Reduced acute rejection and superior 1-year renal allograft survival with basiliximab in patients with diabetes mellitus. The Global Simulect Study Group

BACKGROUND: Renal allograft recipients with diabetes mellitus often demonstrate poorer clinical outcomes than nondiabetic patients. Basiliximab (Simulect), a chimeric anti-interleukin-2 receptor monoclonal antibody, reduced the incidence of acute rejection in renal allograft recipients in 2 multicenter, placebo-controlled, phase III trials. METHODS: An analysis of pooled results from the 2 trials was conducted to compare the efficacy and safety of basiliximab with placebo in renal transplant recipients with and without prior diabetes. Patients received either basiliximab (20 mg on day 0 and day 4 posttransplantation) or placebo in combination with cyclosporine for microemulsion (Neoral) and steroids. RESULTS: A total of 722 patients (150 diabetic, 572 nondiabetic) were eligible for intent-to-treat analysis. At 12 months, basiliximab as compared with placebo reduced the proportion of patients experiencing first acute rejection by 41% in diabetics (P<0.01) and by 29% in nondiabetics (P<0.001). Biopsy-confirmed rejection was reduced by 44% in diabetics (P<0.01) and by 26% in nondiabetics (P<0.01). The first acute rejection episode requiring augmented immunosuppression other than steroids was reduced by 49% in diabetics (P<0.01) and by 41% in nondiabetics (P<0.001); death, graft loss, or first rejection episode was reduced by 43% in diabetics (P=0.001) and by 22% in nondiabetics (P<0.01). Superior graft survival was maintained in diabetic recipients treated with basiliximab versus placebo (96% vs. 86%; P=0.022). There were no significant differences in safety between basiliximab and placebo in both diabetic and nondiabetic patients. CONCLUSIONS: Basiliximab is associated with a significant reduction in acute rejection and an excellent safety profile in renal transplant recipients with and without diabetes mellitus. Superior graft survival was evident in diabetic patients.     

Complications of coronary artery surgery in diabetic patients

Postoperative mortality and morbidity of diabetic versus nondiabetic patients undergoing primary coronary artery bypass grafting (CABG) were analyzed. In 1988, 711 patients had CABG procedures, of which 565 were nondiabetic and 146 diabetic. The two groups of patients were statistically similar in regard to age, weight, tobacco and ethanol use, and preoperative levels of cholesterol, triglycerides, blood urea nitrogen (BUN), and creatinine. Preoperative serum glucose levels were significantly elevated in diabetic patients (182 vs. 106, P less than .001). Cardiac output, ejection fraction, and bypass, crossclamp time, and total operating room times were not different for the two groups. Emergent and urgent procedures had a significantly higher mortality rate than elective cases (11.3% and 6.6% vs. 1.7%, respectively; P less than 0.05), but this was independent of the patient's diabetic status. Women had a higher mortality rate than men (6.5% vs. 2.9%; P = 0.05) although within each gender group, there were no differences between diabetics and nondiabetics. There were 27 patients with complications in the diabetic group (18.5%) and 47 in the nondiabetic group (8.3%; P less than .001). The types of complications within the two groups differed in that wound infections (7.5%), postoperative arrhythmias (4.8%), respiratory failure (4.1%), and intra-aortic balloon pump use (4.1%) were significantly greater (P less than .05) in the diabetic patients compared to the nondiabetic (0.9%, 1.8%, 0.4%, and 1.4%, respectively). Occurrences of postoperative pneumothorax, reoperation, myocardial infarction, stroke, urinary tract infection, and pneumonia were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary artery,aortic wall,and valvular calcification in nondialyzed individuals with type 2 diabetes and renal disease

