Nephrol Dial Transplant (1995) 10 [Suppl. 7]: 58-60
Nephrology
Dialysis
Transplantation
Renal transplantation in patients with type 2 diabetes mellitus
Michael M. Hirschl
Department of Emergency Medicine and Department of Nephrology, University of Vienna, Wahringer Gurtel 18-20, A-1090
Vienna, Austria
Key words: renal transplantation, non-insulindependent diabetes mellitus, vascular complications
Introduction
Dialysis units in several countries throughout the world
are currently overwhelmed by the patient load resulting
from end-stage renal failure due to diabetic nephropathy [1,2]. The acceptance of diabetic patients with
end-stage renal disease (ESRD) for renal replacement
therapy (RRT) has increased over the last years [2].
Whereas renal transplantation for type 1 diabetic
patients is now widely accepted, the appropriate RRT
for type 2 diabetic patients is still a matter of dispute
[2]. As demonstrated by Raine, the majority of type 2
diabetic patients with ESRD remained on chronic
haemodialysis treatment. Only 10-15% of all type 2
diabetic patients received a renal allograft [2,4]. The
aim of this review is to analyse the outcome of type 2
diabetic patients after renal transplantation compared
to type 2 diabetic patients remained on chronic haemodialysis treatment. Additionally, factors influencing the
survival of type 2 diabetic renal allograft recipients
should be identified.
Results
Survival data of diabetic renal allograft recipients
The overall 1-year survival was between 63% and 88%
(Table 1). The 5-year survival ranged from 11% to
59%. There was a significant difference in survival
compared to renal transplant recipients without diabetes mellitus (average 5-year survival: 74% [3]).
Comparison of survival data of type 1 and type 2
diabetic renal allograft recipients
Cumulative survival rate of type 1 and type 2 diabetic
renal allograft recipients are similar. The overall 5-year
survival rate was 62% versus 58% [3].
Comparison of survival rate of type 2 diabetic patients
after renal transplantation and type 2 diabetic patients
maintained on chronic hemodialysis treatment
Survival was better in diabetic renal transplant recipients as compared with diabetic patients maintained on
chronic haemodialysis treatment (Table 2). The age of
renal transplant recipients and patients maintained on
chronic haemodialysis did not differ significantly
Table 1. 1- and 5-year survival of diabetic patients after renal
transplantation
Gonzalez-Carrillo [9]
Hirschl [4]
Krakauer[10]
Correspondence and offprint requests to: Department of Emergency Rimmer [5]
Medicine and Department of Nephrology, University of Vienna, Khauli[ll]
Wahringer Gurtel 18-20, A-1090 Vienna, Austria.
© 1995 European Dialysis and Transplant Association-European Renal Association
1-Year survival
5-Year survival
63%
88%
79%
83%
81%
11%
59%
65% (3-year survival)
not mentioned
45%
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Abstract. The proportion of type 2 diabetic patients
considered for renal transplantation has continuously
increased over the last decade. Type 2 diabetic patients
who received a renal allograft had a higher survival
rate compared with patients maintained on chronic
haemodialysis treatment. Diabetic patients with a history of myocardial infarction, stroke, or peripheral
gangrene before renal transplantation had a worse
prognosis compared with patients without vascular
complications. No significant difference of survival was
observed between type 1 and type 2 diabetic patients
after renal transplantation. The main causes of death
were myocardial infarction and septical peripheral
gangrene. A history of myocardial infarction, stroke,
peripheral gangrene is an independent predictor of
decreased survival in type 2 diabetic patients. Renal
transplantation improved survival of diabetic patients
without vascular complications and should be considered as the treatment of choice in this group of patients.
However, a prospective multicentre study should be
initiated to establish guidelines for the management of
type 2 diabetic patients with end-stage renal disease.
Transplantation with type 2 diabetes mellitus
59
Table 2. Patient survival after start of renal replacement therapy
and according to treatment modality (from Hirschl et al[4])
Hemodialysis
Transplantation
1-Year
3-Year
4-Year
5-Year
46%
88%
8%
80%
4%
69%
2%
59%
Amputated
Non-amputated
(61.4 + 7.1 versus 61.6±7.9 years) and duration of
diabetes was comparable (15.5 + 7 versus 14.9 ±7.3
years). The 5-year survival was 59% in diabetic renal
transplant recipients compared to 2% in diabetic
patients maintained on haemodialysis.
