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Sustained Improvement in Cardiac Function 24 Months Following Pancreas-Kidney Transplant
Sustained Improvement in Cardiac Function 24 Months Following Pancreas-Kidney Transplant M.N. Wicks, D.K. Hathaway, M. Hosein Shokouh-Amiri, D.S. Elmer, R. Mcculley, B. Burlew, and A. Osama Gaber
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UBLISHED data indicate that persons with diabetes experience significantly greater cardiovascular morbidity and mortality when compared with nondiabetics. Diabetic patients with concomitant chronic renal failure experience an additional cardiovascular burden that leads to a twofold greater mortality than occurs in nondiabetic patients with end-stage renal disease.1 Framingham study results clearly indicate that this increased cardiac morbidity leads to a significantly greater risk of heart failure as a result of diabetic cardiomyopathy.2 Although the glycemic control produced by intensive insulin therapy is known to delay the onset of and slow the progression of some of the secondary complications of diabetes,3 contradictory information exists regarding the influence of glycemic control on cardiac function.4 Pancreas transplantation, unlike intensive insulin therapy, leads to permanent normoglycemia. We have previously described improved cardiac function by echocardiography (echo) for pancreas-kidney (PK) recipients at 6 and 12 months posttransplant.1 The purpose of this study was to determine if these changes were sustained at 24 months.
RESULTS
Pretransplant demographic and clinical characteristics of the two groups of insulin-dependent diabetics were equivalent. All PK recipients were normoglycemic posttransplantation, with HbA1c levels averaging 5.6% compared with 8.1% for KA recipients. Although both groups had abnormal echocardiographic values pretransplant, at 24 months posttransplant, PK recipients demonstrated normalization of diastolic and systolic function and geometry, while KA recipients did not improve beyond their pretransplant values (Table 1).
DISCUSSION
These results support our previous finding that the return of normoglycemia following PK transplantation benefits cardiac function and normalizes left ventricular geometry. It is noteworthy that these improvements are sustained to 24 months posttransplantation. Whether these improved out-
MATERIALS AND METHODS M-mode echo with doppler was performed on 19 PK and 9 diabetic kindney-only (KA) recipients who survived to 24 months with functioning grafts. Echo outcomes included measures of systolic (shortening fraction) and diastolic (early/active peak velocity ratio) function and left ventricular geometry (interventricular septal thickness, posterior wall thickness, and left ventricular mass).
From the Departments of Surgery, Medicine, and Department of Acute Care Nursing, The University of Tennessee, Memphis, Tennessee. Address reprint requests to Dr A. O. Gaber University of Tennessee, Memphis 956 Court Avenue, Suite A202 Memphis, TN 38163.
Table 1. Comparison of Posttransplant Outcomes for Pancreas-Kidney and Kidney-Alone Recipients Pretransplant
24 months
Variable
All Transplant Patients (N 5 64)¥
Pancreas-Kidney (N 5 19)
Kidney-Alone (N 5 9)
Shortening fraction Early active peak ratio Interventricular septal thickness Posterior wall thickness Left ventricular mass
28.20 1.40 11.60 11.60 261.00
35.90*† 1.19† 10.50* 10.20* 180.00*†
29.20 0.90 11.60 11.40 230.90
¥These data include all pretransplant insulin dependent diabetic patients including some who have not reached the 24-month measurement point. Pancreas-kidney and kidney-alone recipients were equivalent to the group of 64 with regard to demographic and variables. *P # .05 from baseline; †P # .05 between Pancreas-kidney and kidney-alone at 24 months.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 333–334 (1998)
0041-1345/98/$19.00 PII S0041-1345(97)01294-3 333
334
comes will translate to a reduction in cardiovascular morbidity and mortality in this population is unclear. However, these findings may have broad clinical implications with respect to the significant and continued physical deterioration typically experienced by diabetic patients undergoing dialysis. Clearly, further verification of these findings in a larger sample of patients is warranted.
