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A partially blind diabetic woman who received a cadaveric kidney more than ten years ago obtained worth-while rehabilitation as the result of continuous excellent function of her graft.
When renal transplantation became a practical means of therapy almost two decades ago,1 diabetes mellitus was considered a high risk factor, which precluded candidacy, except when related donors were available. Najarian et al.2 popularized renal3 transplantation in diabetics, provided evidence that patient survival was superior to that with chronic dialysis, and emphasized the necessity for an inter-disciplinary health care team before and after transplantation. In an exhaustive report covering a 10-year period, Najarian et al.2 provided a follow-up for 109 diabetic patients who underwent primary cadaveric renal transplantation under treatment with azathioprine, prednisone, and antilymphocyte globulin (ALG). The one-year cadaveric graft survival of 60% was a high water mark, marred only by the patient mortality which was 30% in the first post-operative year. Discussions of Najarian's paper by several transplantation surgeons made it clear that others were not achieving even this level of success.2 The unsatisfactory results with cadaveric transplantation in diabetic, (or for that matter non-diabetic), patients has been a nagging indictment of the deficiencies of the techniques of immunosuppression, which have changed little since the mid-1960's. Treatment in most centers has been with the double drug combination of azathioprine-prednisone,1,3 and in almost all of the rest, triple drug therapy with azathioprine, prednisone, and anti-lymphocyte globulin (ALG) has been used.2,4 With either approach, high-dose chronic therapy with steroids has been an unusually adverse factor for diabetics, with a predictable increase in insulin needs, and with a high incidence of infections and vascular complications. Minor variations from basic double and triple drug therapy have been reviewed.5 These did not have a major impact. Other attempts to improve the outlook have been with tissue typing,6,7 and with systematic preoperative blood transfusion of the recipient.8 With the introduction by Calne et al.9,10 of the new drug, cyclosporine, as a single immunosuppressive agent, or with the use of cyclosporine plus a limited quantity of steroids as we have recommended,11,12 there has been the prospect of better graft survival with less morbidity. To see if this objective has been realized, we report here the fate of diabetic patients during our early experience with cyclosporine-steroid therapy. For comparison, a small group of patients given azathioprine and steroids during the same time will be included.
