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Transplantation
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Dialysis, Kidney Transplantation, or Pancreas Transplantation for Patients with Diabetes Mellitus and Renal Failure: A Decision Analysis of Treatment Options

Greg A. Knoll and Graham Nichol
JASN February 2003, 14 (2) 500-515; DOI: https://doi.org/10.1097/01.ASN.0000046061.62136.D4
Greg A. Knoll
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Graham Nichol
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Abstract

ABSTRACT. Patients with type 1 diabetes mellitus and end-stage renal disease may remain on dialysis or undergo cadaveric kidney transplantation, living kidney transplantation, sequential pancreas after living kidney transplantation, or simultaneous pancreas-kidney transplantation. It is unclear which of these options is most effective. The objective of this study was to determine the optimal treatment strategy for type 1 diabetic patients with renal failure using a decision analytic Markov model. Input data were obtained from the published medical literature, the United Network for Organ Sharing registry, and patient interviews. The outcome measures were life expectancy (in life-years [LY]) and quality-adjusted life expectancy (in quality-adjusted life-years [QALY]). Living kidney transplantation was associated with 18.30 LY and 10.29 QALY; pancreas after kidney transplantation, 17.21 LY and 10.00 QALY; simultaneous pancreas-kidney transplantation, 15.74 LY and 9.09 QALY; cadaveric kidney transplantation, 11.44 LY and 6.53 QALY; dialysis, 7.82 LY and 4.52 QALY. The results were sensitive to the value of several key variables. Simultaneous pancreas-kidney transplantation had the greatest life expectancy and quality-adjusted life expectancy when living kidney transplantation was excluded from the analysis. These data indicate that living kidney transplantation is associated with the greatest life expectancy and quality-adjusted life expectancy for type 1 diabetic patients with renal failure. Treatment strategies involving pancreas transplantation should be considered for patients with frequent metabolic complications of diabetes and for those patients who favor kidney-pancreas transplantation over kidney transplantation alone. For patients without a living donor, simultaneous pancreas-kidney transplantation is associated with the greatest life expectancy. E-mail: gknoll@ottawahospital.on.ca

Diabetes mellitus (type 1 and type 2) is the leading cause of end-stage renal disease in Western countries (1). From 1993 to 1997, 143,854 patients in the United States developed renal failure from diabetes mellitus (1). Twenty-nine percent of these diabetic patients had type 1 diabetes mellitus (1).

Type 1 diabetic patients with renal failure have several treatment options. They may remain on dialysis or undergo cadaveric kidney transplantation (CKT), living kidney transplantation (LKT), simultaneous pancreas-kidney transplantation (SPKT), or pancreas transplantation after living kidney transplantation (PAKT) (2,3). Renal transplantation offers an improvement in long-term survival and quality of life when compared with dialysis (4,5). A functioning pancreas transplant results in normal or near-normal blood glucose levels and independence from exogenous insulin (2,6); this leads to an improvement in health-related quality of life, as there is no need for daily insulin injections, frequent glucose monitoring, or a strict diet (7,8). However, the tradeoff is that pancreas transplantation is associated with an increased rate of acute rejection (9,10), longer hospital stays (10,11), more readmissions (10,11), more reoperations (10), and more infections (10) when compared with renal transplantation. The main advantage of PAKT over SPKT is the ability to schedule an elective operation and avoid dialysis. However, the tradeoff is that PAKT requires two separate operations and has a reduced pancreas allograft survival rate when compared with SPKT (12).

The optimal treatment strategy for type 1 diabetic patients with renal failure is unknown, and there have been no randomized controlled trials designed to address this problem. Recent observational studies have reported that SPKT leads to an improvement in survival compared with CKT and dialysis (13,14). However, these studies did not evaluate health-related quality of life or the treatment option of PAKT (13,14). The American Diabetes Association and the American Society of Transplantation have recommended that pancreas transplantation be considered for type 1 diabetic patients who have undergone or plan to undergo renal transplantation (15,16). Both reviewed the options of PAKT and SPKT, but neither group made a strong recommendation favoring one treatment strategy over the other (15,16). Others have recommended that SPKT be considered over PAKT unless an identically matched living donor is available (17). A comprehensive review of PAKT was recently published that highlighted the increased use and success of this procedure (18). However, no clear recommendation was made favoring PAKT over SPKT (18).

Decision analysis is an analytic technique that uses explicit quantitative methods to compare the risks and benefits of different strategies under conditions of uncertainty (19). This design is appropriate when the optimal treatment strategy is unknown and each treatment strategy has advantages and disadvantages. Previous decision models comparing kidney and pancreas transplantation have focused on cost and have produced conflicting results. Holohan (20) demonstrated that kidney transplantation alone was more cost-effective than SPKT. However, this model assumed that all the pancreas transplants were initially successful and that no renal allografts failed in the first 3 y posttransplantation (20). In addition, the health-related quality of life ratings for kidney-pancreas transplantation were only estimates and were assumed to be higher than kidney transplantation alone (20). Douzdjian et al. (21) demonstrated that SPKT was more cost-effective than PAKT and kidney transplantation alone (22). However, these models used historical patient and allograft survival data that are now outdated given the recent improvements in transplantation (12,23).

We used a decision analytic model to compare the treatment options (dialysis, CKT, LKT, PAKT, and SPKT) faced by a patient with type 1 diabetes with renal failure. The model incorporated patient preferences along with recent survival data to estimate the life expectancy and quality-adjusted life expectancy of the different treatment strategies.

Materials and Methods

Decision Model

A decision analytic Markov model was constructed to evaluate the outcomes of five different treatment strategies for a hypothetical cohort of type 1 diabetic patients with renal failure: (1) remain on dialysis; (2) undergo CKT; (3) undergo LKT; (4) undergo PAKT; and (5) undergo SPKT (Figure 1; see Appendix for full model). A Markov model is a technique that tracks clinical events over time (24). The time horizon of the model is divided into equal increments known as cycles (24). Patients are in one of a finite number of mutually exclusive health states. Patients can move from one health state to another during each cycle. The probability that a patient moves from one health state to another is based on data from the literature. Summing the time spent in each health state yields the average life expectancy (24). Quality of life can be incorporated into the model by assigning a utility to each health state (24). Utilities are a measure of the strength of one’s preference for a given health state and range from 0 (dead) to 1 (perfect health) (25). Quality-adjusted life expectancy can be calculated by multiplying the utility of a health state by the time spent in that health state.

Figure1
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Figure 1. Schematic representation of the decision model. A diabetic with renal failure can choose one of five treatment strategies: dialysis, living kidney transplantation (LKT), pancreas after living kidney transplantation (PAKT), simultaneous pancreas-kidney transplantation (SPKT), or cadaveric kidney transplantation (CKT). If LKT was chosen, the patient underwent living kidney transplantation within 3 mo. If PAKT was chosen, the patient underwent living kidney transplantation within 3 mo followed by placement on the waiting list for pancreas transplantation. After a period of waiting, the patient received a cadaveric pancreas transplant. If CKT or SPKT was chosen, the patient was placed on the appropriate waiting list. After a period of waiting, the patient received a cadaveric kidney or kidney-pancreas transplant depending on which treatment option was chosen.

For example, in a simple three-state Markov model, patients could either be well, sick, or dead. At the start of the analysis, all patients are in the well state. After each cycle, a certain proportion of patients move from the well state to the sick state and a certain proportion move from the sick state to dead. The cycles are repeated until all patients are in the dead state. The average life expectancy is determined by summing the time spent in the well and sick state.

We used a 3-mo cycle length. The outcome measures were life expectancy (expressed in life-years, LY) and quality-adjusted life expectancy (expressed in quality-adjusted life-years, QALY). The QALY were discounted at the recommended rate of 3% and varied from 0% to 7% in the sensitivity analysis (26). The model was analyzed using the software program DATA 3.5 (Treeage Software, Williamstown, MA).

A typical patient considered in this analysis was a type 1 diabetic patient between 18 and 49 yr of age with the recent onset of permanent kidney failure who had not previously received a kidney or kidney-pancreas transplant. The patients were medically stable and had no contraindication to transplantation. In the primary analysis, patients had a potential living kidney donor and could select any of the five treatment strategies outlined in Figure 1. A secondary analysis was performed to simulate those patients without a living kidney donor. In this analysis, the patients could only choose dialysis, CKT, or SPKT.

If LKT was chosen, the patient underwent transplantation within 3 mo (Figure 1). If PAKT was chosen, the patient underwent living kidney transplantation within 3 mo followed by placement on the waiting list for pancreas transplantation (Figure 1). After a period of waiting, the patient received a cadaveric pancreas transplant. If CKT or SPKT were chosen, the patient was placed on the appropriate waiting list (Figure 1). After a period of waiting, the patient received a cadaveric kidney or kidney-pancreas transplant depending on which treatment option was chosen. While on the waiting list for a cadaveric kidney, pancreas, or kidney-pancreas transplant, the patient may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), have no complication, or receive a transplant (Figure 2A).

Figure2
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Figure 2. Clinical events that may occur while on the waiting list or early post-transplantation. (A) While on the waiting list for cadaveric kidney, kidney-pancreas, or pancreas transplantation alone, the patient may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), have no complications, or receive a transplant. (B) Immediately after surgery for cadaveric kidney, living kidney, simultaneous pancreas-kidney, or pancreas transplantation alone, the patient was at risk for death, postoperative complication (which may result in allograft failure), major infection (which may be fatal or nonfatal), acute rejection (which may result in allograft failure), or have no complications.

