Possible diabetic control options and outcomes
1. Possible diabetic control options, as well as their outcomes in terms of patient survival, postoperative complications, and graft(s) survival.
The patient is 42 years old and suffering from stage 5 chronic kidney disease, and the reason for the development of CKD 5 is diabetic nephropathy. This indicates that the patient’s kidneys are getting closer to failure, or that they might have already failed. In such cases kidney transplantation is done to save the life of the patient. Studies have shown that diabetic patients undergoing renal transplantation have a high rate of cardiovascular mortality post-transplantation. Infection and rejection are at their peak during the first 3 post-translational months where infection and rejection are at their peak. Thus, pre-transplant evaluation is required to check for any abnormalities that can be revered before the transplant. Studies have shown that recipients of kidney transplants having type 2 diabetes have a poor survival rate, with a mortality rate of 5 years. Pancreatic transplantation has been considered an avowed contradiction for T2DM patients . The concept relies on the T2DM pathophysiology where insulin resistance is the issue and extra insulin is not needed. Instead, better responsiveness of the peripheral tissue is required. In the case study, the patient was suffering from CKD5 and the main reason behind developing this condition is diabetic nephropathy. Thus, in this case, A kidney-pancreas transplant can help reduce the complications that might arise due to diabetes.
The next possible option for controlling diabetes is islet transplantation, which is the transplant of isolated pancreatic islets that are harvested from deceased donors. The islets are infused percutaneous in the vein portal. However, islets grafts can result in recipients’ alloimmunization through the production of anti-HLA antibodies de novo in titers that range from 10.8% to 31%. Patients undergoing liver transplantation and having coexisting T2DM islets can be a possible treatment. Studies conducted with five T2DM patients showed that three of them had a normal level of HBA1c and thus no insulin therapy was needed. Patients suffering from diabetes have a high risk of acute rejection after kidney transplantation. Studies have shown that patients who developed allograft rejection had worse glycaemic control in the hours after the surgery. Hyperglycaemia affects both immunity and inflammation during the early engraftment period. All of these factors contribute to graft rejection. With islet grafts, the patient’s diabetes can be controlled further, reducing the risk of associated complications like end-stage kidney disease and helping to improve the patient’s mortality
The next option is bariatric surgery, which can help to treat T2DM. The application of weight loss surgery can help in treating diabetes by controlling the blood glucose level. Further, T2DM is associated with obesity, which further leads to CKD. This option can be a bridge to transplantation for patients who are obese. In cases where the patient is obese, bariatric surgery can help treat diabetes, thus contributing to better patient outcomes and reducing the complications associated with the surgical process due to diabetes.
Hyperglycemia is linked with the risks of slow healing of wounds, infection, as well as loss of administered nutrients with the development of glycosuria. In order to control diabetes, insulin use is the best option as it has the timing flexibility as well as dose in the managing postoperative complications of diabetic patients. The combination of intermediate as well as long-acting insulins, together with short-acting insulins, is determined by the preferences and experience of physicians and health care providers . Intravenous insulin administration can be limited in the ICU as it is linked with the need for monitoring glucose frequently as well as the glucose response rapidity to intravenous insulin. In addition to insulin therapy, medical nutrition therapy, patient education, medical follow-up, and other factors are critical in ensuring long-term, excellent medical and surgical outcomes. the administration will help in facilitating the wound healing process by restoring the skin damage. As long as the patient has ketosis, insulin administration can help in preventing protein breakdown and worsening of ketosis, thus helping in reducing mortality and morbidity and improving patient survival.
Kidney-pancreas transplant and related complications
2. The prospective recipient’s evaluation!
The first step in trnasplanttaion is the evaluation of the recipient. It helps to determine the physical health of the patient but furteht helps to identify psychological issue that might affect the succesfult transplatiton. The evaluation will comprise of physical assessment, social work assesmnet, electrocardiogram, cardiac stress test, echocardiogram, blood test, chaest X-Ray, cardiac catheterization, colonoscopy, 24 hours urine test, panel reactive antibody, tissue typing, nutrition assessment, mammogram, etc.. The patient is 42 years old and suffering from stage 5 chronic kidney disease, and the reason for the development of CKD 5 is diabetic nephropathy. This indicates that the patient’s kidneys are getting closer to failure, or that they might have already failed. In such cases, the most cost-effective treatment is renal transplantation, also known as kidney transplantation. The patient has been presented to the transplant clinic and a transplant assessment needs to be done. Because of the disparity between transplant needs and cadaveric organ availability, the donor pool has been expanded to include living donors. Harvesting an organ from a healthy individual’s needs and transplanting the organs to the recipient requires careful preoperative assessment and evaluation to reduce the risk of complications both to the donor and the recipient (5 ; 6). As the patient is suffering from stage 5 CKD, he has more comorbidities.