BACKGROUND: Individuals with end-stage renal disease (ESRD) have highly prevalent and severe vascular and valvular calcification. We undertook this study to test the hypothesis that vascular and valvular calcification begins and is often severe long before diabetic renal disease progresses to ESRD. METHODS: A total of 32 nondialyzed individuals with type 2 diabetes mellitus and diabetic renal disease (albumin excretion rate>30 microg/min) [mean glomerular filtration rate (GFR), 49.8 +/- 6.1 mL/min/1.73 m2] were identified and compared with a group of 18 normoalbuminuric diabetics. We used 3:1 matching to identify 95 nondiabetic controls without renal disease, matched for age, gender, ethnicity, and the presence/absence of dyslipidemia, hypertension, and known coronary artery disease (CAD). RESULTS: Using electron beam computed tomography (CT), the prevalence of coronary artery calcification was significantly greater among diabetic renal disease individuals (prevalence, 94% vs. 59%, P < 0.001; median score, 238 vs. 10, P < 0.001) than the nondiabetic controls. The coronary artery calcification scores were significantly more severe among diabetic renal disease individuals than either the diabetic or nondiabetic controls. Among individuals with diabetic renal disease, the coronary artery calcification and aortic wall calcification scores were several-fold greater among those with known CAD than among those without. There was also a significantly greater prevalence of aortic and mitral valve calcification among diabetic renal disease individuals than nondiabetic controls (aortic, 23% vs. 6%, P = 0.03; mitral, 25% vs. 2%, P < 0.001). Multivariate analysis using all three groups reproduced these findings and also consistently identified age and diabetic renal disease as additional predictors for the presence or severity of coronary artery and aortic wall calcification. CONCLUSION: In this first, systematic analysis among nondialyzed individuals with diabetic renal disease, these data demonstrate that vascular and valvular calcification is present and often severe long before the disease progresses to ESRD. The data also suggest that the coronary artery and aortic wall calcification may represent atherosclerosis.     

Urinary tract infection in diabetic patients

AIM: The aim of the study was to compare the epidemiological, microbiological and clinical features of diabetic patients with urinary tract infection (UTI) to those of nondiabetic ones. METHODS: A prospective study was performed on 490 consecutive patients with proven UTI. The patients were studied on the basis of a specific questionnaire and hospital records. RESULTS: Of 490 enrolled patients, 89 (18.1%) had diabetes mellitus. The mean age of diabetics and nondiabetics was respectively 64.9 +/- 13.2 (SD) and 54.4 +/- 23.3 years. Most diabetics had asymptomatic bacteriuria and had undergone bladder catheterization more frequently than the nondiabetics. The most frequent causative agents of UTI in diabetics and nondiabetics were: E. coli (respectively, 56.1 vs. 56.8%), Proteus sp. (7.9% vs. 7.2%), Pseudomonas sp. (6.7 vs. 8.2%), Enterococcus sp. (6.7 vs. 7.2%). More than 50% of the isolated Pseudomonas sp. strains in both groups were resistant to gentamicin, piperacillin and norfloxacin. Both diabetics (52.8%) and nondiabetics (42.2%) had recurrent UTI during the follow-up period; the difference in the incidences did not reach statistical significance. CONCLUSION: No significant differences in epidemiological, clinical and microbiological evaluated features of diabetics and nondiabetics were pointed out, except for the higher frequency of bladder catheterization of diabetics than nondiabetics. However, the eradication of UTI seemed to be more difficult in diabetics than in nondiabetics.     

Continuous insulin infusion reduces infectious complications in diabetics following coronary surgery

BACKGROUND: This study was undertaken to evaluate the effects of a continuous insulin infusion protocol on postoperative infection and mortality. METHODS: Patients who underwent coronary artery bypass grafting from January 1997 until December 1998 were included in this study (n = 761). A continuous insulin drip protocol (IDP) designed to titrate blood sugar levels to 120-160 mg/dL in the immediate postoperative period was instituted in 1998. Comparisons of diabetic and nondiabetic data before and after initiation of the IDP were made. RESULTS: Of the 761 patients who underwent coronary revascularization, diabetics accounted for 32%. There was no significant difference in age, gender, diabetic status, urgency of operation, or operative time between 1997 and 1998 diabetics and nondiabetics. Overall, wound infections occurred in 3% (23/761) of patients. In 1997, the infection rate was significantly higher in diabetics than nondiabetics (p = 0.0007). After initiation of the IDP in 1998, the infection rate for the diabetic population was reduced to that of the nondiabetic population. There was no significant difference in the mortality rate between 1997 diabetics (4%) and 1998 diabetics (5%) (p = 0.5759) or in the length of stay for 1997 diabetics versus nondiabetics (p = 0.1906). There were no mortalities among patients with wound infections. CONCLUSION: Initiation of the IDP and the subsequent tight control of blood sugars in the immediate postoperative period proved to reduce the incidence of wound infection in the diabetic population. There was no significant difference in the mortality rate or length of hospitalization.     