Patients could have several outcomes immediately after surgery for cadaveric kidney, living kidney, simultaneous pancreas-kidney, or pancreas transplantation alone (Figure 2B). First, the operation could be technically successful without any complication. Second, a major infection could develop which was either fatal or nonfatal. Third, a postoperative complication could occur which was either successfully treated or resulted in allograft loss. Fourth, acute rejection could occur which was either effectively treated or resulted in allograft loss. Finally, the patient could die from other causes.

Patients on dialysis may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), or have no complication (Figure 3A). After recovery from the postoperative period, a patient with a functioning cadaveric or living kidney transplant may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), have a cytomegalovirus (CMV) infection (which may be fatal or nonfatal), experience renal allograft failure (which requires dialysis), or have no complication (Figure 3B). After the early posttransplant period, a patient with a functioning kidney-pancreas transplant may die, have a CMV infection (which may be fatal or nonfatal), experience pancreas allograft failure (resumes insulin therapy), experience kidney and pancreas allograft failure (which requires dialysis and insulin), or have no complication (Figure 3C). Patients with a functioning pancreas transplant were not at risk for hypoglycemia or ketoacidosis.

Figure3
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Figure 3. Clinical events that may occur on dialysis or late posttransplantation. (A) While on dialysis, the patient may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), or have no complication. (B) After the early posttransplant period, a patient with a functioning cadaveric or living kidney transplant may die, have an episode of hypoglycemia (which may be fatal or nonfatal), have an episode of ketoacidosis (which may be fatal or nonfatal), have a cytomegalovirus (CMV) infection (which may be fatal or nonfatal), experience renal allograft failure (resume dialysis), or have no complication. (C) After the early posttransplant period, a patient with a functioning kidney-pancreas transplant may die, have a CMV infection (which may be fatal or nonfatal), experience pancreas allograft failure (resume insulin), experience kidney and pancreas allograft failure (resume dialysis and insulin), or have no complication. Patients with a functioning pancreas transplant were not at risk for hypoglycemia or ketoacidosis.

Data and Assumptions

Posttransplant Complications.

English-language MEDLINE database was searched from 1995 to February 2001. Relevant articles were identified using the following key words: pancreas transplantation, kidney-pancreas transplantation, kidney transplantation, and renal transplantation. The search yielded 11,670 references. Each title and abstract was reviewed, and a hard copy was obtained for every study considered to have potentially relevant data. Studies were excluded from further review if: no humans were involved; it dealt with a basic science topic; it was a case report; it involved a pediatric population; it was a pharmacokinetic study; it was a non-heart beating donor study; or it involved multi-organ transplants such as heart-kidney transplants. After these exclusions, 1033 publications were retrieved. Review of the reference list from these publications yielded an additional 23 articles. A total of 1056 studies were reviewed in detail. Data were abstracted from randomized and nonrandomized studies to obtain event rates that reflected widespread clinical practice. Rates from multiple sources were combined by using a weighted mean average. The probabilities used in the model and the ranges evaluated in the sensitivity analysis are shown in Table 1.

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Table 1. Base-case probabilities and ranges evaluated in the sensitivity analysis

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Table 1. (Continued)

Acute Rejection.

Biopsy-proven and presumptive rejection episodes were abstracted from the individual studies. If both rates were reported, the presumptive rejection rate was used, as this was a more conservative approach. The rejection rate from patients receiving placebo or azathioprine was not included.

CMV Infection.

Rates of CMV syndrome and tissue-invasive disease were abstracted from the articles. Studies were excluded if antiviral prophylaxis was not given to high-risk patients (27).

Major Infection.

Any infection, such as bacteremia or pneumonia, that would likely require hospitalization was included. Local infections such as cystitis or thrush were excluded. We also excluded intraabdominal infections that required drainage or re-operation, because these were included in the postoperative complication rates described below. The infection rate for SPKT was derived from reports that used enteric-drainage of the pancreatic secretions, because this is the most commonly used technique for this operation (28). The infection rate for PAKT was derived from reports that used bladder-drainage of the pancreatic secretions, because this is the most commonly used technique (28). The probability of death from a major infection posttransplantation was set at 0.066 and was assumed to be the same for all treatment options (29–35).

Postoperative Complications.

Postoperative complications that were considered included intraabdominal infections requiring drainage or re-operation; ureteral leak and stricture; allograft thrombosis; symptomatic lymphocele; grafts that never functioned; and repeat operations for any other indication. The individual complications were combined and modeled as a single term. Asymptomatic lymphoceles were excluded. The postoperative complication rate for SPKT was derived from studies using enteric-drainage; for PAKT, we used studies involving bladder-drainage.

Patient and Allograft Survival.

The UNOS database reports type 1 and type 2 diabetic patients together; therefore, we made a special request for data involving only type 1 diabetic patients in February 2001 (36). UNOS provided the most recent patient and allograft survival rates for type 1 diabetic patients undergoing CKT and LKT. In addition, the mortality rate for type 1 diabetic patients on the cadaveric waiting list was provided. Waiting list death rate, patient survival, and allograft survival for SPKT was obtained from the 2000 UNOS report (23). Pancreas allograft survival for PAKT was obtained from the 2000 UNOS Pancreas registry (28).

Most patients who undergo pancreas transplantation are between 18 and 49 yr of age (23); therefore, the survival data used in the model was confined to this age range. The risk of death is greatest in the first few months after transplantation (5); we therefore used the patient survival rate at 1 yr to derive the initial posttransplant probability of death. Patient survival between 1 and 5 yr posttransplantation was used to derive the cycle-specific probability of death (i.e., the overall probability of death during each 3-mo cycle) after the immediate posttransplant period (37). Death due to specific causes (e.g., death due to CMV infection) was subtracted from the overall probability of death so that we would not overestimate the mortality rate. The mortality rate was assumed to be constant after the first posttransplant year (5,38). Similar methodology was used to obtain the cycle-specific probability of renal and pancreas allograft failure.

Waiting Time.

The probability of receiving a cadaveric kidney or pancreas transplant was obtained from the 1999 UNOS waiting list data (39). For all strategies considered, it was assumed that patients had not undergone previous transplantation. Patient groups with the highest (i.e., blood group AB) and lowest probability of receiving a transplant were used as the range in the sensitivity analysis.

Diabetes-Related Complications.

The probability of severe hypoglycemia was obtained from a meta-analysis comparing intensive and conventional insulin regimens (40). Severe hypoglycemia was defined as any episode of hypoglycemia in which the patient required assistance with treatment from another person (41). The probability of ketoacidosis was obtained from the Diabetes Control and Complications Trial (41). Pancreas transplantation is often recommended for the most labile diabetic patients (42); therefore, the probability of ketoacidosis and hypoglycemia were conservatively varied in the sensitivity analysis. In the Diabetes Control and Complications Trial, there were two deaths directly related to hypoglycemia out of 3788 episodes (41). The probability of death due to hypoglycemia was 0.00053. The probability of death due to ketoacidosis was 0.0055 (41).

Utilities.

Hypothetical scenarios were created to describe the long-term health states dialysis, kidney transplantation, and kidney-pancreas transplantation. These were based on the descriptors contained in the Health Utility Index developed by Torrance and Feeny (43). The standard gamble (25) was completed by a cohort of n = 50 type 1 diabetic patients (who had not received a transplant or started dialysis) to obtain the utility for each health state scenario. The standard gamble was conducted by using a computer-based interview. The computer program contained the health state descriptions, a graphical display of the standard gamble, and instructions. This technique avoided bias in determining the utilities, as all patients received identical amounts of information. To account for the disutility (i.e., negative impact on quality of life) of the short-term health states (e.g., hospitalization for the treatment of infection), we assumed that the utility was zero for the duration of the health state (44). The duration of time spent in the short-term health state was obtained from a survey of four internists with expertise in diabetes mellitus and six nephrologists with expertise in transplantation (Table 1).

Assumptions.

Construction of the model required the following assumptions: (A) The relative risk of acute rejection for LKT was 0.69 compared with CKT (45), because there were only a few studies that provided separate rejection rates for LKT. (B) Acute rejection was modeled to occur within the first 3 mo posttransplant because the majority of rejection episodes occur during this time period (31,32,34,46). (C) CKT and LKT were assigned the same CMV infection rate because most studies did not report the rates separately. (D) The probability of death after CMV infection was assumed to be 0.001 because no data were found on CMV-related mortality. (E) CKT and LKT were assigned the same major infection rate because most studies did not report the rates separately. (F) Patient survival after PAKT was assumed to be the same as SPKT (28). (G) For PAKT, the mortality rate while waiting for a pancreas transplant was set at the same value as a patient with a functioning living kidney transplant. (H) It was assumed that all patients were medically suitable for transplantation; therefore, the mortality rate for patients who remained on dialysis was set at the same rate as type 1 diabetic patients on the cadaveric renal wait list. This assumption was made in order not to bias against the dialysis option, because it has been shown that just being on a waiting list (i.e., eligible for transplantation) is associated with an improvement in survival (5). (I) The model assumed that patients with a functioning cadaveric or living kidney transplant would receive intensive insulin therapy (47) and those on dialysis would receive conventional insulin therapy (48). (J) For PAKT, it was assumed that the pancreas transplant operation would not result in early renal allograft loss (49), late posttransplantation the pancreas could fail alone (without affecting the renal allograft), or the pancreas and kidney could fail together. (K) For SPKT, the pancreas could fail alone (without affecting the renal allograft) or the pancreas and kidney could fail together. (L) PAKT refers only to pancreas after living kidney transplantation. (M) Pancreas allograft failure would require the patient to resume insulin and be at risk for hypoglycemia and ketoacidosis. (N) Renal allograft failure would require the patient to resume dialysis.