WICKS, HATHAWAY, SHOKOUH-AMIRI ET AL
REFERENCES 1. Gaber AO, El-Gebely S, Prasanna S, et al: Transplantation 59:1105, 1995 2. Kannel W, McGee DL: JAMA 241:2035, 1979 3. DCCT Research Group: N Engl J Med 329:977, 1993 4. Bouchard A, Sanz N, Botvinick EH, et al: Am J Med 87:160, 1989
P
UBLISHED data indicate that persons with diabetes experience significantly greater cardiovascular morbidity and mortality when compared with nondiabetics. Diabetic patients with concomitant chronic renal failure experience an additional cardiovascular burden that leads to a twofold greater mortality than occurs in nondiabetic patients with end-stage renal disease.1 Framingham study results clearly indicate that this increased cardiac morbidity leads to a significantly greater risk of heart failure as a result of diabetic cardiomyopathy.2 Although the glycemic control produced by intensive insulin therapy is known to delay the onset of and slow the progression of some of the secondary complications of diabetes,3 contradictory information exists regarding the influence of glycemic control on cardiac function.4 Pancreas transplantation, unlike intensive insulin therapy, leads to permanent normoglycemia. We have previously described improved cardiac function by echocardiography (echo) for pancreas-kidney (PK) recipients at 6 and 12 months posttransplant.1 The purpose of this study was to determine if these changes were sustained at 24 months.
RESULTS
Pretransplant demographic and clinical characteristics of the two groups of insulin-dependent diabetics were equivalent. All PK recipients were normoglycemic posttransplantation, with HbA1c levels averaging 5.6% compared with 8.1% for KA recipients. Although both groups had abnormal echocardiographic values pretransplant, at 24 months posttransplant, PK recipients demonstrated normalization of diastolic and systolic function and geometry, while KA recipients did not improve beyond their pretransplant values (Table 1).
DISCUSSION
These results support our previous finding that the return of normoglycemia following PK transplantation benefits cardiac function and normalizes left ventricular geometry. It is noteworthy that these improvements are sustained to 24 months posttransplantation. Whether these improved out-
MATERIALS AND METHODS M-mode echo with doppler was performed on 19 PK and 9 diabetic kindney-only (KA) recipients who survived to 24 months with functioning grafts. Echo outcomes included measures of systolic (shortening fraction) and diastolic (early/active peak velocity ratio) function and left ventricular geometry (interventricular septal thickness, posterior wall thickness, and left ventricular mass).
From the Departments of Surgery, Medicine, and Department of Acute Care Nursing, The University of Tennessee, Memphis, Tennessee. Address reprint requests to Dr A. O. Gaber University of Tennessee, Memphis 956 Court Avenue, Suite A202 Memphis, TN 38163.
Table 1. Comparison of Posttransplant Outcomes for Pancreas-Kidney and Kidney-Alone Recipients Pretransplant
24 months
Variable
All Transplant Patients (N 5 64)¥
Pancreas-Kidney (N 5 19)
Kidney-Alone (N 5 9)
Shortening fraction Early active peak ratio Interventricular septal thickness Posterior wall thickness Left ventricular mass
28.20 1.40 11.60 11.60 261.00
35.90*† 1.19† 10.50* 10.20* 180.00*†
29.20 0.90 11.60 11.40 230.90
¥These data include all pretransplant insulin dependent diabetic patients including some who have not reached the 24-month measurement point. Pancreas-kidney and kidney-alone recipients were equivalent to the group of 64 with regard to demographic and variables. *P # .05 from baseline; †P # .05 between Pancreas-kidney and kidney-alone at 24 months.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 30, 333–334 (1998)
0041-1345/98/$19.00 PII S0041-1345(97)01294-3 333
334
comes will translate to a reduction in cardiovascular morbidity and mortality in this population is unclear. However, these findings may have broad clinical implications with respect to the significant and continued physical deterioration typically experienced by diabetic patients undergoing dialysis. Clearly, further verification of these findings in a larger sample of patients is warranted.
WICKS, HATHAWAY, SHOKOUH-AMIRI ET AL
REFERENCES 1. Gaber AO, El-Gebely S, Prasanna S, et al: Transplantation 59:1105, 1995 2. Kannel W, McGee DL: JAMA 241:2035, 1979 3. DCCT Research Group: N Engl J Med 329:977, 1993 4. Bouchard A, Sanz N, Botvinick EH, et al: Am J Med 87:160, 1989