Heart Transplantation in Patients With Diabetic End-Organ Damage Before Transplantation

Abstract

Diabetes mellitus with preexisting end-organ damage (EOD) is considered a contraindication for heart transplantation. The outcome of such patients has not been well characterized. Among 138 patients transplanted between 12/88 and 7/94, 29 were diabetic (11 insulin-dependent); of these, 12 had preexisting EOD, defined as a creatinine clearance < or = 50 ml/min, a 24-hour urine protein concentration > or = 500 mg/L or typical symptoms of peripheral or autonomic polyneuropathy, and 17 had no EOD. We compared diabetics with and without EOD and non-diabetics (n = 109) for operative mortality, length of stay, serum creatinine, fasting glucose levels, and postoperative prednisone doses at 1,6, and 12 months. Actuarial survival and freedom from rejection and infection were analyzed. Both diabetic groups were significantly older than nondiabetics, Ischemic time, operative mortality, surgical technique, ICU- and total length of stay were similar. Actuarial survival and freedom from rejection were similar among the three groups. Infection rates including CMV did not differ. Serum creatinine levels increased in all groups compared to pretransplant levels (p = 0.001), but without significant differences among the groups. Post-transplant glucose levels at 6 and 12 months were higher for diabetic patients with EOD than for those without or for nondiabetics (183, 153, and 94 mg/dl at 6 months, p = 0.01; 202, 161, and 102 mg/dl at 12 months, p = 0.0001). Prednisone dosage was lower in diabetics with EOD at 6 months, but did not differ among the three groups at 12 months. The incidence of angiographically proven transplant vasculopathy did not differ at 1 and 2 years. Diabetics with preexisting EOD undergoing heart transplantation experience similar short- and intermediate-term results when compared to diabetics without EOD and nondiabetics. Metabolic control is more difficult to achieve, as indicated by higher fasting glucose levels. Larger and longer-term prospective studies have to confirm our findings, since the shortage of donor organs would increase if such patients were transplanted routinely.

Impact of Pre-Operative Diabetes Mellitus Upon Early and Late Survival After Heart Transplantation: A Possible Era Effect

“…19 In the current study, the incidence rates of acute rejection and CMV infection were not different from those of non-diabetics, in line with previous studies. 4,5,8,9,11 An impaired oral glucose tolerance before heart transplantation was recently described as a suitable predictor of the development of post-transplant diabetes. 13 Thus, post-transplant diabetes is most likely steroid-induced in patients with pre-existing glucose intolerance.…”

“…7 These data have encouraged an extension of heart transplant candidates comprising diabetics with end-organ damage in some institutions, with apparently no disadvantageous outcome. 8,9 In the recent literature, however, one study found an increased risk of serious infection 10 and another noted decreased long-term survival. 11 These results were supported by findings from a large multi-center cardiac transplant research database wherein diabetes mellitus was an independent predictor of death in the late posttransplant phase.…”

Cardiac transplantation in patients with insulin-treated diabetes mellitus

“…Although experience with insulin-treated DM in HT recipients is limited (Badellino et al, 1990;Ladowski et al, 1990;Munoz et al, 1992;Faglia et al, 1990;Livi et al, 1994a) even patients with end-organ damage prior to transplantation do not show a difference in mortality rate and complications (i.e. ; rejection episodes, major and minor infections and graft atherosclerosis) compared to the controls (Aleksic et al, 1996). Two of the retrospectively performed analyses from different centers did not show an increase in risk of rejection, infection, renal dysfunction or CAD in a mixed group (insulin-treated, non-insulin-treated) of diabetic patients (Ladowski et al, 1990;Munoz et al, 1992;Livi et al, 1994b).…”

Heart transplantation in insulin?treated diabetic patients with diabetes?related complications

“…Although some of these studies have shown that DM patients had a higher incidence of infections and a stronger progressing of graft vascular disease, 1‐ to 4‐year survival did not differ significantly compared with non‐DM patients [12,13]. In 1996, Aleksic et al [14] reported that heart transplant recipients with advanced DM had a similar 1‐year survival rate compared with non‐DM patients, despite of slightly higher CMV infections in the group with DM. Others also found no differences in morbidity and mortality between groups with no DM, moderate DM, and advanced DM [15].…”