vascular disease are approximately twice as common in patients with diabetes versus no diabetes once end-stage renal disease has occurred. Patients with diabetes suffer strokes more frequently and at a younger age then do age and gender match non-diabetic stroke patients. Hypertension is the major risk factor for stroke followed by diabetes, heart disease and smoking.

Lower extremity peripheral vascular disease is significant in patients with diabetes. Uremic diabetic patients are at risk for amputation of a lower extremity. These problems typically begin with a foot ulcer associated with advanced soma-tosensory neuropathy.

Mental or emotional illnesses including neuroses and depression are common. Diagnosis and appropriate treatment of these illnesses is an important pretransplant consideration with important implications for ensuring a high degree of medical compliance.

The components of the pretransplant evaluation are very similar to that carried out in kidney-alone transplant patients with special attention to the above medical issues. The history of disease, review of systems, and physical examination are conducted in a similar focused manner. The interventional studies with respect to the workup of cardiovascular disease does require a uniform screening method because of the high prevalence of severe and often silent cardiovascular disease in the diabetic patient. Figure 7.3 illustrates an example of an algorithm for screening transplant candidates with diabetes for coronary artery disease (CAD).

The basic goal of screening is to detect significant, treatable CAD in patients not suspected to have coronary lesions. Noninvasive screening that has high sensitivity and specificity for significant coronary artery disease can be used on low risk patients. Patients considered to be at moderate or high risk for significant CAD should undergo coronary arteriography to determine the severity and location of the lesions. Patients with coronary lesions amenable to angioplasty with stenting or bypass grafting should be treated and re-evaluated and then reconsidered for transplantation. The goal of revascularization is to diminish the perioperative risk of the transplant procedure and to prolong the duration of life posttransplant. Patients that have experienced long waiting periods prior to pancreas transplantation should have their cardiac status assessed at regular intervals.

A liberal policy that virtually all diabetic, uremic patients should undergo coronary angiography is not unreasonable because the current noninvasive tests are relatively insensitive. Also, the techniques of coronary angiography have changed in the last few years, allowing for selected arteriography with very low dose, less toxic contrast agents using biplanar imaging techniques. The nephrotoxic risk of the angiography has been reduced considerably (if a left ventriculogram is omitted) in a preuremic patient with creatinine clearance >20 ml/min.

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