Response to A reassessment of the Survival Advantage of Simultaneous Kidney-Pancreas Versus Kidney-Alone Transplantation

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We find the article by Sung et al1 interesting for 2 reasons: (a) we are pleased that our earlier findings2 were confirmed in this large cohort study and b) we believe strongly that the observation period in this study was too short to show the full benefit of a simultaneous pancreas kidney (SPK) transplantation. Sung et al found an early postoperative survival benefit for kidney transplantation alone from a deceased donor (KTA) over SPK transplantation most likely due to lower surgical morbidity during the KTA procedure. Thereafter, there was an increasing survival benefit for SPK recipients that should be attributable to improved glycemic control by the functioning pancreas allograft. After 10 years, patient survival was 74% for SPK and 71% for KTA recipients. Up to 10 years of follow-up, there was a patient survival benefit for SPK compared to KTA recipients of 0.17 years (P = 0.033), and the authors concluded that SPK compared to KTA was associated with a statistical but not clinically significant increase in survival. At this point, we disagree with Sung et al. They ignore that 74% of their SPK recipients were alive at 10 years with as many as 87% of these patients having a functioning kidney allograft. The majority of patients also had a functioning pancreas allograft at 10 years. These patients are likely to have an additional survival benefit beyond 10 years from the SPK procedure, as suggested by our study.2Already in 2010, we pointed out that length of follow-up is decisive in the evaluation of different transplant strategies for type 1 diabetic patients.3 It takes time until the added surgical risk of the more complex SPK procedure is outweighed by the benefit of glycemic control attributable to a functioning pancreas allograft. According to our experience, a follow-up of only 10 years is likely to result in false impressions and recommendations. In our analysis of SPK and KTA using multivariable Cox analysis to year 20, a highly significant further decrease in the risk of death of SPK recipients during the years 11 to 20 became apparent (HR = 0.51, P < 0.001).3 Even compared to living donor kidney transplantation which commonly is considered the optimal procedure, SPK was associated with significantly improved patient survival beyond year 10 (years 11 to 20, HR = 0.52, P < 0.001).3 Figure 1 shows the updated results obtained in the Collaborative Transplant Study for patient survival in type 1 diabetic patients stratified according to the different transplant strategies.In conclusion, we believe that, especially in type 1 diabetic patients, recommendations for a specific transplant strategy should not be made based on studies with insufficient length of follow-up.

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