Kidney-Pancreas Transplantation

(Journal Article): Low-Protein Vegetarian Diet with Alpha-Chetoanalogues Prior to Pre-emptive Pancreas-Kidney Transplantation
 
Piccoli GB, Motta D, Martina G, Consiglio V, Gai M, Mezza E, Maddalena E, Burdese M, Colla L, Tattoli F, Anania P, Rossetti M, Soragna G, Grassi G, Dani F, Jeantet A, Segoloni GP (Chair of Nephrology, Department of Internal Medicine, University of Turin, Corso Dogliotti 16, 10126 Torino, Italy, giorgina.piccoli(at)unito.it )
 
IN: Rev Diabetic Stud 2004; 1(2):95-102
Impact Factor(s) of Rev Diabetic Stud: 0.125 (2006)

Fulltext:    HTML  PDF

ABSTRACT: BACKGROUND: Pre-emptive pancreas-kidney transplantation is increasingly considered the best therapy for irreversible chronic kidney disease (CKD) in type 1 diabetics. However, the best approach in the wait for transplantation has not yet been defined. AIM: To evaluate our experience with a low-protein (0.6 g/kg/day) vegetarian diet supplemented with alpha-chetoanalogues in type 1 diabetic patients in the wait for pancreas-kidney transplantation. METHODS: Prospective study. Information on the progression of renal disease, compliance, metabolic control, reasons for choice and for drop-out were recorded prospectively; the data for the subset of patients who underwent the diet while awaiting a pancreas-kidney graft are analysed in this report. RESULTS: From November 1998 to April 2004, 9 type 1 diabetic patients, wait-listed or performing tests for wait-listing for pancreas-kidney transplantation, started the diet. All of them were followed by nephrologists and diabetologists, in the context of integrated care. There were 4 males and 5 females; median age 38 years (range 27.9-45.5); median diabetes duration 23.8 years (range 16.6-33.1), 8/9 with widespread organ damage; median creatinine at the start of the diet: 3.2 mg/dl (1.2-7.2); 4 patients followed the diet to transplantation, 2 are presently on the diet, 2 dropped out and started dialysis after a few months, 1 started dialysis (rescue treatment). The nutritional status remained stable, glycaemia control improved in 4 patients in the short term and in 2 in the long term, no hyperkalaemia, acidosis or other relevant side effect was recorded. Proteinuria decreased in 5 cases, in 3 from the nephrotic range. Albumin levels remained stable; the progression rate was a loss of 0.47 ml/min of creatinine clearance per month (ranging from an increase of 0.06 to a decrease of 2.4 ml/min) during the diet period (estimated by the Cockroft-Gault formula). CONCLUSIONS: Low-protein supplemented vegetarian diets may be a useful tool to slow CKD progression whilst awaiting pancreas-kidney transplantation.

TYPE OF PUBLICATION: Case Report

REFERENCES:

