Restoring Access to Kidney Transplantation: Mid-Term Outcomes of Pre-emptive Aorto-Bifemoral Bypass in Candidates with Severe Aorto-Iliac Disease.

The association between peripheral vascular disease (PVD) and survival among kidney transplant (KT) candidates is uncertain. We assessed 3851 adult KT candidates from the Andalusian Registry between 1984 and 2012. Whereas 1975 patients received a KT and were censored, 1876 were on the waiting list at any time. Overall median waitlist time was 21.2 months (interquartile range, 11-37.4). We assessed the association between PVD and mortality in waitlisted patients using a multivariate Cox regression model, with a competing risk approach as a sensitivity analysis. Peripheral vascular disease existed in 308 KT candidates at waitlist entry. The prevalence of PVD among nondiabetic and diabetic patients was 4.5% and 25.3% (P < 0.0001). All-cause mortality was higher in candidates with PVD (45% vs 21%; P < 0.0001). Among patients on the waiting list (n = 1876) who died (n = 446; 24%), 272 (61%) died within 2 years after listing. Cumulative incidence of all-cause mortality at 2 years in patients with and without PVD was 23% and 6.4%, respectively (P < 0.0001); similar differences were observed in patients with and without diabetes. By competing risk models, PVD was associated with a 1.9-fold increased risk of mortality (95% confidence interval [95% CI], 1.4-2.5). This association was stronger in waitlisted patients without cardiac disease (subhazard ratio, 2.2; 95% CI, 1.6-3.1) versus those with cardiac disorders (subhazard ratio, 1.5; 95% CI, 0.9-2.5). No other significant interactions were observed. Similar results were seen after excluding diabetics. Peripheral vascular disease is a strong predictor of mortality in KT candidates. Identification of PVD at list entry may contribute to optimize targeted therapeutic interventions and help prioritize high-risk KT candidates.

Severe aorto-iliac occlusive disease can cause disabling symptoms. The treatment of aorto-iliac occlusive disease has dramatically changed with the introduction of endoluminal techniques. However, according to the Trans-Atlantic Inter-Society Consensus for severe aorto-iliac disease, aorto-bifemoral bypass remains the therapy of choice. A recent addition to the open repair is laparoscopic-assisted aorto-bifemoral bypass, especially in occlusive arterial disease. In this article, we describe a new technique of performing gasless laparoscopic-assisted aorto-bifemoral bypass grafting with a self-designed abdominal wall-lifting system. We dealt with a patient who had a history of coronary artery disease and poor cardiopulmonary functional reserve. He had disabling symptoms of claudication and rest pain on bilateral lower extremities. Aorto-biliac-femoral occlusive disease was diagnosed in him, and he underwent the gasless laparoscopic-assisted aorto-bifemoral bypass. The total procedure time was 260 minutes. The patient was extubated 5 hours postoperatively. He was discharged home without complications 5 days after the surgery. This procedure is attractive not only to minimize the length of the wound and the time to extubation but also to avoid the possible lethal complications associated with the traditional laparascopic pneumoperitoneum. This device and technique can also provide a bridge for young or less-experienced surgeons to be familiar with total laparoscopic aortic surgery from traditional open repair.

Vascular Disease Burden and In-Hospital Outcomes Among Patients Undergoing Percutaneous Coronary Intervention in New York State

Peripheral artery disease (PAD) affects over 200 million adults globally, with its incidence rising to around 20% among individuals over 70 years old. Smoking multiplies the risk of developing PAD by four and has a significant impact on the severity of the disease. Smokers with PAD tend to have shorter lifespans and are more likely to experience critical limb ischemia and require amputation compared to nonsmokers. We have presented a case report of a young male who was diagnosed as a case of Peripheral artery disease with thrombosis of the infra-renal aorta with blockage of the bilateral common iliac artery (TASC type D lesion). The patient was planned for an Aortobifemoral bypass, but intraoperative findings compelled us to change the course of action to an Axillobifemoral bypass. Axillobifemroal bypass is done in only 13.4% of the patient of total number of patients undergoing surgical bypass for Peripheral artery disease. It is done for patients with local issues that complicate standard aorta-femoral reconstruction, such as previous aortoiliac surgeries, prior radiation treatments, extensive intraabdominal adhesions, severe calcification of the aorta, abdominal malignancies, intra-abdominal infections, infections of the aorta or an aortic graft, colostomy or ileostomy, and enterocutaneous fistulas. Recent studies have suggested that the five-year patency rate of Axilofemroral bypass surgeries is 83.7%, comparable to aortobifemoral bypass. Axillobifemroal bypass has comparable results in terms of a five-year patency rate and can done in patients for whom aortobifemoral bypass is difficult to perform.

