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• W2901508442 abstract "In this issue of the American Journal of Transplantation, Fridell et al1Fridell JA, Niederhaus S, Curry M, Urban R, Fox A, Odorico J. The survival advantage of pancreas after kidney transplant [published online ahead of print 2018]. Am J Transplant. https://doi.org/10.1111/ajt.15106Google Scholar retrospectively analyze the outcomes of pancreas transplant recipients from the Organ Procurement and Transplantation Network database. In summary, receiving a pancreas graft increased patient survival when compared to those who remained on the waiting list (WL) for a simultaneous kidney pancreas (SPK). Though these results are not unexpected for SPK recipients, the authors highlight a survival advantage in those who received a kidney transplant and later a pancreas after kidney (PAK). Despite the novelty of these findings, caution may be advisable when interpreting the results and deciding to propose PAK or SPK to patients. PAK transplantation posed an attractive alternative to SPK at the beginning of this century, when average WL for an SPK was increasing. Fridell et al analyze patients included on the WL or transplanted between 1995 and 2010. During this period, patients’ mortality on hemodialysis reduced significantly (as much as 19% between 2003 and 2011) because of the improvement in dialysis techniques, and novel immunosuppression protocols (ie, induction with thymoglobulin) improved the overall results of pancreas transplantation. Therefore, the inclusion of a wide span of time may underrate the long-term patient survival on dialysis and bias the survival benefit observed for the PAK group. The authors demonstrate survival is superior in PAK recipients compared to those remaining on the WL for SPK. Interestingly, long-term PAK survival is inferior to SPK or even kidney transplant alone recipients. These may partially explain the overall reduction in the number of PAK procedures performed in the United States in recent years, or translate a similar experience to that recently published in our group, in which acute rejection incidence was significantly superior in PAK groups without the expected increase in patient nor graft survival.2Ventura-Aguiar P Ferrer J Revuelta I et al.Pancreas outcomes between living and deceased kidney donor in pancreas after kidney transplantation patients.Nephrol Dial Transplant. 2018; 33: 2052-2059Crossref PubMed Scopus (8) Google Scholar Cardiovascular events (CVE) incidence in living-donor kidney transplant alone recipients are superior to those who receive a SPK,3Lindahl JP Hartmann A Aakhus S et al.Long-term cardiovascular outcomes in type 1 diabetic patients after simultaneous pancreas and kidney transplantation compared with living donor kidney transplantation.Diabetologia. 2016; 59: 844-852Crossref PubMed Scopus (28) Google Scholar and the long-term survival benefits have been previously demonstrated if the pancreas had functioned at least 90 days (P = .0442).4Barlow AD Saeb-Parsy K Watson CJE An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK Transplant Registry study.Transpl Int. 2017; 30: 884-892Crossref PubMed Scopus (30) Google Scholar The strict glycemic control obtained through pancreas transplantation may account for this benefit. In the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications trial, in type 1 diabetic patients, the reduction in CVEs in patients under intensive diabetic control reduced the incidence of any cardiovascular disease by 30% and the incidence of major cardiovascular events (nonfatal myocardial infarction, stroke, or cardiovascular death) by 32%.5Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research GroupIntensive diabetes treatment and cardiovascular outcomes in type 1 diabetes: the DCCT/EDIC study 30-year follow-up.Diabetes Care. 2016; 39: 686-693Crossref PubMed Scopus (343) Google Scholar In the article herein published, PAK failed to improve the survival benefit compared to kidney transplant alone (mortality of 28.4 vs 13.7%, respectively). Mortality risk was most evident during the first 90 days, likely because of the risk of surgical complications, but failed to improve as up as 10 years following pancreas transplantation. In summary, pancreas transplantation is the best treatment to patients with end-stage renal disease and type 1 diabetes, but improvement in dialysis treatments and in pancreas graft survival should turn our focus into long-term results rather than 12-month outcomes. A comprehensive knowledge of patients’ expected WL vintage for an SPK is perhaps the key point when offering our patients’ PAK or SPK, in which those with an expected 2-year WL vintage perhaps benefit from a PAK. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation." @default.
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• W2901508442 date "2019-04-01" @default.
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• W2901508442 title "Do we still need to demonstrate the survival benefit of pancreas transplantation?" @default.
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