1. Stratta RJ, Taylor RJ, Ozaki CF, Bynon JS, Miller SA, Knight TF, Fischer JL, Neumann TV, Wahl TO, Duckworth WC. A comparative analysis of results and morbidity in type I diabetics undergoing pre-emptive versus postdialysis combined pancreas-kidney transplantation. Transplantation 1993. 55:1097-1103.
2. Sudan D, Sudan R, Stratta R. Long-term outcome of simultaneous kidney-pancreas transplantation: analysis of 61 patients with more than 5 years follow-up. Transplantation 2000. 69:550-555.
3. Gross CR, Limwattananon C, Matthees B, Zehrer JL, Savik K. Impact of transplantation on quality of life in patients with diabetes and renal dysfunction. Transplantation 2000. 70:1736-1746.
4. Kessler M, Frimat L, Panescu V, Briancon S. Impact of nephrology referral on early and midterm outcomes in ESRD: EPidemiologie de l'Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study. Am J Kidney Dis 2003. 42:474-485.
5. Chantrel F, Enache I, Bouiller M, Kolb I, Kunz K, Petitjean P, Moulin B, Hannedouche T. Abysmal prognosis of patients with type 2 diabetes entering dialysis. Nephrol Dial Transplant 1999. 14:129-136.
6. Stoves J, Bartlett CN, Newstead CG. Specialist follow up of patients before end stage renal failure and its relationship to survival on dialysis. Postgrad Med J 2001. 77:586-588.
7. Harvey JN. Diabetic nephropathy. BMJ 2002. 325: 59-60.
8. Cupisti A, Licitra R, Chisari C, Stampacchia G, D'Alessandro C, Galetta F, Rossi B, Barsotti G. Skeletal muscle and nutritional assessment in chronic renal failure patients on a protein-restricted diet. J Intern Med 2004 255:115-124.
9. Aparicio M, Chauveau P, De Precigout V, Bouchet JL, Lasseur C, Combe C. Does nutrition affect the prognosis of aged hemodialysis patients? Nephrologie 2002 23:77-83.
10. Kopple JD, Berg R, Houser H, Steinman TI, Teschan P. Nutritional status of patients with different levels of chronic renal insufficiency. Modification of Diet in Renal Disease (MDRD) Study Group. Kidney Int 1989. 27: S184-194.
11. Waugh NR, Robertson AM. Protein restriction for diabetic renal disease. Cochrane Database Syst Rev 2000. 2:CD002181.
12. Barsotti G, Navalesi R, Giampietro O, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Effects of a vegetarian, supplemented diet on renal function, proteinuria, and glucose metabolism in patients with 'overt' diabetic nephropathy and renal insufficiency. Contrib Nephrol 1988. 65:87-94.
13. Barsotti G, Ciardella F, Morelli E, Cupisti A, Mantovanelli A, Giovannetti S. Nutritional treatment of renal failure in type 1 diabetic nephropathy. Clin Nephrol 1988. 29:280-287.
14. Piccoli GB, Grassi G, Mezza E, Gai M, Iacuzzo C, Bechis F, Biancone L, Jeantet A, Dani F, Cavallo Perin P, Segoloni GP. Early referral of Type 2 diabetic patients: are we ready for the assault? Nephrol Dial Transplant 2002. 17:1241-1247.
15. Piccoli GB, Soragna G, Mezza E, Putaggio S, Motta D, Gai M, Anania P, Fop F, Bermond F, Burdese M, et al. Lost to follow-up: the bottleneck of early referral to renal units? Med Sci Monit 2003. 9:493-499.
16. Laszlo J. Oncology in Wyngaarden JB, Smith LH Jr, (eds.). Cecil Textbook of Medicine. WB Saunders, PA 1988, pp 1082-1089.
17. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987. 11:8-13.
18. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 2002. 39 (Suppl 1):S1-S266.
19. Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int 1985. 27:58-65.
20. Viberti GC, Mogensen CE, Passa P, Bilous R, Mangili R. St Vincent Declaration, 1994. Guidelines for the prevention of diabetic renal failure in the kidney and hypertension in diabetes mellitus. In: Mogensen CE (ed). Kluwer Academic Publishers, Boston, 1994; pp 527-551.
21. Ritz E, Rychlik I, Locatelli F, Halimi S. End-stage renal failure in type 2 diabetes: A medical catastrophe of worldwide dimensions. Am J Kidney Dis 1999. 34:795-808.
22. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997. 14 (Suppl. 5):S1-S85.
23. Teschan PE, Beck GJ, Dwyer JT, Greene T, Klahr S, Levy AS, Mitch WE, Snetselaar LG, Steinman TI, Walser M. Effect of a ketoacid-aminoacid-supplemented very low protein diet on the progression of advanced renal disease: a reanalysis of the MDRD feasibility study. Clinical Nephrol 1998. 50:273-83.
24. Joss N, Paterson KR, Deighan CJ, Simpson K, Boulton-Jones JM. Diabetic nephropathy: how effective is treatment in clinical practice? Q J Med 2002. 95:41-49.

(Journal Article): Tailored Immunosuppression and Steroid Withdrawal in Pancreas-Kidney Transplantation
 
Rossetti M, Piccoli GB, Burdese M, Guarena C, Giraudi R, Mezza E, Consiglio V, Soragna G, Messina M, Segoloni GP (Chair of Nephrology, Department of Internal Medicine, University of Turin, Corso Bramante 86-88, 10126 Torino, Italy, giorgina.piccoli(at)unito.it )
 
IN: Rev Diabetic Stud 2004; 1(3):129-136
Impact Factor(s) of Rev Diabetic Stud: 0.125 (2006)

