P381 Worldwide organ shortage has prompted the nephrological community to extensively use so called “marginal” donors for renal transplantation; ESRD elderly patients, who ask for being inserted in a transplantation waiting list, have dramatically increased over the past decades; so, previous age limits should be reviewed. Aims: to evaluate results of a policy of free (since 1987) acceptance for recipients aged >65 yrs. Methods: 70 cadaveric transplants performed from 05/1987 to 01/2004 are evaluated (dual 21.4%, single 78.6%, M/F 46/24, retransplant 7%). Mean age of donors was 67.5+/-1.5 yrs and mean age of recipients 67.4+/-2.2. Patients are divided in group A (n=67, mean age 66.5+/-1.5, range 65-70 yrs) and group B (n=13, mean age 72.4+/-1.6, range 70-75 yrs). Routine cardiologic tests were myocardial perfusion scintigraphy and/or stress echography. Number of transplants were: 1987-1992 = 4, 1993-1998 = 14, 1999-2003 = 52. Mean follow up was 22.2 months (0.5-158.8). Immunosuppresive protocols were different according to transplantation eras. Basically all patients were on a low steroid regimen and 56% of them withdrew steroids; main immunosuppresant was cyclosporine A in 50% of patients, tacrolimus in 44%, and rapamicine in 6 %; Azathioprine and MMF were sometimes employed to withdraw the calcineurin inhibitor or steroids. Results: patient and graft actuarial survival (Kaplan-Maier estimates and log-rank for significance) at 1, 2, 3, 5,10 yrs were respectively 85, 78, 78, 74, 49% and 82,75, 75, 67, 44%. During the follow up 17 patients died, 14 in group A (11/14 with a functioning graft) and 3 in group B (all with a functioning graft). Causes of death were: 30% cancer, 23% cardiovascular disease, 23% sepsis, 12% cerebro-vascular hemorrhage, 12% meningitis. Cumulative acute rejection rate was 18.6% (17.5% group A and 23% group B); in 2 cases rejection was the cause of graft loss. More frequent complications were: 52% prostatic hypertrophy, 40% urinary tract infections, 16% diabetes, 11% pneumonia, 10% cardiovascular disease (4 acute myocardial infarction and 3 by pass), 7% urologic complications, 6% gastrointestinal medical pathologies, 6% acute pyelonephritis, 4% cancer, 3% abdominal surgical complications. Conclusions: the Authors reinforce their previous opinion in favour of no need of any predefined age barrier in renal transplantation. An age >65 years do not preclude a transplant good outcome. Since elderly patient survival is influenced by age related comorbid conditions, mainly cardiovascular pathologies, cardiovascular assessment is of cardinal relevance. A careful screening before and a tailored immunosuppressive protocol after transplantation, are two main cornerstones. Immunosuppression is a crucial point because on one hand elderly patients are obviously more fragile but on the other hand an immunological hyporesponsiveness towards the transplanted kidney is not yet been demonstrated.
Several approaches have been used for noninvasive estimation of right atrial pressure (RAP), but, no currently available method has gained any definite validation. The purpose of this study was to evaluate the accuracy of two-dimensional and Doppler echocardiography in estimating mean RAP in patients with cardiac disease.We examined the relation of mean RAP to right atrial size and function, size and respiratory changes of inferior vena cava and Doppler parameters of tricuspid and hepatic vein flow in 114 consecutive patients (77 men, 37 women; mean age 57 +/- 12 years) with various cardiac diseases undergoing cardiac catheterization. Echocardiographic studies were performed within 24 hours before catheterization (mean interval 6 +/- 3 hours). Patients were assigned to 3 groups according to the values of mean RAP (group 1, < or = 8 mmHg; group 2, between 9 and 12 mmHg; group 3, > 12 mmHg).Mean RAP ranged from 3 to 20 mmHg (mean 9.1 +/- 4.3 mmHg). It correlated most strongly with the collapsibility index of inferior vena cava (IVCCI) (r = -0.76), minimal inspiratory diameter of inferior vena cava (r = 0.72) and deceleration time of early tricuspid flow (DT) (r = -0.61). Discriminant analysis demonstrated that IVCCI and DT were major determinants of mean RAP with 81.6% of cases correctly assigned to study groups: 96% of patients of group 1 and 87% of patients of group 3 were identified, whereas the accuracy in identifying the patients of group 2 was lower (46%). An IVCCI > 45% was the best cutoff point in predicting a mean RAP < or = 8 mmHg; an IVCCI < 35% and a DT < 150 msec were the best cutoff points in predicting a mean RAP > or = 15 mmHg. The best multivariate equation predicting mean RAP was: mean RAP = 23.3 - 0.2 IVCCI -0.026 DT (r = 0.80, R2 = 0.64). This equation was 81% sensitive and 84% specific in detecting a mean RAP < or = 8 mmHg and 74% sensitive and 97% specific in detecting a mean RAP > 12 mmHg.Mean RAP can be estimated noninvasively by two-dimensional and Doppler echocardiography. The combined analysis of IVCCI and DT provides an accurate prediction on mean RAP < or = 8 mmHg and > 12 mmHg, whereas the prediction of intermediate values is less accurate.
