Macrovascular events after kidney-pancreas transplantation in type 1 diabetic patients

Ambulatory Blood Pressure Monitoring as a Useful Tool in the Cardiological Assessment of Pancreas Transplant Recipients with Type 1 Diabetes

Having the appropriate tools to identify pancreas recipients most susceptible to coronary artery disease (CAD) is crucial for pretransplant cardiological assessment. The aim of this study is to evaluate the association between blood pressure (BP) indices provided by ambulatory blood pressure monitoring (ABPM) and the prevalence of CAD in pancreas transplant candidates with type 1 diabetes (T1D). This prospective cross-sectional study included adult T1D patients referred for pretransplant cardiological assessment in our center. The study population included 86 participants with a median age of 40 (35-46) years. In multivariate logistic regression analyses, after adjusting for potential confounding factors, higher 24 h BP (systolic BP/diastolic BP/pulse pressure) (OR  =  1.063, 95% CI 1.023-1.105, p = 0.002/OR = 1.075, 95% CI 1.003-1.153, p = 0.042/OR = 1.091, 95 CI 1.037-1.147, p = 0.001, respectively) and higher daytime BP (systolic BP/diastolic BP/pulse pressure) (OR  =  1.069, 95% CI 1.027-1.113, p = 0.001/OR = 1.077, 95% CI 1.002-1.157, p = 0.043/OR = 1.11, 95% CI 1.051-1.172, p = 0.0002, respectively) were independently and significantly associated with the prevalence of CAD. Daytime pulse pressure was the strongest indicator of the prevalence of CAD among all analyzed ABPM parameters. ABPM can be used as a valuable tool to identify pancreas recipients who are most susceptible to CAD. We suggest the inclusion of ABPM in pretransplant cardiac screening in type 1 diabetes patients eligible for pancreas transplantation.

Incidence, risk factors, and outcomes of stroke post-transplantation in patients receiving a steroid sparing immunosuppression protocol

Corticosteroid use after transplantation is associated with an increased incidence of cardiovascular events and death. Cerebrovascular disease is a common cause of morbidity and mortality post-renal transplantation; however, a dedicated analysis of cerebrovascular disease in recipients of a steroid sparing protocol has not been reported. The aim of this study was to examine the incidence, risk factors, and outcomes of CVA in transplant recipients receiving a steroid sparing protocol. We retrospectively analyzed 1237 patients who received a kidney alone or a simultaneous pancreas and kidney (SPK) transplant. Fifty-six of 1237 (4.53%) patients had a CVA post-transplant. All-cause mortality was significantly higher in the CVA group compared with the non-CVA group, OR: 3.4 (1.7-7.0), p < 0.001. Factors found to be associated with increased risk of CVA by multivariate analysis were older age, HR: 1.07 (1.04-1.09), p < 0.001; diabetes at the time of transplantation, HR: 2.83 (1.42-5.64), p = 0.003; corticosteroid use pre-transplant, HR: 3.27 (1.29-8.27), p = 0.013 and recipients of a SPK, HR: 4.03 (1.85-8.79), p < 0.001. This study has identified subgroups of patients who are at increased risk of CVA post-transplant in patients otherwise receiving a steroid sparing immunosuppression protocol.

Follow-up of secondary diabetic complications after pancreas transplantation

PURPOSE OF REVIEW

Successful pancreas transplantation restores physiologic glycemic and metabolic control. Its effects on overall patient survival (especially for simultaneous pancreas-kidney transplantation) are clear-cut. We herein review the available literature to define the impact of pancreas transplantation on chronic complications of diabetes mellitus.

RECENT FINDINGS

With longer-term follow-up, wider patient populations, and more accurate investigational tools (clinical and functional tests, noninvasive imaging, histology, and molecular biology), growing data show that successful pancreas transplantation may slow the progression, stabilize, and even favor the regression of secondary complications of diabetes, both microvascular and macrovascular, in a relevant proportion of recipients.

SUMMARY

Patients who are referred for pancreas transplantation usually suffer from advanced chronic complications of diabetes, which have classically been deemed irreversible. A successful pancreas transplantation is often able to slow the progression, stabilize, and even reverse many microvascular and macrovascular complications of diabetes. Growing clinical evidence shows that the expected natural history of long-term diabetic complications can be significantly modified by successful pancreas transplantation.

The long-term management of pancreas transplantation

Diabetes mellitus (DM) is a major health problem worldwide, which affects 18.2 million individuals (6.3% of the population) in the United States. Currently, the prevalence of Type 1 DM in the United States is estimated to be 1,000,000 individuals, and 30,000 new cases are diagnosed each year. In addition to end-stage renal disease (ESRD), DM is associated with blindness, accelerated atherosclerosis, dyslipidemia, cardio- and cerebrovascular disease, amputation, poor quality of life, and overall lifespan reduction. It accounts for more than 160,000 deaths per year in the United States alone. In 2002, the annual national direct and indirect costs of Types 1 and 2 DM exceeded $130 billion, which included hospital and physician care, laboratory tests, pharmaceutical products, and patient workdays lost because of disability or premature death. Hyperglycemia alone or in concert with hypertension is the primary factor influencing the development of major diabetic complications. From 1990 to 2001, the number of existing ESRD cases to DM increased by more than 300%, while the rate per million populations increased from 167% to 491%. The number is expected to grow 10-fold by 2030 to 1.3 million accounting for 60% of ESRD population. To date, DM is the leading indication for transplantation and is the cause of ESRD in more than 40% of all transplant recipients each year.

Cardiovascular complications of immunosuppressive agents in renal transplant recipients

Fatal and nonfatal cardiovascular events are the most important cause of graft loss in patients with a functioning graft following transplantation. The available data indicate that transplant patients have a high prevalence of hypertension, hyperlipidaemia and new onset diabetes mellitus after transplantation. The aetiology and pathogenesis of post-transplant hypertension, hyperlipidaemia and diabetes are multifactorial. In addition, disease of the native kidney and recurrence of renal disease can contribute to the development of cardiovascular disease in transplant recipients. Most transplant patients are at risk of clinically important drug-drug interactions involving immunosuppressive agents. Adverse reactions and drug-drug interactions should not be neglected when selecting an agent for treatment of cardiovascular risk factors in transplant recipients.