Larsen J L, Stratta R J
Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-3020, USA.
J Investig Med. 1994 Dec;42(4):622-31.
PKT has become an important option in selected IDDM patients being considered for kidney transplantation because of its ability to offer superior glycemic control and improved quality of life. As both kidney graft survival and overall mortality are comparable following PKT and kidney transplantation alone at many centers, neither the survival of the patient nor the success of the kidney transplant need be jeopardized by the addition of a pancreas graft. The greater morbidity of PKT can be justified by the evidence that a pancreas graft will prevent recurrent diabetic nephropathy, result in greater improvements in sensory/motor neuropathy, and in some but not all studies, cause greater stabilization of eye disease. Improvements in lipid profiles observed after PKT but not after kidney transplant alone may predict better cardiovascular outcomes as well. Determination of who should receive an isolated pancreas transplant is more complex. Success rates are lower than after PKT. It remains important to ascertain that the candidate is susceptible to diabetic complications, or has repeated bouts of hypoglycemia or ketoacidosis unresponsive to other measures to justify the risks of long-term immuno-suppression. More difficult to determine is whether or when individuals who have advancing diabetic complications yet relatively preserved renal function (creatinine clearance > 70 mL/min) should become candidates. For now, each individual is considered on a case by case basis and the relative risks and benefits for each individual are carefully assessed. However, patient selection will be greatly aided by further research assessing the long-term risks and benefits of all types of pancreas transplantation. Pancreas transplantation will remain an important option in the treatment of IDDM until alternative strategies are developed that can provide equal glycemic control with less or no immunosuppression or less overall morbidity. Most of the research to date has concentrated on the consequences of pancreas transplantation on microvascular complications. However, cardiovascular disease events represent the greatest cause of mortality in pancreas transplant candidates. Thus, changes in cardiovascular risk after pancreas transplantation may be more important to long-term survival than any other factor and should receive greater attention in future studies.
由于能够提供更好的血糖控制并改善生活质量，胰肾联合移植（PKT）已成为考虑进行肾移植的特定1型糖尿病（IDDM）患者的重要选择。在许多中心，PKT后的肾移植存活率和总体死亡率与单纯肾移植相当，因此增加胰腺移植不会危及患者的生存或肾移植的成功。PKT较高的发病率可通过以下证据来证明：胰腺移植可预防糖尿病肾病复发，在感觉/运动神经病变方面有更大改善，并且在一些（但并非所有）研究中可使眼部疾病得到更大程度的稳定。PKT后观察到的血脂改善情况在单纯肾移植后未出现，这也可能预示着更好的心血管结局。确定谁应接受单独的胰腺移植更为复杂。成功率低于PKT。确定候选人易患糖尿病并发症，或反复出现低血糖或酮症酸中毒且对其他措施无反应，对于证明长期免疫抑制的风险仍然很重要。更难确定的是，糖尿病并发症进展但肾功能相对保留（肌酐清除率>70 mL/分钟）的个体是否以及何时应成为候选人。目前，对每个个体进行逐案考虑，并仔细评估每个个体的相对风险和益处。然而，通过进一步研究评估所有类型胰腺移植的长期风险和益处，将极大地有助于患者的选择。在开发出能够提供同等血糖控制且免疫抑制较少或无免疫抑制或总体发病率较低的替代策略之前，胰腺移植仍将是IDDM治疗的重要选择。迄今为止，大多数研究都集中在胰腺移植对微血管并发症的影响上。然而，心血管疾病事件是胰腺移植候选人死亡的最大原因。因此，胰腺移植后心血管风险的变化对长期生存可能比任何其他因素都更重要，应在未来研究中得到更多关注。
