April 1997

Peripheral Vascular Disease After Kidney-Pancreas Transplantation in Diabetic Patients With End-stage Renal Disease

Author Affiliations

From the Division of Organ Transplantation, Beth Israel-Deaconess Medical Center and Harvard Medical School, Boston, Mass.

Arch Surg. 1997;132(4):358-362. doi:10.1001/archsurg.1997.01430280032004

Objective:  To determine the long-term effect of a functioning pancreas transplant on peripheral vasculopathy.

Design:  We compared the progression of peripheral vascular disease in 39 recipients of successful kidney-pancreas transplants (KPT) with 65 consecutive diabetic patients who received cadaver kidney transplants alone (KTA) during the same period in a nonrandomized, retrospective control study. The mean duration of follow-up was more than 4 years in both groups.

Setting:  Academic subspecialty referral practice.

Patients:  A consecutive sample of all KPT recipients with more than 6 months of pancreas allograft function performed between May 1, 1988, and April 30, 1995. All patients who received cadaver renal transplants for diabetic nephropathy during the same period and who maintained a functioning renal allograft for more than 6 months were included as controls.

Intervention:  Kidney-pancreas transplantation.

Main Outcome Measure:  Progression of peripheral vascular complications (PVC) defined as any midfoot or limb amputation (AMP), any ischemic ulceration requiring treatment (ULCER), and lower-extremity bypass surgery or angioplasty (LEBP). Ulcers leading to amputation were considered as single events (AMP only).

Results:  Thirty-five (90%) of 39 KPT recipients are insulin-free. The KTA recipients had more atherosclerotic risk factors, including a higher incidence of coronary artery disease (P=.008), higher serum cholesterol levels (P=.03), and higher triglyceride levels (P=.04) than KPT recipients. Peripheral vascular complications before transplantation were comparable (P=.94) between groups. After transplantation, there were 35 new PVC (9 AMP, 11 ulcers, and 15 LEBP) in 18 of 39 KPT recipients vs 32 PVC (10 AMP, 8 ulcers, and 14 LEBP) in 20 of 65 KTA recipients (P=.005), indicating that KPT recipients had more PVC than did KTA recipients, despite a functioning pancreas. Seven bypass grafts failed after KPT, resulting in 6 limb amputations. In contrast, only 3 limb amputations were performed in 14 patients undergoing lower-extremity bypass procedures after KTA.

Conclusions:  Despite fewer risk factors for peripheral vasculopathy and the presence of insulin independence, KPT recipients had a higher incidence of PVC than a cohort of uremic diabetic patients undergoing KTA during the same period. These data show that a functioning pancreas allograft performed with a renal transplantation not only does not alter the progression of peripheral vascular disease in patients with renal failure secondary to diabetic nephropathy but also may accelerate PVC.Arch Surg. 1997;132:358-362