First case of simultaneous heart plus kidney transplantation in Chile: case report

Advanced renal disease is a formal contraindication to heart transplantation, and heart failure may make a patient ineligible for kidney transplantation. The International Society of Heart and Lung Transplantation has reported 336 simultaneous heart and kidney transplantations with a 70% rate of 5 year survival. Herein we have presented the first case of simultaneous heart plus kidney transplantation in Chile. The patient is a 62-year-old man with diabetes mellitus and arterial hypertension who in 1997 had a myocardial infarction with cardiogenic shock and acute renal failure. He underwent a coronary bypass but developed progressive heart failure, with an ejection fraction less than 20% and moderate mitral regurgitation. He required chronic hemodialysis and survived a cardiac arrest, receiving an implantable cardioverter defibrillator. Transplantation was performed in 2004 in 2 phases: initially a heart, followed by a kidney transplantation. Immunosuppression included Daclizumab, cyclosporine, mycophenolate mofetil (MMF) and steroids. He developed acute renal failure but did not receive dialysis. He left the hospital at 25 days posttransplantation. Two years following double transplantation, he has not shown acute rejection episodes of either the cardiac or the kidney graft. Both cardiac and renal functions are normal. In conclusion, simultaneous heart plus kidney transplantations offer a good alternative treatment for patients with advanced disease of both organs.

The "flap-shaft" prosthesis for insensate feet with Chopart or Lisfranc amputations

BACKGROUND

The inevitable detachment of tendons and the loss of the forefoot in Chopart and Lisfranc amputations result in equinus and varus of the residual foot. In an insensate foot these deformities can lead to keratotic lesions and ulcerations. The currently available prostheses cannot safely counteract the deforming forces and the resulting complications.

METHODS

A new below-knee prosthesis was developed, combining a soft socket with a rigid shaft. The mold is taken with the foot in the corrected position. After manufacturing the shaft, the lateral third of the circumference of the shaft is cut away and reattached distally with a hinge, creating a lateral flap. By closing this flap the hindfoot is gently levered from the varus position into valgus. Ten patients (seven amputations at the Chopart-level, three amputations at the Lisfranc-level) with insensate feet were fitted with this prosthesis at an average of 3 (range 1.5 to 9) months after amputation. The handling, comfort, time of daily use, mobility, correction of malposition and complications were recorded to the latest followup (average 31 months, range 24 to 37 months after amputation).

RESULTS

Eight patients evaluated the handling as easy, two as difficult. No patient felt discomfort in the prosthesis. The average time of daily use was 12 hours, and all patients were able to walk. All varus deformities were corrected in the prosthesis. Sagittal alignment was kept neutral. Complications were two minor skin lesions and one small ulcer, all of which responded to conservative treatment, and one ulcer healed after debridement and lengthening of the Achilles tendon.

CONCLUSIONS

The "flap-shaft" prosthesis is a valuable option for primary or secondary prosthetic fitting of Chopart-level and Lisfranc-level amputees with insensate feet and flexible equinus and varus deformity at risk for recurrent ulceration. It provided safe and sufficient correction of malpositions and enabled the patients to walk as much as their general condition permitted.

Neurologic Complications After Neuraxial Anesthesia or Analgesia in Patients with Preexisting Peripheral Sensorimotor Neuropathy or Diabetic Polyneuropathy

BACKGROUND

The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after neuraxial anesthesia or analgesia.

METHODS

We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of neuraxial blockade, complications, and block outcome were collected for each patient.

RESULTS

The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of neuraxial technique included spinal anesthesia in 325 (57%) patients, epidural anesthesia or analgesia in 214 (38%) patients, continuous spinal anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%-1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful neuraxial technique. In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications.

CONCLUSIONS

The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia was found to be 0.4% (95% CI 0.1%-1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.

