Prognostic value of dipyridamole thallium-201 screening to minimize perioperative cardiac complications in diabetics undergoing kidney or kidney-pancreas transplantation.

To minimize perioperative cardiac events, we utilize a screening protocol consisting of intravenous dipyridamole thallium-201 myocardial imaging (DPT), with the selective use of coronary angiography based on the presence of reversible defect(s) on DPT test. A retrospective study was performed to determine the prognostic value of this protocol and to identify any clinical parameters predictive of an abnormal DPT test. To accomplish this, a detailed chart analysis of 176 consecutive kidney (n = 89) and kidney-pancreas (n = 87) transplant recipients who had undergone pretransplant DPT testing was performed. The results of the DPT test were interpreted as normal in 111, fixed defect in 15, and reversible defect(s) in 50 patients. Forty-two of the 50 patients with reversible defect(s) underwent coronary angiography. Twelve of the 27 patients with significant coronary artery disease (CAD, > 50% stenosis in one or more coronary arteries) underwent pretransplant revascularization and the remaining 15 were treated medically. Cardiac events (documented acute myocardial infarction or sudden cardiac death) within 6 wk of transplant were stratified by the results of this protocol. Also, various clinical parameters were compared between patients with normal and abnormal (fixed and reversible defect) DPT tests. Only one of the 111 (0.9%) transplant recipients with a normal DPT test had a perioperative cardiac event. None of the 15 (0%) patients with a fixed defect and none of the 15 (0%) patients with reversible defect(s), but a nonsignificant (< 50% narrowing) coronary angiogram, had a perioperative cardiac event. Three of the 27 (11.1%) patients with reversible defect(s) and significant disease on coronary angiography, who had undergone pre-transplant revascularization or were managed medically, had a perioperative coronary event. Of 14 recipients parameters analyzed, age > 50 yr was the only variable predictive of an abnormal DPT test. We conclude that the incidence of perioperative cardiac events in patients with a normal or fixed defect, or reversible defect(s) but a nonsignificant (< 50% narrowing) coronary angiogram is very low, indicating the high correlation of these findings on DPT and an uneventful (cardiac) post-transplant course. The incidence of perioperative cardiac complications amongst the high-risk transplant recipients with reversible defect(s) and significant CAD on coronary angiogram may be minimized by appropriate preoperative medical management or revascularization. None of the clinical variables except age > 50 yr was predictive of an abnormal DPT test.

Post-transplant hyperlipidemia: risk factors and response to dietary modification and gemfibrozil therapy.

A retrospective chart analysis of 200 consecutive, cyclosporine-treated, renal allograft recipients, transplanted between January 1988 and June 1992, was conducted to determine the incidence of and the etiologic variables for post-transplant hypercholesterolemia. In addition, the effectiveness of dietary intervention alone or in combination with gemfibrozil (600 mg b.i.d.), in post-transplant hypercholesterolemia was evaluated. Hypercholesterolemia (> or = 240 mg/dl on two separate determinations, while on maintenance immunosuppression) was present in 138 patients (Group A-69%). When compared to the remaining 62 patients without hypercholesterolemia (Group B-31%), there were no differences in mean age, body weight at transplantation, race, incidence of overt diabetes, systolic and diastolic blood pressure, or serial serum creatinine, albumin, and cyclosporine levels between these groups. Post-transplant hypercholesterolemia was significantly more prevalent in females, in recipients with higher baseline serum total cholesterol levels (mean +/- SEM, Group A = 229.0 +/- 5.0 vs. Group B = 192.0 +/- 6.1 mg/dl, p < 0.001), and in recipients with an elevated fasting blood glucose at 1 year post-transplant (Group A = 150.5 +/- 10.5 vs. Group B = 105.2 +/- 10.7 mg/dl, p < 0.05). In all patients with hypercholesterolemia, a hypocaloric low fat and low cholesterol (< 300 mg/day) diet was initiated at a mean of 0.59 +/- 0.06 years after transplantation with grading of dietary compliance at each follow-up visit (Grade 1, < 300 mg cholesterol; Grade 2, 300-500 mg cholesterol; Grade 3, > 500 mg cholesterol intake in 24 hours).(ABSTRACT TRUNCATED AT 250 WORDS)

Peptic ulcer disease following renal transplantation in the cyclosporine era.

