pidemiological data from CDC suggest that 16 million (I in 20) Americans suffer from Diabetes mellitus in the United States.
Diabetic nephropathy is the primary cause of End stage renal disease (ESRD) in 45% of all patients undergoing chronic
dialysis and in 31% of patients living with kidney transplants in the United States (USRDS-2012). Because of the underlying
metabolic problems, diabetic renal transplant recipients have significantly higher frequency of infections (bacterial and fungal),
rapid progression of occlusive vascular disease (coronary and peripheral arterial occlusion) and bone disease with spontaneous
fractures, compared with the non-diabetic control subjects. Those with pre existing clinical vascular disease have significantly
lower survival and higher morbidity in the post transplant period. Although the ?
? studies have shown depressed T cell
function in a hyperglycemic environment, the risk of clinical acute rejection appears to be equal in both diabetic and non-diabetic
renal allograft recipients. In diabetic ESRD patients, renal transplantation provides significant survival advantage compared to
chronic dialysis (5 year patient survival: 87% vs. 54%). In the transplanted diabetics, cardiovascular disease accounts for 2/3rds
of total deaths and chronic allograft nephropathy for 54% of the graft loss. In those with functioning kidneys, the mean GFR was
73 ml/min. Randomized controlled studies have shown that optimal glycemic control in the post transplant period delays the
recurrence of diabetic microangiopathy in the transplanted kidneys. Of those with functioning kidneys at 6 months, 63% have
attained full rehabilitation and 31% partial rehabilitation and 6% were disabled.
In type I diabetic ESRD patients, simultaneous Kidney-Pancreas transplantation is the preferred modality of therapy.
Compared to cadaver donor Kidney transplantation alone, the addition of pancreas allograft improves the long term survival
(10 year survival: 60% vs. 70%). The euglycemic state attained with a functioning pancreas transplant, lowers the cardiovascular
mortality by 10% and in addition, improves the cardiac systolic and diastolic function and diminishes the pre existing
left ventricular hypertrophy compared to those who received kidney transplant alone. Over a 10 year period, the improved
glycemic state also results in reversal of the microvascular lesions of diabetic nephropathy in native kidneys. In summary, renal
transplantation offers better long term survival and improved quality of life for type II diabetic ESRD patients and the addition
of pancreas transplantation in type I diabetic patients enhances these benefits and also halts the progression of both macro and
micro vascular complications. At present, lack of sufficient donor organs is the major stumbling block in improving the long term
survival and quality of life of diabetic patients with end stage renal disease
Venkateswara K. Rao received his medical degree from Andhra University in India and post graduate training in Nephrology and Renal transplantation
at the University of Cincinnati college of Medicine. He served as Medical director of transplantation programs at Minneapolis, Atlanta and Shreveport.
He published over 100 articles and served on editorial boards of 3 major scientific journals.
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