Clinical Outcome of Peripheral Nerve Decompression in Diabetic and Nondiabetic Peripheral Neuropathy

Surgical decompression of peripheral nerves in patients with diabetes was reported to restore sensation and improve function. In this study, a retrospective review of 12 diabetic and 20 nondiabetic patients with lower-extremity peripheral neuropathy who underwent surgical decompression was performed. Clinical evaluation by Tinel test, muscle power examination, and 2-point discrimination were performed preoperatively, at 6 months, and between 9 and 15 months postdecompression. Clinical outcomes were classified into excellent, good, or fair based on improvement in symptoms and return of function. Thirty-two patients underwent 36 surgeries, in which 99 lower-extremity nerves were decompressed. There was a statistically significant improvement in muscle function (P < 0.001) and 2-point discrimination for the small toe (P = 0.008) and big toe (P = 0.038). At a mean of 7.7 months, 90% of patients showed significant improvement in pain and function. It is concluded that surgical decompression was associated with significant improvement in clinical outcome in patients with diabetic and idiopathic neuropathy with evidence of superimposed compression.

Surgical decompression for painful diabetic peripheral nerve compression and neuropathy: a comprehensive approach to a potential surgical problem

Diabetic nerve decompression is not for every patient. There is a definite learning curve to the surgery and recovery process and the surgeon must be available to the patient for concerns during the recovery period. The surgery itself is not very complex and can be mastered over time. Pain relief and return to activity results have been excellent and overall, the surgical decompression patients fair better in regard to ulcer formation and amputation risk than those without decompression. It is essential to select patients carefully and to make sure that the testing and examination findings discussed in the article are present before surgery.

Practice Advisory: Utility of surgical decompression for treatment of diabetic neuropathy: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

Surgical decompression at the site of anatomic narrowing has been promoted as an alternative treatment for patients with symptomatic diabetic neuropathy. Systematic review of the literature revealed only Class IV studies concerning the utility of this therapeutic approach. Given the current evidence available, this treatment alternative should be considered unproven (Level U). Prospective randomized controlled trials with standard definitions and outcome measures are necessary to determine the value of this therapeutic intervention.

Prevalence of lower-extremity amputation among patients with diabetes mellitus: is height a factor?

BACKGROUND

Taller diabetic patients are at higher risk of peripheral sensory loss than shorter diabetic patients and thus may be at increased risk of lower-extremity ulcers and amputation. In a large telephone survey, the prevalence of lower-extremity amputation among patients with diabetes mellitus was determined and the association between height and lower-extremity amputation evaluated.

METHODS

Of 256,036 patients identified from hospital and clinic databases who had a diagnosis of diabetes and were seen at those institutions between 1995 and 1998, 128,572 were randomly selected to be interviewed by telephone between 1995 and 2002. Of the 93,484 patients who agreed to be interviewed, 386 were excluded (age < 18 years); this left 93,116 diabetec patients (42,970 men and 50,146 women) for inclusion in the study.

RESULTS

Of the 93,116 patients interviewed, 3259 (3.5%) had type 1 diabetes. Lower-extremity amputation was performed in 1.7% and 0.8% of the patients with type 1 and type 2 diabetes, respectively. The prevalence of amputation did not differ significantly between men and women with type 1 diabetes but was significantly higher among men than among women with type 2 diabetes (0.9% v. 0.7%). Height (every 10-cm increment) was significantly associated with lower-extremity amputation (adjusted odds ratio [OR] 1.16, 95% confidence interval [CI] 1.03-1.32). In a subgroup of 9295 patients for whom data on fasting plasma glucose levels and dyslipidemia were available, and after additional adjustment for these 2 variables, body height remained an independent predictor of lower-extremity amputation (adjusted OR for every 10 cm of height 1.79, 95% CI 1.14-2.82).

INTERPRETATION

Height is an independent predictor of lower-extremity amputation among patients with type 1 and type 2 diabetes mellitus.

