Improvement in hypertension in patients with diabetes mellitus after kidney/pancreas transplantation.

BACKGROUND: Hypertension persists in many patients with diabetes mellitus after kidney transplantation. However, the impact of control of diabetes as well as kidney failure on hypertension by combined kidney and pancreas transplantation has not been studied. METHODS AND RESULTS: Between March 1993 and August 1998, 111 patients with type 1 diabetes mellitus underwent successful pancreas transplantation (108 kidney/pancreas transplantation) and another 28 patients with type 1 diabetes mellitus underwent isolated kidney transplantation. Blood pressure measurements and all antihypertensive medications were determined for both groups before transplantation and at 1, 3, 6, and 12 months and at the most recent outpatient evaluation after transplantation. At baseline, the mean blood pressure was 151/88 and 151/83 mm Hg for the kidney/pancreas and isolated kidney transplant patients, respectively. The mean blood pressure decreased to 134/77 mm Hg 1 month after kidney/pancreas transplantation (P<0.001) and decreased further to 126/70 mm Hg (P<0.001) at a mean follow-up of 18 months. This reduction in blood pressure after transplantation occurred despite a decrease in antihypertensive medications and the institution of immunosuppressive agents. At 1 month after kidney/pancreas transplantation, the average number of antihypertensive medications per patient was 0.9+/-1.0, compared with 2.5+/-1.1 before surgery (P<0.001). At 18 months after transplantation, 34% of patients were both normotensive (blood pressure

Simultaneous pancreas-kidney transplantation in the mycophenolate mofetil/tacrolimus era: evolution from induction therapy with bladder drainage to noninduction therapy with enteric drainage.

BACKGROUND: In the past, enteric drainage or the omission of induction immunotherapy has been shown to be predictive of suboptimal outcomes of simultaneous pancreas-kidney (SPK) transplantation. We have reassessed the need for bladder drainage and induction immunotherapy to optimize the outcome of SPK transplantation. METHODS: One hundred consecutive recipients of SPK transplants who received mycophenolate mofetil and tacrolimus immunosuppression were studied. The first 50 recipients had bladder-drained pancreas allografts and received induction immunotherapy. The results were compared with the next 50 recipients who had enteric-drained pancreas allografts, which included a subgroup (n = 17 patients) who were randomized to receive no induction immunotherapy. RESULTS: The 1-year actuarial patient, kidney, and pancreas survival rates in the bladder-drainage group were 98.0%, 94.0%, and 94.0%, respectively. The 1-year actuarial patient, kidney, and pancreas survival rates in the enteric-drainage group were 96.8%, 96.8%, and 89.4%, respectively. In the enteric-drainage group, the incidence of rejection at 1 year was 6.1% in recipients who received induction therapy versus 23.5% in recipients who did not receive induction therapy. The average number of readmissions per recipient was 1.8 in the bladder-drainage group versus 0.9 in the enteric-drainage group. CONCLUSIONS: Primary enteric drainage of the pancreas allograft in recipients of SPK transplantation is the preferred surgical technique in the tacrolimus/mycophenolate mofetil era.

Impact of an abbreviated adenosine protocol incorporating adjunctive treadmill exercise on adverse effects and image quality in patients undergoing stress myocardial perfusion imaging.

BACKGROUND: Limited data are available about the effects of adjunctive treadmill exercise on adverse effects and the image quality of adenosine perfusion imaging. This study compared the incidence of adverse effects and image quality between standard 6-minute adenosine perfusion imaging and a stress test incorporating a 4-minute adenosine infusion with low-level treadmill exercise. METHODS AND RESULTS: Nineteen patients underwent both a 6-minute adenosine technetium-99m sestamibi single photon emission computed tomography (SPECT) imaging study and a 4-minute adenosine Tc-99m sestamibi SPECT study with 6 minutes of simultaneous low-level treadmill exercise. Symptoms were recorded at 1-minute intervals during the stress and recovery periods. Heart-to-liver and heart-to-lung count ratios were determined from anterior planar images. More adverse effects were experienced during the standard adenosine study than during the adenosine study with low-level exercise (2.7+/-1.4 vs. 1.4+/-1.1, P = .0003). The duration adverse effects were experienced was longer during the standard 6-minute adenosine protocol (6.6+/-2.1 minutes vs 3.2+/-2.8 minutes, P<.0001). Additionally, the symptom-severity scores were higher with the standard adenosine study (15.5+/-9.8 vs 4.5+/-5.1, P<.0001). The heart-to-liver ratios were noted to be higher in the 4-minute adenosine protocol with low-level exercise (1.0+/-0.3 vs. 0.6+/-0.2, P = .0003). CONCLUSIONS: In comparison with standard 6-minute adenosine perfusion imaging, a protocol incorporating a 4-minute adenosine infusion with low-level treadmill exercise results in a marked reduction in the quantity and severity of adverse effects and an improvement in image quality.