Pretransplant imaging evaluation is a need globally. As the kidney of the donor is placed extraperitoneal in the iliac fossa of the recipient, anatomy knowledge, mostly the pelvic vascular anatomy, is vital for evaluating the potential vascular targets for the anastomosis. Inflow abnormalities vascularly or atherosclerotic vascular calcification impair graft survival and affect surgical techniques Next, assessment is done of the urinary bladder anatomy. Recipient imaging aims to detect the consonant that might contraindicate transplantation or that might get affected by immunosuppression in the long term that is needed for the transplant recipient. Complications associated with long-term immunosuppression include infection and malignancy. Recipients of kidney transplants are at high risk of post-transplant malignancy. This is attributable to the lack of adequate surveillance received by a transplant patients when compared to general ones. Immunosuppression can result in impairment of DNA repair and a decrease in immune regulation. PTM transmission from donor to recipient can occur. Following that, a chest radiograph is taken regularly to check for infection and lung nodules. chest imaging with computerized tomography may be indicated, depending on the risk factors of the patient for bronchogenic carcinoma . A CT scan of the pelvis and abdomen was also done. The intravenous contrast use depends on the patient’s renal function. in CKD 5, the prevalence of acquired renal cystic disease greater and is linked with a higher rate (6%) of renal cancer. A contrast-enhanced CT examination is generally done to evaluate a suspicious native renal lesion. If this cannot be performed, then we can go for the alternative ones that are the use of the US and non-contrast MR imaging. Cross-sectional imaging like CT is an ideal method to evaluate the bladder anatomy and potential vascular anastomosis targets.
Islet transplantation and associated risks
CKD patients gave a high prevalence of vascular calcification, and as in the X-ray pelvis of vascular calcification, it seems high. Extensive vascular calcification at the anastomosis site may result in difficulty for the surgeons in anastomosing the renal artery of the donor to the recipient artery. In more proximal arteries, the presence of the extensive atherosclerotic disease may prevent an adequate flow of blood to the transplanted kidney. Due to the high risk of peripheral arterial disease (PAD) due to a history of diabetes mellitus and heavy smoking, CT examination is indicated in this patient. Contrast-enhanced CTA can be the best for evaluating noncalcified plaque for inflow disease.
Furthermore, to evaluate the bladder, native kidneys, vascular system, and malignancy, a CT examination will help determine the presence of enough intra-abdominal space in the patient for a transplant as well as for planning the operation. to plan the operation. In ADPKD patients, screening for intracranial aneurysms (ICAs) before initiating surgical interventions is important, as they might have a higher incidence of ICAs, and major elective surgery might affect their intracranial hemodynamics. The imaging of choice includes CTA or time of flight (TOF) MRA, as contrast-enhanced MRA is contraindicated due to the risk of nephrogenic systemic sclerosis
3. Consult with the potential donor about kidney donation and her suitability as a donor.
Donating a kidney can be an emotional process. The transplant centers and Unity have different types of services available post-donation The stay at the hospital post-donation will vary depending on their recovery rate as well as the procedure that has been performed. Although the prospect of donating raises several concerns about one’s health and safety is important to educate the public that people with one kidney can live a normal life. If one kidney is removed, the other one increases its size in order to compensate for the loss due to the kidney donation. Physician exercise can be a good and effective approach to remain healthy. However, it is important to take certain measures in order to protect the kidney from injury. According to studies, avoiding contact sports such as boxing, soccer, football, hockey, wrestling, and martial arts is important.