Retrospective analysis of local sensorimotor deficits after radial artery harvesting for coronary artery bypass grafting

OBJECTIVES: The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass. We analyze patient-based data to determine risk factors for long-term upper limb morbidities associated with RA harvest for coronary artery bypass grafting. STUDY DESIGN/METHODS: Between April 1997 and March 2004, a total of 1030 patients underwent RA harvesting for coronary artery bypass grafting for a total of 1704 harvest sites. Patients were contacted by telephone and asked to report any ongoing severe sensory and functional motor deficits for each harvest site since surgery. Retrospective chart review was performed and preoperative risk factors were evaluated. Patient-based risk factors were evaluated for development of significant long-term local sensorimotor deficits including gender, elderly age (>70 y), diabetes, smoking, and whether the RA was harvested from the dominant hand. RESULTS: Successful evaluation of 629 patients for a total of 1048 RA harvest sites was completed. The mean follow-up time was 48.3 mo (range, 2 to 86 mo). The mean age of the patients analyzed was 62.2 y. On statistical analysis, diabetics and elderly did not report significantly greater functional or sensory deficits than nondiabetics and nonelderly, respectively. There was a significantly higher incidence of sensory deficits in smokers compared with nonsmoker patients (4.2% versus 1.4%; P = 0.005) but no difference in their functional impairment was noted. Harvesting from the dominant hand did not influence the occurrence of sensory or motor functional deficits. CONCLUSIONS: RA harvesting for coronary artery bypass grafting can be done with minimal serious long-term upper limb morbidity in higher risk patients. Based on our findings, harvesting of the RA from the dominant hand is not contraindicated in these patients.     

Renal transplantation in diabetic patients

OBJECTIVE: Diabetes is one of the main causes of end-stage renal disease (ESRD) and admission to hemodialysis, and the demand for kidney transplantation in this population has increased. Our aim was to evaluate the clinical aspects and survival of diabetic patients with kidney transplants by comparing them with the nondiabetic population. MATERIALS AND METHODS: Patients transplanted during the period from 1994 to 2003 were evaluated for this study. The transplant and demographic characteristics were analyzed by the chi-square test and Student t test according to the type of variable. Kaplan-Meier curves and the log-rank test were used to evaluate the graft and patient survival. RESULTS: From a total of 523 consecutive renal transplants, 35 (6.6%) were diabetics who were older than nondiabetics (47 +/- 11 years vs 37 +/- 16, P < .002). Patients received immunosuppression with cyclosporine (84.3%), tacrolimus (11.2%), azathioprine (46.6%), mycophenolate mofetil (43.5%), and steroids (all patients). The diabetic patients had a higher percentage of living donors (33.5% vs 17.2%; P = .04). Graft survival rates at 1, 3, and 5 years were 82.7%, 70.9%, and 63.0% in the diabetic patients and 87.6%, 79.0%, and 72.5% (P = .6) in the nondiabetic patients. Patient survival at 5 years was 90.5% in diabetic patients vs 89.0% in nondiabetic patients (P = .9). CONCLUSIONS: No differences were found in our series in transplant complications or survival in the diabetic patients compared with the nondiabetic patients. Kidney transplants, even with living donors, must be offered to well-selected diabetic patients without reservations.     

Is diabetes a risk factor for patients undergoing open abdominal aortic aneurysm repair?

