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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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D’Elia JA, Bayliss GP, Weinrauch LA. The Diabetic Cardiorenal Nexus. Int J Mol Sci 2022; 23:ijms23137351. [PMID: 35806355 PMCID: PMC9266839 DOI: 10.3390/ijms23137351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/10/2022] Open
Abstract
The end-stage of the clinical combination of heart failure and kidney disease has become known as cardiorenal syndrome. Adverse consequences related to diabetes, hyperlipidemia, obesity, hypertension and renal impairment on cardiovascular function, morbidity and mortality are well known. Guidelines for the treatment of these risk factors have led to the improved prognosis of patients with coronary artery disease and reduced ejection fraction. Heart failure hospital admissions and readmission often occur, however, in the presence of metabolic, renal dysfunction and relatively preserved systolic function. In this domain, few advances have been described. Diabetes, kidney and cardiac dysfunction act synergistically to magnify healthcare costs. Current therapy relies on improving hemodynamic factors destructive to both the heart and kidney. We consider that additional hemodynamic solutions may be limited without the use of animal models focusing on the cardiomyocyte, nephron and extracellular matrices. We review herein potential common pathophysiologic targets for treatment to prevent and ameliorate this syndrome.
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Affiliation(s)
- John A. D’Elia
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
| | - George P. Bayliss
- Division of Organ Transplantation, Rhode Island Hospital, Providence, RI 02903, USA;
| | - Larry A. Weinrauch
- Kidney and Hypertension Section, E P Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA 02215, USA
- Correspondence: ; Tel.: +617-923-0800; Fax: +617-926-5665
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Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med 2021; 10:2525. [PMID: 34200235 PMCID: PMC8201125 DOI: 10.3390/jcm10112525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.
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Affiliation(s)
| | - Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Vassilios Papalois
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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Tabriziani H, Baron P, Abudayyeh I, Lipkowitz M. Cardiac risk assessment for end-stage renal disease patients on the renal transplant waiting list. Clin Kidney J 2019; 12:576-585. [PMID: 31384451 PMCID: PMC6671484 DOI: 10.1093/ckj/sfz039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality and is becoming more prevalent as the population ages and risk factors increase. This is most apparent in the end-stage renal disease (ESRD) patient population. In part, this is due to cofactors such as diabetes and hypertension commonly predisposing to progressive renal disease, as well as being a direct consequence of having renal failure. Of all major organ failures, kidney failure is the most likely to be managed chronically using renal replacement therapy and, ultimately, transplant. However, lack of transplant organs and a large renal failure cohort means waiting lists are often quite long and may extend to 5-10 years. Due to the cardiac risk factors inherent in patients awaiting transplant, many succumb to cardiac issues while waiting and present an increased per-procedural cardiac risk that extends into the post-transplant period. We aim to review the epidemiology of coronary artery disease in this population and the etiology as it relates to ESRD and its associated co-factors. We also will review the current approaches, recommendations and evidence for management of these patients as it relates to transplant waiting lists before and after the surgery. Recommendations on how to best manage patients in this cohort revolve around the available evidence and are best customized to the institution and the structure of the program. It is not clear whether the revascularization of patients without symptoms and with a good functional status yields any improvement in outcomes. Therefore, each individual case should be considered based on the risk factors, symptoms and functional status, and approached as part of a multi-disciplinary assessment program.
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Affiliation(s)
- Hossein Tabriziani
- Transplant Nephrology Attending, Balboa Institute of Transplant (BIT), Balboa Nephrology Medical Group (BNMG), San Diego, CA, USA
| | - Pedro Baron
- Surgical Director of Pancreas Transplant, Transplant Institute, Loma Linda University, Loma Linda, CA, USA
| | - Islam Abudayyeh
- Division of Cardiology, Interventional Cardiology, Loma Linda University, Loma Linda, CA, USA
| | - Michael Lipkowitz
- Clinical Director of the Nephrology and Hypertension Division, Program Director for the Nephrology Fellowship, Georgetown University Medical center, Washington, DC, USA
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Ritsinger V, Hero C, Svensson AM, Saleh N, Lagerqvist B, Eeg-Olofsson K, Norhammar A. Mortality and extent of coronary artery disease in 2776 patients with type 1 diabetes undergoing coronary angiography: A nationwide study. Eur J Prev Cardiol 2017; 24:848-857. [PMID: 28084092 DOI: 10.1177/2047487316687860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background In a modern perspective there is limited information on mortality by affected coronary vessels assessed by coronary angiography in patients with type 1 diabetes. The aim of the present study was to characterise distribution of coronary artery disease and impact on long-term mortality in patients with type 1 diabetes undergoing coronary angiography. Design The design of this research was a nationwide population-based cohort study. Methods Individuals ( n = 2776) with type 1 diabetes undergoing coronary angiography 2001-2013 included in the Swedish National Diabetes Registry and Swedish Coronary Angiography and Angioplasty Registry were followed for mortality until 31 December 2013 (mean 7.1 years). In 79% the indication was stable or acute coronary artery disease. Coronary artery disease was categorised into normal (21%), one- (23%), two- (18%), three- (29%) and left main-vessel disease (8%). Results Mean age was 57 years and 58% were male. Mean diabetes duration was 35 years, glycated haemoglobin was 67 mmol/mol and 44% had normal or one-vessel disease. In multivariate Cox proportional analyses hazard ratio for mortality compared with normal findings was 1.09 (95% confidence interval 0.80-1.48) for one, 1.43 (1.05-1.94) for two, 1.47 (1.10-1.96) for three and 1.90 (1.35-2.68) for left main-vessel disease. Renal failure 2.29 (1.77-2.96) and previous heart failure 1.76 (1.46-2.13) were highly associated with mortality. Standard mortality ratio the first year was 5.55 (4.65-6.56) and decreased to 2.80 (2.18-3.54) after five years. Conclusions In patients with type 1 diabetes referred for coronary angiography mortality is influenced by numbers of affected coronary vessels. The overall mortality rate was higher compared with the general population. These results support early intensive prevention of coronary artery disease in this population.
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Affiliation(s)
- V Ritsinger
- 1 Unit of Cardiology, Department of Medicine, Solna, Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden.,2 Department of Research and Development, Region Kronoberg, Sweden
| | - C Hero
- 3 Department of Medicine, University of Gothenburg, Sweden
| | | | - N Saleh
- 1 Unit of Cardiology, Department of Medicine, Solna, Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - B Lagerqvist
- 5 Department of Medical Sciences, Uppsala University, Sweden
| | - K Eeg-Olofsson
- 3 Department of Medicine, University of Gothenburg, Sweden
| | - A Norhammar
- 1 Unit of Cardiology, Department of Medicine, Solna, Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden.,6 Capio St Göran's Hospital, Stockholm, Sweden
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Rizk DV, Riad S, Hage FG. Screening for coronary artery disease in kidney transplant candidates. J Nucl Cardiol 2015; 22:297-300. [PMID: 25294435 DOI: 10.1007/s12350-014-0006-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Alani H, Tamimi A, Tamimi N. Cardiovascular co-morbidity in chronic kidney disease: Current knowledge and future research needs. World J Nephrol 2014; 3:156-168. [PMID: 25374809 PMCID: PMC4220348 DOI: 10.5527/wjn.v3.i4.156] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/30/2014] [Accepted: 10/16/2014] [Indexed: 02/05/2023] Open
Abstract
Chronic kidney disease (CKD) is recognised as a health concern globally and leads to high rates of morbidity, mortality and healthcare expenditure. CKD is itself an independent risk factor for unfavorable health outcomes that include cardiovascular disease (CVD). Coronary artery disease is the primary type of CVD in CKD patients and a significant cause of death among renal transplant patients. Traditional and non-traditional risk factors for CVD exist in patients with CKD. Traditional factors include smoking, hypertension, dyslipidemia and diabetes which are highly prevalent in CKD patients. Non-traditional risk factors of CKD are mainly uraemia-specific and increase in prevalence as kidney function declines. Some examples of uraemia-specific risk factors that have been well documented include low levels of haemoglobin, albuminuria, and abnormal bone and mineral metabolism. Therapeutic interventions targeted at more traditional risk factors which contribute to CVD, have not had the desired effect on lowering CVD events and mortality in those suffering with CKD. Future research is warranted to delineate clear evidence to the benefit of modifying non-traditional risk factors.