Fulltext:    HTML  PDF

ABSTRACT: BACKGROUND: Recent improvements in simultaneous pancreas-kidney transplantation (SPK) and the striking decrease in acute rejection lead us to focus on the effects of long-term immunosuppression. AIM OF THIS STUDY: Evaluation of a policy of steroid withdrawal and tailored immunosuppression in pancreas-kidney patients treated in a single center. METHODS: review of the clinical charts in 9 SPK recipients (male/female = 5/4, median age 41 years, median follow-up 42 months), by the same operator, under supervision of the two usual caregivers. Therapeutic protocols. Induction phase: all patients received mycophenolate mophetil (starting dose: 2 grams), tacrolimus and steroids, 8 received Simulect, 1 received thymoglobulins. Maintenance therapy was slowly reduced, with the goal of steroid withdrawal. RESULTS: The therapeutic adjustments were mainly determined by two almost opposing elements: 1. Rapid adjustments in the case of side-effects (gastrointestinal problems, infections and neoplasia); 2. Slow tapering off in the case of good organ function. On the other hand, a switch to cyclosporine A and to rapamycine was considered in the case of chronic organ malfunction. By these means, over a median of 42 months follow-up, steroid withdrawal was slowly obtained in 6/9 patients (at a median time of 25 months). CONCLUSIONS: Within the limits of this small-scale study, a tailored immunosuppressive policy allows at least some "positively selected" patients to reach the "dream" of steroid withdrawal after SPK.

TYPE OF PUBLICATION: Original article

REFERENCES:

1. Becker BN, Odorico JS, Becker YT, Groshek M, Werwinski C, Pirsch JD, Sollinger HW. Simultaneous pancreas-kidney and pancreas transplantation. J Am Soc Nephrol 2001. 12:2517-2527.
2. Mohan P, Safi K, Little DM, Donohoe J, Conlon P, Walshe JJ, O'Kelly P, Thompson CJ, Hickey DP. Improved patient survival in recipients of simultaneous pancreas-kidney transplant compared with kidney transplant alone in patients with type 1 diabetes mellitus and end-stage renal disease. Br J Surg 2003. 90:1137-1141.
3. Wynn JJ, Distant DA, Pirsch JD, Norman D, Gaber AO, Ashby VB, Leichtman AB. Kidney and pancreas transplantation. Am J Transplant 2004. 4(Suppl 9):72-80.
4. Freise CE, Kang SM, Feng S, Posselt A, Hirose K, Hirose R, Stock P. Experience with steroid-free maintenance immunosuppression in simultaneous pancreas-kidney transplantation. Transplant Proc 2004. 36:1067-1068.
5. Stratta RJ, Shokouh-Amiri MH, Egidi MF, Grewal HP, Lo A, Kizilisik AT, Nezakatgoo N, Gaber LW, Gaber AO. Long-term experience with simultaneous kidney-pancreas transplantation with portal-enteric drainage and tacrolimus/mycophenolate mofetil-based immunosuppression. Clin Transplant 2003. 17(Suppl 9):69-77.
6. Gonin JM. Maintenance immunosuppression: new agents and persistent dilemmas. Adv Ren Replace Ther 2000. 7:95-116.
7. Kasiske BL, Snyder JJ, Matas AJ, Ellison MD, Gill JS, Kausz AT. Preemptive kidney transplantation: the advantage and the advantaged. J Am Soc Nephrol 2002. 13:1358-1364.
8. Hricik DE. Steroid withdrawal in renal transplant recipients: pro point of view. Transplant Proc 1998. 30:1380-1382.
9. Jordan ML, Chakrabarti P, Luke P, Shapiro R, Vivas CA, Scantlebury VP, Fung JJ, Starzl TE, Corry RJ. Results of pancreas transplantation after steroid withdrawal under tacrolimus immunosuppression. Transplantation 2000. 69:265-271.
10. Humar A, Parr E, Drangstveit MB, Kandaswamy R, Gruessner AC, Sutherland DE. Steroid withdrawal in pancreas transplant recipients. Clin Transplant 2000. 14:75-78.
11. Jindel RM, Joseph JT, Morris MC, Santella RN, Baines LS. Noncompliance after kidney transplantation: a systematic review. Transplant Proc 2003. 35:2868-2872.
12. Kaufman DB, Shapiro R, Lucey MR, Cherikh WS, T Bustami R, Dyke DB. Immunosuppression: practice and trends. Am J Transplant 2004. 4(Suppl 9):38-53.
13. Bassetti M, Salvalaggio PR, Topal J, Lorber MI, Friedman AL, Andriole VT, Basadonna GP. Incidence, timing and site of infections among pancreas transplant recipients. J Hosp Infect. 2004. 56:184-190.