | Cleveland Clinic

Overview Procedure Details Risks / Benefits What is a kidney and pancreas transplant? Combined transplantation of the kidney and pancreas is performed for those who have kidney failure as a complication of insulin-dependent diabetes mellitus (also called Type I diabetes). Kidney and pancreas transplant candidates might be currently on dialysis or might require dialysis in the near future. After combined transplantation of the kidney and pancreas, the kidney will be able to filter and excrete wastes so dialysis will not be needed. The transplanted pancreas will produce insulin to control the diabetes. Am I a candidate for the double transplant? If you have Type I diabetes and you have kidney failure, or if your doctor thinks that kidney failure is beginning, the double transplant (combined kidney and pancreas) can be considered as a treatment option. Your doctor and transplant surgeon can determine if the double transplant is needed based on your medical condition, your overall health, and the results of a pre-transplant evaluation. A pre-transplant evaluation includes a complete physical, consultations with a transplant coordinator and surgeon, and a series of tests, including heart and bladder evaluations. Where does my new kidney and pancreas come from? Kidneys for transplantation come from two sources: living donors and deceased (non-living) donors . Living donors are usually immediate family members or sometimes spouses. Deceased donor kidneys come from people whose families give permission for organ donation at the time of death. Three out of four kidney transplants are performed with deceased donor kidneys. Combined kidney and pancreas transplants and single pancreas transplants are only performed with deceased donor organs. All donors are carefully screened to p Continue reading >>

Kidney Transplantation In Type 2 Diabetic Patients: A Comparison With Matched Non‐diabetic Subjects

Kidney Transplantation In Type 2 Diabetic Patients: A Comparison With Matched Non‐diabetic Subjects

Background. Because they generally are older and frequently have co‐morbidities, patients with type 2 diabetes mellitus and end‐stage renal disease seldom are selected for renal transplantation. Thus, information on transplantation results from controlled studies in this high‐risk category of patients is scarce. We have compared the results of kidney transplantations in type 2 diabetic patients with carefully matched non‐diabetic subjects. Methods. All first cadaveric renal transplants performed in type 2 diabetic patients from January 1, 1988 to December 31, 1998 in our centre were included. Non‐diabetic controls were individually matched with diabetic patients with respect to year of transplantation, sex, age, selected immunological parameters, and graft cold ischaemia. Results. We included 64 type 2 diabetic and 64 non‐diabetic patients who were followed for a mean period of 37±27 and 41±31 months, respectively, after renal transplantation. Patient survival at 1 and 5 years post‐transplant was 85 and 69 vs 84 and 74% (P=0.43, NS), while graft survival rates censored for patient death were 84 and 77 vs 82 and 77% for diabetic and non‐diabetic subjects, respectively (P=0.52, NS). With graft survival results not censored for death with functioning graft, no significant change was seen (diabetic vs non‐diabetic group: 77 and 54 vs 73 and 61%, P=0.19, N Continue reading >>

Pancreas And Kidney Transplants: New Lease On Life

Pancreas And Kidney Transplants: New Lease On Life

The word is used with equal parts hope and disbelief in the diabetes online community. Its alluded to in scientific meetings. And if you ask whether anyone has ever been, you may be told not exactly. But Travis Blackwelder says it out loud, with a sense of wonder: Cured. Blackwelder, 41, of Provo, Utah, was diagnosed with type 1 diabetes when he was 15 years old. He doesnt have it anymore. What he does have is a new pancreas and kidneypumping out insulin and other hormones and filtering toxins from the blood, respectively. He received the two-organ transplant in September 2013. Since then, hes been a new man: no more dialysis for renal failure, no more testing blood glucose, no more insulin shots. I cant imagine going back, he says, and I hope I never have to. My life is totally different. Blackwelder is one of a growing number of people who have had a simultaneous pancreas-kidney transplant, a surgery that, while not an option for most people with diabetes, is life changing and sometimes lifesaving. The most frequent candidates for a simultaneous pancreas-kidney transplant (SPK) are people with diabetes whose kidneys are failing due to nephropathy (kidney disease) . Often, they are on dialysishooked up several times each week to a machine that takes hours to completely filter their bloodand on a strict renal diet. Transplant candidates may also have hypoglycemia unawareness or be unable to control their blood glucose, even with careful monitoring. Some people with diabetes and renal failure have a kidney transplant without a pancreas transplant, but most go in for both, says endocrinologist Sue Kirkman, MD, professor of medicine at the University of North CarolinaChapel Hill. Much less common are pancreas-after-kidney (PAK) transplants and pancreas transplant alone (P Continue reading >>