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Chapter 4: Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD. Kidney Int Suppl (2011) 2013; 3:91-111. [PMID: 25599000 PMCID: PMC4284425 DOI: 10.1038/kisup.2012.67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2012; 60:434-80. [PMID: 22763103 DOI: 10.1016/j.jacc.2012.05.008] [Citation(s) in RCA: 265] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation: endorsed by the American Society of Transplant Surgeons, American Society of Transplantation, and National Kidney Foundation. Circulation 2012; 126:617-63. [PMID: 22753303 DOI: 10.1161/cir.0b013e31823eb07a] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Wang LW, Fahim MA, Hayen A, Mitchell RL, Baines L, Lord S, Craig JC, Webster AC, Cochrane Kidney and Transplant Group. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 2011; 2011:CD008691. [PMID: 22161434 PMCID: PMC7177243 DOI: 10.1002/14651858.cd008691.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse cardiac events. Screening for CAD is therefore an important part of preoperative evaluation for kidney transplant candidates. There is significant interest in the role of non-invasive cardiac investigations and their ability to identify patients at high risk of CAD. OBJECTIVES We investigated the accuracy of non-invasive cardiac screening tests compared with coronary angiography to detect CAD in patients who are potential kidney transplant recipients. SEARCH METHODS MEDLINE and EMBASE searches (inception to November 2010) were performed to identify studies that assessed the diagnostic accuracy of non-invasive screening tests, using coronary angiography as the reference standard. We also conducted citation tracking via Web of Science and handsearched reference lists of identified primary studies and review articles. SELECTION CRITERIA We included in this review all diagnostic cross sectional, cohort and randomised studies of test accuracy that compared the results of any cardiac test with coronary angiography (the reference standard) relating to patients considered as potential candidates for kidney transplantation or kidney-pancreas transplantation at the time diagnostic tests were performed. DATA COLLECTION AND ANALYSIS We used a hierarchical modelling strategy to produce summary receiver operating characteristic (SROC) curves, and pooled estimates of sensitivity and specificity. Sensitivity analyses to determine test accuracy were performed if only studies that had full verification or applied a threshold of ≥ 70% stenosis on coronary angiography for the diagnosis of significant CAD were included. MAIN RESULTS The following screening investigations included in the meta-analysis were: dobutamine stress echocardiography (DSE) (13 studies), myocardial perfusion scintigraphy (MPS) (nine studies), echocardiography (three studies), exercise stress electrocardiography (two studies), resting electrocardiography (three studies), and one study each of electron beam computed tomography (EBCT), exercise ventriculography, carotid intimal media thickness (CIMT) and digital subtraction fluorography (DSF). Sufficient studies were present to allow hierarchical summary receiver operating characteristic (HSROC) analysis for DSE and MPS. When including all available studies, both DSE and MPS had moderate sensitivity and specificity in detecting coronary artery stenosis in patients who are kidney transplant candidates [DSE (13 studies) - pooled sensitivity 0.79 (95% CI 0.67 to 0.88), pooled specificity 0.89 (95% CI 0.81 to 0.94); MPS (nine studies) - pooled sensitivity 0.74 (95% CI 0.54 to 0.87), pooled specificity 0.70 (95% CI 0.51 to 0.84)]. When limiting to studies which defined coronary artery stenosis using a reference threshold of ≥ 70% stenosis on coronary angiography, there was little change in these pooled estimates of accuracy [DSE (9 studies) - pooled sensitivity 0.76 (95% CI 0.60 to 0.87), specificity 0.88 (95% CI 0.78 to 0.94); MPS (7 studies) - pooled sensitivity 0.67 (95% CI 0.48 to 0.82), pooled specificity 0.77 (95% CI 0.61 to 0.88)]. There was evidence that DSE had improved accuracy over MPS (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies which did not avoid partial verification or use a reference standard threshold of ≥70% stenosis (P = 0.09). AUTHORS' CONCLUSIONS DSE may perform better than MPS but additional studies directly comparing these cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
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Affiliation(s)
- Louis W Wang
- St Vincent's HospitalDepartment of CardiologyDarlinghurstNSWAustralia2010
- University of SydneySydney School of Public HealthSydneyNSWAustralia
| | - Magid A Fahim
- Princess Alexandra HospitalDepartment of NephrologyBrisbaneQLDAustralia4102
| | - Andrew Hayen
- University of SydneyScreening and Test Evaluation Program (STEP), Sydney School of Public HealthA27 ‐ Edward Ford BuildingSydneyNSWAustralia2006
| | - Ruth L Mitchell
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Laura Baines
- Newcastle upon Tyne Hospitals NHSRenal ServicesFreeman RdNewcastle upon TyneUKNE7 DN
| | - Stephen Lord
- Newcastle upon Tyne Hospitals NHSCardiology ServicesNewcastle upon TyneUKNE7 7DN
| | - Jonathan C Craig
- University of SydneySydney School of Public HealthSydneyNSWAustralia
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Angela C Webster
- University of SydneySydney School of Public HealthSydneyNSWAustralia
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
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Rivera RF, Mircoli L, Bonforte G, Torri V, Monteforte M, Stella A, Genovesi S. Dipyridamole stress echocardiography in diagnosis and prognosis of hemodialysis patients with asymptomatic coronary disease. Hemodial Int 2011; 15:468-76. [PMID: 22111815 DOI: 10.1111/j.1542-4758.2011.00572.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 06/01/2011] [Indexed: 01/28/2023]
Abstract
The prevalence of coronary artery disease (CAD) is high in hemodialysis (HD) patients. The aim of the study was to assess the diagnostic and prognostic value of dipyridamole stress echocardiography (DSE) in nondiabetic HD patients without signs or symptoms of CAD. In 51 out of 158 evaluated HD patients (21 females, age 67 [33-85] years, HD duration 38 [9-271] months), resting echocardiography and DSE were performed. Exclusion criteria were known CAD, diabetes mellitus, and pulmonary and oncologic pathologies. Logistic regression analysis was carried out to identify predictors of abnormal DSE response, while Cox regression analysis was performed to determine variables associated with total and cardiovascular mortality, after 43.3 (11-60) months of follow-up. Seven patients (14%) showed a positive response to DSE (DSE+). In 5/7, CAD was documented by angiography: All of them underwent coronary revascularization. DSE+ patients had significantly smaller body mass index than patients with a negative response (DSE-): 21.7 ± 1.9 vs. 25.1 ± 3.4 kg/m(2) (p = 0.018). During follow-up, 16 (31%) patients died. Older age hazard ratio [HR = 1.07; confidence interval (CI) = 1.01-1.12; p = 0.02] and higher plasma phosphate levels (HR = 10.41; CI = 2.30-47.17; p < 0.01) were predictors of total mortality. Male gender (HR = 22.7; CI = 1.45-354.4; p = 0.03), older age (HR = 1.24; CI = 1.03-1.50; p = 0.02), longer HD duration (HR = 1.13; CI = 1.01-1.26; p = 0.04), and positive response to DSE (HR = 5.82; CI = 1.04-32.65; p = 0.04) were associated with cardiovascular mortality. Ten percent of asymptomatic HD patients had significant CAD, but timely diagnosis did not seem to improve their prognosis. Total survival was associated with age and higher levels of plasma phosphate, while male gender, older age, longer HD duration, and DSE+ were predictors of cardiovascular mortality.