Sensitivity Analyses

Sensitivity analyses were performed to test the robustness of the results to changes in the value of the variables. One-way sensitivity analysis was performed on each variable over a plausible range while holding all other variables constant. Unless otherwise specified in the text, the range for the sensitivity analysis represented the lowest and highest values found in the literature. For the patient and allograft survival data, the upper and lower values of the 95% confidence interval were used for the sensitivity analysis. Variables that were influential or those that were correlated with each other were evaluated further by two-way sensitivity analyses.

Results

Utilities

Utilities for the health states dialysis, kidney transplantation, and kidney-pancreas transplantation were obtained from 50 patients with type 1 diabetes. The mean (SD) age of respondents was 30.6 (9.7) yr; 68% were female; and the mean duration of diabetes was 14.2 (9.9) yr. The mean utility scores and the ranges elicited from the patients are shown in Table 2.

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Table 2. Utilities for dialysis, kidney transplantation, and kidney-pancreas transplantation

Base-Case Analysis

In the primary analysis, LKT was associated with the greatest life expectancy and quality-adjusted life expectancy for type 1 diabetic patients with renal failure (Table 3). All of the transplant options produced a substantial life expectancy gain compared with dialysis. LKT resulted in a gain of 0.29 QALY (approximately 3.5 mo) compared with PAKT and a gain of 1.2 QALY compared with SPKT.

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Table 3. Life expectancy and quality-adjusted life expectancy of the five different treatment strategies for type 1 diabetic patients with renal failurea

Sensitivity Analyses

One-way sensitivity analyses identified several influential variables (Table 4). The threshold value indicates that point at which there is a change in the preferred treatment strategy. For example, PAKT was the preferred strategy (i.e., associated with the greatest quality-adjusted life expectancy) when the utility for kidney-pancreas health state was above 0.91. PAKT was also preferred when the utility for kidney transplantation was between 0.59 and 0.74. As the probability of diabetes-related complications (ketoacidosis and death from hypoglycemia) increased, PAKT became the preferred strategy over LKT. All other variables in the model did not have threshold values.

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Table 4. Influential variables from one-way sensitivity analysisa

When the utilities for kidney and kidney-pancreas transplantation were varied simultaneously, SPKT was the preferred treatment strategy when the utility for kidney transplantation was below 0.41 (Figure 4). When the utility for kidney transplantation was greater than 0.88, LKT was the preferred strategy regardless of the utility for kidney-pancreas transplantation. Between 0.41 and 0.88 the preferred strategy was dependent on the utility for kidney-pancreas transplantation (Figure 4).

Figure4
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Figure 4. Effect of simultaneously varying the utilities for kidney and kidney-pancreas transplantation. The shaded areas on the graph represent the preferred treatment strategies (i.e., the strategy with the greatest quality-adjusted life expectancy) at the respective utilities for the kidney and kidney-pancreas health states. For example, if the utility for kidney-pancreas transplantation was 0.85 and for kidney transplantation it was 0.80, the graph would intersect in the hatched region (marked on the figure as a solid black square) that represents LKT. At this point, LKT would be the strategy associated with the greatest quality-adjusted life expectancy.

When the probability of hypoglycemia and death from hypoglycemia were varied simultaneously, LKT was the preferred treatment option over a wide range of these two variables (Figure 5). However, PAKT was preferred as the probability of hypoglycemia and death from hypoglycemia increased; SPKT was preferred only when the probabilities for these two variables were both extremely high (Figure 5).

Figure5
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Figure 5. Effect of simultaneously varying the probability of hypoglycemia and the probability of death from hypoglycemia. The shaded areas on the graph represent the preferred treatment strategies (i.e., the strategy with the greatest quality-adjusted life expectancy) at the respective probabilities for hypoglycemia and death from hypoglycemia. For example, if the probability of hypoglycemia was 0.10 and probability of death from hypoglycemia was 0.05 the graph would intersect in the area of vertical lines (marked on the figure as a solid black square) that represents PAKT. At this point, PAKT would be the strategy associated with the greatest quality-adjusted life expectancy.

Separate two-way sensitivity analyses were performed on the following pairs of variables: ketoacidosis and death from ketoacidosis; hypoglycemia and disutility for hypoglycemia; ketoacidosis and disutility for ketoacidosis; and death from hypoglycemia and death from ketoacidosis. In each case, PAKT was preferred as the probabilities of the variables under consideration were increased; SPKT was the preferred strategy only when the variables of interest were both extremely high.

Not all patients have a potential living donor; a secondary analysis was therefore performed without LKT and PAKT as treatment options. In this analysis, SPKT was preferred over CKT and dialysis. One-way sensitivity analysis did not reveal any influential variables; SPKT was the preferred strategy over the plausible range of each variable in the model.

Discussion

The decision to proceed with pancreas transplantation in a type 1 diabetic with renal failure is a tradeoff between the potential improvement in quality of life and the increased risk of posttransplant complications. This analysis demonstrated that LKT was preferred over SPKT or PAKT, resulting in an improvement in life expectancy and quality-adjusted life expectancy. However, the results were sensitive to several important variables.

The preferred treatment strategy was sensitive to changes in the utility values for dialysis, kidney transplantation, and kidney-pancreas transplantation. The results were particularly sensitive to the utility for kidney-pancreas transplantation. When this value was above 0.91 (base case 0.85), PAKT was the preferred strategy. This threshold value is likely clinically important, as nearly one third of patients interviewed assigned kidney-pancreas transplantation a utility of 0.91 or higher. Also, a previous study found that the mean utility for the kidney-pancreas health state was similar to this value (50). When the utility scores for kidney and kidney-pancreas transplantation were varied simultaneously, it was evident that pancreas transplant options would be preferred by patients who value kidney-pancreas transplantation over renal transplantation alone.

Extensive two-way sensitivity analysis was performed on the diabetes-related variables of hypoglycemia, ketoacidosis, disutility of hypoglycemia or ketoacidosis, and the probability of death from hypoglycemia or ketoacidosis. In almost all of the variable combinations, PAKT was the preferred strategy as the probability or disutility of the diabetes-related complication increased. This suggests that diabetic patients with frequent metabolic complications that are associated with a poor quality of life would have a better quality-adjusted survival with PAKT. These results are in agreement with previous recommendations that patients with labile diabetes undergoing renal transplantation would likely benefit from a combined pancreas-kidney transplantation (42). These results are also consistent with the American Diabetes Association position statement on pancreas transplantation alone in nonuremic patients (15). They recommend that pancreas transplantation be considered for patients with frequent and severe metabolic complications (hypoglycemia, hyperglycemia, and ketoacidosis) requiring medical attention, incapacitating problems with exogenous insulin, and failure of insulin therapy to prevent acute complications (15).

The analysis was sensitive to the probability of death while waiting for transplantation. This is clinically relevant, as the death rates on the waiting list for CKT, pancreas transplantation, and SPKT have increased over the past few years (23). In addition, the waiting time to transplant for these organs has also increased substantially (23). SPKT was the preferred treatment if the mortality rate while waiting for SPKT was less than 18.2 deaths per 1000 patient-years. Unfortunately, the mortality rate on the waiting list for SPKT has not been under 30 deaths per 1000 patient-years since 1992 (23).

Interestingly, the results of the analysis were insensitive to the rate of infection, rejection, and postoperative complications after pancreas transplantation. These findings differ from most reviews on pancreas transplantation, which have emphasized the importance of these complications when considering pancreas transplantation (42,51–53). It is likely that the analysis was insensitive to these complications because of the relatively high utility value placed on kidney transplantation. This underscores the importance of patient preferences in choosing treatment strategies for type 1 diabetics with end-stage renal disease.

Compared with PAKT, LKT increased crude life expectancy by approximately 13 mo and quality-adjusted life expectancy by 3.5 mo. Although these gains do not seem large in the context of a person’s entire lifespan, they are similar to and even greater than life expectancy gains of other established medical practices (54).

This analysis has several limitations. First, the input data on posttransplant complications came from several sources, including nonrandomized studies. The use of these data may have underestimated the complication rates, as centers with inferior outcomes would be less likely to publish their results. However, sensitivity analysis demonstrated that the incidence of transplant-related complications did not influence which treatment option was most effective. Second, we assumed that members of the cohort could undergo one treatment strategy and no repeat transplantation was permitted. Although this may bias the analysis in favor of LKT, repeat transplantation is associated with an increased mortality risk in the PAKT category (28) and decreased allograft survival after CKT (55). In addition, repeat transplantation is rarely performed in the SPKT category (28). Finally, we assumed that the health-related quality of life was zero for the duration of the short-term health states and the duration of the short-term health states was estimated from expert opinion. Although this technique is the standard approach used to determine disutilities (44), patient-based preferences may have resulted in more accurate estimates. However, sensitivity analysis carried out over a wide range of values for the short-term health states did not change the preferred treatment strategy.

In conclusion, this analysis has demonstrated that LKT is associated with greater life expectancy and quality-adjusted life expectancy for type 1 diabetic patients with end-stage renal disease. However, PAKT is preferred for patients with frequent and severe metabolic complications of diabetes and for those patients who favor kidney-pancreas transplantation over kidney transplantation alone. For patients without a living donor, SPKT is associated with a greater life expectancy than cadaveric kidney transplantation or dialysis. This analysis has shown that patient preferences are extremely important when choosing treatment strategies for diabetic patients with renal failure. The results of this study can be used by patients and clinicians to match the most suitable treatment option with individual patient preferences.