Options For Diabetic Dialysis Patients

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 transplantliving donor or deceased donor, and kidney alone or combined kidney-pancreas transplantpresents risks and benefits that one should weigh given their situation, says William Bry, M.D., surgical director of California Pacifics Kidney Transplant Program. In general, candidates for kidney-pancreas transplant include: Juvenile onset (type l) diabetic patients under age 60 who are insulin-dependent with kidney failure. 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 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, explain Continue reading >>

Medical Xpress: Kidneys From Diabetic Donors May Benefit Many Transplant Candidates

Medical Xpress: Kidneys From Diabetic Donors May Benefit Many Transplant Candidates

Kidneys from diabetic donors may benefit many transplant candidates A new study indicates that receiving donor kidneys from individuals with diabetes may offer a greater survival benefit than remaining on the waitlist for many transplant candidates. The findings, which appear in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), may help address the growing organ shortage. As the demand for deceased donor kidneys increases, physicians and kidney transplant candidates need better information about the risks associated with using high risk donor kidneyssuch as those from individuals with diabetesto inform their decisions about whether to accept these organs. Jordana Cohen, MD, MSCE (Perelman School of Medicine at the University of Pennsylvania) performed an observational study of 437,619 kidney transplant candidates from the Organ Procurement and Transplantation Network database in the United States, including 8101 recipients of diabetic donor kidneys and 126,560 recipients of non-diabetic donor kidneys. The investigators evaluated patients' risk of dying after transplantation with diabetic donor kidneys compared with remaining on the kidney transplant waitlist. Among transplant recipients who were followed for a median of 8.9 years, the mortality rate was 35 deaths per 1000 person-years. (A person-year is the number of years of follow-up multiplied by the number of people in the study.) Compared with patients who remained on the waitlist or waited for a kidney from a non-diabetic donor, patients who received a diabetic donor kidney had a 9% lower risk of dying during the study. Kidney transplant candidates who were at high risk of dying on the waitlist, especially at centers with the longest average waiting times, benefitted most fr Continue reading >>

Kidney Transplants From Diabetic Donors Will Save More Lives, Sooner

Kidney Transplants From Diabetic Donors Will Save More Lives, Sooner

Kidney Transplants from Diabetic Donors Will Save More Lives, Sooner Penn study finds that accepting a kidney from a deceased diabetic donor may be best option for older patients, those facing long wait times PHILADELPHIA There are more than 98,000 people currently awaiting a kidney transplant in the United States. But the organs are in short supply: only about 17,000 patients will receive transplants each year. For sicker patients and those facing the longest wait timesfive to seven years or more on the waiting lista new study finds there may be a benefit to accepting a kidney from a deceased diabetic donor. In a study published today in the Clinical Journal of the American Society of Nephrology, researchers from the Perelman School of Medicine at the University of Pennsylvania , have found that the best chance of survival, for older patients, those who live in areas with long waits for transplantation, or those who already have diabetes, may come from accepting a kidney from a deceased donor who had diabetes. Most often, these organs are considered high-risk as diabetes is a risk factor for kidney disease, and there may be underlying kidney damage that is not detected in initial organ screenings prior to transplantation, said lead author Jordana Cohen, MD, MSCE, an instructor of Medicine in the division of Renal-Electrolyte and Hypertension. However, there are many patients on the wait list who will die before they receive a kidney transplant. For these patients, based on this study, their best chance of survival and of having a better quality of life may come from accepting this kind of organ. Researchers performed an observational study of 437,619 kidney transplant candidates using data from the Organ Procurement and Transplantation Network database. They identifie Continue reading >>

