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Phase-specific intraoperative glycemic control in simultaneous pancreas-kidney transplantation
Pranjal Kashiv, Manish Ramesh Balwani, Priyanka Tolani, Amit Pasari, Khushboo Saxena, Vivek B Kute
Pranjal Kashiv, Department of Nephrology, All India Institute of Medical Sciences, Nagpur 441108, Mahārāshtra, India
Manish Ramesh Balwani, Department of Nephrology, Saraswati Kidney Care Center, Nagpur 440015, Maharashtra, India
Priyanka Tolani, Department of Internal Medicine, Jawaharlal Nehru Medical College, Wardha 442001, Mahārāshtra, India
Amit Pasari, Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha 442001, Maharashtra, India
Khushboo Saxena, Department of Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad 380016, Gujarāt, India
Vivek B Kute, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad 380016, Gujarat, India
Author contributions: Kashiv P conceptualized the study, designed the methodology, collected data, performed analysis, and drafted the initial manuscript; Balwani MR, Tolani P, Pasari A provided critical supervision, conceptual guidance, and major revisions of the manuscript; Saxena K assisted in data collection, literature review, and preparation of figures and tables; Kute VB contributed to study design, interpretation of results, and final review of the manuscript for important intellectual content; and all authors approved the final version and agree to be accountable for all aspects of the work.
AI contribution statement: AI tools including ChatGPT and Grammarly were used in a limited capacity for language refinement, grammatical correction, and improvement of readability of the manuscript text. No part of the scientific content of the manuscript (including the abstract, introduction, materials and methods, results, discussion, or conclusions) was generated de novo by AI. All scientific concepts, clinical observations, data interpretations, and conclusions are the original work of the authors. AI tools were used only for linguistic polishing and grammatical correction. They did not contribute to data analysis, study design, translation, or substantive scientific writing. No AI tool participated in the design of the study or in the interpretation of its results. All scientific reasoning was performed entirely by the human authors. No images were used in this manuscript; therefore, no AI tools were involved in image generation or editing. The authors take full responsibility for the entire content of the manuscript.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
Corresponding author: Vivek B Kute, DM, MD, FASN, FRCP, Professor, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad 380016, Gujarat, India.
drvivekkute@rediffmail.com
Received: January 20, 2026
Revised: February 18, 2026
Accepted: April 1, 2026
Published online: June 18, 2026
Processing time: 129 Days and 21.3 Hours
In this review summarizes studies addressing a critical and long-overlooked vulnerability in simultaneous pancreas-kidney transplantation (SPKT): Perioperative metabolic instability during the transition from graft ischemia to endocrine recovery after reperfusion. Despite the central role of glycemia in pancreatic graft viability, intraoperative glucose management has remained largely empirical, reactive, and inconsistently standardized across transplant centres. The authors propose a structured, six-phase intraoperative glycemic control framework that aligns glucose targets with discrete operative stages, advancing a physiology-informed alternative to static, threshold-based insulin administration. In their single-centre experience, phase-adapted targets were associated with early insulin-independent euglycemia and the absence of severe hypoglycemia, ketoacidosis, early graft loss, or perioperative mortality. Notably, greater intraoperative glycemic variability clustered among recipients who developed early thrombotic and infectious complications, implicating glucose instability as a potential amplifier of endothelial injury and immunothrombotic risk at a moment of maximal graft vulnerability. Although limited by small sample size, lack of a control cohort, and short follow-up, this work demonstrates that intraoperative metabolic control in SPKT can be conceptualized and implemented using phase-specific objectives rather than uniform glycemic thresholds, laying the groundwork for future prospective validation incorporating time-in-range and variability metrics.
Core Tip: Simultaneous pancreas-kidney transplantation (SPKT) represents a uniquely vulnerable metabolic state in which abrupt endocrine recovery occurs under conditions of ischemia-reperfusion injury and intense perioperative stress. In this review, we highlight the importance of treating intraoperative glycemia as a dynamic biological signal rather than a static safety parameter. A phase-specific approach to intraoperative glycemic control reframes anesthetic management as metabolic stewardship, emphasizing anticipation of predictable physiologic transitions, minimization of glycemic variability, and protection of the pancreatic microcirculation at reperfusion. Aligning glucose management with graft biology may reduce early immunothrombotic and infectious risk and represents an important, pragmatically implementable advance in SPKT care.