Appendix

⇓

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  • © 2003 American Society of Nephrology

References

  1. ↵
    US Renal Data System: USRDS 1999 Annual Data Report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda MD. Am J Kidney Dis 34: 9–176, 1999
    OpenUrl
  2. ↵
    Hricik DE: Kidney-pancreas transplantation for diabetic nephropathy. Semin Nephrol 20: 188–198, 2000
    OpenUrlPubMed
  3. ↵
    Friedman EA: Management choices in diabetic end-stage renal disease. Nephrol Dial Transplant 10 [Suppl 7]: 61–69, 1995
  4. ↵
    Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, Muirhead N: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50: 235–242, 1996
    OpenUrlCrossRefPubMed
  5. ↵
    Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341: 1725–1730, 1999
    OpenUrlCrossRefPubMed
  6. ↵
    Robertson RP, Davis C, Larsen J, Stratta R, Sutherland DE: Pancreas and islet transplantation for patients with diabetes. Diabetes Care 23: 112–116, 2000
    OpenUrlCrossRefPubMed
  7. ↵
    Gross CR, Limwattananon C, Matthees BJ: Quality of life after pancreas transplantation: A review. Clin Transplant 12: 351–361, 1998
    OpenUrlPubMed
  8. ↵
    Gross CR, Kangas JR, Lemieux AM, Zehrer CL: One-year change in quality-of-life profiles in patients receiving pancreas and kidney transplants. Transplant Proc 27: 3067–3068, 1995
    OpenUrlPubMed
  9. ↵
    Douzdjian V, Rice JC, Gugliuzza KK, Fish JC, Carson RW: Renal allograft and patient outcome after transplantation: Pancreas-kidney versus kidney-alone transplants in type 1 diabetic patients versus kidney-alone transplants in nondiabetic patients. Am J Kidney Dis 27: 106–116, 1996
    OpenUrlPubMed
  10. ↵
    Cheung AHS, Sutherland DE, Gillingham KJ, McHugh L, Moudry-Munns K, Dunn DL, Najarian JS, Matas AJ: Simultaneous pancreas-kidney transplant versus kidney transplant alone in diabetic patients. Kidney Int 41: 924–929, 1992
    OpenUrlCrossRefPubMed
  11. ↵
    Lee CM, Scandling JD, Krieger NR, Dafoe DC, Alfrey EJ: Outcomes in diabetic patients after simultaneous pancreas-kidney versus kidney alone transplantation. Transplantation 64: 1288–1294, 1997
    OpenUrlCrossRefPubMed
  12. ↵
    International Pancreas Transplant Registry University of Minnesota, Minneapolis, MN, Vol 13: 1–23, 2001
  13. ↵
    Becker BN, Brazy PC, Becker YT, Odorico JS, Pintar TJ, Collins BH, Pirsch JD, Leverson GE, Heisey DM, Sollinger HW: Simultaneous pancreas-kidney transplantation reduces excess mortality in type 1 diabetic patients with end-stage renal disease. Kidney Int 57: 2129–2135, 2000
    OpenUrlCrossRefPubMed
  14. ↵
    Ojo A, Meier-Kriesche HU, Hanson J, Leichtman A, Magee JC, Cibrik D, Wolfe RA, Port FK, Agodoa LY, Kaufman DB, Kaplan B: The impact of simultaneous pancreas-kidney transplantation on long-term patient survival. Transplantation 71: 82–90, 2001
    OpenUrlCrossRefPubMed
  15. ↵
    American Diabetes Association: Pancreas transplantation for patients with type 1 diabetes. Diabetes Care 23: 117, 2000
    OpenUrlPubMed
  16. ↵
    Kasiske BL, Cangro CB, Hariharan S, Hricik DE, Kerman R, Roth D, Rush D, Vazquez M, Weir MR: The evaluation of renal transplant candidates: Clinical practice guidelines. Am J Transplant 1: 1–95, 2001
    OpenUrlCrossRefPubMed
  17. ↵
    Becker BN, Odorico JS, Becker YT, Grosshek M, Werwinski C, Pirsch JD, Sollinger H: Simultaneous pancreas-kidney and pancreas transplantation. J Am Soc Nephrol 12: 2517–2527, 2001
    OpenUrlFREE Full Text
  18. ↵
    Hariharan S, Pirsch JD, Lu C, Chan L, Pesavento TE, Alexander S, Bumgadner GL, Basadonna G, Hricik DE, Pescovitz M, Rubin N, Stratta R: Pancreas after kidney transplantation. J Am Soc Nephrol 13: 1109–1118, 2002
    OpenUrlFREE Full Text
  19. ↵
    Richardson S, Detsky AS: Users guide to the medical literature. How to use a clinical decision analysis. JAMA 273: 1292–1295, 1995
    OpenUrlCrossRefPubMed
  20. ↵
    Holohan TV: Cost-effectiveness modeling of simultaneous pancreas-kidney transplantation. Int J Technol Assess Health Care 12: 416–424, 1996
    OpenUrlPubMed
  21. ↵
    Douzdjian V, Escobar F, Kupin WL, Venkat KK, Abouljoud MS: Cost-utility analysis of living-donor kidney transplantation followed by pancreas transplantation versus simultaneous pancreas-kidney transplantation. Clin Transplant 13: 51–58, 1999
    OpenUrlCrossRefPubMed
  22. ↵
    Douzdjian V, Ferrara D, Silvestri G: Treatment strategies for insulin-dependent diabetics with ESRD: A cost-effectiveness decision analysis model. Am J Kidney Dis 31: 794–802, 1998
    OpenUrlPubMed
  23. ↵
    2000 Annual Report of the US Scientific Registry for Transplant Recipients and the Organ Procurement and Transplantation Network: Transplant Data: 1990–1999. Washington, DC, US Department of Health and Human Services 2001
  24. ↵
    Sonnenberg FA, Beck JR: Markov models in medical decision making: A practical guide. Med Decis Making 13: 322–338, 1993
  25. ↵
    Torrance GW: Utility approach to measuring health-related quality of life. J Chron Dis 40: 593–600, 1987
    OpenUrlCrossRefPubMed
  26. ↵
    Lipscomb J, Weinstein MC, Torrance GW: Time preference. In: Cost-Effectiveness in Health and Medicine, edited by Gold MR, Siegel JE, Russell LB, Weinstein MC, New York, Oxford University Press, 1996, pp 214–246
  27. ↵
    Jassal SV, Roscoe JM, Zaltzman JS, Mazzulli T, Krajden M, Gadawski M, Cattran DC, Cardella CJ, Albert SE, Cole EH: Clinical practice guidelines: Prevention of cytomegalovirus disease after renal transplantation. J Am Soc Nephrol 9: 1697–1708, 1998
    OpenUrlAbstract
  28. ↵
    Gruessner A, Sutherland DE: Pancreas transplant outcomes for United States cases reported to the United Network for Organ Sharing and non-US cases reported to the International Pancreas Transplant Registry as of October, 2000. In: Clinical Transplants, edited by Terasaki PI, Cecka JM, Los Angeles, UCLA Tissue Typing Laboratory, 2001, pp 45–72
  29. ↵
    van Gelder T, Hilbrands LB, Vanrenterghem Y, Weimar W, de Fijter JW, Squifflet JP, Hene RJ, Verpooten GA, Navarro MT, Hale MD, Nicholls AJ: A randomized double-blind, multicenter plasma concentration controlled study of the safety and efficacy of oral mycophenolate mofetil for the prevention of acute rejection after kidney transplantation. Transplantation 68: 261–266, 1999
    OpenUrlCrossRefPubMed
  30. Nanni G, Panocchia N, Tacchino R, Foco M, Piccioni E, Castagneto M: Increased incidence of infection in verapamil-treated kidney transplant recipients. Transplant Proc 32: 551–553, 2000
    OpenUrlCrossRefPubMed
  31. ↵
    Kahan BD, Rajagopalan PR, Hall M: Reduction of the occurrence of acute cellular rejection among renal allograft recipients treated with basiliximab, a chimeric anti-interleukin-2-receptor monoclonal antibody. Transplantation 67: 276–284, 1999
    OpenUrlCrossRefPubMed
  32. ↵
    Nashan B, Light S, Hardie IR, Lin A, Johnson JR: Reduction of acute renal allograft rejection by daclizumab. Transplantation 67: 110–115, 1999
    OpenUrlCrossRefPubMed
  33. Vincenti F, Kirkman R, Light S, Bumgardner G, Pescovitz M, Halloran P, Neylan J, Wilkinson A, Ekberg H, Gaston R, Backman L, Burdick J: Interleukin-2-receptor blockade with daclizumab to prevent acute rejection in renal transplantation. N Engl J Med 338: 161–165, 1998
    OpenUrlCrossRefPubMed
  34. ↵
    Halloran P, Mathew T, Tomlanovich S, Groth C, Hooftman L, Barker C: Mycophenolate mofetil in renal allograft recipients: a pooled efficacy analysis of three randomized, double-blind, clinical studies in prevention of rejection. Transplantation 63: 39–47, 1997
    OpenUrlCrossRefPubMed
  35. ↵
    Keown P, Hayry P, Mathew T, Morris P, Stiller C, Barker C, Carr L: A blinded, randomized clinical trial of mycophenolate mofetil for the prevention of acute rejection in cadaveric renal transplantation. Transplantation 61: 1029–1037, 1996
