To be, or not to be, on insulin for simultaneous kidney-pancreas transplant: Is that the question?

The prevalence of type 2 diabetes mellitus (T2DM) among patients with kidney failure is nearly 40%. The therapeutic paradigm for the management of T2DM in the setting of chronic kidney disease (CKD) has undergone a dramatic evolution in recent years. Progressive CKD decreases the need for exogenous insulin, allowing noninsulin treatments to be more effective in controlling serum glucose levels. Although diet, exercise, weight loss, and behavioral therapy are important factors in diabetes management, several noninsulin alternatives have risen to the forefront, including glucagon-like peptide 1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 receptor agonists, particularly in patients with cardiovascular risk factors. Consequently, many patients with T2DM and stage 4/5 CKD previously taking insulin no longer require it at transplant referral and are not considered for simultaneous kidney-pancreas transplant (SKPT). Given the diabetogenic effects of calcineurin inhibitors and steroids, coupled with the more rapid elimination of endogenous insulin associated with improved renal function posttransplant, many patients are denied access to SKPT although they will predictably become insulin-requiring after kidney transplant alone. To be, or not to be, on insulin should no longer be the key question in the evaluation of patients with CKD and T2DM for SKPT.