New-onset diabetes after transplantation

New-Onset Diabetes After Transplantation: Comparison Between a Cyclosporine-Based and a Tacrolimus-Based Immunosuppressive Regimen

INTRODUCTION

New-onset diabetes after transplantation (NODAT) is a complication of renal transplantation (RT) with an adverse effect on graft survival.

OBJECTIVES

The purpose of the present study was to compare modifiable or non-modifiable clinical and laboratory parameters as well as the course of patients and transplants between 2 groups of RT recipients with NODAT in relation to the use of either a cyclosporine-based (group A) or a tacrolimus-based immunosuppressive regimen (group B).

MATERIALS AND METHODS

Retrospectively comparing 66 renal transplant recipients with NODAT, multiple clinical, and laboratory parameters were investigated. For statistical analysis, the χ² test, the Student t test, and the patient and graft survival or the Kaplan-Meier analysis from the statistical software SPSS 22.0 for Windows were used.

RESULTS

There was no statistically significant difference in association with the majority of the investigated parameters. In group B (tacrolimus [Tac]), more patients had HbA1c >7.2% at 3 years after RT. The mean value of systolic blood pressure was higher in group A (cyclosporine [CsA]) at 6 months and at 1 year after RT. More patients in group A (CsA) experienced at least one acute rejection episode. Finally, greater levels of cold ischemia time were recorded in group B (Tac) and statistically significant difference was found in connection with the patient and graft survival in the fourth year after RT.

CONCLUSIONS

NODAT in patients on tacrolimus requires the adjustment of modifiable clinical and metabolic parameters and possible change of the immunosuppressive regimen to a cyclosporine-based one.

The impact of diabetes mellitus and glycemic control on clinical outcomes following liver transplant for hepatitis C

Hepatitis C is the leading indication for liver transplantation in the USA and recurrence is universal. The impact of preexisting diabetes, new-onset diabetes after transplant (NODAT), and glycemic control on fibrosis progression has not been studied. This retrospective longitudinal cohort study included adult liver recipients with hepatitis C transplanted between 2000 and 2011. Patients were divided into three groups: preexisting diabetes (n = 41), NODAT (n = 59), and no diabetes (n = 103). Patients with preexisting diabetes (70%) or NODAT (59%) were more likely to develop hepatitis C recurrence (≥stage 1 fibrosis), as compared to non-diabetics (36%, p = 0.006). There was also a trend toward a higher incidence of at least Stage 2 fibrosis (36% and 48% vs. 23%, respectively; p = 0.063). Patients with tight glycemic control had a lower rate of Stage 2 fibrosis development (78% vs. 60%, p = 0.027), while those with good control (<150 mg/dL) also had lower rates of Stage 2 fibrosis (84% vs. 62%, p = 0.004). Multivariable analysis verified a decreased rate of recurrence for patients with blood glucose <138 mg/dL (p = 0.021), after controlling for confounders. These results demonstrate that diabetes is strongly associated with an increased risk of hepatitis C virus-related fibrosis development and glycemic control may reduce the risk and severity of recurrence.

Tacrolimus and angiotensin receptor blockers associated with changes in serum adiponectin level in new-onset diabetes after renal transplantation: single-center cross-sectional analysis

We analysed whether pre- and post-transplant serum adiponectin levels in renal transplant patients were associated with new-onset diabetes after transplantation (NODAT). The mean post-transplant follow-up duration was 47.9 months. Of 98 previously non-diabetic renal transplant patients, 12 were diagnosed with NODAT and 86 without (non-NODAT). There was a significant inverse correlation between mean post-transplant serum adiponectin level and homeostasis model assessment for insulin resistance (HOMA-IR) (r = -0.22, P = 0.03), and a positive correlation between follow-up duration after transplantation and HOMA-IR (r = 0.28, P = 0.005). The mean pre- and post-transplant serum adiponectin levels in NODAT patients were significantly lower than those in non-NODAT patients (13.3 vs. 21.0 microg/ml and 13.0 vs. 16.4 microg/ml, P = 0.01 and 0.03 respectively). In addition, the post-transplant serum adiponectin level in patients treated with tacrolimus (TAC) was significantly lower than that in patients with cyclosporine (14.3 vs. 18.7 microg/ml, P = 0.01), while, that level in patients treated with angiotensin receptor blockers (ARB) was significantly higher than that in patients without treatment of ARB (17.9 vs. 14.7 microg/ml, P = 0.01). Our results indicate that post-transplant serum adiponectin levels are decreased after transplantation in association with insulin resistance in the development of NODAT, and that TAC and ARB influence the level of adiponectin in serum.

[Sequelae of organ transplantation]

Transplant medicine has significantly changed the prognosis of diseases leading to terminal organ failure. It has evolved from an experimental procedure to standard therapy for liver, kidney and cardio-vascular diseases. Transplant medicine combines operative organ replacement with the management of severely ill patients before transplantation, as well as life-long follow-up of organ graft recipients. Ten year survival rates of 65% to over 90% have led to a steady increase of transplanted patients seen by general medical care providers which represents a challenge for practicing internists. Apart from organ-specific conditions, infectious, immunosuppressant-associated and metabolic consequences determine long-term survival. These include virus reactivation, graft rejection, anastomotic problems but more importantly general mortality determining factors such as diabetes, renal insufficiency and hypertension, which are often a consequence of immunosuppressant administration. They directly impact long-term survival. The awareness and treatment of these secondary conditions of organ transplantation in routine medical practice contributes significantly to secure the long term success of transplant medicine.

Risk factors associated with the onset and progression of posttransplantation diabetes in renal allograft recipients

OBJECTIVE

The aim of this study was to assess the incidence of posttransplantation diabetes mellitus (PTDM) in renal allograft recipients and to investigate factors contributing to the onset and progression of PTDM and its underlying pathogenic mechanism(s).

RESEARCH DESIGN AND METHODS

A total of 77 patients with normal glucose tolerance (NGT) were enrolled in this study. An oral glucose tolerance test was performed 1 week before transplantation and repeated at 1 and 7 years after transplantation.

RESULTS

The overall incidence of PTDM was 39% at 1 year and 35.1% at 7 years posttransplantation. The incidence for each category of PTDM was as follows: persistent PTDM (P-PTDM) (patients who developed diabetes mellitus within 1 year of transplantation and remained diabetic during 7 years), 23.4%; transient PTDM (T-PTDM) (patients who developed diabetes mellitus during the 1st year after transplantation but eventually recovered to have NGT), 15.6%; late PTDM (L-PTDM) (patients who developed diabetes mellitus later than 1 year after transplantation), 11.7%; and non-PTDM during 7 years (N-PTDM7) (patients who did not develop diabetes mellitus during 7 years), 49.3%. Older age (> or = 40 years) at transplantation was a higher risk factor for P-PTDM, whereas a high BMI (> or = 25 kg/m2) and impaired fasting glucose (IFG) at 1 year posttransplantation were higher risk factors for L-PTDM. Impaired insulin secretion rather than insulin resistance was significantly associated with the development of P- and L-PTDM.

CONCLUSIONS

Impaired insulin secretion may be the main mechanism for the development of PTDM. Older age at transplantation seems to be associated with P-PTDM, whereas a high BMI and IFG at 1 year after transplantation were associated with L-PTDM.