Donors are further encouraged to have long-term follow-ups and a blood test, pressure check, and urine test are done per year One of the most common concerns that the donor might experience is that kidney donation can affect their life expectancy. In the case study, the donor is just 32 years old, and there might be these concerns that might lead to mental distress. Counseling the patient and educating them about the complications as well as strategies to live a better life is important post-donation. According to studies, the living donation does not affect life expectancy and increases the risk of kidney failure. it is important to remember that risk factors like hypertension can lead to end-stage kidney disease. Thus, while this matter is still under debate, it is important to maintain a normal BP by adopting a healthy lifestyle, self-management, administrative duties of medication, etc.
Bariatric surgery and its significance
Studies have shown that living donors might develop hypertension, and thus it is important to educate the patient about the risks associated with donation. The patient will have scars after the operation, and studies have shown that donors might suffer from pain, hernia, nerve damage, intestinal obstruction, etc. However, the involvement of social work intervention can help in reducing the anxiety that the patient can experience during donation. Supporting the donor emotionally and empathetically, as well as developing coping skills, can help them improve their cognitive function and reduce their burden of thought. Educating the donor on the benefits of joining a support group can help them communicate with others and share their experiences, which can help reduce stress and anxiety. Engaging with others who have had similar experiences can help them adjust to their new situation.
Donations can elicit a range of emotions, including anxiety, relief, depression, and joy. it is important that the door is referred to the social workers at the transplant hospitals, and that providing counseling can help to manage difficult emotions. In the case study, the donor is a 32-year-old sister of a 42-year-old patient. The patient is suffering from CKD 5 because of diabetic nephropathy. The patient’s sister has expressed her interest in donating one kidney to the patient. The donor’s blood pressure is controlled by 3 agents that are beta-blockers, angiotensin receptor antagonists, and calcium channel blockers. According to studies, kidney donation is a reasonable risk procedure for the donor as long as the screening as well as selection process is constructed in a way that reduces the risk of lifetime cardiovascular disease or kidney disease for the donor through the selection of people who are at a lower risk level for these outcomes . One of the most common reasons to discourage a potential kidney donor from being a candidate for donating a kidney is the presence of high arterial blood pressure. The rationale behind this is that high blood pressure is linked with high risk of end-stage kidney disease and a high risk of cardiovascular disease.
Accepting kidney transplants for living people with hypertension remains a matter of concern for the safety of the recipient as well as uncertainty regarding allograft outcome. Concerns about the donor’s safety arose as a result of hypertension is a risk factor for developing end-stage kidney disease. a reduction in renal mass might cause higher risk of kidney disease. Studies have shown that living donors with well-controlled hypertension, being nonobese (BMI 30), and the absence of end-organ damage are suitable for kidney donation. Studies have also shown that hypertensive kidney donors have complicated perioperative BP management. If they are on angiotensin-converting enzyme inhibitors, diuretics, and angiotensin-receptor blockers before donation, they need to be modified preoperatively due to volume shifts as well as adaptive hyperfiltration, which might be time-consuming as a current regimen, dosing flexibility, and choice of agents might result in side-effects.
In comparison with normotensive donors, the outcomes of allograft are conflicting for hypertensive donors. BP, which is controlled through 1 or 2 medications, is not a contraindication to kidney donation. However, the contradiction to donations involves poorly managed BP, end-organ damage, and the administration of 3 or more antihypertensive medications. However, the criteria for hypertension have significantly changed in the last few years. To be inclusive of kidney donors having elevated BP, it is important to allow them for controlling their blood pressure in an effective manner. According to recent studies, hypertensive donors are not “marginal” donors. Few of the guidelines suggest the use of AHMs or 24-hour ABPM BP readings > 140/90 mm Hg as a contraindication to donation. Studies have shown that if hypertensive donors were allowed to donate, there was not any increased risk of cardiovascular health issues. However, it is important to have personalized pharmacotherapy, beneficial lifestyle changes, and attend follow-up appointments to manage BP before and after donation of kidney.
Insulin administration and related factors
4. Proceeding with a donor who is normotensive and not on any medications, she has no proteinuria, but she has 2+ of blood on the dipstick.