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Affiliation(s)
- Rodolfo F Rivera
- Dipartimento di Medicina Clinica e Prevenzione, Università degli Studi di Milano Bicocca, Milan, Italy
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Lentine KL, Hurst FP, Jindal RM, Villines TC, Kunz JS, Yuan CM, Hauptman PJ, Abbott KC. Cardiovascular risk assessment among potential kidney transplant candidates: approaches and controversies. Am J Kidney Dis 2009; 55:152-67. [PMID: 19783341 DOI: 10.1053/j.ajkd.2009.06.032] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 06/22/2009] [Indexed: 01/07/2023]
Abstract
Cardiovascular disease is the most common cause of death after kidney transplantation. However, uncertainties regarding the optimal assessment of cardiovascular risk in potential transplant candidates have produced controversy and inconsistency in pretransplantation cardiac evaluation practices. In this review, we consider the evidence supporting cardiac evaluation in kidney transplant candidates, generally focused on coronary artery disease, according to the World Health Organization principles for screening. The importance of pretransplant cardiac evaluation is supported by the high prevalence of coronary artery disease and the incidence and adverse consequences of acute coronary syndromes in this population. Testing for coronary artery disease may be performed noninvasively by using modalities that include nuclear myocardial perfusion studies and dobutamine stress echocardiography. These tests have prognostic value for mortality, but imperfect sensitivity and specificity for detecting angiographically defined coronary artery disease in patients with end-stage renal disease. Associations of angiographically-defined coronary artery disease with subsequent survival also are inconsistent, likely because plaque instability is more critical for infarction risk than angiographic stenosis. The efficacy and best methods of myocardial revascularization have not been examined in large contemporary clinical trials in patients with end-stage renal disease. Biomarkers, such as cardiac troponin, have prognostic value in end-stage renal disease, but require further study to determine clinical applications in directing more expensive and invasive cardiac evaluation.
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Affiliation(s)
- Krista L Lentine
- Center for Outcomes Research, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
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Dickinson S, Rogers T, Kasiske B, Bertog S, Tadros G, Malik J, Wilson R, Panetta C. Coronary artery disease in young women and men with long-standing insulin-dependent diabetes. Angiology 2008; 59:9-15. [PMID: 18319217 DOI: 10.1177/0003319707304579] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2024]
Abstract
The prevalence and predictors of coronary artery disease were examined in people aged 40 years and younger with insulin-dependent diabetes mellitus. Analysis was performed on those who presented between 1999 and 2003 for kidney and/or pancreas transplant at the University of Minnesota, as all patients who have diabetes mellitus are required to have perioperative cardiology evaluation. The mean age was 33.5 +/- 4.4 years for 88 subjects, all had insulin-dependent diabetes mellitus, and 33% were dialysis dependent. Severe coronary artery disease was found in 18.2% of women and in 24.2% of men. Three-vessel coronary artery disease trended less in women (9.1%) compared with men (12.1%). Multivariate predictors for severe and 3-vessel coronary artery disease included prior coronary artery disease, hypertension duration, and ST-T wave changes on electrocardiogram. Coronary artery disease is twice as high as expected in young woman. Studies on early management for atherosclerosis are warranted in this high-risk population.
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Leskinen Y, Groundstroem K, Virtanen V, Lehtimäki T, Huhtala H, Saha H. Prediction of coronary artery disease by transesophageal echocardiographic detection of thoracic aortic plaque in patients with chronic kidney disease. Nephron Clin Pract 2006; 103:c157-61. [PMID: 16636584 DOI: 10.1159/000092913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Accepted: 12/30/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Our aim was to examine the significance of thoracic aortic plaque detected by transesophageal echocardiography (TEE) in the prediction of coronary artery disease (CAD) in patients with chronic kidney disease (CKD). METHODS We examined 118 patients (mean age 52 +/- 12 years) with CKD and followed them for a mean of 3.4 +/- 0.8 years. The study group included 52 predialysis patients with moderate to severe CKD (plasma creatinine > or = 200 micromol/l), 32 patients on dialysis treatment, and 34 renal transplant recipients. At baseline, TEE was performed to evaluate thoracic aortic atherosclerosis. CAD was defined by a history of a documented myocardial infarction, a coronary angiogram or a post-mortem autopsy finding showing significant occlusive CAD by the end of the follow-up period. RESULTS CAD was documented in 31 (26%) of the 118 study patients. The presence of thoracic aortic plaque had a sensitivity of 100% and a specificity of 37% for CAD and the positive and negative predictive values were 36 and 100%, respectively. In the subset of 36 patients with morphological findings of coronary arteries by angiogram or autopsy, the presence of large thoracic aortic plaques (> or = 3 mm in diameter) had a 73% sensitivity and 90% specificity for significant coronary artery stenosis. The positive and negative predictive values were 95 and 56%, respectively. CONCLUSION TEE may be used for detecting high-risk patients with CKD; the absence of thoracic aortic plaque predicted the absence of CAD, and the presence of large aortic plaques predicted significant coronary artery stenosis.
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Affiliation(s)
- Yrjö Leskinen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
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Berl T, Henrich W. Kidney-Heart Interactions: Epidemiology, Pathogenesis, and Treatment. Clin J Am Soc Nephrol 2005; 1:8-18. [PMID: 17699186 DOI: 10.2215/cjn.00730805] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tomas Berl
- University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Kälble T, Lucan M, Nicita G, Sells R, Burgos Revilla FJ, Wiesel M. EAU guidelines on renal transplantation. Eur Urol 2005; 47:156-66. [PMID: 15661409 DOI: 10.1016/j.eururo.2004.02.009] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2004] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To produce a guidelines text, on behalf of the European Association of Urology, providing insights in the issues surrounding renal transplantation. METHOD A group of international experts in renal transplantation carried out a non-structured literature review on available medical databases and urological literature. RESULT A guideline text is presented providing an overview of key issues involved in the patients' management such as assessment of donors, pre-transplant evaluation, techniques, management, post-transplant care, etc. CONCLUSION The current text represents a consensus statement developed by a group of international experts in renal transplantation.
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Affiliation(s)
- T Kälble
- Department of Urology, Städt. Klinikum Fulda, Philipps-University Marburg Pacelliallee 4, D-36043 Fulda, Germany.
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Ramanathan V, Goral S, Tanriover B, Feurer ID, Kazancioglu R, Shaffer D, Helderman JH. Screening asymptomatic diabetic patients for coronary artery disease prior to renal transplantation. Transplantation 2005; 79:1453-8. [PMID: 15912119 DOI: 10.1097/01.tp.0000164147.60036.67] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is a significant contributor to excess mortality in renal transplant candidates with diabetes mellitus (DM). Prior studies relating to risk stratification for significant CAD in diabetics are confined to Caucasian type 1 DM patients. METHODS To assess the prevalence of clinically silent CAD and to identify variables that are associated with CAD, we retrospectively analyzed the cardiac catheterization data of 97 asymptomatic type 1 and 2 DM kidney and kidney-pancreas transplant candidates. RESULTS Thirty-three percent of type 1 and 48% of type 2 DM patients had significant stenosis (> or = 70%) in 1 or more coronary arteries. On multivariate logistic regression analysis, body mass index (BMI) >25 was significantly associated with CAD (relative risk = 4.8, P = 0.002). The age of the patient (7% increase in risk/year, P = 0.01; or relative risk = 3.0 if age >47 years, P = 0.032) and smoking history (2% increase in risk/pack-year of smoking, P = 0.10) were also associated with CAD. African American patients, who comprised 30% of the sample, had a 71% lower risk compared with Caucasian patients (P = 0.03). Factors that were not significantly associated with CAD included gender, type of diabetes, and whether dialyzed for >6 months prior to catheterization. CONCLUSIONS We conclude that a notable proportion (approximately one-third to one-half) of asymptomatic type 1 and type 2 diabetic renal transplant candidates have significant CAD. Additionally, young African American DM patients with no smoking history and a BMI </=25 are at reduced risk, and invasive tests may not be necessary in this group.