Symptomatic and asymptomatic peripheral artery disease and the risk of abdominal aortic aneurysm: The Atherosclerosis Risk in Communities (ARIC) study

Our aim was to assess the mortality and vascular morbidity risk of elderly individuals with asymptomatic versus symptomatic peripheral artery disease (PAD) in the primary care setting. This prospective cohort study included 6880 representative unselected patients >or=65 years of age with monitored follow-up over 5 years. According to physician diagnosis, 5392 patients had no PAD, 836 had asymptomatic PAD (ankle brachial index <0.9 without symptoms), and 593 had symptomatic PAD (lower-extremity peripheral revascularization, amputation as a result of PAD, or intermittent claudication symptoms regardless of ankle brachial index). The risk of symptomatic compared with asymptomatic PAD patients was significantly increased for the composite of all-cause death or severe vascular event (myocardial infarction, coronary revascularization, stroke, carotid revascularization, or lower-extremity peripheral vascular events; hazard ratio, 1.48; 95% confidence interval, 1.21 to 1.80) but not for all-cause death alone (hazard ratio, 1.13; 95% confidence interval, 0.89 to 1.43), all-cause death/myocardial infarction/stroke (excluding lower-extremity peripheral vascular events and any revascularizations; hazard ratio, 1.18; 95% confidence interval, 0.92 to 1.52), cardiovascular events alone (hazard ratio, 1.20; 95% confidence interval, 0.89 to 1.60), or cerebrovascular events alone (hazard ratio, 1.33; 95% confidence interval, 0.80 to 2.20). Lower ankle brachial index categories were associated with increased risk. PAD was a strong factor for the prediction of the composite end point in an adjusted model. Asymptomatic PAD diagnosed through routine screening in the offices of primary care physicians carries a high mortality and/or vascular event risk. Notably, the risk of mortality was similar in symptomatic and asymptomatic patients with PAD and was significantly higher than in those without PAD. In the primary care setting, the diagnosis of PAD has important prognostic value.

