Vitamin D deficiency and clinical outcome in patients with chronic heart failure: A review.

AIM: The aim of this review was to summarize evidence on the role of Vitamin D deficiency in heart failure (HF), from pathophysiological mechanisms to clinical effects of Vitamin D supplementation. DATA SYNTHESIS: Chronic HF secondary to left ventricular (LV) systolic dysfunction is a growing health problem, still associated with poor clinical outcome. In recent years, experimental and epidemiological evidence focused on the role of Vitamin D in HF. Cross sectional studies demonstrated that prevalence of HF is increased in patients with Vitamin D deficiency or parathyroid hormone (PTH) plasma level increase, whereas longitudinal studies showed enhanced risk of developing new HF in patients with Vitamin D deficiency. In addition, in patients with established HF, low plasma levels of Vitamin D are associated with worsening clinical outcome. Yet, clinical studies did not definitively demonstrate a benefit of Vitamin D supplementation for preventing HF or ameliorating clinical outcome in patients with established HF. CONCLUSIONS: Despite convincing experimental and epidemiological data, treatment with Vitamin D supplementation did not show clear evidence of benefit for preventing HF or influencing its clinical course. Ongoing clinical studies will hopefully shed lights on the effects of Vitamin D supplementation on clinical endpoints along the spectrum of HF.

Early and late residual renal function and surgical complications in living donors: a 15-year experience at a single institution.

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31-74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.

Pancreas retransplantation: ideal timing and early and late results.

Surgical complications are the leading cause of pancreatic graft loss among diabetic patients who undergo pancreas transplantation alone (PTA), or combined with kidney transplantations (PK) or after kidney transplantations (PAK). Therapeutic effects on secondary complications of diabetes justify pancreas retransplantation (re-PT) when the first graft is lost. However, the appropriate timing for retransplant and related problems is not known. We present our initial experience on re-PT performed on seven diabetic patients who lost their first pancreas grafts (PK) due to surgical complications (venous thrombosis in five and enteric fistula in two). Five re-PT were performed a few days after the first PT without a second course of induction therapy, while two patients received re-PT some months later with reinduction therapy. In the early re-PT group, one patient died some hours after the second surgical procedure due to pulmonary embolism, while four patients lost their second grafts due to accelerated rejection within 2 years from re-PT. In the late re-PT group, both patients have good graft function without signs of rejection. Our initial experience showed discouraging results in the group of early re-PT, due to accelerated rejection episodes leading to a high incidence of graft loss. Late re-PT accompanied by reinduction therapy seemed to have better results.

Laparosopic hand-assisted living donor nephrectomy: the Niguarda experience.

Perioperative donor morbidity, a barrier to living organ donation, may be mitigated by the laparoscopic approach. From September 2002 to September 2004, 15 living donors, of ages ranging from 36 to 59 years, underwent laparoscopic nephrectomy. We used a hand-assisted device to increase the safety of the procedure. The average operating time was 200 minutes. The average blood loss was about 100 mL. The patients resumed oral intake and started walking within 1 day. The average postoperative hospital stay was 6 days. Although laparoscopic operating times were longer than those for traditional surgery, we showed benefits to the laparoscopic donor to be less postoperative pain, better cosmesis, shorter recovery time, and faster return to normal activities. We therefore consider laparoscopic nephrectomy a good alternative to traditional surgery for selected patients. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the gold standard for donor nephrectomy in the near future.

Surgical complications are the main cause of pancreatic allograft loss in pancreas-kidney transplant recipients.

