Chronic kidney disease (CKD) has become a real epidemic around the world, mainly due to ageing and
diabetic nephropathy. Although
diabetic nephropathy due to
type 1 diabetes mellitus (T1DM) has been studied more extensively, the vast majority of the diabetic CKD patients suffer from
type 2 diabetes mellitus (T2DM).
Renal transplantation has been established as a first line treatment for
diabetic nephropathy unless there are major
contraindications and provides not only a better quality of life, but also a significant survival advantage over dialysis. However, T2DM patients are less likely to be referred for
renal transplantation as they are usually older, obese and present significant comorbidities. As pre-emptive
renal transplantation presents a clear survival advantage over dialysis, all T2DM patients with CKD should be referred for early evaluation by a transplant center. The transplant center should have enough time in order to examine their eligibility focusing on special issues related with
diabetic nephropathy and explore the best options for each patient. Living donor
kidney transplantation should always be considered as the first line treatment. Otherwise, the patient should be listed for deceased donor
kidney transplantation. Recent progress in
transplantation medicine has improved the "transplant menu" for T2DM patients with
diabetic nephropathy and there is an ongoing discussion about the place of simultaneous pancreas kidney (SPK)
transplantation in well selected patients. The initial hesitations about the different pathophysiology of T2DM have been forgotten due to the almost similar short- and long-term results with T1DM patients. However, there is still a long way and a lot of ethical and logistical issues before establishing SPK
transplantation as an ordinary treatment for T2DM patients. In addition recent advances in
bariatric surgery may offer new options for severely obese T2DM patients with CKD. Nevertheless, the existing data for T2DM patients with advanced CKD are rather scarce and
bariatric surgery should not be considered as a cure for
diabetic nephropathy, but only as a bridge for
renal transplantation.