A number of studies have compared results after aortic procedures in diabetics vs nondiabetics but few have focused specifically on abdominal aortic aneurysm surgery. An analysis of prospective data was carried out in the Vascular Surgery Registry (Beth Israel Deaconess Medical Center, Boston, MA) and identified 421 patients (422 grafts) who underwent elective open repair of an abdominal aortic aneurysm between 1990 and 1999. The influence of diabetes mellitus on outcome was assessed by dividing the patients into two groups: 52 diabetic and 370 nondiabetic patients. Postoperative mortality was 1.7% overall (n = 7) and proportionally higher in the diabetic population, although this did not reach statistical significance (3.8% vs 1.4%, p = 0.19). However, cumulative survival at 1 year and 3 years was essentially identical for diabetic vs nondiabetic patients (91.0% vs 92.6% and 70.0% vs 73.5%, respectively) and did not diverge until 5 years after surgery (25.0% vs 50.9% respectively [p > 0.05]). Overall, major complications occurred in 11 diabetics (21.2%) vs 58 nondiabetics (15.7%, p = 0.32). Specific complications that were increased in the diabetic population included pancreatitis (5.8% vs 1.1%, p = 0.01) and pneumonia (11.5% vs 3.2%, p = 0.006). Notably, overall cardiac morbidity was not higher in patients with diabetes mellitus (1.9% vs 4.3%, p = 0.41). Our data suggest that after elective open abdominal aortic aneurysm repair, patients with diabetes mellitus may have a higher rate of certain complications when compared to patients without diabetes mellitus. These differences however, do not preclude the expectation of excellent results of open abdominal aortic aneurysm repair in patients with diabetes mellitus.     

Long-term survival after kidney and kidney-pancreas transplantation in diabetic patients

PURPOSE: To investigate the influence of diabetes mellitus on patient and graft survival among renal versus renal-pancreatic recipients. METHODS: Among 270 renal transplants performed from 1985 to 2002, a total of 204 (75%) were in diabetic patients and 66 (25%) in nondiabetic patients. Among the 204 diabetic patients 161 (60%) kidneys were transplanted simultaneously with a pancreatic graft (SKPT group). The overall group of patient included 164 (61%) men and 106 (39%) women with mean time on dialysis of 31 +/- 21 months (range 0 to 126 months). The mean duration of diabetes was 24 +/- 7 years (range 5 to 51 years). Ninety-nine percent of the patients were on renal replacement therapy (79% hemodialysis and 20% peritoneal dialysis). RESULTS: The overall rejection rate was similar (NS). Both patient and kidney graft survival rates were worse in diabetics. Patient survival was 82% at 5 years among patients undergoing SKPT, 60% in diabetics receiving only a kidney, and 88% in nondiabetic transplanted patients. Kidney graft survival at 5 years was 77% in diabetics receiving SKPT, 68% in diabetics receiving a kidney alone, and 82% in nondiabetic patients. Overall patient survival was significantly greater among nondiabetics (P =.002) or in diabetics who received SKPT compared with diabetics who only had a kidney transplant (P =.001). CONCLUSIONS: This retrospective clinical evaluation confirms that combined pancreas and kidney transplantation should be the first choice to insulin-dependent diabetes mellitus (IDDM) patients with end-stage diabetic nephropathy.     

Diabetes mellitus is associated with subnormal serum levels of free testosterone in men

OBJECTIVE: To evaluate the relationship between diabetes mellitus (DM) and serum levels of free (FT) and total (TT) testosterone. PATIENTS AND METHODS: A cross-sectional study was carried out including 746 men, of whom 116 (15.6%) were diabetics. Both groups, diabetic and nondiabetic, were paired according to age. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated, and a stratification analysis correlating DM and elevated BMI (>25 kg/m(2)) and WHR (>1) with the presence of subnormal FT and TT levels was performed. RESULTS: FT and TT serum levels were subnormal in 46% and 34% of diabetics, respectively, and in 24% and 23% of nondiabetics. Subnormal FT levels were strongly correlated with DM (odds ratio (OR) 2.7; 95% confidence interval (CI) 1.8-4.1) but not with elevated BMI (OR 1.4; 95% CI 1.0-2.0). Subnormal TT levels were more strongly associated with elevated BMI and WHR (OR 2.6; 95% CI 1.7-3.9 and 2.0; 1.4-2.9) than with DM (1.7; 1.1-2.6 and 2.0; 1.3-3.2). CONCLUSION: These data strongly suggest that DM is associated with subnormal FT levels, and that TT levels are influenced more by obesity and central adiposity.     

