Endocrine Abstracts

Introduction: Today simultaneous pancreas-kidney transplantation (SPKT) is an effective method of treatment for patients with type 1 diabetes mellitus (T1D) and terminal stage of diabetic nephropathy (DN) on renal replacement therapy by hemodialysis. It solves several problems: reduces the severity of intoxication syndrome, contributes to the achievement of euglycemia in most cases, that allows to delay progression of micro- and macrovascular diabetic complications. Case DescriptionА 56-years-old Caucasian woman with T1D, end-stage renal disease (ESRD) underwent successful SPKT in October 2014 after 8 years haemodialysis therapy. T1D was diagnosed 34 years ago. Insulin therapy was initiated immediately, but glycemic compensation hadn’t been achived after T1D onset due to lack of constant glycemic self-control (patient had 3 diabetic ketoacidosis, impaired awareness of hypoglycemia). Late diagnosis of DN (macroalbuminuria, uremia, blood pressure over 180/110 mm Hg since 2002) and late nephroprotective therapy prescription led to rapid progression of chronic kidney disease (CKD) to the terminal stage. Nonproliferative and proliferative diabetic retinopathy OS and OD respectively were diagnosed in 2011, neuropathic osteoarthropathy (DNOAP) of the right ankle joint - 2013. During 7 years after transplantation she is still euglycaemic without insulin therapy (glycated hemoglobin 5.7%, C-peptide 1.93 ng/ml) with creatinine of 70-90 μmol/l, estimated glomerular filtration rate 45.8 mL/min (stage 3a normoalbuminuric CKD), normal hemoglobin and blood pressure levels. Continuous glucose monitoring registrated hypoglycemic episodes (2.0 mmol/l). The tertiary hyperparathyroidism (HPT) treatment with cinacalcet stabilized calcium-phosphorus metabolism (corrected calcium for albumin 2.38 mmol/l, phosphate 1.03 mmol/l, parathyroid hormone 107.9 pg/ml, 25(OH)D 41.3 ng/ml), bone densitometry scores: T-score is −3.7 at the femoral neck, −2.0 L1-L4, -5.5 total radius. Surgical treatment of HPT was recommended. Patient received the standard triple immunosuppressive therapy, now receives double therapy. Despite euglycemia diabetes complications progressed to proliferative retinopathy OU, hemophthalmos OS, bilateral DNOAP in 2021. The patient has cardiovascular complications: cerebrovascular disease, atherosclerosis (stenosis of the right common carotid artery 35%, the right posterior tibial artery – 65%).

Conclusion: SPKT is the best treatment option for patients with T1D and ESRD. Unfortunately, even successful SPKT can’t guarantee reverse development of diabetic complications, persisting at the moment of transplantation. The progression of complications may be associated with the continued influence of accumulated "metabolic memory" markers (advanced glycation end products (AGEs), receptor for AGEs, etc.). After transplantation such patients need strict control by nephrologist, endocrinologist, cardiologist, etc. to maintain positive results of euglycaemia and kidney function normalization.