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Affiliation(s)
- Venkataraman Ramanathan
- Division of Nephrology, O'Brien Kidney Research Center, Baylor College of Medicine, Houston 77030, TX, USA.
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Porter GA, Norton TL, Lindsley J, Stevens JS, Phillips DS, Bennett WM. Relationship between elevated serum troponin values in end-stage renal disease patients and abnormal isotopic cardiac scans following stress. Ren Fail 2003; 25:55-65. [PMID: 12617333 DOI: 10.1081/jdi-120017468] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
One hundred asymptomatic high-risk renal transplant candidates were screened for asymptomatic coronary artery disease using stress cardiac isotopic imaging. The cardiac markers, serum cTnT, cTnI, and CKMB, were collected pre and post stress testing. Of the 99 patients whose cardiac scans were technically satisfactory, 32 were normal, 49 had a definite imaging abnormality and the scan was indeterminate in the remaining 18 patients. Based on these results, patients were stratified into either normal, indeterminate or abnormal scan groups. They then were analyzed to detect any correlations between cardiac perfusion defects and either elevated pre-stress cardiac markers or consistent changes 24h after stress testing. While the mean pre-stress serum values for both cardiac troponin T (0.117 +/- 0.12 microgram/L) and cardiac troponin I (0.235 +/- 0.89 microgram/L) were increased in the abnormal cardiac scan group, only the cTnT value proved to differ significantly from the normal group (p < 0.01). For the indeterminate group neither marker was different from the normal scan group. Only an elevated serum cTnT > 0.1 microgram/L (OR 3.042, p = 0.030) proved to discriminate an abnormal scan in this population. It is concluded that the increase in pre-stress serum cTnT encountered in patients with chronic renal failure, with or without evidence of overt, symptomatic coronary artery disease, may represent a combination of subclinical myocardial damage and a prolonged half-life of the marker in the serum. Because of the frequency of elevated serum concentrations of cTnT and, to a lesser degree cTnI, the physician should exercise caution when interpreting a single elevated Troponin value during the evaluation of chest pain in patients with end-stage renal disease. A cTnT > 0.1 microgram/L increases the likelihood of finding significant coronary artery disease three fold in high-risk ESRD patients being evaluated for renal transplantation.
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Affiliation(s)
- George A Porter
- Division of Nephrology, Hypertension and Clinical Pharmacology, PP 262 Department of Medicine, Oregon Health Sciences University, Portland, Oregon, USA
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Fuster D, Magriñá J, Ricart MJ, Pascual J, Laterza C, Setoain FJ, Vidal-Sicart S, Mateos JJ, Martín F, Muxí A. Noninvasive assessment of cardiac risk in type I diabetic patients being evaluated for combined pancreas-kidney transplantation using dipyridamole-MIBI perfusion. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01005.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schwarz U, Buzello M, Ritz E, Stein G, Raabe G, Wiest G, Mall G, Amann K. Morphology of coronary atherosclerotic lesions in patients with end-stage renal failure. Nephrol Dial Transplant 2000; 15:218-23. [PMID: 10648668 DOI: 10.1093/ndt/15.2.218] [Citation(s) in RCA: 424] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND An excessive rate of cardiac death is a well-known feature of renal failure. Coronary heart disease is frequent and the possibility has been raised that the natural history of the coronary plaque is different in uraemic patients. We assessed the morphology of coronary arteries in patients with end-stage renal failure and compared them with coronary arteries of matched non-uraemic control patients. METHODS Fifty-four cases were identified at autopsy who met the inclusion criteria: cases, end-stage renal disease (n=27); controls, non-renal patients with coronary artery disease (n=27). At autopsy all three coronary arteries were prepared at corresponding sites for investigations: (i) qualitative analysis (after Stary), (ii) quantitative measurements of intima and media thickness (by planimetry), (iii) immunohistochemical analysis of the coronary plaques and (iv) X-ray diffraction of selected calcified plaques. RESULTS Qualitative analysis of the coronary arteries showed significantly more calcified plaques of coronary arteries in patients with end-stage renal failure. Plaques of non-uraemic patients were mostly fibroatheromatous. Media thickness of coronary arteries was significantly higher in uraemic patients (187+/-53 microm vs 135+/-29 microm in controls) and intima thickness tended to be higher (158+/-38 microm vs 142+/-31 microm) but this difference was not statistically significant. Plaque area (4.09+/-1. 50 mm(2) vs 4.39+/-0.88 mm(2)) was comparable in both groups. Lumen area, however, was significantly lower in end-stage renal patients. Immunohistochemical analysis of the cellular infiltrate in coronary arteries showed no major differences in these advanced plaques of uraemic and non-uraemic subjects. CONCLUSION Coronary plaques in patients with end-stage renal failure are characterized by increased media thickness and marked calcification. In contrast to the previous opinion the most marked difference compared to non-uraemic controls does not concern the size, but the composition of the plaque. Deposition of calcium within the plaques may contribute to the high complication rate in uraemic patients.
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Affiliation(s)
- U Schwarz
- Department of Internal Medicine, Heidelberg, Germany
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24
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Herzog CA, Marwick TH, Pheley AM, White CW, Rao VK, Dick CD. Dobutamine stress echocardiography for the detection of significant coronary artery disease in renal transplant candidates. Am J Kidney Dis 1999; 33:1080-90. [PMID: 10352196 DOI: 10.1016/s0272-6386(99)70145-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Prophylactic coronary revascularization may reduce the risk for cardiac events in diabetic renal transplant candidates. No published data exist on the accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of angiographically defined coronary artery disease (CAD) in renal transplant candidates. The purpose of this study is to examine the accuracy of DSE for the detection of CAD in high-risk renal transplant candidates compared with coronary angiography. Fifty renal transplant candidates with diabetic nephropathy (39 patients) or end-stage renal disease (ESRD) from other causes (11 patients) underwent prospectively performed DSE, followed by quantitative coronary angiography (QCA) and qualitative visual assessment of CAD severity. Twenty of 50 DSE tests were positive for inducible ischemia. Twenty-seven patients (54%) had a stenosis of 50% or greater by QCA, 12 patients (24%) had a stenosis of greater than 70% by QCA, and 16 patients (32%) had a stenosis greater than 75% by visual estimation. The sensitivity and specificity of DSE for CAD diagnosis were respectively 52% and 74% compared with QCA stenosis of 50% or greater, 75% and 71% compared with QCA stenosis greater than 70%, and 75% and 76% for stenosis greater than 75% by visual estimate. On long-term follow-up (22.5 +/- 10.1 months), 6 of 30 patients (20%) with negative DSE results and 11 of 20 patients (55%) with positive DSE results had a cardiac death, myocardial infarction (MI), or coronary revascularization. Six of 27 patients (22%) with a QCA stenosis of 50% or greater had a cardiac death or MI compared with none of the 23 patients (0%) with QCA stenosis less than 50% (P = 0.025). We conclude that DSE is a useful but imperfect screening test for angiographically defined CAD in renal transplant candidates.
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Affiliation(s)
- C A Herzog
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, Australia.
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Amann K, Ritz E. Cardiac disease in chronic uremia: pathophysiology. ADVANCES IN RENAL REPLACEMENT THERAPY 1997; 4:212-24. [PMID: 9239426 DOI: 10.1016/s1073-4449(97)70030-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In chronic uremia, apart from frequent coronary lesions, further abnormalities of the heart recently reported include (1) left ventricular hypertrophy, not completely explained by hypertension, (2) interstitial myocardial fibrosis, for which parathyroid hormone is a permissive factor, (3) reduced myocardial perfusion reserve, secondary to functional and structural changes of intramyocardial arteries and to reduced capillary density, (4) abnormalities of myocardial metabolism, which act in concert with restriction of blood flow by microvascular abnormalities to reduce ischemic tolerance. Such metabolic abnormalities include diminished responsiveness to beta-adrenergic stimulation, abnormal control of intracellular calcium concentration, impaired maintenance of energy-rich nucleotide concentrations under conditions of ischemia, impaired insulin-mediated glucose uptake, and abnormalities of myocardial oxidative metabolism.
