Renal failure and Diabetes mellitus: kidney, pancreas and kidney-pancreas transplantation

Chronic renal failure (CRF)

To date there is no therapy to cure chronic kidney failure. A correct therapy can slow down the worsening of the disease and limit the discomfort for the person over time. The therapy depends on the degree of kidney failure and the original condition that caused it. In severe cases of kidney failure, where medical therapy is no longer sufficient to ensure the balance of the body, it becomes necessary to resort to dialysis (peritoneal dialysis or hemodialysis) or kidney transplantation.  Dialysis, however, is associated with complications and high mortality.

In fact, dialysis treatment causes cardiovascular damage, skeletal changes, anemia, and growth retardation among children. In addition, the quality of life during dialysis is compromised. For these reasons, renal transplantation is considered the treatment of choice for patients in need of renal replacement therapy. Kidney transplantation requires the availability of an organ to be transplanted either from a living donor or from a cadaveric donor. Living kidney transplantation is now a well-established and constantly developing practice in our country. Due to data widely supported by the literature of safety for the donor and better outcome for the recipient, it should always be considered as the first therapeutic option for patients with advanced CRF for a number of advantages compared to non-living donor transplantation:

• possibility of performing the procedure before the start of dialysis (pre emptive transplantation),
• planning the intervention in order to optimize its success and allow pre-treatment of the recipient if necessary,
• reduce the time of ischemia and therefore the risks of delayed recovery of renal function,
• identify the best immunological matches and thus reduce the risks of rejection.

All these conditions allow the short and long term results of living transplantation to be better than those of cadaveric donor transplantation both in terms of renal function and survival. In addition, from a general perspective, the increased number of living transplants is essential to deal with the chronic shortage of nonliving donors, which leads to a potential lengthening of dialysis waiting times and overcrowding of cadaveric waiting lists for immunosuppressive therapy.

Diabetes Mellitus (DM)

Diabetes is a disease in which blood glucose (sugar) levels are excessively high due to the absence or reduced functioning of insulin, a hormone produced in the pancreas. Insulin is needed to get glucose "into" the body's cells, where it can be used as nutrition. In the absence of insulin, glucose cannot enter the cells and remains in the circulation, resulting in what is known as "hyperglycemia" (an excess of sugar in the blood). A particular form of diabetes, type 1 diabetes (also known as "juvenile" or autoimmune), develops when the body's immune system attacks and destroys the cells in the pancreas responsible for producing insulin. As a result, the pancreas is no longer able to produce insulin in individuals with type 1 diabetes. Therefore, these people require insulin from outside, administered through injections, to keep their blood sugar (blood sugar) levels within normal ranges. Many studies have shown that keeping blood sugar within normal ranges is important in reducing the risk of developing the complications associated with poorly controlled diabetes, such as blindness, kidney failure, nervous system damage, heart attack, stroke, unconsciousness, and coma.

Pancreas transplantation is a well-established therapeutic procedure worldwide for the treatment of type 1 diabetes among people who have difficulty with blood sugar control. Most pancreas transplants are performed simultaneously with or following kidney transplantation, while isolated pancreas transplantation is reserved for a smaller number of patients who meet the criteria for this procedure.

In addition to pancreas transplantation, another therapeutic option is the transplantation of Langerhans insulae. Using advanced laboratory techniques, it is possible to separate these cell aggregates from the whole pancreas taken from the donor, thus reducing to a minimum (5 to 10 mL) the tissue to be transplanted. In this case a major surgery is avoided, as the transplantation procedure is performed by the simple infusion of the islets into the liver. In order to achieve the expected optimal function, which results in a clear improvement of metabolic compensation, with disappearance of hyper- and hypoglycemia fluctuations, normalization of glycated hemoglobin and reduction of insulin requirements up to total discontinuation (50-60% of cases), it is usually necessary to undergo two or more infusions, several months apart, since a single infusion does not guarantee a sufficient beta cell mass to achieve the desired goals. In fact, the processing of the pancreas in the laboratory does not allow the total amount of islets to be recovered.