Peptic ulcer disease (PUD) remains a well-known sequela of renal transplantation, and, when complications occur, morbidity and mortality can be significant. For this reason, all patients at our center undergo a pretransplant upper gastrointestinal series (UGI). Patients with evidence of active ulcer disease on UGI and/or a history of PUD undergo upper gastrointestinal endoscopy and do not undergo transplantation until healing is demonstrated. Following transplantation, antiulcer prophylaxis is utilized for 6 weeks (in patients without pretransplant PUD) or 3 months (in patients with pretransplant PUD). To help define the incidence and significance of PUD in the cyclosporine era, as well as the value of pretransplant screening and posttransplant ulcer prophylaxis, a retrospective chart analysis of 254 patients who underwent renal or renal/pancreas allograft transplanted between January 1984 and December 1989 was accomplished. Twenty-six patients (10%) presented with symptomatic PUD at a mean of 7.8 months posttransplant. The incidence of PUD was 10% in patients with a negative pretransplant history and UGI, 15% in patients with a positive pretransplant history and negative UGI and endoscopy, and 0% in patients with a positive pretransplant history and UGI. Age, sex, primary disease, donor source, and number of rejection episodes were not significantly different in recipients with or without PUD. At the time of presentation, 23 patients (88%) had completed their antiulcer prophylaxis. Four patients (15%) died secondary to ulcer disease including two of three (66%) following surgical treatment and two of 23 (9%) during medical treatment. Posttransplant PUD continues to result in significant morbidity and mortality in the cyclosporine era. Pretransplant screening, including UGI and endoscopy, is not a reliable predictor of posttransplant, symptomatic PUD. Based on this study, it is concluded that all patients should receive longer periods of antiulcer prophylaxis, independent of previously defined pre- and posttransplant risk factors.

Fluid collections developing after pancreatic transplantation: radiologic evaluation and intervention.

The usefulness of real-time sonography, duplex sonography, computed tomography (CT), cystography, diagnostic aspiration, and percutaneous drainage in the diagnosis and treatment of peri-pancreatic-transplant fluid collections was retrospectively assessed in 46 recipients of extraperitoneal pancreatic transplants. Forty-four abnormalities were identified in the extraperitoneal space at sonography, including four pancreatic pseudocysts associated with malfunction of the pancreatic duct, seven abscesses, six hematomas, nine urinomas, six early postoperative fluid collections that spontaneously resolved, six cases of pancreatitis, and six cases of vascular occlusion. Sonography (including pulsed Doppler sonography) was the procedure of choice in detecting fluid collections and diagnosing pancreatitis, rejection, vascular thrombosis, and pancreatic duct malfunction. CT was diagnostic in four of six hematomas; cystography was diagnostic in seven of nine urinomas. Sonographically guided percutaneous intervention enabled three patients to avoid surgery and allowed optimal surgical planning for six patients.

Evolution of synchronous renal and pancreatic transplantation.

The utilization of pancreatic transplantation as a therapeutic option in type I diabetics is dependent on demonstrating its safety and efficacy. A protocol for synchronous renal and segmental pancreatic transplantation, utilizing pancreaticocystostomy, was initiated in February 1985, and through December 1988, 44 patients (mean age 34.8 years) received dual allografts. At last follow-up, 25 patients had functioning kidneys, and 17 patients were insulin independent 4 to 50 months after transplantation, with a mean fasting blood glucose level of 86 mg/100 ml. As our experience increased, three factors were identified as reducing pancreatic allograft and patient survival: vascular thrombosis, inadequate control of pancreatic secretions, and coronary artery disease. As a result, our protocol was modified to include postoperative heparin, external stenting of the pancreaticocystostomy, and dipyridamole thallium testing to screen for coronary artery disease. With these modifications, technical failures and postoperative morbidity were reduced with a resultant increase in 6-month graft and patient survival. These results provide impetus for considering synchronous renal and pancreatic transplantation as a therapeutic option for type I diabetics with end-stage renal disease.