Suzanne A. Miller

Carotid intima media thickness decreases after pancreas transplantation

BACKGROUND Pancreas transplantation (PTX) improves diabetic microvascular complications, but it is unknown whether PTX alters macrovascular disease. Carotid intima media thickness (IMT) has been shown to correlate with cardiovascular events, so this study was designed to evaluate changes in carotid IMT after PTX. METHODS Four groups were studied: PTX candidates (n=60); successful PTX recipients (n=89; mean time since PTX=4.0+/-0.3 years); patients with type 1 diabetes but without nephropathy (n=20); and normal controls (n=32). Mean IMT and mean of maximum carotid IMT measurements (mean-max IMT), hemoglobin A1C, serum creatinine, body mass index (BMI), blood pressure, smoking status, use of hypolipidemic medications, and fasting lipids were determined in all groups. RESULTS Age, gender distribution, and BMI were not different among the groups. Duration of diabetes was also equal between pre- and post-PTX groups. Mean and mean-max IMT were greatest pre-PTX and decreased after PTX (P<0.05) to a value that was not different from controls. Hemoglobin A1C and creatinine decreased, and high density lipoprotein (HDL) increased after PTX (P<0.05), but there were no significant differences in other lipids, BMI, use of lipid lowering agents, blood pressure, or smoking status. CONCLUSIONS Carotid IMT is lower after PTX, suggesting a reduction in overall cardiovascular risk independent of changes in use of hypolipidemic agents, smoking, blood pressure, BMI, or lipids, except HDL. Improved carotid IMT after successful PTX predicts a reduction in future vascular disease events and suggests that the macrovascular disease of type 1 diabetes is at least partially reversible with improved glucose control.

Lipid Status After Pancreas-Kidney Transplantation

Objective –This study was performed to determine the net effects of euglycemia, resolution of renal failure, immunosuppressant drugs, and hyperinsulinemia on fasting lipid profiles of patients with renal failure and insulin-dependent diabetes mellitus (IDDM) after combined pancreas-kidney transplantation (PKT). Research Design and Methods –Thirty subjects with IDDM received PKT between April 1989 and October 1990, and all were studied. Mean ± SE age was 35.2 ± 1.3 yr; 19 recipients were men, and 11 were women. All had a functioning pancreatic allograft post-PKT. Fasting lipid profiles including total cholesterol (C), triglyceride (TG), high-density lipoprotein cholesterol (HDL-chol), and C/HDL-chol were compared before and after PKT (38–555 days divided into groups: preoperation and 0–2, 3–8, and 9–19 mo). Results –Significant hyperlipidemia was observed preoperatively (means ± SE): C, 5.92 ± 0.27 mM; HDL-chol, 1.07 ± 0.09 mM; TG, 5.85 ± 0.56 mM; and C/HDL-chol, 6.49 ± 0.83. All lipids and C/HDL-chol dropped immediately after PKT (0-2 mo vs. preoperation, all P < 0.01, except HDL-chol). After this immediate postoperative period, C, HDL-chol, and TG stabilized at new concentrations. C (5.44 ± 0.22 mM) and TG (4.54 ± 0.48 mM) levels were < preoperation (not statistically significant and P < 0.05, respectively). HDL-chol was greater than preoperative values (1.29 ± 0.06 mM, P < 0.05). C/HDL-chol dropped after PKT (0-2 mo, 4.85 ± 0.18, P < 0.01) and continued to decrease throughout the observation period (3-8 mo, 4.42 ± 0.23; 9-19 mo, 4.23 ± 0.23; both P < 0.01 vs. preoperation). There was no statistical difference between lipid concentrations in male and female subjects. Conclusions –The lipid status of subjects with IDDM and renal failure was abnormal before PKT and once lipid concentrations stabilized after PKT (> 2 mo), HDL-chol was higher and TG and C/HDL-chol levels were significantly lower than preoperative values. If these changes are sustained, risk of future cardiovascular disease in this group of patients might be significantly reduced.

A comparative analysis of results and morbidity in type I diabetics undergoing preemptive versus postdialysis combined pancreas-kidney transplantation

Although combined pancreas-kidney transplantation (PKT) has become a valid treatment option for selected type I diabetics, the timing of PKT relative to the degree of nephropathy remains controversial. We analyzed results and morbidity in 30 type I diabetics undergoing PKT after starting dialysis (PKT:D) versus 31 type I diabetics undergoing PKT prior to dialysis (PKT:ND). The two groups were similar with the respect to age, duration and severity of diabetes, gender, race, preservation time, retransplants, sensitization, HLA-matching, and CMV status. The mean preoperative serum creatinine was higher in the PKT:D group (9.9 +/- 3.4 vs. 3.9 +/- 1.9 mg/dl PKT:ND, P < 0.01). All patients were managed with quadruple immunosuppression with OKT3 induction. Actuarial patient survival is 100% (PKT:D) and 96.8% (PKT:ND). Renal and pancreas allograft survival are 97% and 93%, respectively, in both groups. The incidence of rejection, infection, operative complications, reflux pancreatitis, and total hospital days was similar in both groups. Long-term renal and pancreas allograft function and quality of life were like-wise comparable. No adverse coagulation or immunologic effects were noted in the PKT:ND group. Rehabilitation potential favored the PKT:ND group. PKT can be performed safely and effectively in the absence of uremia. In selected type I diabetics with significant nephropathy, we believe that PKT is the best treatment option and need not be considered as preemptive, especially in view of increasing waiting times and the variable progressive nature of diabetic complications.