After three decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for patients with insulin-dependent diabetes mellitus (IDDM) and advanced diabetic nephropathy with end-stage renal disease (ESRD) and for those approaching ESRD. Vascularized pancreas transplantation is currently the only available form of autoregulating, total endocrine replacement therapy that reliably achieves an insulin-independent euglycemic state and normal glucose homeostasis, resulting in the successful management of diabetes mellitus. The trade-offs for normal glucose homeostasis are the operative risks of the pancreas transplant procedure and the need for chronic immunosuppression. Free islet grafts have the same potential, but their efficacy requires further evaluation. With improvements in organ retrieval and preservation technology, refinements in diagnostic methods and surgical techniques, advances in clinical immunosuppression and anti-infective prophylaxis, and increased experience with donor and recipient selection, success rates for pancreas transplantation have continued to improve. From 1966 through October 2000, >15,000 pancreas transplants were performed throughout the world and reported to the International Pancreas Transplant Registry (IPTR) (1). In the past decade, the majority (83%) of pancreas transplants were performed in combination with a kidney transplant [simultaneous pancreas/kidney transplants (SPKT)] for patients with ESRD attributable to diabetic nephropathy. The current 1-yr actuarial patient, kidney, and pancreas (with complete insulin independence) graft survival rates after SPKT are 95, 92, and 84%, respectively (1). Solitary pancreas transplants comprised the remaining cases, including sequential pancreas after kidney transplants (PAKT) (12%) and pancreas transplants alone (PTA) (5%) (1). Although the annual rate of pancreas transplants has steadily increased, the number of solitary pancreas transplants has increased disproportionately in recent years; in 1999, 75% of transplants were SPKT, 18% PAKT, and 7% PTA. The current 1-yr patient survival rate after solitary pancreas transplantation is 95%, and the 1-yr actuarial pancreas graft survival rates are 73% for PAKT and 70% for PTA (1). The differences in graft survival rates for SPKT, PAKT, and PTA have been attributed to increased rates of graft loss resulting from rejection and thrombosis after solitary pancreas transplantation. Pancreas transplantation should be considered an acceptable therapeutic alternative to continued insulin therapy for diabetic patients with imminent or established ESRD who have undergone or plan to undergo a kidney transplant, because the successful addition of a pancreas does not jeopardize patient survival rates, may improve kidney graft survival rates, and will restore normoglycemia (2). PAKT is advocated for diabetic patients with well functioning kidney transplants, because these patients already require chronic immunosuppression and the additional risk is primarily that of the surgical procedure (3,4). Currently, many transplant centers are experienced in performing SPKT; only a few centers have accumulated much experience with PAKT. The improved success of SPKT has prompted many centers to offer pancreas transplantation for patients with type 1 diabetes mellitus who have undergone successful kidney transplantation. PAKT increases the likelihood of more diabetic recipients receiving a pancreas transplant and eliminates many of the organ-allocation issues associated with SPKT. The increased interest in PAKT is attributable to several factors. New immunosuppressive medications have reduced acute rejection rates and enhanced pancreas graft survival rates (5). Better surgical techniques, patient selection, and immunologic monitoring have also improved short- and long-term success rates after pancreas transplantation (6). Finally, the recent decision by Medicare to reimburse providers for the procedure has eliminated the financial burden for many potential recipients. Despite these advancements, there are no clear guidelines for donor and recipient selection, immunologic monitoring, the choice of immunosuppressive agents, or the timing of PAKT. This lack has prompted the Pancreas Committee of the American Society of Transplantation to review the current status of PAKT. History and Background Dr. Richard Lillehei performed the first pancreas transplant at the University of Minnesota in 1966 (7). Pancreas transplantation was abandoned at that center in 1973, after 14 transplants had been performed with only one successful pancreas graft functioning for 1 yr. The program was resumed in 1978. Throughout the world, only 1157 pancreas transplants were performed between 1966 and 1987, with three-fourths of the transplants being performed after 1982 (8). Despite a multitude of surgical approaches for duct drainage and the use of cyclosporin A (CsA) after 1983, the 1-yr patient and pancreas graft survival rates were only 76 and 37%, respectively (8). During this early experience, it became evident that SPKT was associated with better graft survival rates than was either PAKT or PTA. Historically, major impediments to successful pancreas transplantation were the management of exocrine secretions, the inability to monitor the pancreas for rejection, and high rates of rejection, thrombosis, and pancreatitis. In the past two decades, significant improvements in the surgical and medical management of pancreas transplants have occurred. The management of pancreatic exocrine secretions improved with the development of bladder drainage, which allowed for measurement of urinary amylase levels, facilitating prediction of acute rejection episodes (9). Improvements in immunosuppression made possible a return to enteric drainage of the exocrine secretions by preventing episodes of acute rejection and eliminating the need for high-dose