Manske C L, Wang Y, Thomas W
Department of Medicine, University of Minnesota School of Medicine, Minneapolis, USA.
Lancet. 1995;346(8991-8992):1658-62. doi: 10.1016/s0140-6736(95)92838-3.
In the United States diabetes in now the principle cause of end-stage renal disease. For diabetic patients undergoing cadaveric kidney transplantation, a combined kidney-pancreas (KP) transplant is often recommended because this option is perceived to carry no additional risk. However, most transplant centres have restricted KP transplantation to patients with few diabetic complications and no coronary artery disease. We compared survival rates after KP transplantation with those after kidney transplantation alone in clinically similar though non-randomised patient groups. In 173 consecutive diabetic renal transplant candidates, 3-year patient survival in 54 KP recipients was 68%, versus 90% in 46 patients who received a cadaveric kidney alone (p = 0.01). The remaining patients had a living-related-donor kidney transplant, either alone (65) or followed 4-20 months later by a pancreas transplant (8), with survival similar to that with a cadaveric kidney. Independent variables associated with early death were age, history of congestive heart failure, and pancreas transplantation. A serious complication of pancreas transplantation was infection, or which 14 of 54 recipients required pancreatectomy; KP recipients had a higher death rate from infection in the first 12 months (p = 0.034). In view of the excess mortality associated with KP transplantation, we suggest that the combined operation should be reserved for young patients with no history of congestive heart failure, or for patients in whom hyperglycaemia is life-threatening. A randomised trial is needed to compare the long-term outcomes of these procedures.
在美国，糖尿病目前是终末期肾病的主要病因。对于接受尸体肾移植的糖尿病患者，通常建议进行肾胰联合移植（KP），因为这种选择被认为不会带来额外风险。然而，大多数移植中心已将KP移植限制于糖尿病并发症少且无冠状动脉疾病的患者。我们在临床情况相似但未随机分组的患者组中，比较了KP移植后的生存率与单纯肾移植后的生存率。在173例连续的糖尿病肾移植候选者中，54例KP受者的3年患者生存率为68%，而46例仅接受尸体肾移植的患者为90%（p = 0.01）。其余患者接受了亲属活体供肾移植，单独移植（65例）或在4至20个月后接受胰腺移植（8例），其生存率与尸体肾移植相似。与早期死亡相关的独立变量为年龄、充血性心力衰竭病史和胰腺移植。胰腺移植的一个严重并发症是感染，54例受者中有14例因感染需要行胰腺切除术；KP受者在最初12个月内死于感染的发生率更高（p = 0.034）。鉴于KP移植相关的额外死亡率，我们建议联合手术应仅用于无充血性心力衰竭病史的年轻患者，或用于高血糖危及生命的患者。需要进行一项随机试验来比较这些手术的长期结果。