Kidney/pancreas Transplant

Kidney/pancreas Transplant

Whole organ pancreas transplantation is intended for patients with type 1 diabetes with secondary complications. The majority of patients will have kidney failure due to diabetic nephropathy and will either undergo a simultaneous kidney and pancreas transplant or will have received a prior kidney transplant with stable function. Patients with advanced heart disease may not be candidates for pancreas transplantation. A small minority of patients may qualify for pancreas transplantation alone or islet transplantation if they have life-threatening episodes of hypoglycemic unawareness or extremely unstable diabetes. Each patient is evaluated for pancreas or islet transplantation on an individual basis. Simultaneous Pancreas/Kidney (SPK) Transplantation Candidate Criteria To be considered for Simultaneous Pancreas/Kidney (SPK) Transplant Evaluation, individuals must meet the following criteria: 1. Type I Insulin-Dependent Diabetes Mellitus less than 45 years of age - Individuals over age 45 considered on an individual basis after approval by the Director of Pancreas Transplant Program 2. Problems with conventional therapies to manage glucose control (ADA Guidelines, 1998) history of metabolic complications requiring medical care incapacitating clinical and/or emotional problems with exogenous insulin therapy life-threatening hypoglycemic unawareness a) creatinine clearance of 25 ml./min. or less b) elevated serum creatinine, where the renal function is inadequate to support the patient in the face of immunosuppression with either cyclosporine or tacrolimus Note: Individuals with renal insufficiency may be evaluated before initiating dialysis or placement of dialysis access. Since the waiting time for a cadaver SPK transplant is usually more than one year, and can exceed two Continue reading >>

Transplanting Diabetic Kidneys Better Than Remaining On Waitlist

Transplanting Diabetic Kidneys Better Than Remaining On Waitlist

Transplanting Diabetic Kidneys Better Than Remaining on Waitlist Transplanting Diabetic Kidneys Better Than Remaining on Waitlist Overall, recipients of diabetic donor kidneys had a 9% lower chance of dying compared with remaining on the waitlist. Transplanting high-risk diabetic donor kidneys provides a survival advantage over staying on the waitlist for many candidates, researchers reveal. Using the Organ Procurement and Transplantation Network database, Jordana B. Cohen, MD, MSCE, of the University of Pennsylvania in Philadelphia, and colleagues compared 8101 recipients of diabetic donor kidneys and 126,560 recipients of nondiabetic donor kidneys who underwent surgery following the first diabetic donor kidney transplant in 1994. Over a median follow-up of 8.9 years, the mortality rate was 35 deaths per 1000 person-years, according to results published online ahead of print in the Clinical Journal of the American Society of Nephrology. Recipients of diabetic donor kidneys had 9% lower odds of dying from any cause compared with patients who stayed on the waitlist indefinitely or ultimately received a non-diabetic donor kidney. When accepted by appropriate candidates, diabetic donor kidneys have the potential to shorten waitlist times, and ideally reduce the risk of death on the waitlist, Dr Cohen and the team stated. Patients with high mortality risk with long wait times appear to benefit most, they added. This group includes people with diabetes. In contrast, recipients of diabetic donor kidneys who were younger than 40 years experienced no survival benefit from diabetic donor kidneys. Notably, using marginal diabetic donor kidneys carried risks. Diabetic donor kidneys with a more than 85% score on the Kidney Donor Profile Index (KDPI) offered no survival benefit. Am Continue reading >>

Outcomes Of Simultaneous Pancreas-kidney Transplantation In Type 2 Diabetic Recipients

Outcomes Of Simultaneous Pancreas-kidney Transplantation In Type 2 Diabetic Recipients

Outcomes of Simultaneous Pancreas-Kidney Transplantation in Type 2 Diabetic Recipients *Department of Medicine, David Geffen School of Medicine, University of CaliforniaLos Angeles, Los Angeles, California; Department of Nephrology, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil; and Department of Nephrology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan, Republic of China Suphamai Bunnapradist, 1033 Gayley Avenue, Suite 208, Los Angeles, CA, 90024. Phone: 310-794-8516; Fax: 310-794-8589; E-mail: bunnapradist{at}mednet.ucla.edu Background and objectives Type 2 diabetic patients with end-stage renal disease may receive a simultaneous pancreas-kidney (SPK) transplant. However, outcomes are not well described. Risks for death and graft failure were examined in SPK type 2 diabetic recipients. Design, setting, participants, & measurements Using the United Network for Organ Sharing database, outcomes of SPK transplants were compared between type 2 and type 1 diabetic recipients. All primary SPK adult recipients transplanted between 2000 and 2007 (n = 6756) were stratified according to end-stage pancreas disease diagnosis (type 1: n=6141, type 2: n=582). Posttransplant complications and risks for death and kidney/pancreas graft failure were compared. Results Of the 6756 SPK transplants, 8.6% were performed in recipients with a type 2 diabetes diagnosis. Rates of delayed kidney graft function and primary kidney nonfunction were higher in the type 2 diabetics. Five-year overall and death-censored kidney graft survival were inferior in type 2 diabetics. After adjustment for other risk factors, including recipient (age, race, body weight, dialysis time, and cardiovascular comorbidities), donor, and transpla Continue reading >>

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