    OpenUrlCrossRefPubMed
  36. ↵
    Based on UNOS OPTN data as of March 3, 2001. Available at www.unos.org
  37. ↵
    Miller DK, Homan SM: Determining transition probabilities: Confusion and suggestions. Med Decis Making 14: 52–58, 1994
  38. ↵
    Hornberger JC, Best JH, Garrison LP, Jr: Cost-effectiveness of repeat medical procedures: Kidney transplantation as an example. Med Decis Making 17: 363–372, 1997
    OpenUrlCrossRefPubMed
  39. ↵
    Harper AM: The OPTN waiting list. In: Clinical Transplants, edited by Terasaki PI, Cecka JM, Los Angeles, UCLA Tissue Typing Laboratory, 2001, pp 73–83
  40. ↵
    Egger M, Smith GD, Stettler C, Diem P: Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: A meta-analysis. Diabet Med 14: 919–928, 1997
    OpenUrlCrossRefPubMed
  41. ↵
    The Diabetes Control and Complications Trial Research Group: Adverse events and their association with treatment regimens in the diabetes control and complications trial. Diabetes Care 18: 1415–1427, 1995
    OpenUrlAbstract/FREE Full Text
  42. ↵
    Ryan EA: Pancreas transplants: For whom?. Lancet 351: 1072–1073, 1998
    OpenUrlCrossRefPubMed
  43. ↵
    Feeny D, Furlong W, Boyle M, Torrance GW: Multi-attribute health status classification systems. Pharmacoeconomics 7: 490–502, 1995
    OpenUrlCrossRefPubMed
  44. ↵
    Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP: A convenient approximation of life expectancy (The DEALE): Use in medical decision making. Am J Med 73: 889–897, 1982
    OpenUrlCrossRefPubMed
  45. ↵
    Meier-Kriesche HU, Ojo A, Magee JC, Cibrik DM, Hanson JA, Leichtman AB, Kaplan B: African-American renal transplant recipients experience decreased risk of death due to infection: Possible implications for immunosuppressive strategies. Transplantation 70: 375–379, 2000
    OpenUrlCrossRefPubMed
  46. ↵
    Kahan BD: Efficacy of sirolimus compared with azathioprine for reduction of acute renal allograft rejection: A randomised multicentre study. Lancet 356: 194–202, 2000
    OpenUrlCrossRefPubMed
  47. ↵
    Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329: 977–986, 1993
    OpenUrlCrossRefPubMed
  48. ↵
    Tzamaloukas AH, Friedman EA: Diabetes, In: Handbook of Dialysis, 3rd edition, edited by Daugirdas JT, Blake PG, Ing TS, Philadelphia, Lippincott Williams and Wilkins, 2001, pp 453–465
  49. ↵
    Cheung AHS, Matas A, Gruessner RG, Dunn DL, Moudry-Munns K, Najarian JS, Sutherland DE: Should uremic diabetic patients who want a pancreas transplant receive a simultaneous cadaver kidney-pancreas transplant or a living related donor kidney first followed by cadaver pancreas transplant? Transplant Proc 25: 1184–1185, 1993
    OpenUrlPubMed
  50. ↵
    Kiberd BA, Larson T: Estimating the benefits of solitary pancreas transplantation in nonuremic patients with type 1 diabetes mellitus: A theoretical analysis. Transplantation 70: 1121–1127, 2000
    OpenUrlCrossRefPubMed
  51. ↵
    Manske CL: Risks and benefits of kidney and pancreas transplantation for diabetic patients. Diabetes Care 22 [Suppl 2]: B114–B120, 1999
  52. White SA, London NJ: Pancreas and islet transplantation. Br J Surg 85: 1313–1315, 1998
    OpenUrlCrossRefPubMed
  53. ↵
    Dafoe DC, Scandling JD, Waskerwitz JA, Beinin ML: What is the optimal approach for the end-stage diabetic nephropathy patient considering simultaneous pancreas-kidney transplantation? Adv Ren Replace Ther 5: 232–240, 1998
    OpenUrlPubMed
  54. ↵
    Wright JC, Weinstein MC: Gains in life expectancy from medical interventions-standardizing data on outcomes. N Engl J Med 339: 380–386, 1998
    OpenUrlCrossRefPubMed
  55. ↵
    Cecka JM: The UNOS Scientific Renal Transplant Registry — 2000. In: Clinical Transplants, edited by Cecka JM, Terasaki PI, Los Angeles, UCLA Tissue Typing Laboratory, 2001, pp 1–18
  56. Flechner SM, Goldfarb DA, Fairchild R, Modlin CS, Fisher R, Mastroianni B, Boparai N, O’Malley KJ, Cook DJ, Novick AC: A randomized prospective trial of low-dose OKT3 induction therapy to prevent rejection and minimize side effects in recipients of kidney transplants. Transplantation 69: 2374–2381, 2000
    OpenUrlCrossRefPubMed
  57. Kreis H, Cisterne JM, Land W, Wramner L, Squifflet JP, Abramowicz D, Campistol JM, Morales JM, Grinyo JM, Mourad G, Berthoux FC, Brattstrom C, Lebranchu Y, Vialtel P: Sirolimus in association with mycophenolate mofetil induction for the prevention of acute graft rejection in renal allograft recipients. Transplantation 69: 1252–1260, 2000
    OpenUrlCrossRefPubMed
  58. Miller J, Mendez R, Pirsch JD, Jensik SC: Safety and efficacy of tacrolimus in combination with mycophenolate mofetil (MMF) in cadaveric renal transplant recipients. Transplantation 69: 875–880, 2000
    OpenUrlCrossRefPubMed
  59. Johnson C, Ahsan N, Gonwa T, Halloran P, Stegall M, Hardy M, Metzger R, Shield C III, Rocher L, Scandling J, Sorensen J, Mulloy L, Light J, Corwin C, Danovitch G, Wachs M, van Veldhuisen P, Salm K, Tolzman D, Fitzsimmons WE: Randomized trial of tacrolimus (Prograf) in combination with azathioprine or mycophenolate mofetil versus cyclosporine (Neoral) with mycophenolate mofetil after cadaveric kidney transplantation. Transplantation 69: 834–841, 2000
    OpenUrlCrossRefPubMed
  60. Morales JM, Andres A, Morales E, Herrero JC, Cubas A, Praga M, Hernandez E, Ortuno T, Dominguez-Gil B, Carreno A, Delgado M, Manzanares C: Tacrolimus, mycophenolate mofetil and corticosteroids as primary immunosuppression after renal transplantation at the Hospital 12 de Octubre, Madrid. Transplant Proc 31: 75S–77S, 1999
    OpenUrlCrossRef
  61. Forsythe J: Tacrolimus and mycophenolate mofetil in cadaveric renal transplant recipients. Transplant Proc 31: 69S–71S, 1999
    OpenUrlCrossRefPubMed
  62. Meier-Kriesche HU, Friedman G, Jacobs M, Mulgaonkar S, Vaghela M, Kaplan B: Infectious complications in geriatric renal transplant patients: Comparison of two immunosuppressive protocols. Transplantation 68: 1496–1502, 1999
    OpenUrlCrossRefPubMed
  63. Mari JM: Induction treatment with mycophenolate mofetil, cyclosporine, and low-dose steroids with subsequent early withdrawal in renal transplant patients: Results of the Spanish Group. Transplant Proc 31: 2256–2258, 1999
    OpenUrlCrossRefPubMed
  64. Puig JM, Lloveras J, Fernandez-Crespo P, Mir M, Inigo V, Manresa JM, Masramon J: Mycophenolate mofetil, along with ATG and cyclosporine, significantly lowers the incidence of acute rejection episodes in renal transplant recipients. Transplant Proc 31: 2259–2260, 1999
    OpenUrlCrossRefPubMed
  65. Wuthrich RP, Weinreich T, Ambuhl PM, Schwarzkopf AK, Candinas D, Binswanger U: Reduced kidney transplant rejection rate and pharmacoeconomic advantage of mycophenolate mofetil. Nephrol Dial Transplant 14: 394–399, 1999
    OpenUrlCrossRefPubMed
  66. Brennan DC, Flavin K, Lowell JA, Howard TK, Shenoy S, Burgess S, Dolan S, Kano JM, Mahon M, Schnitzler MA, Woodward R, Irish W, Singer GG: A randomized, double-blinded comparison of Thymoglobulin versus Atgam for induction immunosuppressive therapy in adult renal transplant recipients. Transplantation 67: 1011–1018, 1999
    OpenUrlCrossRefPubMed
  67. Yang HC, Holman MJ, Langhoff E, Ulsh PJ, Dellock CA, Gupta M, Ahsan N: Tacrolimus/“low-dose” mycophenolate mofetil versus microemulsion cyclosporine/“low-dose” mycophenolate mofetil after kidney transplantation–1-year follow-up of a prospective, randomized clinical trial. Transplant Proc 31: 1121–1124, 1999
    OpenUrlCrossRefPubMed
  68. Lebranchu Y: Comparison of two corticosteroid regimens in combination with CellCept and cyclosporine A for prevention of acute allograft rejection: 12 month results of a double-blind, randomized, multi-center study. Transplant Proc 31: 249–250, 1999
    OpenUrlCrossRefPubMed
  69. Tacrolimus in renal transplantation: A comparison of induction versus noninduction therapy (triple therapy): Three-month results. Transplant Proc 31: 330–331, 1999
