medwireNews: People with type 1 diabetes who undergo pancreatic islet-after-kidney (IAK) transplantation have significantly better survival rates and are less likely to return to dialysis than those who undergo kidney transplantation alone, research suggests.
François Pattou (CHU Lille, France) and co-investigators say their findings “potentially serve as compelling grounds for advocating wider access to islet transplantation in patients with type 1 diabetes undergoing kidney transplant, as reimbursement of islet transplantation is provided in few countries worldwide.”
The KAIAK study, with its target emulation trial design, included data for 2391 patients with type 1 diabetes who received a kidney transplant in France between 2000 and 2017. Of these, 47 also received islet transplantation (≤3 sequential islet infusions in 6 months).
After taking various confounding factors into account, 40 patients who underwent IAK transplantation were propensity score matched with 80 patients treated with kidney transplantation alone.
During the 16-year study period, 33% of patients in the IAK transplantation group and 45% of those in the kidney transplantation alone group returned to dialysis or died. The mortality rates were 20% and 31%, respectively, with most deaths due to infection, the researchers report in The Lancet Diabetes & Endocrinology.
They found that the adjusted risk for the primary outcome of patient–graft survival, a composite measure that included death, re-transplantation, or return to dialysis, was a significant 56% lower with IAK transplantation than with kidney transplantation alone. This risk reduction was mainly due to a significant 59% lower risk for death with IAK transplantation than kidney transplantation alone, Pattou et al remark.
In line with this, the investigators revealed that life expectancy with a functional graft was a significant 19.6 months longer among IAK transplant recipients than among kidney transplant only recipients, at 13.2 years versus 11.5 years.
Similarly, overall life expectancy was 20.1 months longer with IAK transplantation than with kidney only transplantation, at 13.7 years versus 11.9 years.
Using this information, Pattou and colleagues calculated that 4.0 patients needed to be treated with IAK transplantation to prevent a single death or return to dialysis, and 3.2 needed to be treated to prevent a single death.
Of note, IAK transplantation was not associated with a reduced risk for death-censored graft survival, defined as the probability of returning to dialysis or requiring re-transplantation, where death while being transplanted is not considered as graft failure.
In terms of glycemic control, the patients who underwent IAK transplantation had significantly lower glycated hemoglobin levels than those given kidney transplantation alone at all timepoints from 6 months to 5 years.
In an accompanying comment, Shareen Forbes (University of Edinburgh, UK) and Thomas Kay (University of Melbourne, Victoria, Australia) say the KAIAK study “demonstrates the value of β-cell replacement in a vulnerable patient group that have poor glycaemic control, often with co-morbidities which make intensifying insulin management challenging.”
They add: “Integrating this innovative therapy into current clinical practice to improve long-term prognosis is crucial and the availability of this therapeutic option is key: urgent assessment of the policy implications is required with a need for health-care systems to expand reimbursement and availability of this intervention.”
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