Effects of Isoflurane and Sevoflurane Anesthesia on Arteriovenous Shunt Flow in the Lower Limb of Diabetic Patients without Autonomic Neuropathy

Background: Failure of sympathetic nerve control caused by diabetic neuropathy results in vasodilation of arteriovenous shunts. The aim of this study was to test the hypothesis that the function of arteriovenous anastomoses was disordered in mild diabetic patients without apparent neuropathy, and that volatile anesthetics opened arteriovenous shunts more greatly in nondiabetic patients than diabetic patients.

Methods: Autonomic system function was assessed by cardiovascular reflex tests. Arterial-venous oxygen content difference (A-V[DELTA]O2) and partial oxygen pressure index (Pvo2/Pao2, the ratio of oxygen tension in femoral vein blood to that in femoral artery blood) were measured before and during isoflurane or sevoflurane anesthesia in 16 diabetic and 22 nondiabetic patients. Skin temperatures of the foot and leg were measured in 14 diabetic and 15 nondiabetic patients using thermography before and during anesthesia.

Results: Pvo2/Pao2 before anesthesia was significantly higher in diabetic patients. In nondiabetics, venous oxygen content significantly increased and A-V[DELTA]O2 markedly decreased during anesthesia, but these parameters were unchanged in diabetics. Foot temperatures were higher in diabetics before anesthesia, and increased gradually and significantly in both groups during anesthesia, but with a greater increase in nondiabetic patients. Induction of anesthesia caused a larger decrease in leg temperature in diabetics than in nondiabetics.     

Effects of isoflurane and sevoflurane anesthesia on arteriovenous shunt flow in the lower limb of diabetic patients without autonomic neuropathy

BACKGROUND: Failure of sympathetic nerve control caused by diabetic neuropathy results in vasodilation of arteriovenous shunts. The aim of this study was to test the hypothesis that the function of arteriovenous anastomoses was disordered in mild diabetic patients without apparent neuropathy, and that volatile anesthetics opened arteriovenous shunts more greatly in nondiabetic patients than diabetic patients. METHODS: Autonomic system function was assessed by cardiovascular reflex tests. Arterial-venous oxygen content difference (A-VDeltaO2) and partial oxygen pressure index (Pvo2/Pao2, the ratio of oxygen tension in femoral vein blood to that in femoral artery blood) were measured before and during isoflurane or sevoflurane anesthesia in 16 diabetic and 22 nondiabetic patients. Skin temperatures of the foot and leg were measured in 14 diabetic and 15 nondiabetic patients using thermography before and during anesthesia. RESULTS: Pvo2/Pao2 before anesthesia was significantly higher in diabetic patients. In nondiabetics, venous oxygen content significantly increased and A-VDeltaO2 markedly decreased during anesthesia, but these parameters were unchanged in diabetics. Foot temperatures were higher in diabetics before anesthesia, and increased gradually and significantly in both groups during anesthesia, but with a greater increase in nondiabetic patients. Induction of anesthesia caused a larger decrease in leg temperature in diabetics than in nondiabetics. CONCLUSIONS: Diabetic patients have a higher Pvo2/Pao2 and a small core-to-peripheral temperature gradient before anesthesia, suggesting latent dysfunction of the autonomic nerve system, even in the absence of autonomic neuropathy. Volatile anesthesia opens the arteriovenous shunt in nondiabetics to a greater extent than in diabetic patients.     