steroid therapy, which impaired healing of the enteric anastomosis. Finally, techniques were developed for the diagnosis of rejection via percutaneous biopsy, facilitating monitoring for rejection among recipients of either PAKT or PTA (10). Current Status As indicated in Table 1, advances in immunosuppression and surgical techniques have improved the overall results for SPKT, as reported by the IPTR (1). Some individual centers have reported >90% survival rates for pancreatic allografts at 1 yr (11–13). Although previously there was debate regarding the appropriateness of SPKT in the therapy of type 1 diabetes mellitus (14,15), excellent outcomes after SPKT are now being achieved (1,11–13,16,17). The American Society of Transplantation (18) and the American Diabetes Association (2) consider SPKT an appropriate treatment for diabetic patients with ESRD attributable to type 1 diabetes mellitus. Moreover, SPKT and PAKT are now (since July 1999) reimbursed by Medicare. Table 1 presents the results observed for PAKT in different eras, indicating that outcomes have improved with time. Notably, in every era, outcomes of PAKT lag behind those achieved with SPKT. PAKT performed after living-donor kidney transplantation has two major benefits (3,19). Living-donor transplants demonstrate the best long-term survival rates, and use of a living-donor kidney does not remove a cadaveric donor kidney from the pool of organs available for potential transplant recipients. Table 1: One-year survival results after SPKT, PAKT, and PTAaDonor Selection Donor selection and organ procurement are of paramount importance for the success of PAKT. Most heart-beating donors who have been declared brain-dead and are suitable for kidney, liver, and heart donation are also suitable for pancreas donation (Table 2). Although there is some evidence to suggest that donor hyperglycemia may have an adverse effect on initial and long-term allograft function, the presence of hyperglycemia or hyperamylasemia is not a contraindication for pancreas donation. Table 2: Cadaveric pancreas donationaIn general, ideal pancreas donors range in age from 10 to 40 yr and range in weight from 30 to 80 kg. As the results of pancreas transplantation have improved and experience has increased, previous contraindications for pancreas donation have become mere risk factors for successful outcomes (Table 2). According to IPTR data, the following variables are associated with increased risks of pancreas allograft thrombosis: (1) donor age of >40 yr, (2) cardiovascular or cerebrovascular cause of brain death, and (3) pancreas preservation time of >24 h (1). The results of anecdotal experience suggest that (1) >150% of ideal body weight or a body mass index (BMI) of >30 kg/m2 for the donor may be associated with an increased risk of early pancreas graft loss (attributable to thrombosis, pancreatitis, infection, or primary nonfunction); (2) a donor liver biopsy with >25 to 30% macrovascular steatosis may be associated with a fatty pancreas, leading to an increased risk of early graft loss; and (3) fatty infiltration of the pancreas (as opposed to peripancreatic fat) may be associated with an increased risk of early graft loss (20,21). The presence of donor obesity or a fatty pancreas may be an underappreciated cause of early graft loss after PAKT. There are currently no data available regarding the utility of donor pancreas biopsies, particularly with respect to steatosis. The importance of an experienced retrieval team for in situ assessment of pancreatic anatomic features must be emphasized. Pancreas donors may be categorized as ideal, good, or marginal. By using donor age, weight/BMI, and the cause of brain death as the three most important factors, rapid accurate assessments of the quality of the donor pancreas can usually be made before actual intraoperative assessment, which is the next most important factor. PAKT donors must be either ideal or good. If either the donor or recipient is marginal, then there is a greater likelihood of a poor outcome. Compared with SPKT, the inherent risk of thrombosis is much higher (two- to threefold) for PAKT (22). In contrast to other transplanted organs, the solitary pancreas is susceptible to thrombosis because of its low microcirculatory flow based on collateral circulation. In the absence of the antiplatelet and anticoagulative effects of uremia, PAKT recipients may be prone to vascular thrombosis. For this reason, cold ischemia should be kept to a minimum and serious consideration should be given to routine perioperative anticoagulation therapy for the recipient. Recipient Selection In the past, most pancreas transplants were performed with younger recipients. However, the most recent analysis by the IPTR indicated that >25% of the recipients in 1998 and 1999 were >44 yr of age (1). Recipient age remains a significant risk factor for death after SPKT but not PAKT. These data must be interpreted with caution, because there were fewer recipients of PAKT in the analysis. Specific selection criteria for PAKT are based on the presence of established secondary diabetic complications or hyperlabile diabetes mellitus, with adequate cardiac and renal functional reserve (23). Indications for pancreas transplantation include IDDM and the predicted ability of the patient to tolerate the operative procedure, the requisite intense immunosuppression after transplantation, and possible associated complications (Table 3). Patient selection is facilitated by a comprehensive medical evaluation before transplantation, performed by a multidisciplinary team, that confirms the diagnosis of IDDM, determines the ability of the patient to withstand the operative procedure, establishes the absence of any exclusion criteria (Table 4), and documents end-organ complications for monitoring after transplantation. The primary determinants for