Orthotic Management of the Neuropathic Limb

The most common complaint of neuropathic patients is that they were unaware of the neuropathic pathway until it caused a complication. Foot treatment, protection, and amputation prevention historically have been overlooked or covered only slightly in medical education. Chronic neuropathic complications have been seen to have an unavoidable outcome. In many areas, there are no certified orthotists or local health care practitioners who are trained in off-loading techniques. The goal of treatment of a neuropathic or dysvascular patient is to preserve the limb and ambulatory function. Techniques can be shared between disciplines for improved outcomes for neuropathic patients. The combined team expertise with state-of-the-art techniques have enabled wound healing, limb salvage, and improved quality of life for this high-risk population.

Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions

Since 1992 it has been reported that patients with diabetes mellitus recover sensibility and obtain relief of pain from neuropathy symptoms by decompression of lower-extremity peripheral nerves. None of these reports included a series with more than 36 diabetic patients with lower-extremity nerves decompressed, and only recently has a single report appeared of the results of this approach in patients with nondiabetic neuropathy. No previous report has described a change in balance related to restoration of sensibility. A prospective study was conducted of 100 consecutive patients (60 with diabetes and 40 with idiopathic neuropathy) operated on by a single surgeon, other than the originator of this approach, and with the postoperative results reviewed by someone other than these two surgeons. Each patient had neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and the tibial nerve released in the four medial ankle tunnels. After at least 1 year of follow-up, 87% of patients with preoperative numbness reported improved sensation, 92% with preoperative balance problems reported improved balance, and 86% whose pain level was 5 or greater on a visual analog scale from 0 (no pain) to 10 (the most severe pain) before surgery reported an improvement in pain. Decompression of compressed lower-extremity nerves improves sensation and decreases pain, and should be recommended for patients with neuropathy who have failed to improve with traditional medical treatment.

Surgical decompression in lower-extremity diabetic peripheral neuropathy

Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation.

Amelioration of diabetic peripheral neuropathy by implantation of hematopoietic mononuclear cells in streptozotocin-induced diabetic rats

This study was performed in order to evaluate the angiogenic effect of implantation of either peripheral blood mononuclear cells (PBMNCs) or bone marrow mononuclear cells (BMMNCs) on diabetic peripheral neuropathy. Streptozotocin (50 mg/kg) was injected intravenously into 6-week-old male Lewis rats. Four weeks after the induction of diabetes, 6 x 10(7) of PBMNCs or 1 x 10(8) of BMMNCs were implanted into the left hindlimb muscle. Motor nerve conduction velocity (MNCV) was monitored before and after implantation. At the end of the experiment, bilateral nerve blood flow (NBF) was measured by laser Doppler and the number of vessels in the sciatic nerves quantified by Factor VIII staining of the sections. Diabetes resulted in an approximately 20% reduction (P < 0.01) in sciatic MNCV. Four weeks after implantation, MNCV was improved by 54% with PBMNCs and by 67% with BMMNCs (both P < 0.01). Moreover, the effects of implantation were almost abolished by administration of VEGF-neutralizing antibody. Sciatic NBF was reduced by approximately 50% by diabetes (P < 0.05). This reduction in perfusion was improved by 74% by implantation of PBMNCs and by 62% by implantation of BMMNCs (P < 0.05 and P < 0.01, respectively). These effects were observed only in the implanted limb. Immunohistochemical staining of sciatic nerve sections for Factor VIII showed no significant increase in the number of vessels in the sciatic nerve following implantation of either PBMNCs or BMMNCs. These data suggest that implantation of hematopoietic mononuclear cell fractions is associated with an improvement in MNCV as a result of arteriogenic effects in the sciatic nerve, and that VEGF may contribute to this effect. This improvement occurred in the absence of angiogenesis. Implantation of these cell fractions may therefore be a potential new therapeutic method for treating diabetic peripheral neuropathy.