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Affiliation(s)
- K Amann
- Pathologisches Institut, Universität Heidelberg, Germany
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26
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Foley RN, Parfrey PS. Cardiac disease in chronic uremia: clinical outcome and risk factors. ADVANCES IN RENAL REPLACEMENT THERAPY 1997; 4:234-48. [PMID: 9239428 DOI: 10.1016/s1073-4449(97)70032-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cardiac disease is common and is the major killer in end-stage renal disease (ESRD). Cardiac failure is a highly malignant condition in ESRD patients. Cardiac failure mediates most of the adverse prognostic impact of ischemic heart disease. Left ventricular (LV) abnormalities are already present at initiation of dialysis therapy in approximately 80% of patients. These abnormalities (ie, systolic dysfunction in approximately 15%, LV dilatation with preserved systolic function in 30%, concentric LV hypertrophy [LVH] in 40%) independently predict ischemic heart disease and cardiac failure, and are the largest baseline predictor of mortality after 2 years on dialysis therapy. The associations between classical risk factors (eg, hyperlipidemia, smoking, hypertension) and cardiac outcomes in ESRD are inconsistent. "Uremic" risk factors represent a nascent, but potentially important field. In our prospective 10-year study of 433 patients starting renal replacement therapy, we identified the following as major independent risk factors for cardiac disease: (1) hypertension (concentric LVH, LV dilatation, ischemic heart disease, cardiac failure, inverse relationship with mortality); (2) anemia (LV dilatation, cardiac failure, death); and (3) hypoalbuminemia (ischemic heart disease, cardiac failure, death). Transplantation dramatically improved LV abnormalities, suggesting that a uremic environment is cardiotoxic. Multiple risk factors act in concert to produce cardiac disease in ESRD; many of these are avoidable, suggesting that the enormous burden of disease can be reduced considerably.
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Affiliation(s)
- R N Foley
- Division of Nephrology, Memorial University, St John's, Newfoundland, Canada
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Bates JR, Sawada SG, Segar DS, Spaedy AJ, Petrovic O, Fineberg NS, Feigenbaum H, Ryan T. Evaluation using dobutamine stress echocardiography in patients with insulin-dependent diabetes mellitus before kidney and/or pancreas transplantation. Am J Cardiol 1996; 77:175-9. [PMID: 8546087 DOI: 10.1016/s0002-9149(96)90591-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The purpose of this study was to examine the ability of dobutamine stress echocardiography to stratify patients with juvenile onset, insulin-dependent diabetes mellitus who are being considered for kidney and/or pancreas transplantation, into high-or low-risk groups for future cardiac events. Fifty-three such patients underwent dobutamine stress echocardiography before kidney and/or pancreas transplantation. Cardiac events, including cardiac death, nonfatal myocardial infarction, unstable angina, pulmonary edema, and need for coronary revascularization, occurring between the time of the dobutamine stress echocardiogram and the last patient follow-up contact were retrospectively identified. Twenty patients 938%) had an abnormal dobutamine stress echocardiogram. Eleven patients had 15 cardiac events over a mean (+/- SD) follow-up period of 418 +/- 269 days. Event rates were 45% among those with an abnormal, versus 6% among those with a normal dobutamine stress echocardiogram (p = 0.002). The result of the dobutamine stress test independently predicted prognosis in a multivariate analysis (p = 0.003, odds ratio = 12.7). We conclude that dobutamine stress echocardiography accurately stratifies patients with juvenile onset, insulin-dependent diabetes being considered for kidney and/or pancreas transplantation for risk of future cardiac events.
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Affiliation(s)
- J R Bates
- Department of Medicine, Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis 46202-4800, USA
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28
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Tezcaner T, Yorgancioğlu C, Moldibi O, Catav Z, Erbay B, Zorlutuna IY. Coronary bypass surgery in a renal transplant patient. Int Urol Nephrol 1996; 28:583-7. [PMID: 9119649 DOI: 10.1007/bf02550971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Coronary bypass surgery in a patient with functioning renal graft is reported. Surgery was carried out using standard operative techniques providing some precautions for renal graft protection: i.e. adequate mean perfusion pressure, volume replacement, and renal outflow during cardiopulmonary bypass, and appropriate prophylactic antibiotic and immunosuppressive therapy. Postoperative course was uneventful and blood urea nitrogen and serum creatinine levels were comparable to the preoperative levels. Three months after operation the patient was found to be asymptomatic.
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Affiliation(s)
- T Tezcaner
- Department of Thoracic and Cardiovascular Surgery, Bayindir Medical Center, Ankara, Turkey
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Reis G, Marcovitz PA, Leichtman AB, Merion RM, Fay WP, Werns SW, Armstrong WF. Usefulness of dobutamine stress echocardiography in detecting coronary artery disease in end-stage renal disease. Am J Cardiol 1995; 75:707-10. [PMID: 7900665 DOI: 10.1016/s0002-9149(99)80658-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The cardiovascular evaluation of patients with end-stage renal disease (ESRD) has been hampered by the suboptimal sensitivity and specificity of currently employed diagnostic tests. Dobutamine stress echocardiography (DSE) is a recently developed technique which is accurate for the diagnosis of coronary artery disease (CAD) in general populations. The purpose of this study was to assess its diagnostic accuracy and prognostic implications in patients with ESRD. Patients with ESRD (n = 97) underwent DSE as part of a preoperative evaluation before being listed for renal transplantation. Patients were followed for 12 +/- 6 months (range 1 to 24) after the study. Rest and dobutamine stress echocardiograms were analyzed for regional and global function. Coronary angiography was performed in 30 patients, and 25 underwent renal transplantation in the follow-up period. DSE had a sensitivity of 95% (92% for 1-vessel, 100% for > or = 2-vessel disease), specificity of 86%, and accuracy of 90% for the detection of CAD. During the follow-up period, 6 patients died; DSE revealed inducible ischemia in 4, and catheterization before death revealed multivessel CAD in 2. Conversely, a normal DSE identified a very low risk population, with a 97% probability of being free of cardiac complications or death during the follow-up period. We conclude that DSE accurately identifies CAD in patients with ESRD and identifies a cohort of patients at low risk for cardiac complications.
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Affiliation(s)
- G Reis
- Department of Medicine, University of Michigan, Ann Arbor 48109-0119, USA
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30
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Fitzgerald R. Nierentransplantation: Präoperative Optimierung, peri- und postoperative Betreuung. Transplantation 1995. [DOI: 10.1007/978-3-7091-7678-8_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fabrega AJ, Rivas PA, Pollak R. Pancreas-kidney transplantation for intensivists: perioperative care and complications. J Intensive Care Med 1994; 9:281-9. [PMID: 10155187 DOI: 10.1177/088506669400900603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Simultaneous pancreas-kidney transplantation is a therapeutic option for type I diabetics with end-stage renal disease. It aims to correct the uremic state, to normalize glucose hemeostasis, and to ameliorate diabetic complications. Careful donor-recipient selection and meticulous intra-operative and postoperative care will substantially impact recipient morbidity. An understanding of the technical aspects of the surgical procedure and its metabolic and immunological consequences is necessary to successfully manage a pancreas-kidney transplant recipient, many of whom are nursed in intensive care units. A successful outcome is predicted in early recognition of technical complications and aggressive management of rejection to achieve the current 1-year graft survival rates of 75% for pancreas transplants and 84% for kidney transplants.
