Transplant Options for Patients With Diabetes and Advanced Kidney Disease: A Review

Optimal glycemic control in kidney transplant recipients with diabetes is associated with improved morbidity, mortality and allograft survival. Transplant options for patients with diabetes requiring insulin therapy and chronic kidney disease who are suitable candidates for kidney transplantation should include consideration of β-cell replacement therapy: pancreas or islet transplantation. International variation, related to national regulatory policies, exists in offering one or both of these options to suitable candidates, and is further affected by pancreas/islet allocation policies and waiting list dynamics. Selection of appropriate candidates depends on patient age, co-existent morbidities, timing of referral to the transplant center (pre-vs. on dialysis) and availability of living kidney donors. Early referral is therefore of the utmost importance (ideally when eGFR is <30 ml/min/1.73 m2), to ensure adequate time for informed decision making and thorough pre-transplant evaluation. Obesity, CVD, peripheral vascular disease, smoking, and frailty are some of the conditions that need to be considered prior to acceptance on the transplant list, and ideally prior to dialysis becoming imminent. This review offers insights into selection of pancreas/islet transplant candidates by transplant centers and an update on post-transplant outcomes, which may have practice implications for referring nephrologists.