Impact of diabetes on outcome following isolated minimally invasive bypass grafting of the left anterior descending artery

Background

The outcome in patients treated by conventional coronary artery bypass grafting (CABG) for coronary artery disease is negatively influenced by the presence of diabetes. The relative effect of diabetes in patients undergoing isolated minimally invasive revascularization of the left anterior descending artery (LAD) using the internal thoracic artery (ITA) has as yet not specifically been looked at. Thus, this study sought to evaluate the impact of diabetes on mid-term outcome following minimally invasive coronary artery bypass grafting (MIDCAB).

Methods

From 1996 to 1999, 411 patients received a MIDCAB procedure at our institution and were now followed up. In this study population there were 63 diabetic patients (15.3%) and 348 nondiabetic patients (84.7%). Isolated proximal stenoses or an occlusion of the LAD were present in 262 patients (63.7%), whereas 149 (36.3%) had multi-vessel disease (MVD) at the time of the MIDCAB procedure. The clinical outcome was evaluated by questionnaires sent to the patients and their physicians.

Results

The mean follow-up was 29.4 ± 11.1 months. The incidence of myocardial infarction was significantly higher in diabetics as compared to nondiabetics (9.5% vs 3.2%, p = 0.034). Diabetics and nondiabetics had similar rates of subsequent revascularization procedures during follow-up. Cumulative total survival of diabetic and nondiabetic patients was not statistically different. The 3-year cardiac mortality was however significantly higher in diabetic than in nondiabetic patients if MVD was initially present (Kaplan-Meier estimate: 10.7% vs 2.5%, relative risk [RR] = 5.5, p = 0.017 by log-rank test). The 3-year cardiac mortality in diabetic and nondiabetic patients with isolated disease of the LAD (single vessel disease [SVD]) was not significantly different. After adjustment of baseline characteristics by Cox regression analysis the 3-year risk of cardiac death was significantly higher in the diabetic group (RR = 1.82, CI 95%:1.2 to 3.3, p = 0.045).

Conclusions

The results support diabetes to be an independent risk factor for outcome in patients with MVD undergoing a MIDCAB procedure in analogy to those undergoing CABG procedures. Diabetics with isolated disease of the LAD, however, benefit out of proportion from this treatment modality.     

Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus

OBJECTIVE: Increased risk of deep sternal infections has prohibited routine bilateral internal thoracic artery grafting in diabetic patients. The technique for harvesting the skeletonized internal thoracic artery provides the potential to minimize this risk. The purpose of this study was to compare the outcome of bypass grafting with bilateral skeletonized internal thoracic arteries in diabetic and nondiabetic patients. METHODS: From May 1996 to April 1998, 231 consecutive diabetic and 534 nondiabetic patients underwent bilateral skeletonized internal thoracic artery grafting. Mean age was 66 years. Compared with the nondiabetic group, the diabetic group comprised more women (29% vs 18%, P =.001), had a greater prevalence of hypertension (53% vs 44%, P =.019) and congestive heart failure (20% vs 14%, P =.016), but a lower prevalence of preoperative acute myocardial infarction (26% vs 34%, P =.027). RESULTS: Operative mortality of diabetic patients was comparable with that of nondiabetic patients (3% vs 2.6%). The two groups also had similar occurrences of deep sternal infection (2.6% vs 1.7%, respectively, P =.40). Deep sternal infection was significantly more prevalent in obese, diabetic women (3/20 = 15%) than in diabetic patients without this combination of risk factors (3/211 = 1.4%, P <.0001) (odds ratio 11.1, confidence interval 2.1-59.4). Diabetic patients also had a higher incidence of stroke (3.5% vs 0.9%, P =.014). Three-year actuarial survival of diabetic patients was lower (91.3% vs 94.7%, P =.083). CONCLUSIONS: Bilateral skeletonized internal thoracic artery grafting is a good surgical revascularization option in diabetic patients. Operative mortality and prevalence of sternal infection are comparable with those of nondiabetic patients. However, the risk of sternal infection in obese diabetic women is high, and for them we advocate the use of a single artery instead of bilateral internal thoracic arteries.     

