Phase-specific intraoperative glycemic control in simultaneous pancreas-kidney transplantation

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.