We read with interest the “KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation” published in the April 2020 issue of Transplantation,1 and we congratulate the authors for this important work. However, we are surprised to see the omission of patients with type 2 diabetes mellitus (DM) (often identified by having a normal c-peptide) as potential candidates for simultaneous pancreas-kidney transplantation (SPK) (Recommendation 8.1.1: We suggest candidates with ESKD and type 1 DM be considered for simultaneous pancreas-kidney transplantation in regions where this procedure is available [2A]). Numerous studies in the past decade have shown that carefully chosen SPK recipients with type 2 DM have comparable outcomes including patient and graft survival, reduction in overall morbidity, and improvement in quality-of-life metrics as those with type 1 DM. An analysis of the primary deceased donor pancreas transplants in patients with type 2 DM reported to International Pancreas Transplant Registry/United Network of Organ Sharing between 1995 and 2015 showed that SPK is a safe procedure with excellent pancreas and kidney graft outcome in patients with type 2 DM.2 In addition, in the United States, the Organ Procurement and Transplantation Network policy reflecting careful review of these data does not differentiate between type 1 and type 2 DM patients for SPK candidacy and allows the treatment option for any diabetic patient on insulin.3 Certainly, careful patient selection is paramount.
Furthermore, restriction of SPK solely to type 1 DM patients disadvantages African Americans. In the United States, White Americans are more likely to develop type 1 DM, but the prevalence of type 2 DM is 1.4-fold to 2.3-fold higher in African Americans compared with White Americans. African Americans bear a disproportionate burden of the morbidity associated with diabetes, including a higher rate of retinopathy, microalbuminuria, end-stage kidney disease, lower-extremity amputation, and significant mortality. The waiting time for transplant is longer for African Americans than White candidates, and living-donor kidney transplantation rate is lowest for African Americans compared with all other racial groups. SPK allows for both shorter waiting time and often better-quality kidneys as compared with receiving a deceased donor kidney transplant alone, when living-donor kidney transplantation is not an option.
Although a major revision to the US pancreas allocation system in 2014 has resulted in a demonstrable increase in pancreas transplant volume, the needs of the diabetic community remain unmet.4 Largely driven by SPK, pancreas transplants in patients with type 2 DM have increased, with comparable results to type 1 DM recipients.5 The proportion of patients with type 2 DM on the waiting list increased to 14.6% in 2018 (Figure 1), with SPK candidates accounting for 74.2% of the list.5 We respectfully request that KDIGO guidelines incorporate current evidence and practice to recommend SPK to medically suitable diabetic patients on insulin regardless of type. This change would be an important step to reduce the inequities in access to transplant benefits to racial minorities with type 2 DM.
1. Chadban SJ, Ahn C, Axelrod DA, et al. KDIGO clinical practice guideline on the evaluation and management of candidates for kidney transplantation. Transplantation. 2020;104:S11–S103.
2. Gruessner AC, Laftavi MR, Pankewycz O, et al. Simultaneous pancreas and kidney transplantation—is it a treatment option for patients with type 2 diabetes mellitus? An analysis of the international pancreas transplant registry. Curr Diab Rep. 2017;17:44.
3. Pancreas Transplantation Committee. OPTN/UNOS Policy Notice Proposal to Change Waiting Time Criteria for Kidney-Pancreas Candidates. Available at https://optn.transplant.hrsa.gov/media/2541/pancreas_policynotice_201807.pdf
. Accessed October 15, 2020.
4. Parsons RF, Alhamad T, Lentine KL, et al. Survey on solid organ pancreas transplantation in the United States: plenty of insulin, short on procedures! [abstract]. Am J Transplant. 2020;20(suppl 3). Available at https://atcmeetingabstracts.com/abstract/survey-on-solid-organ-pancreas-transplantation-in-the-united-states-plenty-of-insulin-short-on-procedures/
. Accessed October 17, 2020.
5. Kandaswamy R, Stock PG, Gustafson SK, et al. OPTN/SRTR 2018 annual data report: pancreas. Am J Transplant. 2020;20:131–192.