Pancreas transplantation at Northwestern University.

The collective advances made by many groups have significantly improved the results of pancreas transplantation. We have focused on the development of safe and effective immunotherapy, including a new protocol of rapid withdrawal of corticosteroids, the analysis of surgical technique of pancreas exocrine drainage on outcome and the role of SPK transplantation in patients with significant cardiovascular disease. We have found that multimodal immunotherapy including induction with tacrolimus-based maintenance combined with either MMF or sirolimus, with or without corticosteroids, resulted in excellent patient and graft survival rates with low rates of rejection. In this setting, enteric drainage was preferable to bladder drainage because of a lower rate of complications leading to hospital readmissions. Careful pretransplant screening for cardiovascular disease should be routinely performed for all SPK candidates. If successful coronary revascularization can be achieved, these patients can safely undergo SPK transplantation, with 5-year outcomes similar to those for recipients without coronary disease. Finally, we have observed that pancreas transplantation has an important ameliorating effect on hypertension that is independent of the method of pancreas exocrine drainage.

Impact of limited treadmill exercise on adenosine Tc-99m sestamibi single-photon emission computed tomographic myocardial perfusion imaging in coronary artery disease.

Limited exercise combined with dipyridamole increases myocardial perfusion defect severity compared with dipyridamole alone. The impact of limited exercise combined with adenosine on myocardial perfusion defect severity is unknown. This study compares myocardial perfusion defect severity with adenosine alone and adenosine combined with limited exercise. Thirty-two patients with coronary artery disease underwent on separate days and in randomized order technetium-99m sestamibi (25 to 30 mCi) single-photon emission computed tomographic imaging at rest, after adenosine (140 microg/kg/min x 6 minutes), and after adenosine (140 microg/kg/min x 4 minutes) during 6 minutes of modified Bruce treadmill exercise (adenosine-exercise). Radiopharmaceutical was injected at 3 and 5 minutes during adenosine and adenosine-exercise, respectively. Images were interpreted by a consensus agreement of 3 nuclear cardiologists without knowledge of patient identity, stress protocol, or clinical data using a 17-segment model and 5-point scoring system. A summed stress score (SSS), summed rest score (SRS), and summed difference (SSS-SRS) score (SDS) were calculated for each image. Peak stress heart rate and rate-pressure product were higher for adenosine-exercise than adenosine (102 +/- 19 vs 81 +/- 11 beats/min and 13,972 +/- 4,265 vs 10,623 +/- 2,131, respectively; both p <0.001). Sensitivity for detection of > or = 50% coronary stenosis was 75% and 72% for adenosine-exercise and adenosine, respectively (p = NS). There were no differences in SSS and SDS between adenosine-exercise and adenosine (8.2 +/- 5.9 vs 8.1 +/- 6.3 and 4.9 +/- 4.1 vs 5.2 +/- 4.6, respectively; both p = NS). Thus, in patients with coronary artery disease, limited treadmill exercise combined with adenosine does not increase myocardial perfusion defect severity compared with standard adenosine technetium-99m sestamibi single-photon emission computed tomographic myocardial perfusion imaging.

The use of cancellous bone for closure of oroantral and oronasal defects.

Two patients who were successfully treated with cancellous bone grafts for closure of large oroantral or oronasal defects have been presented. In attempting closure of such large defects, it is important to follow certain principles. The oral, antral, and nasal mucosa must be free of infection and inflammation, continuity must exist between the oroantral and oronasal mucosa, and water-tight closure of the oroantral and oronasal flaps must be achieved. Preoperative and postoperative antibiotics and steroids are recommended.