Studies have shown that improving the transplantation rate is the only alternative available. The prospective pool of donors is growing with the increase in life expectancy. In prospective donors, the risk of cardiovascular diseases might be high due to the presence of prehypertension, obesity, metabolic syndromes, and asymptomatic urinary abnormalities like microscopic hematuria or hematuria. Although these asymptomatic urinary abnormalities may indicate the kidney disease later in life, the cause remains unknown. In the past, due to a higher perceived long-term risk, these candidates were denied the kidney donation option. However, if the risk is the minimum, these marginal donors should be given the chance to decide whether to take the risk or not. In such cases, ethnic community involvement can be fruitful. In the case study, if the donor is normotensive, has 2+ of blood on the dipstick, has no proteinuria, and is not on any medications, it might be indoctrinated that the patient is suffering from hematuria. Isolated hematuria may occur due to glomerular bleeding or extraglomerular causes such as prostatic disease, nephrolithiasis, urothelial malignancy, etc.
Glomerular bleeding occurs mainly because of 1 of the 3 disorders: thin basement membrane nephropathy, IgAN, or Alport’s syndrome. It is important to carry out a careful history and renal function assessment followed by repeated urinalysis on the family members. This can help in identifying the inheritance type and the genetic basis of the disease. Urine cytology, renal imaging, and cystourethroscopy should be performed on those with persistent microscopic hematuria to rule out the possibility of urothelial malignancy. renal ultrasound should be done to detect structural pathology like tumors, neoplasia, cysts etc., but its ability to detect small tumors is quite limited Computed tomography is also recommended with intravenous contrast. Prospective kidney donors must be informed about isolated, persistent, and asymptomatic microscopic hematuria which precludes the donation possibility. If the patient is determined to proceed then the biopsy is the next step.
A kidney biopsy will help determine whether the condition is IgAN, AS, or TBMN. In the event that the donor has AS and IgAN, they are not considered a candidate for donation. As TBMN and AS share historical abnormalities, there are high chances the patina might resemble TBMN, but in reality, it is AS. TBMN gets transmitted in an autosomal-dominant manner, thus screening is helpful for making this diagnosis. Immunohistochemistry and electron microscopy is helpful in differentiating TBMN from AS. Immunostaining can help in analyzing type IV collagen expression that will show no staining in Alport, normal staining in TBMN, and discontinuous staining in female carriers. TBMN with risk factors like hypertension and proteinuria must not be accepted as donors. However, controversies are still present regarding whether patients with TBMN and isolated hematuria to be accepted as donors or not. It will be suggested to not go for donation as this can affect the life of the patient as well as the donor. Understanding the cause of appearance of blood in urine is important to rule out the possibility of hematuria and thus the donors can opt for kidney donation.
5. The effect of alcohol consumption and smoking on transplantation outcomes
Cigarette smoking can result in chronic obstructive airway diseases, cancer, and coronary arteriopathies. Cigarette smoking is also linked to increased graft loss and mortality in kidney transplant recipients. It can result in poorer survival of the kidney that has been transplanted, mainly due to its role in vascular diseases, endothelial dysfunction, and atherosclerosis. Recipients of kidney transplants who have a smoking habit are at a higher risk of having coronary artery diseases. A lower survival rate due to smoking cigarette has been reported in various studies. Furthermore, smoking is linked with a high risk of developing cardiovascular diseases. As in the case of the study, the kidney transplant recipient has the prevalence of atherogenic risk factors that are hypertension and diabetes, and smoking is a risk factors that can lead to a high risk of cardiovascular events. Further, cigarette smoking causes high levels of activity of the sympathetic nervous system, increased thickness of the arterioles, loss of glomerular filtration rate, and worsens proteinuria in CKD.
