Clinical Briefing: Transplantation for Diabetic
Patients with Kidney Disease
March/April 2008
Home to one of the oldest and most-established kidney
transplant programs in
the world, the Penn Transplant Institute is among the few transplant centers
currently providing comprehensive care for diabetic patients
with end-stage renal
disease (ESRD). Diabetes is
associated with a mortality rate that exceeds 50% within
three years of dialysis initiation.
Given
these risks, preemptive kidney transplantation from a living
donor is the preferred treatment at Penn for eligible
patients with diabetic nephropathy. Preemptive kidney transplantation
has been found to result in dramatic survival and quality
of life benefits to patients with advanced kidney disease.
For
patients with type 1 diabetes, the Penn Transplant Institute
offers the option of pancreas
transplantation. The pancreas
is most often transplanted simultaneously with a kidney (simultaneous
pancreas/kidney transplant, or SPK). Patients who receive
a living donor kidney may subsequently receive a pancreas
at a later time (pancreas after kidney, or PAK). Islet after
kidney transplantation is available for selected patients
as part of an investigational study.
Case Study
Mr. L, a 47-year-old man with type 1 diabetes
and stage 4 chronic kidney disease, was referred to the Penn
Transplant Institute for evaluation. Comorbidities related
to diabetes included retinopathy, gastroparesis and labile
hyperglycemia.
On examination, Mr. L's BMI was 28, BP 150/77
mmHg, pulse was 86 bpm. Medications included insulin glargine
24 U/d, cinacalcet HCl 180 mg/d, furosemide 40 mg/d, lisinopril
20 mg/d and epoetin alfa 5,000 U/wk. Laboratory evaluation
revealed a random serum glucose level at 174 mg/dl; C-peptide
0.45 ng/ml; BUN 62 mg/dl; serum creatinine (Cr) 4.8 mg/dl;
and albumin 3.8 g/dl. A persantine-MIBI cardiac stress test
was negative. Mr. L was placed on the regional waiting list
for a simultaneous pancreas-kidney transplant.
At this time,
Mr. L's wife – 42 years old, in excellent health with normal
kidney function – was
determined to be a compatible living kidney donor. Mr. L's
residual kidney function declined progressively. His estimated
GFR 11 months later was 12 ml/min; he had increasing fatigue
and anorexia.
Mr. L and his wife decided to proceed with
a pre-emptive living donor kidney transplantation; he would
remain on the waiting list for a subsequent pancreas. Kidney
transplantation was accomplished following laparoscopic nephrectomy
from Mrs. L. Both patients had uneventful recoveries.
“Successful
transplantation in diabetic patients with advanced
kidney disease can result in substantial improvement
in life expectancy and profound improvements
in quality of life.”
– Roy
D. Bloom, MD
Medical Director,
Penn Kidney/Pancreas Transplant Program |
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Six
months post-transplantation, Mr. L had a Cr of 1.4 mg/dl
and felt “great” other
than symptoms related to intermittent hypoglycemia. The next
year, he underwent successful pancreas transplantation and
experienced immediate euglycemia. His HgbA1c was 5.7% within
four months of transplant. Today, more than three years after
living donor kidney transplantation and 20 months after pancreas
transplant, his prognosis is considered excellent.
Our Team of Faculty
An international leader in kidney transplantation,
the Penn Transplant Institute is comprised of a multidisciplinary
team of specialists with expertise in managing transplant-related
issues pertaining to kidney diseases, infectious diseases,
diabetes, cardiology, radiology and nephropathology.
These
clinicians are strongly supported by an experienced and dedicated
infrastructure of personnel whose common goal is to work
with patients, their families and primary nephrologists to
provide comprehensive care for renal transplant patients.
This network of providers develops individualized treatment
and follow-up care from initial evaluation through postoperative
care and beyond.
Transplant Nephrology
Roy D. Bloom, MD
Medical Director, Kidney/Pancreas
Transplant Program
Associate Professor of Medicine
Robert A. Grossman, MD
Professor of Medicine
Simin Goral, MD
Associate Professor of Medicine
Alden M. Doyle, MD, MPH,
MS
Assistant Professor of Medicine
Karen Warburton, MD
Assistant Professor of Clinical Medicine
Transplant Surgery
Ali Naji, MD, PhD
Surgical Director, Kidney Transplant
Program;
J. William White Professor
of Surgical Research
Peter L. Abt, MD
Assistant Professor of Surgery
Clyde F. Barker, MD
John Rhea Barton Professor of Surgery;
Donald Guthrie Professor of Surgery
Transplant Pharmacist
Jennifer Trofe, PharmD
Adjunctive Assistant Professor of Medicine
Transplant Infectious Diseases
Emily Blumberg, MD
Associate Professor of Medicine
Nephrology
Hospital of the University
of Pennsylvania
Jeffrey S. Berns, MD
Professor of Medicine and Pediatrics
Debbie Cohen, MD
Assistant Professor of Medicine
Joel
Glickman, MD*
Clinical Associate Professor of Medicine
Robert Grossman,
MD
Professor of Medicine
Sidney
Kobrin, MD*
Associate Professor of Medicine
Raymond Townsend, MD
Professor of Medicine
Alan Wasserstein, MD
Associate Professor of Medicine
Penn Presbyterian Medical
Center
Raphael Cohen, MD
Clinical Associate Professor
of Medicine
Brenda Hoffman, MD
Associate Professor of Clinical
Medicine
Michael Rudnick, MD
Associate Professor of Medicine
Renal Pathology
John Tomaszewski, MD
Professor of Pathology and
Laboratory Medicine
*Also at Penn Medicine at Radnor
Selected Clinical Studies
- Clinical, Immunologic, and
Pharmacologic Consequences of
Kidney Transplantation in People
with HIV Infection
- Coronary Screening for Kidney
Transplantation (COST study)
- Use of Novel Immunosuppressive
Agents in Kidney Transplantation e.g.
Belatacept, AEB, ISA 247, Alafacept
- Outcomes in Kidney
Transplant
Patients with Hepatitis C Infection
- Arterial Mechanics
after Kidney
Donation
- Cardiovascular Disease and Coronary
Calcification in Kidney Recipients
Access
Patient appointments are available at:
Penn Transplant Institute
Kidney and Pancreas Transplant Program
Hospital of the University
of Pennsylvania
Rhoads Ground Level
3400 Spruce Street
Philadelphia, PA 19104
To refer a patient and/or consult
with a doctor:
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Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
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