Metabolic and cardiovascular effects of beta cell replacement in type 1 diabetes.

Type 1 diabetes is associated with high morbidity and mortality, mostly due to the acute and chronic complications of the disease. Restoration of the lost beta cell mass by pancreas transplantation is the treatment of choice in selected type 1 diabetic patients. Growing data show that successful pancreas transplantation normalizes the metabolic alterations of diabetes, and can slow the progression, stabilize, and even favor the regression of secondary complications of the disease, including those at the cardiovascular level.

Long-term (5 years) efficacy and safety of pancreas transplantation alone in type 1 diabetic patients.

BACKGROUND: Although combined pancreas and kidney transplantation is an established procedure for the treatment of type 1 diabetes (T1D) in patients with end-stage renal disease, the role of pancreas transplant alone (PTA) in the therapy of T1D subjects with preserved kidney function is still matter of debate. METHODS: We report our single-center experience of PTA in 71 consecutive T1D patients all with a posttransplant follow-up of 5 years. Patient and pancreas (normoglycemia in the absence of any antidiabetic therapy) survivals were determined, and several clinical parameters (including risk factors for cardiovascular diseases) were assessed. Cardiac evaluation and Doppler echocardiographic examination were also performed, and renal function and proteinuria were evaluated. RESULTS: Actual patient and pancreas survivals at 5 years were 98.6% and 73.2%, respectively. Relaparotomy was needed in 18.3% of cases. Restoration of endogenous insulin secretion was accompanied by sustained normalization of fasting plasma glucose concentrations and HbA1c levels as well as significant improvement of total cholesterol, low-density lipoprotein-cholesterol, and blood pressure. An improvement of left ventricular ejection fraction was also observed. Proteinuria (24 hours) decreased significantly after transplantation. One patient developed end-stage renal disease. In the 51 patients with sustained pancreas graft function, kidney function (serum creatinine and glomerular filtration rate) decreased over time with a slower decline in recipients with pretransplant glomerular filtration rate less than 90 mL/min. CONCLUSIONS: PTA was an effective and reasonably safe procedure in this single-center cohort of T1D patients.

Results of pancreas transplantation alone with special attention to native kidney function and proteinuria in type 1 diabetes patients.

We report on our single-center experience with pancreas transplantation alone (PTA) in 71 patients with type 1 diabetes, and a 4-year follow-up. Portal insulin delivery was used in 73.2% of cases and enteric drainage of exocrine secretion in 100%. Immunosuppression consisted of basiliximab (76%), or thymoglobulin (24%), followed by mycophenolate mofetil, tacrolimus, and low-dose steroids. Actuarial patient and pancreas survival at 4 years were 98.4% and 76.7%, respectively. Relaparatomy was needed in 18.3% of patients. Restored endogenous insulin secretion resulted in sustained normalization of fasting plasma glucose levels and HbA1c concentration in all technically successful transplantations. Protenuria (24-hour) improved significantly after PTA. Renal function declined only in recipients with pretransplant glomerular filtration rate (GFR) greater than 90 ml/min, possibly as a result of correction of hyperfiltration following normalization of glucose metabolism. Further improvements were recorded in several cardiovascular risk factors, retinopathy, and neuropathy. We conclude that PTA was an effective and reasonably safe procedure in this single-center experience.

Weight loss and quality of life in chronic heart failure patients.