    OpenUrlCrossRefPubMed
  70. Shapiro R, Jordan ML, Scantlebury VP, Vivas C, Marsh JW, McCauley J, Johnston J, Randhawa P, Irish W, Gritsch HA, Naraghi R, Hakala TR, Fung JJ, Starzl TE: A prospective, randomized trial of tacrolimus/prednisone versus tacrolimus/prednisone/mycophenolate mofetil in renal transplant recipients. Transplantation 67: 411–415, 1999
    OpenUrlPubMed
  71. Baker GM, Martin JE, Jang R, Schroeder TJ, Armitstead JA, Myre S, First MR: Pharmacoeconomic analysis of mycophenolate mofetil versus azathioprine in primary cadaveric renal transplantation. Transplant Proc 30: 4082–4084, 1998
    OpenUrlCrossRefPubMed
  72. Lee CM, Markezich AJ, Scandling JD, Dafoe DC, Alfrey EJ: Outcome in cadaveric renal transplant recipients treated with cyclosporine A and mycophenolate mofetil versus cyclosporine A and azathioprine. J Surg Res 76: 131–136, 1998
    OpenUrlCrossRefPubMed
  73. Roth D, Colona J, Burke GW, Ciancio G, Esquenazi V, Miller J: Primary immunosuppression with tacrolimus and mycophenolate mofetil for renal allograft recipients. Transplantation 65: 248–252, 1998
    OpenUrlPubMed
  74. Schweitzer EJ, Yoon S, Fink J, Wiland A, Anderson L, Kuo PC, Lim JW, Johnson LB, Farney AC, Weir MR, Bartlett ST: Mycophenolate mofetil reduces the risk of acute rejection less in African-American than in Caucasian kidney recipients. Transplantation 65: 242–248, 1998
    OpenUrlPubMed
  75. Wiesel M, Carl S: A placebo controlled study of mycophenolate mofetil used in combination with cyclosporine and corticosteroids for the prevention of acute rejection in renal allograft recipients: 1-year results. J Urol 159: 28–33, 1998
    OpenUrlCrossRefPubMed
  76. Florence LS, Howard DR, Chapman PH, Lieberman J, Perkinson DT, Marks WH: Reduction in the incidence of early rejection in cadaveric renal allograft recipients treated with ATGAM induction and sequential mycophenolate mofetil. Transplant Proc 29: 313–314, 1997
    OpenUrlCrossRefPubMed
  77. Vanrenterghem Y, Lebranchu Y, Hene R, Oppenheimer F, Ekberg H: Double-blind comparison of two corticosteroid regimens plus mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection. Transplantation 70: 1352–1359, 2000
    OpenUrlCrossRefPubMed
  78. Arnold AN, Wombolt DG, Whelan TV, Chidester PD, Restaino I, Gelpi B, Stewart M, Hurwitz RL, McCune TR: Mycophenolate mofetil, with cyclosporine and prednisone, reduces early rejection while allowing the use of less antilymphocytic agent induction and cyclosporine in renal recipients with delayed graft function. Clin Transpl 14: 421–426, 2000
  79. Triemer HL, Pearson TC, Odom KL, Larsen CP: Analysis of a single-center experience with mycophenolate mofetil based immunosuppression in renal transplantation. Clin Transpl 14: 413–420, 2000
    OpenUrlCrossRef
  80. Shen GK, Alfrey EJ, Knoppel CL, Dafoe DC, Scandling JD: Eradication of cytomegalovirus reactivation disease using high-dose acyclovir and targeted intravenous ganciclovir in kidney and kidney/pancreas transplantation. Transplantation 64: 931–933, 1997
    OpenUrlCrossRefPubMed
  81. Peddi VR, Hariharan S, Munda R, Schroeder TJ, First MR: Impact of ganciclovir prophylaxis on cytomegalovirus infection in cadaveric kidney versus combined kidney and pancreas transplantation. Transplant Proc 27: 3076–3077, 1995
    OpenUrlPubMed
  82. Isenberg AL, Shen GK, Singh TP, Hahn A, Conti DJ: Failure of ganciclovir prophylaxis to completely eradicate CMV disease in renal transplant recipients treated with intense anti-rejection immunotherapy. Clin Transpl 14: 193–198, 2000
    OpenUrlCrossRef
  83. Lowance D, Neumayer HH, Legendre CM, Squifflet JP, Kovarik J, Brennan PJ, Norman D, Mendez R, Keating MR, Coggon GL, Crisp A, Lee IC: Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. N Engl J Med 340: 1462–1470, 1999
    OpenUrlCrossRefPubMed
  84. Humar A, Gillingham KJ, Payne WD, Dunn DL, Sutherland DE, Matas AJ: Association between cytomegalovirus disease and chronic rejection in kidney transplant recipients. Transplantation 68: 1879–1883, 1999
    OpenUrlCrossRefPubMed
  85. Sancho A, Gorriz JL, Crespo JF, Avila A, Alcaraz MJ, Garcia Ramos JL, Pallardo LM: Prophylaxis of cytomegalovirus disease with intravenous ganciclovir in renal transplantation. Transplant Proc 31: 2337–2338, 1999
    OpenUrlCrossRefPubMed
  86. Brennan DC, Garlock KA, Singer GG, Schnitzler MA, Lippmann BJ, Buller RS, Gaudreault-Keener M, Lowell JA, Shenoy S, Howard TK, Storch GA: Prophylactic oral ganciclovir compared with deferred therapy for control of cytomegalovirus in renal transplant recipients. Transplantation 64: 1843–1846, 1997
    OpenUrlCrossRefPubMed
  87. Pirsch JD, Miller J, Deierhoi MH, Vincenti F, Filo RS: A comparison of tacrolimus (FK506) and cyclosporine for immunosuppression after cadaveric renal transplantation. Transplantation 63: 977–983, 1997
    OpenUrlCrossRefPubMed
  88. Conti DJ, Shen G, Singh T, Isenberg A, Freed BM: Ganciclovir prophylaxis of cytomegalovirus disease. Transplant Proc 29: 804–806, 1997
    OpenUrlCrossRefPubMed
  89. Cattral MS, Hemming AW, Greig PD, Rowsell C, Chari R, Cole E, Donat D, Wright E, Levy GA: Outcome of kidney transplantation alone versus synchronous pancreas-kidney transplantation in type 1 diabetics. Transplant Proc 30: 1938–1939, 1998
    OpenUrlCrossRefPubMed
  90. Nashan B, Moore R, Amlot P, Schmidt AG, Abeywickrama K, Soulillou JP: Randomised trial of basiliximab versus placebo for control of acute cellular rejection in renal allograft recipients. Lancet 350: 1193–1198, 1997
    OpenUrlCrossRefPubMed
  91. Kiberd B, Panek R, Clase CM, MacDonald AS, McAlister V, Belitsky P, Lawen J: The morbidity of prolonged wound drainage after kidney transplantation. J Urol 161: 1467–1469, 1999
    OpenUrlCrossRefPubMed
  92. Mehrsai AR, Khajehmugehi AR, Khan ZH, Nikoubakht MR, Taheri M: Evaluation of surgical technique complications and their impact on the outcome in 230 kidney recipients. Transplant Proc 30: 718–720, 1998
    OpenUrlCrossRefPubMed
  93. Hashimoto Y, Nagano S, Ohsima S, Takahara S, Fujita T, Ono Y, Kinukawa T: Surgical complications in kidney transplantation: Experience from 1200 transplants performed over 20 years at six hospitals in central Japan. Transplant Proc 28: 1465–1467, 1996
    OpenUrlPubMed
  94. MacNeily AE, Leal GRJ, Heaton JPW: Surgical Complications of Renal Transplantation in a Small Centre Revisited in the Post-Cyclosporine Era. Ann R Coll Physicians Surg Can 33: 77–80, 2000
    OpenUrl
  95. Sansalone CV, Aseni P, Minetti E, Di Benedetto F, Rossetti O, Manoochehri F, Vertemati M, Giacomoni A, Civati G, Forti D: Is lymphocele in renal transplantation an avoidable complication? Am J Surg 179: 182–185, 2000
    OpenUrlCrossRefPubMed
  96. Bischof G, Rockenschaub S, Berlakovich G, Langle F, Muhlbacher F, Fugger R, Steininger R: Management of lymphoceles after kidney transplantation. Transpl Int 11: 277–280, 1998
    OpenUrlCrossRefPubMed
  97. Rivera M, Marcen R, Burgos J, Arranz M, Rodriguez R, Teruel JL, Ortuno J: Treatment of posttransplant lymphocele with povidone-iodine sclerosis: Long-term follow-up. Nephron 74: 324–327, 1996
    OpenUrlPubMed
  98. Pourmand G, Mehrsai AR, Taheri M: Evaluation of endourological interventions used to treat urological complications in 394 kidney recipients. Transplant Proc 32: 524–525, 2000
    OpenUrlCrossRefPubMed
  99. Salomon L, Saporta F, Amsellem D, Hozneck A, Colombel M, Patard JJ, Chopin D, Abbou CC: Results of pyeloureterostomy after ureterovesical anastomosis complications in renal transplantation. Urology 53: 908–912, 1999
    OpenUrlCrossRefPubMed
  100. Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson ML: Urological complications in renal transplantation: Impact of a change of technique. Br J Urol 79: 499–502, 1997
    OpenUrlPubMed