recipient selection are the presence of diabetic complications, the degree of nephropathy, and cardiovascular risks (Table 3). With increasing experience, previous absolute contraindications have become relative contraindications, and relative contraindications have become risk factors for pancreas transplantation (Table 4). Table 3: Indications for pancreas transplantation and eligibility guidelinesTable 4: Absolute and relative contraindications and risk factors for pancreas transplantationDiabetic patients who have previously received a renal allograft, from either a living or cadaveric donor, are considered potential candidates for PAKT if their creatinine clearance values are >40 ml/min with either CsA or tacrolimus (FK) immunosuppression (23). If the patient is not receiving a calcineurin inhibitor for the kidney transplant, a minimal creatinine clearance value of 55 ml/min is recommended (Table 3). Addition of a calcineurin inhibitor (or an increase in the dose for PAKT) generally results in a 25% decrease in baseline creatinine clearance. It is unclear how to factor the level of proteinuria into the decision-making, particularly because the use of a calcineurin inhibitor decreases the actual level of proteinuria. In this setting, a trial of high-dose CsA or FK before pancreas transplantation (CsA or FK challenge) may be indicated, to ascertain the effects of the drug on the patient's creatinine clearance, serum creatinine levels, and protein excretion (24,25). Patients with significant nephropathy of the previously transplanted kidney, renal dysfunction because of CsA/FK toxicity, or acute or chronic rejection, with lower creatinine clearance values, may not be suitable recipients for PAKT. A baseline kidney biopsy is important, for documentation, quantification, and monitoring of the progression of nephropathy after PAKT. However, there are few data on the use of the biopsy results to guide recipient selection. The presence of chronic allograft nephropathy might be a contraindication to PAKT for patients with otherwise stable renal allograft function. The cardiac status of each candidate must be carefully assessed, because significant (and silent) coronary artery disease is not uncommon in this population. The cardiac evaluation should include a noninvasive functional assessment, such as an exercise or pharmacologic stress test, in addition to echocardiography. Coronary angiography is reserved for specific indications, such as age of >45 yr, diabetes mellitus for >25 yr, a positive smoking history, longstanding hypertension, a previous major amputation attributable to peripheral vascular disease, a history of cerebrovascular disease, or an abnormality indicated by the history, physical examination, or noninvasive cardiac studies (23). Histories of previous myocardial infarctions, angioplasty, stenting, or coronary artery bypass grafting are not contraindications for PAKT, because excellent outcomes have been reported for patients who have undergone previous cardiac interventions (26). However, sudden cardiac death, in the absence of significant structural heart disease, continues to be a major cause of cardiac death after pancreas transplantation (27). For this reason, a number of centers are beginning to test cardiac autonomic function for these patients, using laboratory cardiovascular tests and 24-h heart rate variability measurements (28). These new methods may be able to detect alterations in autonomic function before the onset of disabling symptoms. In general, age of >65 yr, heavy smoking, a left ventricular ejection fraction of <40%, a recent myocardial infarction, and severe obesity (>150% of ideal body weight or BMI of >30 kg/m2) are viewed as contraindications for PAKT (Table 4) (23). Most patients who are <45 yr of age are acceptable candidates for PAKT, provided that no significant coronary artery disease is present. Diabetic patients who are >45 yr of age are not candidates until proven otherwise and must undergo extensive cardiovascular and peripheral vascular evaluation. Prolonged immunosuppressive therapy for kidney transplantation may be associated with multiple medical complications, and these factors should be considered before PAKT. Recipient weight criteria are similar to those used for donor selection. Male recipients of >100 kg and female recipients of >80 kg, depending on their height and body habitus, demonstrate higher rates of surgical complications after pancreas transplantation (29). Therefore, a BMI of >30 kg/m2 is considered an absolute contraindication and a BMI of >27.5 kg/m2 is a relative contraindication for PAKT. A history of compliance with medication regimens and scheduled follow-up monitoring is an important factor in patient selection. Other exclusion criteria that are applicable to all solid-organ transplant recipients include the presence of active infection or recent malignancy, active substance abuse or dependence, a recent history of noncompliance or psychiatric illness, and positive HIV or hepatitis B virus serologic results (Table 4). Timing of PAKT A major dilemma for recipients with a suitable living donor is whether to proceed with the kidney transplant, followed by a pancreas transplant, or to undergo a SPKT. Because the results of PAKT are now approaching those of SPKT, the need for another surgical procedure and enhanced immunosuppressive therapy should be weighed against the limited organ availability, the prolonged waiting time for a cadaveric donor kidney/pancreas transplant, and the increased mortality rates during dialysis. Under these circumstances, it may be preferable to consider a living-donor kidney transplant followed by a cadaveric pancreas transplant. There are several factors to be considered in determining the optimal timing of PAKT. Ideally, some time should after the kidney transplant, to of graft function, surgical and reduced