Review
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World J Transplant. Jun 24, 2014; 4(2): 102-110
Published online Jun 24, 2014. doi: 10.5500/wjt.v4.i2.102
Transplant options for patients with type 2 diabetes and chronic kidney disease
Costas Fourtounas
Costas Fourtounas, Department of Internal Medicine-Nephrology, Patras University Hospital, 26500 Patras, Greece
Author contributions: Fourtounas C solely contributed to this paper.
Correspondence to: Costas Fourtounas MD, PhD, Associate Professor of Internal Medicine-Nephrology, Department of Internal Medicine-Nephrology, Patras University Hospital, Rio, Patras, 26500, Greece. cfourt@usa.net
Telephone: +30-69-44763781   Fax: +30-26-10999724
Received: November 28, 2013
Revised: March 20, 2014
Accepted: May 14, 2014
Published online: June 24, 2014
Processing time: 234 Days and 4.4 Hours
Abstract

Chronic kidney disease (CKD) has become a real epidemic around the world, mainly due to ageing and diabetic nephropathy. Although diabetic nephropathy due to type 1 diabetes mellitus (T1DM) has been studied more extensively, the vast majority of the diabetic CKD patients suffer from type 2 diabetes mellitus (T2DM). Renal transplantation has been established as a first line treatment for diabetic nephropathy unless there are major contraindications and provides not only a better quality of life, but also a significant survival advantage over dialysis. However, T2DM patients are less likely to be referred for renal transplantation as they are usually older, obese and present significant comorbidities. As pre-emptive renal transplantation presents a clear survival advantage over dialysis, all T2DM patients with CKD should be referred for early evaluation by a transplant center. The transplant center should have enough time in order to examine their eligibility focusing on special issues related with diabetic nephropathy and explore the best options for each patient. Living donor kidney transplantation should always be considered as the first line treatment. Otherwise, the patient should be listed for deceased donor kidney transplantation. Recent progress in transplantation medicine has improved the “transplant menu” for T2DM patients with diabetic nephropathy and there is an ongoing discussion about the place of simultaneous pancreas kidney (SPK) transplantation in well selected patients. The initial hesitations about the different pathophysiology of T2DM have been forgotten due to the almost similar short- and long-term results with T1DM patients. However, there is still a long way and a lot of ethical and logistical issues before establishing SPK transplantation as an ordinary treatment for T2DM patients. In addition recent advances in bariatric surgery may offer new options for severely obese T2DM patients with CKD. Nevertheless, the existing data for T2DM patients with advanced CKD are rather scarce and bariatric surgery should not be considered as a cure for diabetic nephropathy, but only as a bridge for renal transplantation.

Keywords: Bariatric surgery; Cardiovascular complications; Diabetes; Renal transplantation; Pancreas transplantation

Core tip: Kidney transplantation has been established as a first line treatment for patients with type 2 diabetes mellitus (T2DM) and diabetic nephropathy, as it is accompanied with a significant survival advantage over dialysis. Pre-emptive living donor kidney transplantation should be the ultimate goal unless there are obvious contraindications and all patients should be referred for early evaluation by a transplant center. There is an ongoing debate about the exact role of simultaneous pancreas kidney transplantation. At the moment it should be offered only in well selected T2DM patients. Bariatric surgery may serve as a bridge for renal transplantation for severely obese T2DM patients with chronic kidney disease.