The presence of severe vascular complications
(/><0.0003) and the duration of diabetes (P<0.0061)
were inversely related to outcome [4]. In patients with
a history of myocardial infarction, stroke or peripheral
gangrene a serious decrease in survival was observed.
Thus, the 1-year and the 5-year survival rates were
only 40% and 2% for type 2 diabetic renal allograft
recipients (Figure 1).
Significant coronary artery disease (>70% stenosis
of a coronary vessel or moderate to severe left ventricular dysfunction) reduced survival of diabetic patients
significantly (Table 3).
Beginning one year after transplantation the rate of
patient loss appeared to be greater in amputees than
in nonamputees (Table 4).
survival probability (%)
100
2
3
4
5
years
WITHOUT SVC
WITH SVC
Fig. 1. Influence of severe vascular complications (SVC) on survival.
Table 3. Influence of coronary artery disease (CAD) on survival of
diabetic renal allograft recipients (from Khauli et al. [11])
With CAD
Without CAD
*P< 0.0002.
1-Year survival
5-Year survival
94%
76%
40%*
19%'
2-Year survival
4-Year survival
89%
75%
96%
86%
Table 5. Causes of death in type 2 diabetic patients after renal
transplantation
Grennfell[12]
Rinuner [5]
Hirschl [4]
Gonzalez-Carrillo [9]
Stroke
Sepsis
Ma
Others
25%
30%
16%
0%
38%
23%
16%
40%
23%
30%
50%
40%
14%
17%
18%
20%
Causes of death
Cardiovascular disease and sepsis were the most
common causes of death accounting for two-third of
deaths. Causes of death were similarly distributed in
patients with and without a history of vascular
complications. However, death occurred significantly
earlier, if vascular complications were present before
haemodialysis treatment was begun (5.6+1.8 versus
18.5 + 2 months; P<0.01) (Table 5).
Discussion
In the last 10 years, the number of diabetic patients
with ESRD accepted for RRT has increased worldwide
[2]. Whereas renal transplantation for type 1 diabetic
patients is now widely accepted, the optimal treatment
for type 2 diabetic patients with ESRD is still
controversially discussed [2]. Type 2 diabetic patients
are often not considered for renal transplantation. As
demonstrated by Hirschl et al. type 2 diabetic patients
without vascular complications should be considered
for renal transplantation, as survival of these patients
improved markedly as compared to type 2 diabetic
patients maintained on chronic haemodialysis treatment [4]. In contrast, renal transplantation was not
able to improve the survival rate of type 2 diabetic
patients with ESRD, if a history of vascular complications was evident. Therefore, with regard to the shortage of organ donors, the higher perioperative and
postoperative morbidity and mortality, a conservative
treatment should be considered.
Controversial results as to the influence of the type
of diabetes have been reported. As demonstrated in
the recent literature, no such differences could be
observed, with similar survival rates in type 1 and
type 2 diabetic patients [3]. It can be assumed that a
difference in the proportion of patients with vascular
complications between the two groups may have biased
reported data on survival rates in type 1 and type 2
diabetic patients. As no differences between the type 1
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Factors prior to transplantation related to survival of
type 2 renal allograft recipients
1
Table 4. Patient survival in amputated versus nonamputated diabetic
renal allograft recipients [6]
60
References
1. Gebert S, Lippert J, Ritz E. The apparent 'epidemic' increase in
the incidence of renal failure from diabetic nephropathy. Nephron
1993; 65: 160
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and type 2 diabetic patients after renal transplantation
could be observed, a different management of both
groups with regard to the consideration for renal
transplantation is not justified. As the existence of
severe vascular complications reduces greatly the survival of type 2 diabetic patients, it seems necessary to
establish preoperative diagnostic procedures, which
allow the identification of low- and high risk patients
prior to transplantation. Myocardial infarction remained one of the main causes of death in type 2
diabetic renal allograft recipients after transplantation.
Therefore, non-invasive and invasive evaluation of the
cardiac status of transplant candidates with type 2
diabetes mellitus seems mandatory. Surgical intervention has been described as a potential therapeutic
alternative with acceptable mortality but increased
morbidity [8]. In conclusion, renal transplantation is
able to improve the prognosis of type 2 diabetic
patients with end-stage renal disease and without vascular complications. The presence of vascular complications prior to transplantation reduces the survival
of type 2 diabetic patients. However, the interpretation
of these data must be made with caution, because
most of the Studies were retrospective. A prospective
multicentre study should be initiated to establish guidelines for the management of type 2 diabetic patients
with end-stage renal failure.
M.M. Hirschl
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