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Affiliation(s)
- A J Fabrega
- Department of Surgery, University of Illinois at Chicago 60680, USA
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Sutherland DE, Gores PF, Farney AC, Wahoff DC, Matas AJ, Dunn DL, Gruessner RW, Najarian JS. Evolution of kidney, pancreas, and islet transplantation for patients with diabetes at the University of Minnesota. Am J Surg 1993; 166:456-91. [PMID: 8238742 DOI: 10.1016/s0002-9610(05)81142-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Transplantation began at the University of Minnesota in 1963. Treatment of diabetes and its complications has been emphasized since 1966, when the first pancreas-kidney transplant was done. Of 3,640 kidneys transplanted by 1992, 1,373 were for diabetic recipients, including 658 from living donors and 715 from cadaver donors. The results progressively improved; since 1984, survival rates of kidney grafts have been similar for diabetic and nondiabetic recipients, with three fourths of the grafts functioning at 4 years. As of 1992, 501 pancreas transplants had been done, including 170 simultaneous with a kidney, 142 after a kidney, and 188 alone for nonuremic diabetic patients; again, the results have improved: by the 1990s, graft survival rates were similar in the 3 recipient categories. Successful pancreas transplants have been shown by our coworkers to stabilize or improve neuropathy and prevent recurrence of diabetic nephropathy in kidney grafts. In an attempt to simplify endocrine replacement therapy, we have done 63 human islet transplants, 34 as allografts for patients with type I diabetes and 29 as autografts after total pancreatectomy to treat chronic pancreatitis. Insulin independence occurs for about 50% of islet autograft recipients. Two recent islet allograft recipients treated with 15-deoxyspergualin have had sustained insulin independence. We anticipate that endocrine replacement therapy by transplantation will become routine for diabetic patients as methods to prevent rejection are refined.
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Affiliation(s)
- D E Sutherland
- Department of Surgery, University of Minnesota, Minneapolis
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Manske CL, Thomas W, Wang Y, Wilson RF. Screening diabetic transplant candidates for coronary artery disease: identification of a low risk subgroup. Kidney Int 1993; 44:617-21. [PMID: 8231036 DOI: 10.1038/ki.1993.289] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Coronary artery disease is the major cause of death in diabetic renal transplant recipients. Because one-third of diabetic transplant candidates have clinically silent coronary artery disease, many transplant centers recommend coronary angiography prior to transplantation. However, angiography is expensive and may precipitate acute renal failure. Therefore, we developed a noninvasive screening algorithm to identify patients at low risk for coronary artery disease (CAD), defined as one or more coronary stenoses > or = 50% diameter. We performed coronary angiography in 141 consecutive asymptomatic Caucasian type I diabetic renal transplant candidates. Fourteen of 16 patients age 45 or older had CAD. One hundred and twenty-five patients under age 45 were randomly divided into two groups. Ninety patients were used to identify clinical factors significantly associated with CAD which included smoking for five or more pack years, nonspecific ST-T wave changes on electrocardiogram, and diabetes duration 25 years or longer. The screening algorithm, "CAD is predicted in diabetic transplant candidates under age 45 with any of the above risk factors," was then tested in the remaining 35 patients and in 35 additional patients. In these 70 patients, the algorithm had a sensitivity of 97% and a negative predictive accuracy of 96%. We conclude that coronary angiography should be recommended to Caucasian type I diabetic renal transplant candidates age 45 or older because of the high probability of disease. In patients younger than 45 without a smoking history, ST-T wave changes on EKG, or diabetes longer than 25 years, the likelihood of CAD is low and angiography can be avoided.
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Affiliation(s)
- C L Manske
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis
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Yokoyama H, Yoshitake E, Otani T, Uchigata Y, Kawagoe M, Kasahara T, Omori Y. Carotid atherosclerosis in young-aged IDDM associated with diabetic retinopathy and diastolic blood pressure. Diabetes Res Clin Pract 1993; 21:155-9. [PMID: 8269816 DOI: 10.1016/0168-8227(93)90063-b] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To determine whether young patients with IDDM already have atherosclerosis and what factors would relate to atherosclerosis, we examined the intimal-medial thickness (IMT) of the common carotid artery by ultrasonography. Subjects were 29 young patients with IDDM (aged 17-39 years, duration 4-31 years) without manifest macroangiopathy and 13 healthy controls of comparable age (22-29 years). The carotid artery IMT of young patients with IDDM were significantly higher than those of controls (0.60 +/- 0.09 vs. 0.46 +/- 0.02 mm, P < 0.0001). The levels of IMT significantly correlated to diastolic blood pressure (r = 0.45, P < 0.02), and were higher in those with proliferative retinopathy than those without retinopathy (0.66 +/- 0.09 vs. 0.55 +/- 0.08 mm, P < 0.02). The levels of IMT showed no significant correlation to the attained age, duration of IDDM, HbA1c, systolic blood pressure, and cholesterol level. These findings suggest the usefulness of this examination for the early detection of diabetic macroangiopathy, and point to a close relationship between microangiopathy and macroangiopathy in IDDM.
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Affiliation(s)
- H Yokoyama
- Diabetes Center, Tokyo Women's Medical College, Japan
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Manske CL, Wang Y, Rector T, Wilson RF, White CW. Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure. Lancet 1992; 340:998-1002. [PMID: 1357450 DOI: 10.1016/0140-6736(92)93010-k] [Citation(s) in RCA: 235] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Insulin-dependent diabetic patients found to have substantial coronary artery disease at the time of assessment for renal transplantation have 2-year survival of less than 50%. Because most of these patients have no angina symptoms their management is controversial. We tried to find out whether coronary artery revascularisation in such patients might decrease the combined incidence of unstable angina, myocardial infarction, and cardiac death. 151 consecutive insulin-dependent diabetic candidates for renal transplantation underwent coronary angiography. 31 had stenoses greater than 75% in one or more coronary arteries, atypical chest pain or no chest pain, and a left ventricular ejection fraction greater than 0.35. Of these, 26 agreed to be randomly assigned medical treatment (a calcium-channel-blocking drug plus aspirin) or revascularisation (angioplasty or coronary bypass surgery). 10 of 13 medically managed and 2 of 13 revascularised patients had a cardiovascular endpoint within a median of 8.4 months of coronary angiography (p < 0.01). 4 medically managed patients died of myocardial infarction during follow-up. Thus, revascularisation decreased the frequency of cardiac events in insulin-dependent diabetic patients with chronic renal failure and symptomless coronary artery stenoses. These findings suggest that diabetic renal transplant candidates should be screened for silent coronary artery disease, because revascularisation may decrease cardiac morbidity and mortality in this population.
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Affiliation(s)
- C L Manske
- Department of Medicine, University of Minnesota, School of Medicine, Minneapolis
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Weinrauch LA, D'Elia JA, Gleason RE, Hampton LA, Smith-Ossman S, DeSilva RA, Nesto RW. Usefulness of left ventricular size and function in predicting survival in chronic dialysis patients with diabetes mellitus. Am J Cardiol 1992; 70:300-3. [PMID: 1632392 DOI: 10.1016/0002-9149(92)90608-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To identify patients at high risk for sudden death, a group of stable patients on maintenance dialysis with diabetes mellitus were studied for up to 135 months to determine if there were clinical, laboratory or echocardiographic predictors of high risk. Eighty-two patients on maintenance dialysis who underwent clinical, laboratory evaluation and echocardiography were enrolled and followed for a mean of 25 months for cardiac and noncardiac complications. Thirty-seven patients with normal wall motion and left ventricular (LV) internal diameter had a mean survival of 35.8 months; 28 patients survived greater than 12 months. Seven patients with normal LV wall motion and dilated LV cavities had a mean survival of 45.7 months; 7 patients survived greater than 12 months. Fifteen patients with abnormal LV wall motion and normal internal LV dimensions had a mean survival of 17 months; 7 patients survived greater than 12 months. Twenty-three patients with both abnormal LV wall motion and dilated LV cavities had a mean survival of 7.8 months; 5 patients survived greater than 12 months. Although echocardiographic abnormalities predicted cardiac mortality at 6 and 12 months, the combination of an abnormal standard electrocardiogram at baseline, clinical history of angina pectoris, and prior documented myocardial infarction or congestive heart failure did not. When the study group was divided by mode or duration of dialysis, presence or absence of diabetes, or use of cardioactive drugs, echocardiographic LV wall motion abnormalities remained the most important determinant of survival.
