Simultaneous pancreas and kidney transplant (SPK) has yielded promising outcomes for patients with challenging Type 2 Diabetes Mellitus (T2MD) and may prove particularly important to patients dealing with health care disparities who have limited access to diabetes therapies.

Lisa McElroy, MD, MS, a Duke abdominal transplant surgeon and researcher, encourages more frequent consideration of SPK as an option for many patients with T2DM and kidney damage.

“Some specialists suggest that pancreas transplant has been rendered extinct because of the availability of insulin pumps and monitors for patients with diabetes,” McElroy says. “But this is actually a falsehood because a substantial number of patients with diabetes simply lack access to these advanced therapies.”

McElroy, whose research focuses on equitable access to transplant for historically marginalized populations, says that barriers to care limit access to continuous glucose monitors (CGM) and insulin pumps.

“We can and should be expanding this transplant option to our patients with diabetes,” McElroy says, citing key advantages:

• Shorter wait times for SPK compared to kidney alone; additionally, the quality of the kidney is almost always higher.
• Steady improvement in patient graft survival following SPK.
• Independence from insulin and glucose monitoring.
• Improved metabolic control.
• Longer life expectancy and improved quality of life compared with no transplant or kidney transplant alone.

“I encourage transplant clinicians to remember that this is therapy has the potential to do a lot of good for many patients,” McElroy says. “That is especially true for those patients with uncontrolled diabetes who lack access to care.”

Stuart J. Knechtle, MD, executive director of the Duke Transplant Program, is also an advocate for the procedure. “Combined pancreas-kidney transplantation is an outstanding solution for many patients with brittle diabetes and renal failure,” Knechtle says. “It should be used more often to extend and improve quality of life.”

Jashalynn German, MD, a senior research fellow in the Division of Endocrinology, Metabolism and Nutrition, recognizes the need for improved referral practices.  "Referrals for pancreas transplantation have historically been considered as options exclusively for Type 1 Diabetes Mellitus patients and referrals for kidney transplantation in T2DM patients are often considered after patients have progressed to severe renal dysfunction. With growing data highlighting the benefits of SPK transplantation in poorly controlled T2DM, there is a vast opportunity to improve disparities and outcomes related to diabetes." 

Baseline survival rates are poor among patients with unmanaged T2DM and renal failure, McElroy says. SPK improves outcomes compared to kidney transplant alone within that patient population and is more effective at extending life compared to pancreas transplant alone (PTA).

Identifying options for patients with uncontrolled T2DM is critical to their long-term health, McElroy says, because many of those individuals lack access to continuous glucose monitors and insulin pumps. Additionally, as a result of kidney dysfunction and unpredictable insulin metabolism, as well as diabetes-related complications such as gastroparesis which complicates food intake and digestion, these patients often struggle with the complex diet and medication regimens needed to attain diabetes control, says Matthew J. Ellis, MD, medical director of the Duke Kidney and Pancreas Transplant Program.

“I often see patients, mostly affected by social determinants of health, with very brittle diabetic disease,” McElroy says. “They are usually on dialysis and are often labeled as non-compliant.

But diabetes is simply a more challenging condition to treat for these patients. In many cases, they should not be described as non-compliant and, if appropriate, should be considered for SPK.”

According to Scientific Registry of Transplant Recipients data, the number of pancreas transplants nationally decreased in 2020 to 962 compared with 1015 in 2019. This is due at least partly to the COVID-19 pandemic, the registry reports. The number of SPK and PTA transplants decreased by 5.2% and 12.1%, respectively, while pancreas after kidney transplants increased 9.1%.

McElroy predicts SPK and PTA transplants will increase as transplant teams recognize the value of the procedure. “If we are continuing to get so much better at this, why are we not doing more of these procedures? This is a particularly significant question for patients in our region in the Southeast U.S., where diabetes prevalence is growing so dramatically.”