LONG-TERM RENAL-FUNCTION IN TYPE-I DIABETICS AFTER KIDNEY OR KIDNEY-PANCREAS TRANSPLANTATION - INFLUENCE OF NUMBER, TIMING, AND TREATMENT OF ACUTE REJECTION EPISODES

Background. Previous studies comparing renal function in diabetic subj ects receiving either a kidney or kidney-pancreas transplant generally have indicated no differences; however, these studies have been limit ed by inclusion of either a small number of patients or selected patie nts followed for relatively short periods of time. Methods. To compare long-term renal function and factors affecting renal function in type I diabetic patients receiving either kidney or kidney-pancreas transp lants, the slopes of regression lines generated by plotting the recipr ocal of serum creatinine (1/Cr) versus time were measured in 109 conse cutive patients followed for at least 12 and up to 102 months after tr ansplantation. Multivariate analyses included linear regression using the slope of 1/Cr versus time as the dependent variable and logistic r egression using a positive or negative slope as the dependent variable . Results. Significant differences between kidney-pancreas (n=64) and kidney recipients (n=45) included a smaller proportion of African-Amer icans, lower rates of HLA matching, lower levels of panel-reactive ant ibodies, shorter cold ischemia times, a lower incidence of delayed gra ft function, and a higher incidence of acute renal allograft rejection episodes in the kidney-pancreas group, Trough cyclosporine blood leve ls were significantly higher in the kidney-pancreas group for the firs t 12 posttransplant months. The slopes of 1/Cr versus time were negati ve in each group with a trend toward a more negative slope in the kidn ey-pancreas group, Multivariate analyses indicated that a concomitant pancreas allograft did not influence long-term renal function, The tot al number of renal rejection episodes was the best independent predict or of a negative slope of 1/Cr versus time, However, use of OKT3 for t he treatment of rejection within the first 3 months of transplantation exerted a surprisingly beneficial effect on long-term renal function, a phenomenon that was most apparent in the kidney-alone group, Conclu sions. The frequency and timing of acute rejection episodes are more i mportant than the influence of a simultaneously transplanted pancreati c allograft in determining long-term function of the transplanted kidn ey. A concerning trend toward late deterioration of renal function in kidney-pancreas recipients suggests that the benefits of sustained eug lycemia, shorter cold ischemia times, lower rates of sensitization, an d early use of OKT3 ultimately may be outweighed by the negative effec ts of more frequent renal rejection episodes.