We examined surgical complications among a group of diabetic type 1 patients (IDDM) with end-stage renal disease (ESRD) who had undergone pancreas-kidney transplantations (PK). Between October 1993 and August 2004, 70 SPK were performed using bladder (n = 14) or enteric (n = 56) drainage. Donors were selected according to standard criteria (mean age, 27.6 years; range, 17-49). All patients received cyclosporine-based immunosuppression. All pancreata functioned immediately, whereas 2 patients needed postoperative dialysis. Four patients (5.7%) lost their pancreatic graft due to vascular thrombosis; both patients underwent urgent allograft pancreaectomy and pancreas retransplantation (re-PT). One of them (1.4%) experienced a venous thrombosis and died due to a pulmonary embolism at 12 hours after re-PT. The other 3 patients had uneventful postoperative courses and were discharged with good pancreatic and renal function. Three patients in the bladder group (21.4%) had an anastomotic leak, which resolved with a bladder catheter. Four patients in the enteric group (7.1%) who experienced an anastomotic leak needed a second surgical procedure but in 3 of them allograft pancreatectomy was necessary. Relaparotomy was required in the other 3 patients due to hemorrhage (1 patient) or occlusion (2 patients). Acute rejection episodes, which occurred in 16 patients (22.8%), were treated with steroid boluses. With a mean follow-up of 72 months (range, 3-129), 2 patients have died at 8 and at 36 months, respectively, after SPK due to acute myocardial infarction (2.9%). Chronic rejection was the leading cause of pancreatic failure in 5 patients (7.1%) and of renal failure in 2 patients (2.8%). Patient, kidney, and pancreas survival rates were 95.8%, 92.9%, and 81.5%, respectively. Surgical complications were the leading cause of pancreatic allograft loss in IDDM and ESRD patients submitted to SPK.

[Pancreas transplantation. Experience in the first 50 patients at the Niguarda Hospital of Milan: clinical outcome and open questions]. / Il trapianto di pancreas. Esperienza dell'Ospedale Niguarda sui primi 50 pazienti: dubbi e certezze.

AIM: Personal experience in 50 patients who underwent combined pancreas-kidney transplantation (PKT), with particular reference to mortality and surgical complications is reported. METHODS: Between October 1993 and December 2001, 50 adult patients (36 males and 14 females), mean age 37 years (range 25-60), with chronic renal failure, and Insulin Dependent Diabetes Mellitus (IDDM), underwent 54 pancreas transplantation (4 patients retransplanted) and 52 kidney transplantation (2 patients retransplanted). Different surgical procedures have been employed during the period of 9 years. All patients underwent the same immunosuppressive regimen; the mean length of follow-up was 49 months. During the follow-up, 30 out of 43 patients who maintained a good graft function fulfilled a questionnaire about their quality of life following the criteria of the Medical Outcome Study (MOS). RESULTS: All patients became euglycemic immediately after the surgical procedure. One patient died post-operatively due to pulmorary thromboembolism after pancreas retransplantation for acute venous thrombosis; 1 other patient died 9 months after the procedure for acute myocardial infarction. Four patients developed acute venous thrombosis. All these patients underwent pancreas retransplantation, but 3 of these patients who survived the procedure lose the graft function for chronic rejection within 1 year. Fourteen patients showed acute rejection, 7 patients CMV infection. Three patients showed hyperchloremic acidosis, 12 patients bronchopulmonar infection and 7 patients urinary infection. Among surgical complications anastomotic fistula in 6 patients was also recorded. Five patients out of 50 lose the pancreatic graft function. After 1 from PKT, 83% of patients who fulfilled a questionnaire were strongly satisfied about their quality of life. No patients developed de novo tumors following chronic immunosuppression. The 5-year survival for patient, kidney and pancreas was 95.6%, 93.4% and 84.7% respectively. CONCLUSIONS: Our experience in 50 patients submitted to PKT shows no graft loss due to acute rejection. Surgical complications (acute venous thrombosis) and chronic rejection are the most important factors leading to graft loss. A graft in "head-up" position, a short portal vein of the graft, a "no-touch technique" during pancreas retrieval can be some of the most important factors which can reduce the rate of surgical complications. Combined kidney-pancreas transplantation showed in our experience a low mortality rate and a moderate incidence of morbidity and should be considered, at the moment, the treatment of choice for patients with renal failure and IDDM.