Validation of a screening protocol for identifying low-risk candidates with type 1 diabetes mellitus for kidney with or without pancreas transplantation.
BACKGROUND
Certain clinical risk factors are associated with significant coronary artery disease in kidney transplant candidates with diabetes mellitus. We sought to validate the use of a clinical algorithm in predicting post-transplantation mortality in patients with type 1 diabetes. We also examined the prevalence of significant coronary lesions in high-risk transplant candidates.


METHODS
All patients with type 1 diabetes evaluated between 1991 and 2001 for kidney with/without pancreas transplantation were classified as high-risk based on the presence of any of the following risk factors: age >or=45 yr, smoking history >or=5 pack years, diabetes duration >or=25 yr or any ST-T segment abnormalities on electrocardiogram. Remaining patients were considered low risk. All high-risk candidates were advised to undergo coronary angiography. The primary outcome of interest was all-cause mortality post-transplantation.


RESULTS
Eighty-four high-risk and 42 low-risk patients were identified. Significant coronary artery stenosis was detected in 31 high-risk candidates. Mean arterial pressure was a significant predictor of coronary stenosis (odds ratio 1.68; 95% confidence interval 1.14-2.46), adjusted for age, sex and duration of diabetes. In 75 candidates who underwent transplantation with median follow-up of 47 months, the use of clinical risk factors predicted all eight deaths. No deaths occurred in low-risk patients. A significant mortality difference was noted between the two risk groups (p = 0.03).


CONCLUSIONS
This clinical algorithm can identify patients with type 1 diabetes at risk for mortality after kidney with/without pancreas transplant. Patients without clinical risk factors can safely undergo transplantation without further cardiac evaluation.
Ma
Irene W Y
IW
Division of Nephrology, Stanford University, CA, USA. ima@stanfordalumni.org
Valantine
Hannah A
HA
Shibata
Atsuko
A
Waskerwitz
Jane
J
Dafoe
Donald C
DC
Alfrey
Edward J
EJ
Tan
Jane C
JC
Millan
Maria
M
Busque
Stephan
S
Scandling
John D
JD
D017668:Age of Onset; D000704:Analysis of Variance; D002096:C-Peptide / Q000097:blood; D001026:Coronary Artery Bypass; D003922:Diabetes Mellitus, Type 1 / Q000601:surgery*; D003928:Diabetic Nephropathies / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D015203:Reproducibility of Results; D012307:Risk Factors; D012907:Smoking
D002096:C-Peptide