The impact of simultaneous pancreas-kidney transplantation on long-term patient survival

Background. Simultaneous pancreas-kidney transplantation (SPK) ameliorates the progression of microvascular diabetic complications but the procedure i s associated with excess initial morbidity and an uncertain effect on patie nt survival when compared with solitary cadaveric or living donor renal tra nsplantation, We evaluated mortality risks associated with SPR, solitary re nal transplantation, and dialysis treatment in a national cohort of type 1 diabetics with end-stage nephropathy. Methods. A total of 13,467 adult-type 1 diabetics enrolled on the renal and renal-pancreas transplant waiting list between 10/01/88 and 06/30/97 were followed until 06/30/98. Time-dependent mortality risks and life expectancy were calculated according to the treatment received subsequent to wait-lis t registration: SPK; cadaveric kidney only (CAD); living donor kidney only (LKD) transplantation; and dialysis [wait-listed, maintenance dialysis trea tment (WLD)]. Results. Adjusted 10 year patient survival mas 67% or SPK vs. 65% for LKD r ecipients (P=0.19) and 46% for CAD recipients (P<0.001), The excess initial mortality normally associated with renal transplantation and the risk of e arly infectious death was S-fold higher in SPK recipients. The time to achi eve equal proportion of survivors as the WLD patients was 170, 95, and 72 d ays for SPK, CAD, and LKD recipients, respectively (P<0.001), However, the adjusted 5-year morality risk (RR) using WLD as the reference and the expec ted remaining life years were 0.40, 0.45, and 0.75 and 23.4, 20.9, and 12.6 years for SPK, LKD, and CAD, respectively. There was no survival benefit i n SPK recipients greater than or equal to 50 years old (RR=1.38, P=0.81), Conclusions. Among patients with type 1 DM with end-stage nephropathy, SPK transplantation before the age of 50 years was associated with long-term im provement in survival compared to solitary cadaveric renal transplantation or dialysis.