OBJECTIVES: To evaluate the impact of a planned body weight reduction on quality of life (QoL) in obese/overweight chronic heart failure (CHF) patients. METHODS: Thirty-four obese/overweight chronic heart failure patients (24 men, mean age 67.8 +/- 9.4 years) underwent a 6-month dietary programme. An assessment of clinical and biochemical parameters was executed before and after dietary programme. The QoL was judged by means of the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and at the end of the programme. RESULTS: End-study BMI (P < 0.005) and body weight (P < 0.04) values were significantly reduced. We observed a significant improvement in the mean New York Heart Association (NYHA) functional class value (P < 0.02) and in the left ventricle ejection fraction (LVEF) (P < 0.05). The end-study KCCQ scores were significantly increased in seven out of eight domains. We identified a cut-off value of body weight loss of 3 kg to separate responder patients from the nonresponder ones. Only responder group patients showed a significant variation in BMI (P < 0.04), body weight (P < 0.03), mean NYHA class value (P < 0.05), LVEF (P < 0.05). Moreover, all KCCQ domain scores significantly increased in the responder group only. CONCLUSION: A diet-based body weight reduction improved the quality of life and, perhaps, the cardiac function. Benefits are already evident with a small reduction in body weight.

Survival and hospitalization in a nurse-led domiciliary intervention for elderly heart failure patients.

AIM: Heart failure in the elderly population represents a complex clinical situation associated with frequent hospitalizations and numerous comorbidities. The present study aimed to evaluate the impact of a domiciliary-based nurse-led strategy in a group of very elderly patients affected by heart failure who were regularly seen at an outpatient heart failure clinic (HFC). METHODS: Patients were periodically assessed in their homes by two trained nurses under supervision of the cardiologists of the HFC. During each visit, the nurses examined clinical status and adherence to medication. When necessary, they also gathered venous blood samples for laboratory analysis and recorded an electrocardiogram. In addition, they provided key information regarding disease management to patients as well as to their care givers. During the baseline visit and, subsequently, every 6 months, an echocardiogram was performed at the HFC. RESULTS: Forty-four patients (52.4% male, median age 82 years) were followed up for a mean of 25 +/- 12 months. Compared to an equally long time period before randomization, during follow-up, a significant reduction in cardiac hospitalizations (from 1.83 +/- 1.54 to 1.07 +/- 1.39, P = 0.004), total hospitalizations (from 2.09 +/- 1.71 to 1.52 +/- 1.68, P = 0.003), HFC visits (from 3.31 +/- 2.33 to 2.24 +/- 1.38, P = 0.03) and New York Heart Association (NYHA) class (from 2.74 +/- 0.70 to 2.49 +/- 0.61, P = 0.04) was observed. Total 1-year mortality was 25% and was predicted by several clinical (weight loss, NYHA class), laboratory (hyperuricaemia, anaemia, renal failure, hyposodiemia) and echocardiographic (end-systolic diameter, ejection fraction, systolic pulmonary artery pressure) parameters. Multivariate analysis revealed that hyperuricaemia was as an independent predictor of mortality (odds ratio = 1.53, P = 0.038). CONCLUSIONS: The present study demonstrates that a domiciliary-based strategy in elderly patients affected by heart failure guarantees clinical stability and reduces hospitalizations as well as outpatient visits.

Pancreas transplant alone determines early improvement of cardiovascular risk factors and cardiac function in type 1 diabetic patients.

BACKGROUND: The effects of pancreas transplant alone (PTA) on cardiovascular risk factors (CRF) and cardiac function in type 1 diabetes mellitus (T1DM) patients are still unsettled. METHODS: We studied 13 T1DM patients who received PTA with portal drainage and 11 matched control patients. Parameters of glucose and lipid metabolism and several additional classic CRF were assessed before and up to 6 months posttransplant. Cardiac morphology and function were assessed by Doppler echocardiographic examination. RESULTS: Insulin independence was promptly achieved and then maintained after PTA. Total and low-density lipoprotein cholesterol levels were significantly lower after transplantation, whereas high-density lipoprotein cholesterol and triglyceride concentrations did not change. Both systolic and diastolic blood pressure values and fibrinogen levels improved significantly. In addition, PTA determined a significant amelioration of several morphologic and functional cardiac indices. None of the measured parameters changed in the control patients. CONCLUSIONS: PTA with portal drainage induces an early improvement of CRF and ameliorates cardiac function in patients with T1DM.