immunosuppression before pancreas transplantation. However, long-term recipients may experience significant complications secondary to diabetes mellitus and chronic immunosuppression. from the University of outcomes for pancreas transplants performed or after kidney transplantation. the PAKT pancreas transplantation after kidney transplantation, with the remaining being performed after kidney transplantation. of complications such as thrombosis, exocrine and were similar for the two pancreas rejection rates at and graft and patient survival rates at yr for early PAKT were and values for PAKT were and These values were not is to transplant the cadaveric pancreas during the same surgical procedure as the living-donor kidney transplantation. This requires the living donor and the recipient to until a suitable cadaveric pancreas However, centers this have performed such a few after patients for transplantation The major of such an are the of another surgical procedure and the use of a of high-dose immunosuppressive living-donor pancreas transplants from a center have been the 1-yr pancreas, kidney, and patient survival rates were 95, and 95%, respectively However, to the donor, and potential risks to the recipient during the may this complications and attributable to to after kidney transplantation require further evaluation. Patients considered for PAKT should undergo appropriate evaluation of their transplant infection history and serologic In levels, and should be in an immunologic to appropriate organ In for PAKT may the pancreas donor not only with the recipient but also with the previous kidney donor The of disease remains a The timing of PAKT must be on an individual depending on donor and recipient Despite these from living donors for PAKT recipients increase the cadaveric recipient between and Pancreas Transplantation on transplant that the of pancreas transplantation are not that after kidney transplantation may some recipients from receiving PAKT. include the immunologic renal dysfunction disease, or donor vascular active or cardiovascular myocardial infarction, heart or peripheral vascular and rejection is associated with lower long-term kidney graft survival rates It is not whether patients who experience an acute rejection after kidney transplantation may greater to acute rejection after PAKT. are also by acute rejection Patients with kidney because of renal dysfunction disease, or donor vascular should be for PAKT with PAKT is in the presence of acute such as or or of diabetic complications, such as peripheral and cerebrovascular should be weighed against the benefits of pancreas transplantation. Patients who experience significant decreases in cardiac function and those with coronary artery disease, cerebrovascular with or vascular disease that is not to should not be considered for PAKT. In general, patients with limited those at higher risk for graft and those with active complications should be from PAKT. The success rates for pancreas transplantation to in because of refinements in surgical The surgical procedure of three as the pancreas is and the to and from the pancreas graft is the exocrine drainage is These techniques are not different from those for SPKT. The management of pancreatic exocrine secretions a surgical and is a potential cause of complications after transplantation. Historically, the urinary bladder has been the preferred for drainage of exocrine secretions from the transplanted pancreas drainage the measurement of urinary amylase for a for monitoring of pancreatic graft function and diagnosis of However, this can be associated with several complications, such as pancreatitis, urinary bladder urinary and the pancreatic exocrine secretions can be into the This has in and has been by an increasing number of transplant centers According to recent data from the of SPKT, of PAKT, and of PTA are (1). of this procedure include graft vascular thrombosis, and data that enteric drainage is a alternative to bladder drainage for pancreas However, enteric drainage has been reserved for pancreas transplants with kidney transplants from the same In such cases, the measurement of urinary amylase is not for the diagnosis of rejection, because renal function monitoring on the immunologic status of the recipient. In bladder drainage has been considered the surgical of choice for PAKT, because urinary amylase monitoring remains a for the of rejection Moreover, there is some evidence that solitary pancreas transplantation with enteric exocrine drainage, with of may be associated with rejection and lower immunologic graft loss rates, with other transplantation techniques for PAKT The number of immunosuppressive drug available for pancreas transplant recipients has increased in the past yr. The IPTR reported allograft survival rates associated with immunosuppressive regimens for patients who received PAKT between and 1999 before and of (1). The results are in Table of PAKT recipients were given for patients reported to the IPTR received at during the and early of immunosuppression. patients who received therapy, the 1-yr pancreas graft survival rates, to the immunosuppressive were as There was a better survival rates with the For patients who not undergo the 1-yr pancreas graft survival rates were as 25% In the IPTR analysis that the use of therapy was associated with higher 1-yr pancreas graft survival In the combination of and FK a higher 1-yr pancreas graft survival Although these data must be in a it may be to such a because of the number of at each center and the high immunologic risks associated with PAKT. Because FK at higher has been associated with impaired glucose regimens may be for this population. Table One-year pancreas graft survival rates after PAKT to there has been no experience with immunosuppression among PAKT recipients. However, a recent of an of SPKT recipients