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Affiliation(s)
- L A Weinrauch
- John Cook Renal Unit, Joslin Diabetes Center, Department of Medicine, New England Deaconess Hospital 02215
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Weinrauch LA, D'Elia JA, Monaco AP, Gleason RE, Welty F, Nishan PC, Nesto RW. Preoperative evaluation for diabetic renal transplantation: impact of clinical, laboratory, and echocardiographic parameters on patient and allograft survival. Am J Med 1992; 93:19-28. [PMID: 1626568 DOI: 10.1016/0002-9343(92)90675-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the impact on renal transplant patients and graft survival of clinical, laboratory, and echocardiographic parameters commonly measured prior to surgery. PATIENTS Forty-seven consecutive diabetics with preoperative echocardiograms at the time of transplantation. METHODS Clinical history, standard chest roentgenogram, electrocardiogram, blood tests, echocardiograms, and HLA testing at baseline; follow-up from 2 to 7 years with periodic reassessment of graft function. RESULTS Patient survival did not appear to be influenced by age, sex, or type of allograft. A history of either myocardial infarction, congestive heart failure, or angina was present in 15 patients with 3-year survival of 50% (72% if not present, p less than 0.05). Histocompatibility testing did not impact on survival. Serum sodium, potassium, calcium, phosphate, and calcium-phosphate product did not discern different survival groups. A hematocrit greater than 30% was present in 15 patients with 3-year survival of 43% (73% if not present, p less than 0.05). Greater than 10% antibody sensitization of the recipient resulted in a 3-year survival of 38% in eight patients (68% if not present, p less than 0.05). Radiologic evidence of cardiomegaly or congestive heart failure and standard electrocardiographic evidence for left ventricular hypertrophy or strain did not impact on survival. Echocardiographic measurements of left ventricular end-diastolic diameter, posterior wall thickness, or ejection fraction were also not predictive. Increased end-systolic diameter (10 patients, 30% 3-year survival versus 69%, p less than 0.05) and decreased velocity of circumferential fiber shortening (11 patients, 45% 3-year survival versus 71%, p less than 0.05) both appeared to be related to survival. Increased accuracy of prediction could be obtained by adding risk factors so that a history of coronary artery disease and increased end-systolic diameter predicted 3-year survival of 42% versus 82% if neither was present. In terms of graft survival, no clinical, radiographic, or electrocardiographic result yielded predictive information. Among the laboratory tests, only highly antibody-sensitized patients (eight patients, 0% 3-year survival versus 66% 3-year survival, p less than 0.001) showed different survival patterns. Echocardiographic elevated end-systolic diameter predicted a significantly (p less than 0.001) decreased graft survival (3-year survival 33% versus 63%). CONCLUSION Preoperative prediction of patient and graft survival in diabetic renal transplantation may be enhanced by echocardiographic assessment of systolic load and function. For patients with normal systolic function, whose hematocrit is below 30%, with preformed antibodies less than 10%, renal transplantation has an excellent prognosis; invasive cardiac procedures are not likely required. Since these risk factors are likely additive, a high-risk group may be identified. These latter patients should undergo coronary angiography.
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Affiliation(s)
- L A Weinrauch
- Department of Medicine, New England Deaconess Hospital, Boston, Massachusetts
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Mahmoud R, Raccah D, Alessi M, Aillaud M, Juhan-Vague I, Vague P. Fibrinolysis in insulin dependent diabetic patients with or without nephropathy. ACTA ACUST UNITED AC 1992. [DOI: 10.1016/0268-9499(92)90067-r] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Ionic and nonionic contrast materials are similarly efficacious in providing excellent images with minimal risk to the patient. In comparison with ionic media, the nonionic agents produce minor alterations in intracardiac and peripheral pressures as well as in electrocardiographic intervals and morphology. In addition, nonionic media are less often associated with undesirable symptoms, such as flushing and vomiting. At the same time, ionic and nonionic media are accompanied by a similar incidence of nephrotoxicity, serious arrhythmias, and death. Finally, nonionic contrast material is substantially more expensive than ionic media. In light of this marked difference in cost, one could argue that nonionic media should be reserved for "high-risk" patients, that is, those with a history of a serious adverse reaction to ionic contrast media and those in whom contrast-induced hypotension would be particularly deleterious.
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Affiliation(s)
- W C Brogan
- Department of Internal Medicine (Cardiovascular Division), University of Texas Southwestern Medical Center, Dallas 75235
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Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging. A diagnostic tool comes of age. Circulation 1991; 83:363-81. [PMID: 1991361 DOI: 10.1161/01.cir.83.2.363] [Citation(s) in RCA: 230] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- K A Brown
- Cardiology Unit, University of Vermont, College of Medicine, Burlington
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Abstract
Diabetic patients may have various abnormalities in left ventricular systolic and diastolic function not attributable to coronary heart disease, hypertension or other known cardiac disease. Although the exact causes of this diabetic heart muscle disease or "diabetic cardiomyopathy" are still incompletely understood, several mechanisms may contribute to it including disturbed myocardial energy metabolism, microvascular changes, structural changes in collagen, increased myocardial fibrosis, and cardiac autonomic neuropathy. Perhaps the most typical feature of diabetic heart muscle disease is an abnormal filling pattern of the left ventricle, suggesting reduced compliance or prolonged relaxation. Left ventricular systolic function is commonly normal at rest in asymptomatic diabetic patients, but it frequently becomes abnormal during exercise. The abnormalities in left ventricular systolic function may be partly reversible along with an improvement of metabolic control of diabetes. It is not known how frequently subclinical abnormalities in left ventricular function in diabetic patients result in clinically manifest heart failure.
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Affiliation(s)
- M I Uusitupa
- Department of Clinical Nutrition, University of Kuopio, Finland
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Manske CL, Sprafka JM, Strony JT, Wang Y. Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. Am J Med 1990; 89:615-20. [PMID: 2239981 DOI: 10.1016/0002-9343(90)90180-l] [Citation(s) in RCA: 314] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the incidence of, risk factors for, and outcome of contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. PATIENTS AND METHODS Fifty-nine insulin-dependent diabetics with a mean serum creatinine level of 522 mumol/L (5.9 mg/dL) underwent coronary angiography as part of a pretransplant evaluation. Twenty-four azotemic diabetics undergoing inpatient evaluation not including angiography for transplantation formed the control group. Serum creatinine measurements obtained at baseline and after radiocontrast exposure were compared in patients and control subjects. Risk factors for contrast nephropathy were evaluated in patients with a 25% or greater increase in serum creatinine. RESULTS Serum creatinine was significantly elevated 24 hours after radiocontrast exposure in patients (557 +/- 141 mumol/L versus 522 +/- 141 mumol/L, mean +/- SD; p less than 0.001) but not in controls. Seven patients required dialysis within 6 days of coronary angiography and two additional patients required dialysis within 14 days. Contrast nephropathy, defined as a serum creatinine increase of greater than 25% when measured 48 hours after radiocontrast exposure, occurred in 50% of patients and no controls. Univariate analysis of risk factors for contrast nephropathy revealed a significant association with dye quantity (p = 0.002), mean arterial pressure less than 100 mm Hg (p = 0.02), and ejection fraction less than 50% (p = 0.04). Stepwise logistic regression verified the independence of dye quantity and low mean arterial pressure but not low ejection fraction as risk factors for contrast nephropathy. Follow-up serum creatinine values were not significantly different in patients and control subjects. CONCLUSIONS Azotemic patients with diabetes are at high risk of developing contrast nephropathy even when less than 100 mL of radiocontrast agent is used. The acute renal failure is reversible but precipitates the need for short-term dialysis in some patients. Radiocontrast quantity is an important risk factor not previously noted. The incidence of contrast nephropathy can be minimized by using less than 30 mL of radiocontrast agent.