  101. Makisalo H, Eklund B, Salmela K, Isoniemi H, Kyllonen L, Hockerstedt K, Halme L, Ahonen J: Urological complications after 2084 consecutive kidney transplantations. Transplant Proc 29: 152–153, 1997
    OpenUrlCrossRefPubMed
  102. Benoit G, Blanchet P, Eschwege P, Alexandre L, Bensadoun H, Charpentier B: Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: A prospective randomized study. J Urol 156: 881–884, 1996
    OpenUrlCrossRefPubMed
  103. Blanchet P, Hammoudi Y, Eschwege P, Droupy S, Bensadoun H, Hiesse C, Charpentier B, Benoit G: Urinary complications after kidney transplantation can be reduced. Transplant Proc 32: 2769, 2000
    OpenUrlCrossRefPubMed
  104. Arslan G, Moray G, Bilgin N, Karamehmetoglu M, Buyukpamukcu N, Haberal M: Early operative morbidity and mortality in 1051 consecutive kidney transplants over 20 years at our centers. Transplant Proc 28: 2311, 1996
    OpenUrlPubMed
  105. Nane I, Kadioglu TC, Tefekli A, Kocak T, Ander H, Koksal T: Urologic complications of extravesical ureteroneocystostomy in renal transplantation from living related donors. Urol Int 64: 27–30, 2000
    OpenUrlCrossRefPubMed
  106. Bassiri A, Simforoosh N, Gholamrezaie HR: Ureteral complications in 1100 consecutive renal transplants. Transplant Proc 32: 578–579, 2000
    OpenUrlCrossRefPubMed
  107. Samhan M, Gopalkrishnan G, alMousawi M: Urologic complications in renal recipients. Transplant Proc 31: 3214–3215, 1999
    OpenUrlCrossRefPubMed
  108. Hussain M, Khalique M, Askari H, Lal M, Hashmi A, Hussain Z, Naqvi A, Rizvi A: Surgical complications after renal transplantation in a living-related transplantation program at SIUT. Transplant Proc 31: 3211, 1999
    OpenUrlCrossRefPubMed
  109. Kumar A, Kumar R, Bhandari M: Significance of routine JJ stenting in living related renal transplantation: A prospective randomised study. Transplant Proc 30: 2995–2997, 1998
    OpenUrlCrossRefPubMed
  110. D’Alessandro AM, Pirsch JD, Knechtle SJ, Odorico JS, Van der Werf WJ, Collins BH, Becker YT, Kalayoglu M, Armbrust MJ, Sollinger HW: Living unrelated renal donation: the University of Wisconsin experience. Surgery 124: 604–610, 1998
    OpenUrlCrossRefPubMed
  111. Karakayali H, Bilgin N, Moray G, Demirbas M, Ozkardes H: Major urological complications in 1051 consecutive renal transplants. Transplant Proc 28: 2339–2340, 1996
    OpenUrlPubMed
  112. Masahiko H, Kazunari T, Tokumoto T, Ishikawa N, Yagisawa T, Toma H: Comparative study of urosurgical complications in renal transplantation: Intravesical versus extravesical ureterocystoneostomy. Transplant Proc 32: 1844–1846, 2000
    OpenUrlCrossRefPubMed
  113. Humar A, Sutherland DE, Ramcharan T, Gruessner RW, Gruessner AC, Kandaswamy R: Optimal timing for a pancreas transplant after a successful kidney transplant. Transplantation 70: 1247–1250, 2000
    OpenUrlCrossRefPubMed
  114. Gruessner RW, Sutherland DE, Drangstveit MB, Wrenshall L, Humar A, Gruessner AC: Mycophenolate mofetil in pancreas transplantation. Transplantation 66: 318–323, 1998
    OpenUrlCrossRefPubMed
  115. Basadonna GP, Auersvald LA, Oliveira SC, Friedman AL, Lorber MI: Pancreas after kidney transplantation: HLA mismatch does not preclude success. Transplant Proc 29: 667, 1997
    OpenUrlCrossRefPubMed
  116. Gruessner RW: Tacrolimus in pancreas transplantation: A multicenter analysis. Clin Transpl 11: 299–312, 1997
  117. Jindal RM, Dubernard JM: Towards a specific immunosuppression for pancreas and islet grafts. Clin Transpl 14: 242–245, 2000
  118. Biesenbach G, Margreiter R, Konigsrainer A, Bosmuller C, Janko O, Brucke P, Gross C, Zazgornik J: Comparison of progression of macrovascular diseases after kidney or pancreas and kidney transplantation in diabetic patients with end-stage renal disease. Diabetologia 43: 231–234, 2000
    OpenUrlCrossRefPubMed
  119. Stratta RJ, Gaber AO, Shokouh-Amiri MH, Reddy KS, Alloway RR, Egidi MF, Grewal HP, Gaber LW, Hathaway D: Evolution in pancreas transplantation techniques: simultaneous kidney-pancreas transplantation using portal-enteric drainage without antilymphocyte induction. Ann Surg 229: 701–708, 1999
    OpenUrlCrossRefPubMed
  120. Smets YF, van der Pijl JW, van Dissel JT, Ringers J, de Fijter JW, Lemkes HH: Infectious disease complications of simultaneous pancreas kidney transplantation. Nephrol Dial Transplant 12: 764–771, 1997
    OpenUrlCrossRefPubMed
  121. Kaufman DB, Leventhal JR, Koffron A, Gheorghiade M, Elliott MD, Parker MA, Abecassis MM, Fryer JP, Stuart FP: Simultaneous pancreas-kidney transplantation in the mycophenolate mofetil/tacrolimus era: Evolution from induction therapy with bladder drainage to noninduction therapy with enteric drainage. Surgery 128: 726–737, 2000
    OpenUrlCrossRefPubMed
  122. Rasaiah SB, Light JA, Sasaki TM, Currier CB: A comparison of daclizumab to ATGAM induction in simultaneous pancreas-kidney transplant recipients on triple maintenance immunosuppression. Clin Transpl 14: 409–412, 2000
    OpenUrlCrossRef
  123. Humar A, Kandaswamy R, Granger D, Gruessner RW, Gruessner AC, Sutherland DE: Decreased surgical risks of pancreas transplantation in the modern era. Ann Surg 231: 269–275, 2000
    OpenUrlCrossRefPubMed
  124. Freise CE, Narumi S, Stock PG, Melzer JS: Simultaneous pancreas-kidney transplantation: An overview of indications, complications, and outcomes. West J Med 170: 11–18, 1999
    OpenUrlPubMed
  125. Fornairon S, Desgrandchamps F, Cattan P, Meria P, Anidjar M, Bedrossian J, Teillac P, Le Duc A, Legendre C: Can we improve the results of simultaneous pancreas-kidney transplantation? Transplant Proc 30: 2818–2819, 1998
    OpenUrlCrossRefPubMed
  126. Bruce DS, Newell KA, Woodle ES, Cronin DC, Grewal HP, Millis JM, Ruebe M, Josephson MA, Thistlethwaite JR Jr: Synchronous pancreas-kidney transplantation with portal venous and enteric exocrine drainage: Outcome in 70 consecutive cases. Transplant Proc 30: 270–271, 1998
    OpenUrlCrossRefPubMed
  127. Gruessner RW, Sutherland DE, Troppmann C, Benedetti E, Hakim N, Dunn DL, Gruessner AC: The surgical risk of pancreas transplantation in the cyclosporine era: an overview. J Am Coll Surg 185: 128–144, 1997
    OpenUrlPubMed
  128. Busing M, Heimes M, Martin D, Schulz T, Dehof S, Kozuschek W: Simultaneous pancreas-/kidney transplantation–the Bochum experience. Exp Clin Endocrinol Diabet 105: 92–97, 1997
    OpenUrlPubMed
  129. Stratta RJ, Weide LG, Sindhi R, Sudan D, Jerius JT, Larsen JL, Cushing K, Grune MT, Radio SJ: Solitary pancreas transplantation. Experience with 62 consecutive cases. Diabetes Care 20: 362–368, 1997
    OpenUrlAbstract/FREE Full Text
  130. Kinkhabwala M, Wilkinson A, Danovitch G, Rosenthal JT, Tooley TK, Sanford A, Imagawa D, Rudich S, Seu P, Busuttil RW, Shackleton CR: The role of whole organ pancreas transplantation in the treatment of type I diabetes. Am J Surg 171: 516–520, 1996
    OpenUrlCrossRefPubMed
  131. Jones JW, Mizrahi SS, Bentley FR: Success and complications of pancreatic transplantation at one institution. Ann Surg 223: 757–762, 1996
    OpenUrlCrossRefPubMed
  132. Lenisa L, Castoldi R, Socci C, Motta F, Ferrari G, Spotti D, Caldara R, Secchi A, Pozza G, Di C, V: Cost-effective treatment for diabetic end-stage renal disease: Dialysis, kidney, or kidney-pancreas transplantation? Transplant Proc 27: 3108–3113, 1995
    OpenUrlPubMed
  133. Douzdjian V, Gugliuzza KG, Fish JC: Multivariate analysis of donor and recipient risk factors for renal and pancreas allograft failure after pancreas-kidney transplantation. Transplant Proc 27: 3128–3129, 1995
    OpenUrlPubMed
  134. Douzdjian V, Rajagopalan PR: Primary enteric drainage of the pancreas allograft revisited. J Am Coll Surgeons 185: 471–475, 1997
    OpenUrlCrossRefPubMed
  135. Steurer W, Bonatti H, Obrist P, Spechtenhauser B, Ladurner R, Mark W, Gardetto A, Margreiter R, Konigsrainer A: Incidence of intraabdominal infection in a consecutive series of 40 enteric-drained pancreas transplants with FK506 and MMF immunosuppression. Transplant Int 13 [Suppl 1]: S195–S198, 2000