low rates of allograft rejection among patients who received in combination with low of FK with the recent of successful islet transplantation using and FK it that the use of regimens and steroid in the treatment of PAKT recipients will increase in the next few after PAKT of the pancreas transplant for rejection is an of management and is important after PAKT. With SPKT, the clinical of kidney transplant rejection usually pancreas Therefore, the serum creatinine can be used as a of rejection and the need for of the pancreas transplant for PAKT recipients is more because such as serum amylase levels, levels, and of other pancreatic are The development of hyperglycemia is a particularly of rejection and is usually of a severe rejection The routine use of FK can also be associated with which may the diagnosis of have been used for and diagnosis of pancreas The most used are measurement of serum amylase and for pancreas transplants, measurement of urinary amylase serum amylase or suggest possible rejection but poor and for of other serum such as serum and pancreatic become during pancreas transplant rejection, but such are not available and are not to the use of serum amylase or measurements for the diagnosis of rejection The use of methods such as with and angiography for the diagnosis of rejection has also been Although each of these excellent of the pancreas, the diagnostic is poor and the utility for the diagnosis of rejection is not well Finally, the glucose rate after glucose has been to greater and than either urinary amylase or serum measurements for the diagnosis of rejection among patients receiving CsA but not The for the diagnosis of pancreas rejection is now pancreas biopsy major have been developed for the diagnosis of rejection, and percutaneous biopsy with biopsy is used only for pancreas transplants and requires of the bladder for of pancreatic biopsy is the of choice and is a to (10). It can be used for enteric and pancreas A was by of rejection from to and is based on the presence of or and The was observed to the to or of PAKT The benefits of after SPKT have been well However, benefits observed after PAKT have not been well This lack is attributable to the that fewer PAKT are performed at each a recent increase in has with immunosuppressive such as and It is to the observed after SPKT to PAKT. Most of the studies that to demonstrate a with respect to follow-up and baseline with follow-up of among diabetic patients who received SPKT during the early of and those who not undergo therapy before transplantation, with of among diabetic patients who received kidney transplants only Diabetic patients who SPKT significant improvements in heart rate variability with diabetic patients who kidney transplantation only (28). was to improve among recipients who SPKT, with diabetic patients who received only kidney transplants has also been to with long-term glucose be to the development of diabetic nephropathy, as in the Diabetes and It was after 10 yr of normoglycemia after established of diabetic nephropathy be with in and and in the have been to improve after SPKT, with diabetic patients who received only kidney transplants It has been that among patients with poor and a number of studies have in most after SPKT, with in and and improved of diabetic recipients of SPKT kidney transplants alone have reported improvements in including physical function, and It is that recipients who undergo PAKT will also experience these It has been reported that SPKT recipients increased early mortality rates, with diabetic patients who only kidney transplants However, those studies were and the results may be to the of SPKT. With long-term follow-up monitoring, mortality rates were the same from in and mortality rates after SPKT, with kidney transplants However, those studies experienced in appropriate SPKT recipients with grafts functioning were with patients who had either or their pancreas transplants Diabetic recipients who in a SPKT were performed were with patients in a different transplants were performed be a SPKT kidney transplantation treatment of patients on the same transplant waiting A recent analysis by the patient survival rates for living-donor transplants and cadaveric SPKT with cadaveric donor transplants Patient mortality rates were higher after SPKT; the relative risk of death by yr was with living-donor and cadaveric donor transplantation. follow-up data for PAKT are not The of hyperglycemia associated with PAKT should have similar effects on survival rates, as well as diabetic However, this remains to be with a patient such as that of the In the pancreas transplantation should the most for diabetic recipients to insulin The major of PAKT, with SPKT, is the ability to use a kidney from a living donor, followed by successful cadaveric pancreas transplantation. an does not have a effect on the cadaveric donor pool for kidney transplant recipients. of successful islet transplantation for using and have interest islet transplantation eliminates the need for a major surgical procedure, with its potential These results have not been at other and long-term follow-up monitoring is In the use of a donor for the pancreas transplant remains a of transplantation, with islet transplantation. this the clinical results of PAKT the use of the procedure for diabetic kidney transplant recipients. In the and total number of PAKT performed have steadily increased in recent because of a number of factors. (1) The results have continued to improve with advances in immunosuppressive therapy current 1-yr pancreas graft survival rate for PAKT recipients who undergo in with FK and therapy is (1). (2) Living-donor kidney transplantation followed by PAKT the kidney donor pool and transplantation as a scheduled (3) for PAKT are much than those for SPKT. the number of solitary pancreas transplants may improve donor and