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Affiliation(s)
- C L Manske
- Department of Medicine, University of Minnesota School of Medicine, Minneapolis
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Brown KA, Rimmer J, Haisch C. Noninvasive cardiac risk stratification of diabetic and nondiabetic uremic renal allograft candidates using dipyridamole-thallium-201 imaging and radionuclide ventriculography. Am J Cardiol 1989; 64:1017-21. [PMID: 2816731 DOI: 10.1016/0002-9149(89)90800-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The ability of noninvasive risk stratification using dipyridamole-thallium-201 (Tl-201) imaging and radionuclide ventriculography to predict perioperative and long-term cardiac events (myocardial infarction or cardiac death) was evaluated in 36 uremic diabetic and 29 nondiabetic candidates for renal allograft surgery. Of the 35 patients who underwent renal allograft surgery 8 +/- 7 months after the study, none had transient Tl-201 defects (although 13 had depressed left ventricular ejection fraction) and none developed perioperative cardiac events. During a mean follow-up of 23 +/- 11 months, 6 (9%) patients developed cardiac events. Logistic regression analysis was used to compare the predictive value of clinical data (including age, sex, diabetes, chest pain history, allograft recipient) and radionuclide data. Presence of transient Tl-201 defect and left ventricular ejection fraction were the only significant predictors of future cardiac events (p less than 0.01). No other patient variables, including diabetes or receiving a renal allograft, had either univariate or multivariate predictive value. All 3 patients with transient Tl-201 defects had cardiac events compared with only 3 of 62 (5%) patients without transient Tl-201 defect (p less than 0.0001). Mean left ventricular ejection fraction was lower in patients with cardiac events (44 +/- 13%) compared with patients without cardiac events (57 +/- 9%, p less than 0.005). Overall, 5 of 6 patients with cardiac events had either transient Tl-201 defects or depressed left ventricular ejection fraction. Dipyridamole-Tl-201 imaging and radionuclide ventriculography may be helpful in identifying uremic candidates for renal allograft surgery who are at low risk for perioperative and long-term cardiac events.
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Affiliation(s)
- K A Brown
- Department of Medicine, University of Vermont College of Medicine, Burlington
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Abstract
Diabetes mellitus is a significant condition affecting major segments of all population groups studied. With the introduction of insulin and oral hypoglycemic therapy, and with better understanding of diet and weight control over the past half century, the primary causes of diabetic morbidity and mortality have shifted in varying proportions from metabolic derangements, infection, and renal insufficiency to different types of cardiovascular disease. Despite extensive clinical and laboratory research on the etiology, pathogenesis, and even the existence of cardiovascular disease associated with diabetes mellitus, however, considerable debate is still apparent in this field. Our purpose is to present an overview of the subject of diabetic heart disease, with a critical analysis of epidemiologic, clinical, and pathological data. Some of this material will be addressed from the perspective of research in this area over the past decade by one of us (SMF), particularly in experimental hypertensive and diabetic cardiomyopathy. However, overall, an attempt will be made to provide an objective and balanced analysis, in order to answer the question: does diabetic heart disease exist?
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Affiliation(s)
- K H van Hoeven
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
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Vitolo E, Madoi S, Sponzilli C, Palvarini M, Silvestri D, Castini D, Morabito A. Vectorcardiographic evaluation of diabetic cardiomyopathy and of its contributing factors. ACTA DIABETOLOGICA LATINA 1988; 25:227-34. [PMID: 3239349 DOI: 10.1007/bf02624817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In order to investigate the prevalence of vectorcardiographic bites, expression of small areas of fibrosis, atrophy or degeneration of the myocardium, we studied, using the vectorcardiograms (VCG) of 101 diabetic patients (35 with insulin-dependent and 66 with non-insulin-dependent diabetes mellitus, aged from 25 to 60 years, without hypertension, coronary artery disease, or intraventricular conduction defects) and 228 normal control subjects, matched for age and sex. The prevalence of bites was 38.6% in diabetic patients and 10.0% in the control group (p less than 0.001). Diabetic patients were also subdivided into groups according to age, sex, metabolic control, risk factors for coronary heart disease, type of diabetes, duration of diabetes and diabetic microangiopathy. No correlation was found between any of the variables investigated nor of a combination of these, and the presence of bites. We conclude that VCG is a sensitive test for cardiac involvement in diabetic patients but that it cannot be used to identify any specific factor able to influence the onset and evolution of this involvement.
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Affiliation(s)
- E Vitolo
- Istituto di Scienze Biomediche Sacco, Università di Milano, Italy
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Lamb AS, Johnson WM. Premature coronary artery atherosclerosis in a patient with Prader-Willi syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS 1987; 28:873-80. [PMID: 3688025 DOI: 10.1002/ajmg.1320280412] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A 26-year old white male with Prader-Willi syndrome (PWS) and non-insulin-dependent diabetes mellitus presented with asymptomatic bilateral lower limb swelling. An electrocardiogram was consistent with an inferior wall myocardial infarction of unknown age and a graded exercise test using the Bruce protocol was consistent with inferolateral ischemia. Subsequent cardiac catheterization showed severe, inoperable, three-vessel coronary artery disease. Atherosclerotic coronary artery disease in PWS has been documented only once in the literature, and then only postmortem. This case provides further (and for the first time, premortem) documentation that premature atherosclerotic coronary artery disease may play an important but presently unrecognized role in the morbidity and mortality in PWS.
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Affiliation(s)
- A S Lamb
- Department of Medicine, Dwight David Eisenhower, Army Medical Center, Fort Gordon, Georgia
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Rubler S, Gerber D, Reitano J, Chokshi V, Fisher VJ. Predictive value of clinical and exercise variables for detection of coronary artery disease in men with diabetes mellitus. Am J Cardiol 1987; 59:1310-3. [PMID: 3591685 DOI: 10.1016/0002-9149(87)90910-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Sixty-eight men with diabetes mellitus (mean age 53 +/- 10 years) and no symptoms of cardiac dysfunction enrolled in a long-range study for detection of latent coronary artery disease. The testing included maximal treadmill stress with thallium-201 scintigraphy and echocardiography. Radionuclide angiography was available in 35 men (52%), and 24 (35%) had gated scanning with exercise. Of the 68 patients, 14 (21%) had a mild (9 patients) or moderate (5 patients) decrease in ejection fraction on radionuclide angiography, echocardiography or both. Fifty-two men agreed to remain in the study and have been followed for 12 to 18 months (mean 41 +/- 19). Ten coronary events have occurred. Four of the men died (2 suddenly) and 6 have angina pectoris. Three patients have had vascular complications. Of the clinical and exercise variables studied, exercise duration effectively predicted an adverse outcome, while the odds ratio in favor of a coronary event increased by 36 times in those with thallium-201 defects and 7 times in those with ST-segment changes on exercise. Radionuclide angiographic responses during exercise were abnormal in 5 of 6 patients with events, but were also abnormal in 12 of 29 men (41%) who did not have coronary artery disease. Clinical variables such as blood pressure, cholesterol level and family history were not predictive of outcome, nor was maximal heart rate during exercise. Thus, diabetic mean who can exercise for 440 seconds on a treadmill using a bruce protocol are at low risk of a coronary event.(ABSTRACT TRUNCATED AT 250 WORDS)
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