Recipient selection and evaluation for vascularized pancreas transplantation

Vascularized pancreas transplantation (PT) is becoming an accepted therapy for selected type I diabetic patients. However, selection and evaluation criteria remain uncertain. In the last 3.5 years, we have interviewed 205 and evaluated 151 diabetic patients for PT. The degree of renal dysfunction (creatinine clearance below 45 ml/min) was used to select patients for combined pancreas-kidney transplantation (PKT) or solitary pancreas transplantation (PTA) (clearance above 70 ml/min). The cardiovascular evaluation (stress thallium study with liberal use of coronary angiography) was used to determine operative risk and provided the other major selection criterion. A total of 104 patients were selected as candidates for PT; 70 have undergone PKT with 98.6% patient survival (1 cardiovascular death), 97.1% kidney graft survival, and 94.2% pancreas graft survival. Thirty-three evaluated patients (24.1%) were not accepted as candidates for PT; 13 have undergone cadaveric kidney transplantation, 5 were placed on the kidney waiting list, and 9 have died. Criteria for PTA include 2 or more diabetic complications or hyperlabile diabetes. Patient (n = 12) and pancreas graft survival after PTA is 83.3 and 50%, respectively. Our conclusion is that a multidisciplinary approach was used for recipient selection for PT based on degree of nephropathy, cardiovascular risk, and presence of diabetic complications. Nearly 75% of diabetic patients evaluated were acceptable candidates for PT. Only 4 (3.8%) of these selected patients died while awaiting or undergoing PT, thus optimizing the use of scarce allograft resources and providing evidence for appropriate patient selection.

Lipid status after combined pancreas-kidney transplantation and kidney transplantation alone in type I diabetes mellitus.

This study was designed to compare changes in lipid status following organ transplantation between type I diabetes mellitus (DM-I) patients receiving combined pancreas-kidney transplantation (PKT) with those receiving kidney transplantation alone (KTA). A retrospective chart review was used to identify pre- and posttransplantation fasting total cholesterol (TC) and triglyceeides (TG) in three groups: DM-I patients receiving KTA (DM:KTA; n=14), DM-I patients receiving PKT (DM:PKT; n=20), and kidney transplant recipients without DM (NDM; n=16). The groups were matched for age, gender, weight, duration of dialysis, smoking history, and duration of diabetes mellitus. Linear regression was used to analyze differences in lipid trends over time (up to 24 months posttransplantation) and the effects of prednisone dose, cyclosporine dose, and serum creatinine. Preoperative TC was significantly lower in the DM:KTA group (P<0.05) compared with DM:PKT or NDM. There were no significant differences in preoperative TG between the three groups. TC and TG decreased over time only in DM:PKT (P=0.0112, P=0.0278, respectively). TC increased and TG was unchanged over time in DM:KTA (P=0.0003, P=0.1103, respectively). Neither TC nor TG changed over time in NDM. Trends of TC and TG for DM:PKT were significantly different from DM:KTA (P<0.01 for both). Trend of TC for NDM was also significantly different from DM:PKT (P=0.0061). Prednisone dose was significantly related to TC in DM:KTA and NDM (P<0.01) while cyclosporine dose was significantly related to TC for DM:KTA only (P=0.0013) in the presence of time. None of the variables tested (prednisone dose, cyclosporine dose, and serum creatinine) significantly affected TG in the presence of time. In summary, TC and TG decreased over time only in DM:PKT. In contrast, TC increased while TG was unchanged in

Analysis of hospital charges after simultaneous pancreas-kidney transplantation in the era of managed care

BACKGROUND The purpose of this study was to analyze and compare hospital charges in simultaneous pancreas-kidney transplant (SPKT) recipients before and after implementation of managed care principles. METHODS Two groups were compared: 14 consecutive SPKT patients transplanted in 1991 vs. 15 consecutive SPKT patients transplanted in 1995. All patients underwent whole organ pancreas transplantation with bladder drainage and received quadruple immunosuppression with OKT3 induction. The two groups were well-matched; outliers were excluded (four in 1991 and five in 1995), and no attempt was made to convert 1991 to 1995 dollars. Patient and graft survival rates were 100%, and no major early complications occurred. All SPKTs were performed in a single hospital setting, and all inpatient charges for the initial hospitalization were analyzed retrospectively and itemized by service. RESULTS Pharmacy, organ acquisition, and clinical laboratory services accounted for nearly 80% of charges in each group. For the initial transplant hospitalization, the 1995 group experienced significant reductions in: (1) length of stay (16.3+/-1.4-135+/-3.5 days, P=0.03); (2) total number of laboratory tests (392+/-15-224+/-60, P<10(-3)); (3) clinical laboratory charges (

Viral prophylaxis in combined pancreas-kidney transplant recipients

23,623+/-

Reproductive hormones after pancreas transplantation.

1,780-

Anti-Insulin Antibodies Are a Cause of Hypoglycemia Following Pancreas Transplantation

11,165+/-

CYCLOSPORINE CHALLENGE IN THE DECISION OF COMBINED KIDNEY-PANCREAS VERSUS SOLITARY PANCREAS TRANSPLANTATION

3,091, P<10(-6)); and (4) total inpatient charges with organ acquisition charges excluded (