In the case study, the patient’s estimated glomerular filtration rate (eGFR) of 15–59, and proteinuria can worsen with smoking cigarettes. This can further result in the transplanted kidney undergoing various stressors like cold ischemia, delayed graft function, warm ischemia, etc., which later lead to rejection as well as exposure to calcineurin inhibitors. These factors thus affect the survival of the graft. Studies have shown that quitting smoking for > 5 years before transplantation decreases the risk of graft failure by thirty-four percent. However, heavy smoking has a high risk of heart failure in comparison to moderate smoking. Smoking more than 25 packs of cigarettes per year at transplantation was associated with about a 30% greater risk of graft failure. In the case study, the patient is a heavy smoker and she has been consuming 20 cigarettes per day for the last fifteen years, increasing her risk of graft failure. Thus, the impact of smoking is deleterious on graft survival irrespective of whether it causes chronic obstructive airway disease. As mentioned earlier, cigarette smoking causes high levels of activity of the sympathetic nervous system, increased thickness of the arterioles, loss of glomerular filtration rate, and worsens proteinuria in CKD, Smoking cigarettes can result in chronic obstructive airway disease. However, studies have shown that the graft survival rate was reduced even when the patients with chronic obstructive airway diseases were eliminated. Smoking is linked with increased mortality in recipients of children transplanted One meta-analysis, conducted in solid organ transplantation, indicated a low rate of patient survival and a high rate of mortality among cigarette smokers. Previously, smoking more than 25 packs of cigarettes per year was linked with high mortality. Though active smoking was linked with reduced graft survival when compared to past smoking, both active and past smoking caused increased mortality rates for the recipients. Several epidemiologic studies have found late allograft rejection in bone marrow, heart, and kidney transplant recipients who smoke. smoking cigarettes affects the proper functioning of white blood cells.
Studies have shown that migration, as well as chemotaxis of polymorph nuclear cells, is reduced in smokers in comparison to nonsmokers. Macrophages isolated from the lungs of smokers have potent inhibitory effects on lymphocytes, causing a decrease in cellular immunity. It might lead to reduced pro-inflammatory cytokines like IL-1, IL-6, tumor necrosis factor, and IL-2. Moreover, there is an increase in CD8+ lymphocytes and a decrease in CD4+ cells in heavy smokers. As CD4+ lymphocytes are vital for the proliferation of B cells, decreased levels can result in the production of fewer antibodies. Further increases in CD8+ cells are linked with malignancy and infection. As a result, kidney transplant recipients may have lower immunity and a higher risk of infection. Smoking thus increases the risk of developing diseases like Legionnaires’ disease, influenza, varicella infections, tuberculosis, etc.
Next, the transplant recipients who are alcohol-dependent survive for shorter periods when compared to non-alcohol-dependent ones. According to the Cox model, alcohol dependency was linked with a high risk of graft failure. Studies have shown a J-shaped association among hypertension and alcohol consumption, were having 3 or more drinks a day increased the occurrence of hypertension. Thus, heavy alcohol consumption is linked with hypertension, which may lead to the development of renal disease. Further, in the case study, the patient drinks alcohol regularly, which can affect her outcomes post-transplantation.
Patients who are dependent on alcohol might have lifestyle habits that affect their survival, and they might not be compliant with their follow-up care and post-transplant treatment. All these together can result in poor recipient survival and graft survival. Studies have shown that more than two drinks a day increses the rsik of ESRD by 4 times and increased rsik of renal failure by 10 folds. Progressing microcirculatory bed alteration, parenchymatous organs fat degeneration, as well as atrophic and sclerotic processes in the lungs, brain, and liver were found in the patient with regular alcohol consumption. However, as chronic heavy alcohol consumption is linked to hypertension, the renal disease might develop. Alcohol affects the immune system through rising the circulating IgA levels, which is linked to cytokine production dysregulation and antibody production. The impact of acute alcohol ingestion includes the inhibition of pro-inflammatory cell activation. Prolonged consumption of alcohol leads to the activation of macrophages and monocytes and causes increases in proinflammatory cytokines that include interleukin (IL)-1, IL-6, tumor necrosis factor-a, IL-8, etc. (20) Furthermore, chronic alcohol ingestion leads to antioxidant glutathione depletion and severe oxidative stress. TGF-b is linked with chronic allograft nephropathy, causing renal graft fibrosis and early loss of function.
References
Fourtounas C. Transplant options for patients with type 2 diabetes and chronic kidney disease. World journal of transplantation. 2014 Jun 24;4(2):102.
Wang J, Chen K, Li X, Jin X, An P, Fang YI, Mu Y. Postoperative adverse events in patients with diabetes undergoing orthopedic and general surgery. Medicine. 2019 Jun;98(14).
Cohen JB, Tewksbury CM, Torres Landa S, Williams NN, Dumon KR. National postoperative bariatric surgery outcomes in patients with chronic kidney disease and end-stage kidney disease. Obesity surgery. 2019 Mar;29(3):975-82.