Embolization of a Ruptured Pseudoaneurysm With Massive Hemorrhage Following Pancreas Transplantation: A Case Report

Pseudoaneurysm associated with an arterioenteric fistula is rare, but its clinical manifestations may represent a dramatic event that involves diagnostic and therapeutic problems. We report a case of an arterioduodenal fistula related to a ruptured pseudoaneurysm after simultaneous pancreas-kidney transplantation (SPK) with massive gastrointestinal hemorrhage treated by embolization of the Y graft. A 51-year-old man with type I diabetes and end-stage renal disease underwent SPK. No rejection episodes were documented; the patient was discharged with normal pancreatic and renal function. Two months later the patient was readmitted for an episode of massive lower digestive bleeding and hypotension. The Y-graft was embolized in order to obtain a prompt arrest of the bleeding. The procedure was successful and the patient progressively recovered. Once the hypovolemia was completely corrected, the graft was removed. An arterioenteric fistula between donor mesenteric artery and duodenum was confirmed. Few reports exist in the literature regarding the development of a pseudoaneurysm after pancreas transplantation. To our best knowledge only one case of pseudoaneurysm rupture into donor duodenum has been recently published. In our case angiography recognized the site of the pseudoaneurysm and its rupture into donor duodenum. Embolization of the Y-graft appeared the most rapid, simple, and safe approach to obtain the prompt arrest of the massive bleeding. Embolization of the Y-graft may represent a valid option in the presence of life-threatening hemorrhage.

Comparable Kidney Graft Survival of Type 1 Diabetics Treated With Simultaneous Pancreas-Kidney Transplantation and Nondiabetic Patients Treated With Cadaveric Renal Transplantation

Simultaneous pancreas-kidney transplantation (SPK) is now a common treatment for insulin-dependent diabetic patients with end-stage renal disease. This study analyzed the patient and graft survival rates of 231 kidney transplantations (KTX) in nondiabetic patients and of 95 SPK in diabetic patients between January 1, 1998 and December 31, 2001. The SPK group showed significantly better patient and graft survival rates after 5 years than the KTX group (96% and 90% vs 85% and 75%, respectively; P < .05). Even the serum creatinine level during the first 2 years showed significantly lower levels in the SPK group (P < .01). The patients in the SPK group were significantly younger. They received organs from younger donors than the patients in the KTX group (P < .01). The cold ischemia time and the time on previous dialysis were also shorter in the SPK group (P < .01). However, the number of HLA mismatches was higher in the SPK patients (P < .01). Limiting the analysis to recipients younger than 60 years, donors younger than 58 years, and cold ischemia time to <19 hours, there was no difference in graft or patient survival. These data suggest that donor and recipient age as well cold ischemic time have a greater impact on early outcome and postoperative complications of renal transplants than HLA matching.

Effect of Achilles tendon lengthening on ankle muscle performance in people with diabetes mellitus and a neuropathic plantar ulcer

BACKGROUND AND PURPOSE

The effect of a tendo-Achilles lengthening (TAL) procedure on ankle muscle performance has not been clearly established. The purpose of this study was to compare the effects of TAL and total-contact casting (TCC) with TCC alone on ankle muscle performance in subjects with diabetes mellitus (DM) and a neuropathic plantar ulcer.

SUBJECTS

Subjects were randomly assigned to either a TAL group (3 female and 12 male subjects) or a TCC group (4 female and 10 male subjects).

METHODS

Muscle performance measurements were obtained using an isokinetic dynamometer.

RESULTS

Concentric plantar-flexor peak torque decreased 31% after TAL but returned to the baseline level after 8 months. Dorsiflexor peak torque did not change in either group. Plantar-flexor passive torque at 0 degrees of dorsiflexion decreased after TAL but increased to 60% of the baseline level after 8 months. Maximal dorsiflexion angle increased 11 degrees after TAL and remained increased at 8 months.

DISCUSSION AND CONCLUSION

The TAL resulted in an increase in ankle dorsiflexion range of motion and a temporary reduction in concentric plantar-flexor peak torque and passive torque at 0 degrees of dorsiflexion. If TAL is being considered for people with DM and a neuropathic forefoot ulcer, the initial compromise in plantar-flexor muscle performance should be addressed.