  136. Farney AC, Cho E, Schweitzer EJ, Dunkin B, Philosophe B, Colonna J, Jacobs S, Jarrell B, Flowers JL, Bartlett ST: Simultaneous cadaver pancreas living-donor kidney transplantation: A new approach for the type 1 diabetic uremic patient. Ann Surg 232: 696–703, 2000
    OpenUrlCrossRefPubMed
  137. Cattral MS, Bigam DL, Hemming AW, Carpentier A, Greig PD, Wright E, Cole E, Donat D, Lewis GF: Portal venous and enteric exocrine drainage versus systemic venous and bladder exocrine drainage of pancreas grafts: Clinical outcome of 40 consecutive transplant recipients. Ann Surg 232: 688–695, 2000
    OpenUrlCrossRefPubMed
  138. Petruzzo P, Da Silva M, Feitosa LC, Dawahra M, Lefrancois N, Dubernard JM, Martin X: Simultaneous pancreas-kidney transplantation: Portal versus systemic venous drainage of the pancreas allografts. Clin Transpl 14: 287–291, 2000
  139. Merion RM, Henry ML, Melzer JS, Sollinger HW, Sutherland DE, Taylor RJ: Randomized, prospective trial of mycophenolate mofetil versus azathioprine for prevention of acute renal allograft rejection after simultaneous kidney-pancreas transplantation. Transplantation 70: 105–111, 2000
    OpenUrlPubMed
  140. Margreiter R, Steurer W, Spechtenhauser B, Konigsrainer A: Kidney transplantation together with another solid organ from the same donor — A single-center progress report. Clin Nephrol 53: 38–43, 2000
  141. Cantarovich D, Giral-Classe M, Hourmant M, Dantal J, Blancho G, Karam G, Soulillou JP: Low incidence of kidney rejection after simultaneous kidney-pancreas transplantation after antithymocyte globulin induction and in the absence of corticosteroids: results of a prospective pilot study in 28 consecutive cases. Transplantation 69: 1505–1508, 2000
    OpenUrlCrossRefPubMed
  142. Peddi VR, Kamath S, Munda R, Demmy AM, Alexander JW, First MR: Use of tacrolimus eliminates acute rejection as a major complication following simultaneous kidney and pancreas transplantation. Clin Transpl 12: 401–405, 1998
    OpenUrl
  143. Sollinger HW, Odorico JS, Knechtle SJ, D’Alessandro AM, Kalayoglu M, Pirsch JD: Experience with 500 simultaneous pancreas-kidney transplants. Ann Surg 228: 284–296, 1998
    OpenUrlCrossRefPubMed
  144. Schulz T, Martin D, Heimes M, Klempnauer J, Buesing M: Tacrolimus/mycophenolate mofetil/steroid-based immunosuppression after pancreas-kidney transplantation with single shot antithymocyte globulin. Transplant Proc 30: 1533–1535, 1998
    OpenUrlCrossRefPubMed
  145. Fabrega AJ, Corwin CL, Hunsicker L: Mycophenolate mofetil versus azathioprine in simultaneous pancreas-kidney transplant recipients on cyclosporine. Transplant Proc 30: 1562–1563, 1998
    OpenUrlCrossRefPubMed
  146. Elkhammas EA, Yilmaz S, Henry ML, Yenchar J, Bumgardner GL, Pelletier RP, Ferguson RM: Simultaneous pancreas/kidney transplantation: Comparison of mycophenolate mofetil versus azathioprine. Transplant Proc 30: 512, 1998
    OpenUrlCrossRefPubMed
  147. Bruce DS, Woodle ES, Newell KA, Millis JM, Cronin DC, Loss GE, Pellar S, Josephson MA, Thistlethwaite JR Jr: Effects of tacrolimus, mycophenolate mofetil, and cyclosporine microemulsion on rejection incidence in synchronous pancreas-kidney transplantation. Transplant Proc 30: 507–508, 1998
    OpenUrlCrossRefPubMed
  148. Kahl A, Bechstein WO, Platz K, Muller A, Berweck S, Venz S, Neuhaus P, Frei U: First results with a quadruple therapy regimen including tacrolimus and mycophenolate mofetil in patients after combined pancreas and kidney transplantation. Transplant Proc 30: 505–506, 1998
    OpenUrlCrossRefPubMed
  149. Henry ML, Elkhammas EA, Bumgardner GL, Pelletier RP, Ferguson RM: Outcome of 300 consecutive pancreas-kidney transplants. Transplant Proc 30: 291, 1998
    OpenUrlCrossRefPubMed
  150. Stegall MD, Simon M, Wachs ME, Chan L, Nolan C, Kam I: Mycophenolate mofetil decreases rejection in simultaneous pancreas-kidney transplantation when combined with tacrolimus or cyclosporine. Transplantation 64: 1695–1700, 1997
    OpenUrlCrossRefPubMed
  151. Stratta RJ: Simultaneous use of tacrolimus and mycophenolate mofetil in combined pancreas-kidney transplant recipients: a multi-center report. Transplant Proc 29: 654–655, 1997
    OpenUrlCrossRefPubMed
  152. Davidson I, Lu C, Munschauer C, Balfe P, Stephan R, Coorpender L: Intestinal drainage of the exocrine pancreatic allograft revisited: A better choice? Transplant Proc 29: 639, 1997
    OpenUrlCrossRefPubMed
  153. Odorico JS, Leverson GE, Becker YT, Pirsch JD, Knechtle SJ, D’Alessandro AM, Sollinger HW: Pancreas transplantation at the University of Wisconsin. In: Clinical Transplants, edited by Terasaki PI, Cecka JM, Los Angeles, UCLA Tissue Typing Laboratory, 2000, pp 199–210
  154. Ciancio G, Lo MA, Buscemi G, Miller J, Burke GW: Use of tacrolimus and mycophenolate mofetil as induction and maintenance in simultaneous pancreas-kidney transplantation. Transplant Int 13 [Suppl 1]: S191–S194, 2000
  155. Zibari GB, Aultman DF, Abreo KD, Lynn ML, Gonzalez E, McMillan RW, Dies D, Work J, McDonald JC: Roux-en-y venting jejunostomy in pancreatic transplantation: A novel approach to monitor rejection and prevent anastomotic leak. Clin Transpl 14: 380–385, 2000
    OpenUrlCrossRef
  156. Hesse UJ, Troisi R, Jacobs B, Van Vlem B, de Hemptinne B, Van Holder R, Vermassen F, De Roose J, Lameire N: A single center’s clinical experience with quadruple immunosuppression including ATG or IL2 antibodies and mycophenolate mofetil in simultaneous pancreas-kidney transplants. Clin Transpl 14: 340–344, 2000
  157. Cattral MS, Hemming AW, Greig PD, Rowsell C, Chari R, Wright E, Donat D, Cole E, Levy GA: Low incidence of rejection after synchronous pancreas-kidney transplantation with Neoral. Transplant Proc 30: 1946, 1998
    OpenUrlCrossRefPubMed
  158. Stratta RJ: Ganciclovir/acyclovir and fluconazole prophylaxis after simultaneous kidney-pancreas transplantation. Transplant Proc 30: 262, 1998
    OpenUrlCrossRefPubMed
  159. Bruce DS, Newell KA, Josephson MA, Woodle ES, Piper JB, Millis JM, Seaman DS, Carnrike CL, Jr., Huss E, Thistlethwaite JR, Jr: Long-term outcome of kidney-pancreas transplant recipients with good graft function at one year. Transplantation 62: 451–456, 1996
    OpenUrlCrossRefPubMed
  160. Kohli V, Velosa J, Sterioff S, Munn SR: Prophylaxis for cytomegalovirus in pancreas transplant recipients using intravenous ganciclovir. Transplant Proc 27: 2993, 1995
    OpenUrlPubMed
  161. Manske CL, Wang Y, Thomas W: Mortality of cadaveric kidney transplantation versus combined kidney-pancreas transplantation in diabetic patients. Lancet 346: 1658–1662, 1995
    OpenUrlCrossRefPubMed
  162. Javor KA, Kotsanos JG, McDonald RC, Baron AD, Kesterson JG, Tierney WM: Diabetic ketoacidosis charges relative to medical charges of adult patients with type 1 diabetes. Diabetes Care 20: 349–354, 1997
    OpenUrlAbstract/FREE Full Text
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Journal of the American Society of Nephrology: 14 (2)
Journal of the American Society of Nephrology
Vol. 14, Issue 2
1 Feb 2003
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Dialysis, Kidney Transplantation, or Pancreas Transplantation for Patients with Diabetes Mellitus and Renal Failure: A Decision Analysis of Treatment Options
Greg A. Knoll, Graham Nichol
JASN Feb 2003, 14 (2) 500-515; DOI: 10.1097/01.ASN.0000046061.62136.D4

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Dialysis, Kidney Transplantation, or Pancreas Transplantation for Patients with Diabetes Mellitus and Renal Failure: A Decision Analysis of Treatment Options
Greg A. Knoll, Graham Nichol
JASN Feb 2003, 14 (2) 500-515; DOI: 10.1097/01.ASN.0000046061.62136.D4
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