Diffuse Coronary Artery Disease and Dystrophic Calcification of the Radial Artery— Is There an Association?

Arterial revascularization is an attractive surgical option in the management of coronary artery disease (CAD). In the recent years, the radial artery (RA) has enjoyed resurgence in popularity as the preferred arterial conduit of choice after the internal mammary artery. Despite renewed interest in RA conduits, little is known of the prevalence of preexisting disease in this vessel, and in particular which patient subgroups are most affected, hence implications for long-term graft patency remain uncertain. We present our experience of three patients with diffuse CAD, found to have dystrophic calcification of their radial arteries intraoperatively. In all cases, the radial arteries were used, and the patients remain well and symptom-free. Soft tissue X-rays of the contra lateral forearm taken postoperatively demonstrated obvious calcification in the radial arteries in all patients. Diffuse CAD may reflect calcific disease in the RA. Suitability of a calcified RA as a conduit for CABG depends on long-term patency, which requires further evaluation.     

Diffuse Coronary Artery Disease and Dystrophic Calcification of the Radial Artery—Is There an Association?

Abstract   Arterial revascularization is an attractive surgical option in the management of coronary artery disease (CAD). In the recent years, the radial artery (RA) has enjoyed resurgence in popularity as the preferred arterial conduit of choice after the internal mammary artery. Despite renewed interest in RA conduits, little is known of the prevalence of preexisting disease in this vessel, and in particular which patient subgroups are most affected, hence implications for long-term graft patency remain uncertain. We present our experience of three patients with diffuse CAD, found to have dystrophic calcification of their radial arteries intraoperatively. In all cases, the radial arteries were used, and the patients remain well and symptom-free. Soft tissue X-rays of the contra lateral forearm taken postoperatively demonstrated obvious calcification in the radial arteries in all patients. Diffuse CAD may reflect calcific disease in the RA. Suitability of a calcified RA as a conduit for CABG depends on long-term patency, which requires further evaluation.     

Ist Diabetes mellitus ein eigenständiger Risikofaktor in der Karotischirurgie?

Background

The status of diabetes mellitus as a predictor of poor outcome after carotid endarterectomy (CEA) is controversial. The objective of this study was to evaluate and compare the perioperative death and stroke rates after CEA in patients with and without diabetes.

Material and methods

A retrospective analysis of 1,291 patients (mean age 68.6 years, SD 8.9 years; 920 men) undergoing CEA for carotid artery stenosis between January 1999 and January 2005 was performed.

Results

Of this study population, 28.4% (n=366) were diabetic. The same proportion of symptomatic patients was seen in both groups (48% diabetics vs. 43% nondiabetics; not significant). No differences regarding surgical technique, degree of stenosis, operating time, or clamping time were observed. Selective shunting was used significantly more often in diabetics (32%) than in nondiabetics (24%; p=0.002, odds ratio 1.535, 95% confidence interval 1.177–2.001). The perioperative stroke rate in diabetic patients was 3.8% (n=14/366) compared to 2.8% (25/925) in nondiabetic patients (p=0.343). The overall mortality was 0.54% (n=7/1,291); 0.27% (n=1) in diabetics and 0.62% (n=6) in nondiabetics (p=0.408). The combined death and stroke rate was 3.4% in diabetics versus 4.1% in nondiabetics (p=0.584).

Conclusion

In this study, the presence of diabetes did not influence perioperative stroke and death rates after CEA. Shunt insertion was significantly more frequent in diabetic patients.     

