Prognosis And Risk Factor Analysis Of Simultaneous Pancreas-Kidney Transplantation In Diabetes Mellitus Patients

Objective:For patients with end-stage renal disease(ESRD)complicated by diabetes mellitus,simultaneous pancreas-kidney transplantation(SPKT)is a viable treatment option when the disease has progressed to the point of requiring kidney transplant.We conducted a study comparing transplant kidney and patient survival rates,as well as identifying postoperative risk factors for patient survival,between SPKT patients and deceased donor kidney transplant(DDKT)patients as a control group among kidney transplant recipients with T1 DM or T2 DM.Methods:This study is based on the Kidney-Pancreas Transplant Database(KIDPAN DATA)released by the United Network for Organ Sharing(UNOS)in June 2021,which contains relevant data on all kidney and pancreas transplant events that have occurred in the United States since January 27,2003.We retrospectively analyzed kidney transplant recipients with type 1 or type 2 diabetes mellitus who underwent kidney transplantation or simultaneous pancreas-kidney transplantation(SPKT)between January 27,2003 and January 1,2021,and divided patients into DDKT and SPKT groups according to the surgical procedure.Follow-up data for included patients were collected until June 2021.We used the Kaplan-Meier method to compare transplant kidney and patient survival rates between the two groups,and used univariate and multivariate COX regression models to analyze independent risk factors affecting patient survival after surgery.Results:1.There were 10,977 and 6,367 recipients with type 1 diabetes mellitus(T1DM)who underwent SPKT and DDKT,respectively,and 1,561 and 48,669 recipients with type 2diabetes mellitus(T2DM)who underwent SPKT and DDKT,respectively.In both T1 DM and T2 DM patients,compared to the DDKT group,patients who received SPKT had lower recipient age,recipient BMI,Panel reactive antibody(PRA)levels,waiting time,dialysis time,transplant history,peripheral vascular disease history,diabetes onset age,donor age,donor BMI,Kidney Donor Profile Index(KDPI),and cold ischemic time,as well as a higher proportion of male recipients and male donors,private insurance coverage,death due to traumatic brain injury,and number of HLA mismatches.In terms of early prognosis,both T1 DM and T2 DM patients showed a lower incidence of delayed graft function,longer hospitalization time,and lower serum creatinine at discharge in the SPKT group than in the DDKT group.Unlike T2 DM patients,T1 DM patients who underwent SPKT had a lower incidence of primary non-function of the transplanted kidney than those who underwent DDKT.2.The Kaplan-Meier survival analysis demonstrated that in T1 DM transplant recipients,both the graft and patient survival were superior in the SPKT group compared to the DDKT group(P<0.001),with median survival times of 15.44 years and 9.92 years,respectively.Similarly,in T2 DM transplant recipients,both the graft and patient survival were better in the SPKT group compared to the DDKT group(P<0.001),with median survival times of 13.73 years and 8.91 years,respectively.3.By propensity score matching,we obtained subgroups with the same number of patients and no statistically significant differences in matching variables.Kaplan-Meier survival analysis was performed on the generated subgroups.The results of subgroup analysis showed that in both T1 DM and T2 DM transplant recipients,SPKT patients had better transplant kidney and patient survival than DDKT patients(P<0.001).4.We performed COX regression analysis to calculate the hazard ratio(HR)of SPKT group compared with DDKT group.The results showed that,compared with DDKT group,in T1 DM renal transplant recipients,the use of SPKT reduced the risk of death by 38%(a HR,0.62 [0.57–0.68]);in T2 DM renal transplant recipients,the use of SPKT reduced the risk of death by 32%(a HR,0.68 [0.59–0.78]).5.The results of univariate and multivariate COX regression analysis showed that in T1 DM patients receiving SPKT,recipient age,recipient BMI,recipient race,presence of private health insurance,transplantation history,recipient peripheral vascular disease history,donor age,donor race,donor history of hypertension,and cold ischemia time of the donated kidney were independent risk factors for post-SPKT patient survival.In T2 DM patients,recipient race and cold ischemia time of the donated kidney were independent risk factors for post-SPKT patient survival.Conclusion:Compared to DDKT,SPKT results in better long-term transplant kidney and patient survival rates in both T1 DM and T2 DM kidney transplant recipients.The use of SPKT reduces the risk of death by 38% and 32% in T1 DM and T2 DM kidney transplant recipients,respectively,compared to DDKT.In T1 DM patients,we recommend SPKT for recipients of other races and those with private health insurance.In T2 DM patients,we recommend SPKT for recipients of other races.