Prognostic Ability of Tinel Sign in Determining Outcome for Decompression Surgery in Diabetic and Nondiabetic Neuropathy

During the past 12 years, 6 studies reported restoration of sensation and relief of pain in the foot by decompression of the tibial nerve and its distal branches in diabetic neuropathy. Although a positive Tinel sign related to favorable outcomes in some of the reports, this relationship was not evaluated specifically. In this study, the presence of the Tinel sign, positive or negative, over the tibial nerve was recorded in 46 patients with diabetic neuropathy and in 40 patients with idiopathic neuropathy. Outcomes were dichotomized into either a good/excellent or failure/poor category. Postoperative data were analyzed at 1 year. In diabetic neuropathy, the presence of a positive Tinel sign had a sensitivity of 88%, a specificity of 50%, and a positive predictive value of 88% in identifying patients who would have a good/excellent outcome. In idiopathic neuropathy, the presence of a positive Tinel sign had a sensitivity of 95%, a specificity of 56%, and a positive predictive value of 93% in identifying patients who would have a good/excellent outcome. It is concluded that a positive Tinel sign is a reliable indicator of successful outcome from decompression of the tibial nerve in patients with diabetes with symptomatic neuropathy, and in patients with symptomatic idiopathic neuropathy.

Reducing the incidence of foot ulceration and amputation in diabetes

Diabetes is a common disease that is associated with numerous complications, including foot ulceration and amputation. In diabetic patients, the incidence of foot ulcers ranges from 1.0% to 4.1%, and the incidence of lower-extremity amputations ranges from 2.1 to 13.7 per 1000. Risk factors for developing foot ulcers and subsequent amputation include neuropathy, peripheral vascular disease, and trauma. To reduce these complications, several preventive strategies have been devised, from reducing risk factors to improving treatment and management.

Diabetic neuropathy: review of a surgical approach to restore sensation, relieve pain, and prevent ulceration and amputation

Diabetic neuropathy occurs in a stocking and glove distribution consistent with a systemic metabolic disease. Historically, this concept led to the conclusion that the only role for surgery in a patient with diabetic neuropathy is for treatment of wounds, amputation, or reconstruction of a Charcot foot. This article reviews the basic scientific and clinical research that support the concepts that metabolic neuropathy renders the peripheral nerve susceptible to compression in patients with diabetes and that decompression of lower extremity peripheral nerves in these patients can relieve pain, restore sensation, and prevent ulceration and amputation.

The role of surgical decompression for diabetic neuropathy

Surgical decompression of peripheral nerves for the treatment of diabetic peripheral neuropathy has been studied and previously reported. These studies reported decreased pain and some studies showed improved sensory function. The role that this surgery can play remains controversial.

Outcome of surgical release among diabetics with carpal tunnel syndrome11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes with those of patients with idiopathic CTS.

DESIGN

Prospective case series.

SETTING

Ambulatory care in Italy.

PARTICIPANTS

Twenty-four consecutive patients with diabetes type 1 or 2 and CTS (mean age, 66.7 y) were matched for age and sex with 72 patients (mean age, 66.2 y) with idiopathic CTS.

INTERVENTIONS

All patients underwent surgical release of CTS by the mini-incision of palm technique.

MAIN OUTCOME MEASURES

Clinical and electrophysiologic evaluation and patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status before and 1 and 6 months after surgery.

RESULTS

After surgical release, almost all patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. One month after surgery, there was a significant improvement in clinical status, BQ scores, and distal conduction velocities of the median nerve. A further improvement was evident at 6-month follow-up. There were no differences between the 2 groups in the number of surgical complications, in clinical and electrophysiologic status, or in BQ scores before and after surgery. The improvement in distal conduction velocities of the median nerve, BQ scores, and clinical and electrophysiologic status were similar in the 2 groups after surgery.

CONCLUSION

Diabetes is not a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes have the same probability of positive surgical outcome as patients with idiopathic CTS.