Kheir MM, Tan TL, Kheir M, Maltenfort MG, Chen AF. Postoperative blood glucose levels predict infection after total joint arthroplasty. JBJS. 2018 Aug 15;100(16):1423-31.
Harmath CB, Wood CG, Berggruen SM, Tantisattamo E. Renal pretransplantation work-up, donor, recipient, surgical techniques. Radiologic Clinics. 2016 Mar 1;54(2):217-34.
Alalawi F, Alnour H, Sharma A, Shaheen I, Kim JJ. Renal Transplant Recipient Workup; Obstacles and Challenges. J Renal Transplant Sci. 2019;2(1):60-72.
Yao J, Tovmassian D, Lau H, Allen R, Yuen L, Laurence J, Pleass H. Live kidney donor allograft lithiasis: a systematic review of stone related morbidity in donors. Transplantation. 2020 Sep 1;104(S3):S240.
Pittman J, Deans R, Brännström M. Medical Work-Up of the Recipient. Uterus Transplantation. 2020:73-8.
Kobiela J, Dobrzycka M, Danielewicz R, Jo?czyk J, ?achi?ski AJ, ?ledzi?ski Z, D?bska-?lizie? A. Colonoscopy as part of pre-transplant work-up in successful kidney transplant candidates: single-center experience and review of literature. Annals of Transplantation. 2018;23:782.
Adams MA, Andacoglu O, Crouch CE, de Santibañes M, Jackson WE, Jalal A, Montasser IF, Rubman S, Spiro M, Raptis DA, Miller C. Does pre?operative counselling of the donor improve immediate and short?term outcomes after living liver donation?–A review of the literature and expert panel recommendations. Clinical Transplantation. 2022 Mar 28:e14636.
Mjøen G, Maggiore U, Kessaris N, Kimenai D, Watschinger B, Mariat C, Sever MS, Crespo M, Peruzzi L, Spasovski G, Sørensen SS. Long-term risks after kidney donation: how do we inform potential donors? A survey from DESCARTES and EKITA transplantation working groups. Nephrology Dialysis Transplantation. 2021 Sep;36(9):1742-53.
Rastogi A, Yuan S, Arman F, Simon L, Shaffer K, Kamgar M, Nobakht N, Bromberg JS, Weir MR. Blood pressure and living kidney donors: a clinical perspective. Transplantation Direct. 2019 Oct;5(10).
Townsend RR, Reese PP, Lim MA. Should living kidney donors with hypertension be considered for organ donation?. Current opinion in nephrology and hypertension. 2015 Nov 1;24(6):594-601.
Yacoub R, Akl NK. Urinary tract infections and asymptomatic bacteriuria in renal transplant recipients. Journal of global infectious diseases. 2011 Oct;3(4):383.
Go??biewska J, D?bska-?lizie? A, Komarnicka J, Samet A, Rutkowski B. Urinary tract infections in renal transplant recipients. InTransplantation proceedings 2011 Oct 1 (Vol. 43, No. 8, pp. 2985-2990). Elsevier.
Coussement J, Scemla A, Hougardy JM, Sberro-Soussan R, Amrouche L, Catalano C, Johnson JR, Abramowicz D. Prevalence of asymptomatic bacteriuria among kidney transplant recipients beyond two months post-transplant: A multicenter, prospective, cross-sectional study. PloS one. 2019 Sep 6;14(9):e0221820.
Vadivel N, Stankovic A, Rennke HG, Singh AK. Accepting prospective kidney donors with asymptomatic urinary abnormalities: are we shooting in the dark?. Kidney international. 2007 Jan 2;71(2):173-7.
Khalil MA, Tan J, Khamis S, Khalil MA, Azmat R, Ullah AR. Cigarette smoking and its hazards in kidney transplantation. Advances in Medicine. 2017 Jul 27;2017.
Khalil MA, Tan J, Khamis S, Khalil MA, Azmat R, Ullah AR. Cigarette smoking and its hazards in kidney transplantation. Advances in Medicine. 2017 Jul 27;2017.
Gueye AS, Chelamcharla M, Baird BC, Nguyen C, Tang H, Barenbaum AL, Koford JK, Shihab F, Goldfarb-Rumyantzev AS. The association between recipient alcohol dependency and long-term graft and recipient survival. Nephrology Dialysis Transplantation. 2007 Mar 1;22(3):891-8.
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