Advance Care Planning and Palliative Care Consultation in Kidney Transplantation

COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health.

IntroductionSevere aorto-iliac steno-occlusive atherosclerotic disease is a major cause of morbidity and amputation in patients with peripheral arterial disease. While both open surgical and endovascular revascularisation are standard treatments in this patient group, there is no high-quality randomised evidence to determine which approach offers superior clinical and cost-effectiveness, leading to uncertainty and poor outcomes after intervention.Methods and analysisThe EVOCC trial is a national, multicentre, parallel-group, superiority randomised controlled trial comparing open surgery to endovascular revascularisation in patients with symptomatic severe aorto-iliac occlusive disease. A total of 628 participants across 30 NHS sites in the UK will be randomised 1:1 to receive either open surgery or endovascular (minimally invasive) intervention. The primary outcome is amputation-free survival, defined as time to first event (major lower limb amputation or death). Secondary outcomes include mortality, cardiovascular events, hospital readmissions, re-interventions and quality-of-life measures. An internal pilot phase (10 sites, 6-month duration) will assess recruitment feasibility. A QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.Ethics and disseminationThe trial has received ethical approval from a UK Research Ethics Committee (REC reference: 23/SW/0065; trial registration reference: ISRCTN14591444). Informed consent will be obtained from all participants.The EVOCC trial is the first RCT assessing the clinical and cost-effectiveness of open vs endovascular revascularisation for severe aorto-iliac disease worldwide. The results will provide robust evidence to inform clinical practice and healthcare policies globally. Results will be disseminated via patient groups, online lay summaries, a trial website, social media, presentations in conferences, a formal scientific publication in a medical journal and direct communications with policymakers across borders.Trial registration numberISRCTN14591444.

In the general population, up to 10% of people younger than 70 years and 15% to 20% of people older than 70 years have peripheral arterial disease (PAD). Symptomatic and asymptomatic PAD has an estimated prevalence of 13% in the over 50 years age group. However, asymptomatic PAD can account for up to 75% of PAD patients and only 10% of PAD patients have typical intermittent claudication. People with PAD are at an increased risk of death, heart and cerebrovascular disease and are recommended to receive treatment to manage their cardiac risk. They suffer from significant functional limitations in their daily activities and the most severely affected are at risk of limb loss. Many people with PAD do not have any symptoms. Only some people have discomfort or pain in the lower legs when walking, so PAD often goes undetected. Given the high incidence of asymptomatic and undiagnosed PAD, it is important to determine the effectiveness of a screening intervention in preventing cardiovascular adverse outcomes, both fatal and non-fatal. To determine the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals in terms of reduction of all-cause mortality, cardiovascular events (for example myocardial infarction and stroke), morbidity from PAD (intermittent claudication, amputation, reduced walking distance) and improvement in quality of life. The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10). All published and unpublished randomised controlled trials (RCTs) of screening for PAD were sought without language restriction. Studies identified for potential inclusion in the review were independently assessed by both review authors. We planned to conduct data collection and analysis in accordance with the Cochrane Handbook for Systematic Review of Interventions. No RCTs were identified that met the inclusion criteria. Unfortunately, no randomised controlled trial data are available regarding screening for PAD. Therefore, we are unable to determine the effects of screening for PAD in order to guide decision making by healthcare providers and planners. High quality randomised controlled trials evaluating the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals in terms of reduction of all-cause mortality, cardiovascular events (for example myocardial infarction and stroke), morbidity from PAD (intermittent claudication, amputation, reduced walking distance) and improvement in quality of life are needed.

Strongyloidiasis is a chronic and asymptomatic infection in immunocompetent patients. Immunocompromised patients, such as organ transplant candidates, can develop severe forms of this disease, and the best way to prevent progression to these forms is early diagnosis. Serological techniques using specific IgG and immune complexes (IC) detection can help in the diagnosis of these patients. This study aimed to detect specific anti-Strongyloides IC and IgG antibodies in kidney transplant (KT) and liver transplant (LT) candidates. A total of 100 blood samples was collected from transplant candidates (50 blood samples each from KT and LT candidates). Serum was obtained and analysed using enzyme-linked immunosorbent assay for IC and IgG detections. The IC levels showed frequencies of 18% and 2% in the KT and LT groups, respectively, whereas anti-Strongyloides IgG was detected in 34% and 12% of KT and LT candidates, respectively. The correlation between IC and IgG detection is poor in KT candidates, while in LT candidates, there is a significant positive correlation. The detection of IC can be an additional tool for the diagnosis of strongyloidiasis, especially when associated with the detection of specific IgG anti-Strongyloides antibodies.

Prevalence of frailty among kidney transplant candidates and recipients in the United States: Estimates from a National Registry and Multicenter Cohort Study.

Would you like to participate? Factors impacting on participant recruitment for quality use of medicines interventions in residential aged care

Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care.