P225 The ever growing number of so called marginal donors (MDs) and the elderly uremics request for graft are features of today scenario of renal transplantation. The policy of an “old for old” allocation – i.e. offering kidneys from MDs to elderly candidates – seems to fit well with this condition, as well as to enhance a maximal kidney utilization. Aims: aim of the study is to present the two year results of a protocol we adopted in our Centre in order to avoid the nephrotoxic effect of calcineurin-inhibitors (CNIs) whose impact could be magnified in the milieu of elderly candidates. This protocol is a two-phases immunosuppression, initially CNI free. Methods: the protocol consists of an induction phase with basiliximab 2 doses iv, steroid and mycophenolate mofetil (MMF) 2gr/day and of a maintenance phase with CNI (mainly tacrolimus) when serum creatinine (sCr) is below 2.5 mg/dl. From this time MMF is rapidly stopped and steroid is tapered to 5 mg at day 45, with the aim of minimization/withdrawal. MDs are defined on the basis of clinical (age > 50 years, presence of comorbid conditions), histological (Karpinsky score on harvesting time biopsies) and functional (Cockroft-Gault formula = CG) criteria. Kidneys from 89 MDs were transplanted as single (n=43) or dual (n=46) grafts (G1). 38 grafts from MDs at a lesser degree of marginality rate, CNI treated from day 1, were used as control group (G2). Mean follow up was: 22.5±10.5 months in G1 and 26.1±15.9 months in G2. Results delayed graft function (DGF) rate is statistically higher in G1: 46% vs 27%. Overall patient and graft survival at 12-24 months were:100-97% and 96-91% in G1; 94-94% and 88-88% in G2. As for biopsy proven acute rejection (AR) rates: overall 12.4% (G1), 13.0% (G2); at month 1: 7.0% (G1), 8.8% (G2). AR was the cause for graft loss in 2/89 in G1 and 1/38 in G2. sCr and clearance (CG formula) at 6, 12 and 24 months were respectively in G1: 1.6±0.5, 1.6±0.5, 1.5±0.5 mg/dl and 48±19, 48±18, 52±18 cc’; in G2: 1.6±0.6, 1.7±0.7, 1.7±0.8 mg/dl and 55±19, 56±23, 61±29 cc’. After 2 years, 70% of the patients in G1 and 50% in G2 were off steroids. No significant difference was found between the two groups for all these data. Conclusions: our results give support to the ongoing adoption of a CNI free protocol for grafts harvested from MDs, on the basis of its safety and effectiveness in recipients whose DGF rate and risk factors for nephrotoxicity are both high. The feasibility on an “old for old” transplantation program may help in counteracting the effect of organ shortage.
Background The independent prognostic impact of diabetes mellitus ( DM ) and prediabetes mellitus (pre‐ DM ) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre‐ DM on survival outcomes in the GISSI ‐HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca‐Heart Failure) trial. Methods and Results We assessed the risk of all‐cause death and the composite of all‐cause death or cardiovascular hospitalization over a median follow‐up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI ‐ HF trial, who were stratified by presence of DM (n=2852), pre‐ DM (n=2013), and non‐ DM (n=2070) at baseline. Compared with non‐ DM patients, those with DM had remarkably higher incidence rates of all‐cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%). Conversely, both event rates were similar between non‐ DM patients and those with pre‐ DM . Cox regression analysis showed that DM , but not pre‐ DM , was associated with an increased risk of all‐cause death (adjusted hazard ratio, 1.43; 95% CI , 1.28–1.60) and of the composite end point (adjusted hazard ratio, 1.23; 95% CI , 1.13–1.32), independently of established risk factors. In the DM subgroup, higher hemoglobin A1c was also independently associated with increased risk of both study outcomes (all‐cause death: adjusted hazard ratio, 1.21; 95% CI , 1.02–1.43; and composite end point: adjusted hazard ratio, 1.14; 95% CI , 1.01–1.29, respectively). Conclusions Presence of DM was independently associated with poor long‐term survival outcomes in patients with chronic heart failure. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 00336336.
The incidence and prevalence of elderly patients are progressively increasing in most dialysis facilities with consequent medical assistance difficulties and the need to find a suitable care unit. Particularly in this age group, the clinical assessment is often difficult and the selection criteria vary widely, not only from country to country, but also from one dialysis unit to another unit in the same area. The authors discuss some of the more complex arguments for and against dialysis in elderly patients. For some of the more difficult cases, Kantian deontology and its three ethical principles of beneficence, non-maleficence and autonomy can facilitate the decision-making process regarding the acceptance or refusal of the therapy. The central role of the patients themselves, the involvement of the family, the discussion of the individual case within the dialysis team, and the good performance of the pre-dialysis program are particularly important. In certain cases it is possible to actually discontinue the treatment, or not initiate it, by using different arguments in competent or incompetent patients. In conclusion, the difficult choice of whether to treat or turn down an elderly patient must depend exclusively on the medical clinical assessment of each case, whereas economical considerations can incorrectly influence that choice.
The present study examines the potential electromagnetic interference effects induced by cellular telephones on ICDs. We developed ad hoc protocols to conduct both in vitro and in vivo trials on most of the implantable cardioverter defibrillators available on the international market. Trials were conducted with three cellular telephones: two GSM (Global System for Mobile Communication) and one TACS (Total Access Communication System). A human trunk simulator was used to carry out in vitro observations on six ICDs from five manufacturers. In vivo tests were conducted on 13 informed patients with eight different ICD models. During the trials in air, GSM telephones induced interference effects on 4 out of the 6 cardioverter defibrillators tested. Specifically, pulse inhibition, reprogramming, false ventricular fibrillation, and ventricular tachycardia detections occurred, which would have entailed inappropriate therapy delivery had this been activated. Effects were circumscribed to the area closely surrounding the connectors. When the ICD was immersed in saline solution, no effects were observed. Three cases of just ventricular triggering with the interfering signal were observed in vivo.