Survival differences between peritoneal dialysis and hemodialysis among "large" ESRD patients in the United States

BACKGROUND: It has been hypothesized that peritoneal dialysis compared to hemodialysis may be less effective in large patients with end-stage renal disease (ESRD). METHODS: We tested this hypothesis in a cohort of 134,728 new ESRD patients who were initiated on dialysis from May 1, 1995 to July 31, 1997 using data from United States Renal Data System (USRDS). Cox regression models evaluated the association of body mass index (BMI) in quintiles (8.8-20.9, 20.9-23.5, 23.5-26.1, 26.1-30.0, 30.0-75.2 kg/m(2)) with mortality over 2 years in peritoneal dialysis and hemodialysis patients separately, while time-dependent models evaluated the relative risk (RR) of death by modality for each BMI quintile. RESULTS: For hemodialysis, the adjusted RR of death was greatest for patients with BMI 30.0 (RR = 0.97, 95% CI 0.96-0.99 for diabetic and RR = 0.97, 95% CI 0.95-0.98 for nondiabetic patients) compared with the referent (23.5-26.1; RR = 1.00). For peritoneal dialysis, the RR of death was also higher for patients with a BMI <20.9 (RR = 1.20, 95% CI 1.00-1.43 for diabetic and RR = 1.39, 95% CI 1.19-1.64 for nondiabetic patients) but no survival advantage was associated with higher BMI values. The RR of death (peritoneal dialysis/hemodialysis) for each BMI quintile was 0.99, 1.12, 1.26 (P < 0.01), 1.15 (P < 0.01), and 1.44 (P < 0.0001) for diabetic and were 1.07, 1.01, 0.96, 1.04, and 1.22 (P < 0.01) for nondiabetic patients, respectively. CONCLUSION: We conclude that body size modifies the impact of dialysis modality on mortality risk among new ESRD patients in the United States. The selection of hemodialysis over peritoneal dialysis was associated with a survival advantage in patients with large body habitus.     

Aortic reconstruction for occlusive disease. Comparable results in diabetics

The case reports of 100 consecutive patients receiving aortic bifurcation grafts strictly for occlusive disease were reviewed. Fifty-seven diabetics and 43 nondiabetics constituted the study group. Mean age and preoperative risk factors were otherwise comparable. Sixty-eight percent of operations in diabetics were for limb salvage as compared with 47% in the nondiabetic group. All 100 patients survived the operation and left the hospital with open grafts. The complication rate was similar in both groups. Mean follow-up was 48 months in the diabetic group vs 58 months in the nondiabetic group. Thirty-three percent of the diabetics were dead at four years, a survival rate one half of that of the nondiabetics. Nine percent of patients in each group suffered late limb graft occlusions, a cumulative graft patency of 94% at five years. Limb loss and subsequent distal reconstruction were comparatively low although higher in the diabetic group. This suggests more and progressive distal arterial disease in the diabetics and not an unsuccessful inflow procedure. We conclude that aortic reconstruction can be safely carried out in diabetics with high graft patency and limb salvage rates.     

Poor outcome in patients with diabetes mellitus undergoing liver transplantation.

BACKGROUND: Relatively few studies have examined the influence of pretransplant diabetes on survival after an orthotopic liver transplant (OLT), and those published to date show only minor increases in infection rates among diabetics and no increase in mortality. METHODS: We examined the effect of diabetes mellitus on survival after OLT. 1005 adults underwent OLT between 1982 and May 1997. Seventy-eight patients with pretransplant diabetes mellitus (7.8% of all OLT, 38 insulin treated, 25 tablet treated, 15 diet controlled) were identified and compared with controls matched for age, sex, and date of first transplant and also with all nondiabetic adult liver recipients undergoing OLT during the same period. RESULTS: In patients undergoing OLT survival was worse in diabetics than in the comparison group (P=0.002) and vs. all adult nondiabetics undergoing (n=927) (P=0.004); in diabetics with alcoholic liver disease (ALD) vs. all nondiabetics with alcoholic liver disease (P= <0.0001); and in insulin-treated compared with non-insulin-treated diabetics (P=0.05). Multivariate analysis showed type of diabetes (P=0.001) and ALD (P=0.024) to be the most significant independent variables adversely affecting survival. Survival in diabetics undergoing OLT could be further stratified according to whether diabetics were insulin treated. CONCLUSIONS: Poorer outcome in the diabetics undergoing OLT, particularly in those with ALD, suggests the need for a more detailed pre-OLT assessment of these patients, particularly those with insulin and tablet controlled diabetes.