Posttransplant diabetes mellitus after kidney transplantation with different immunosuppressive agents

The importance of different immunosuppressive regimens in the development of posttransplant diabetes mellitus

Solid-organ transplantation is the optimal long-term treatment for most patients with end-stage organ failure. After solid-organ transplantation, short-term graft survival significantly improved (1). However, due to chronic allograft nephropathy and death with functioning graft, long-term survival has not prolonged remarkably (2). Posttransplant immunosuppressive medications consist of one of the calcineurin inhibitors in combination with mycophenolate mofetil (MMF) or azathioprine (Aza) and steroids. All of them have different adverse effects, among which posttransplant diabetes mellitus (PTDM) is an independent risk factor for cardiovascular (CV) events and infections causing the death of many transplant patients and it may directly contribute to graft failure (3). According to the criteria of the American Diabetes Association (4), diabetes mellitus (DM) is defined by symptoms of diabetes (polyuria and polydipsia and weight loss) plus casual plasma glucose concentration ≥ 11.1 mmol/L or fasting plasma glucose (FPG) ≥ 7.0 mmol/L or 2-h plasma glucose level ≥ 11.1 mmol/L following oral glucose tolerance test (OGTT). This metabolic disorder occurring as a complication of organ transplantation has been recognized for many years. PTDM, which is a combination of decreased insulin secretion and increased insulin resistance, develops in 4.9/15.9% of liver transplant patients, in 4.7/11.5% of kidney recipients, and in 15/17.5% of heart and lung transplants [cyclosporine A (CyA)/tacrolimus (Tac)-based regimen, respectively] (5). Risk factors of PTDM can be divided into non-modifiable and modifiable ones (6), among which the most prominent is the immunosuppressive therapy being responsible for 74% of PTDM development (7). Emphasizing the importance of the PTDM, numerous studies have determined the long-term outcome. On the basis of these studies, graft and patient survival is tendentiously (8) or significantly (9, 10) decreased for those developing PTDM.

Suitable calcineurin inhibitor concentrations for liver transplant recipients in the Chinese population

AIM

The aim was to deduce suitable calcineurin inhibitor concentrations for the Chinese liver transplantation population.

METHODS

We retrospectively studied 97 liver transplant recipients who displayed stable liver and renal function. No grafts were obtained from prisoners, procurements were performed with donor consent conforming to international ethics regulations. At 3, 6, and 12 months, we increased the concentrations and doses of calcineurin inhibitors as well as the values of alanine transaminase and serum creatinine.

RESULTS

Twenty-eight recipients received cyclosporine and 69 tacrolimus. The mean cyclosporine daily dosages were 203 ± 62 mg at 3, 188 ± 55 mg at 6, and 173 ± 52 mg at 12 months, the tacrolimus daily dosages were 3.08 ± 0.98, 2.82 ± 0.98, and 2.58 ± 0.93 mg, respectively. The corresponding mean cyclosporine peak concentrations (C(2)) were 806 ± 322 ng/mL, 681 ± 206 ng/mL, and 644 ± 190 ng/mL and the mean tacrolimus trought concentrations (C(0)) 6.61 ± 3.02 ng/mL, 5.85 ± 2.44 ng/mL, and 5.22 ± 2.33 ng/mL, respectively. In both groups, transaminases and serum creatinine were stable over time.

CONCLUSIONS

An individualized immunosuppressive regimen for the local population is necessary. We delayed calcineurin inhibitors with subsequent low-dose mycophenolate mofetil plus minimized calcineurin inhibitors, which seemed to be nephroprotective and safe for Chinese liver transplantation patients.

Drug-induced endocrine disorders in the intensive care unit

The neuroendocrine response to critical illness is key to the maintenance of homeostasis. Many of the drugs administered routinely in the intensive care unit significantly impact the neuroendocrine system. These agents can disrupt the hypothalamic-pituitary-adrenal axis, cause thyroid abnormalities, and result in dysglycemia. Herein, we review major drug-induced endocrine disorders and highlight some of the controversies that remain in this area. We also discuss some of the more rare drug-induced syndromes that have been described in the intensive care unit. Drugs that may result in an intensive care unit admission secondary to an endocrine-related adverse event are also included. Unfortunately, very few studies have systematically addressed drug-induced endocrine disorders in the critically ill. Timely identification and appropriate management of drug-induced endocrine adverse events may potentially improve outcomes in the critically ill. However, more research is needed to fully understand the impact of medications on endocrine function in the intensive care unit.

Current and evolving immunosuppressive regimens in kidney transplantation

The advent of novel immunosuppressive agents with increased potency now offers multiple treatment options for transplant physicians. However, variable efficacy, drug-drug interactions, and adverse effects associated with long-term immunosuppression continue to complicate the clinical management of kidney transplant recipients. Currently, investigators are challenged to develop regimens that take into account not only efficacy, but also dosing, monitoring, safety, and patient quality of life. Recent research has focused on evaluating new combinations of approved agents that seek to improve outcomes by improving control of immunologic events with fewer complications. This article reviews current practice and recent studies to give all health care providers who manage kidney transplant recipients a better understanding of current regimens and general trends in immunosuppressive therapy.

Posttransplant diabetes mellitus in kidney transplant recipients receiving calcineurin or mTOR inhibitor drugs

BACKGROUND

The aim of this study was to evaluate the incidence and risk factors for posttransplant diabetes mellitus (PTDM; defined as new insulin use and/or new hyperglycemia) in 528 kidney recipients using different immunosuppressive agents.

METHODS

Maintenance therapy included mycophenolate mofetil or azathioprine plus glucocorticoids in combination with Group I cyclosporine (263); Group II tacrolimus (60); or Group III sirolimus (205).

RESULTS

The mean follow-up was 39.2 (range 9.0-103.8) months. Overall, the number of patients needing insulin was 7.4% (39/528). The incidences for Groups I, II, and III of 7.6%, 11.7%, and 5.9%, respectively, were not statistically different. Characteristics of patients with PTDM included older age (P=0.007); greater body weight (kg) at transplant, 6 months, and 12 months, respectively (P<0.001); greater BMI (kg/m2) at transplant, 6 months, and 12 months, respectively (P<0.001); more acute rejection episodes 28.2% vs. 13.5% (P=0.012); and increased incidence in African Americans (P=0.03). Multivariable analysis demonstrated increased risk for PTDM (defined as new insulin use) for tacrolimus, (hazard ratio [HR] 3.794, P=0.007); treated rejections (HR 2.491, P=0.0115); age (HR 1.407, P=0.0116); and BMI (HR 1.153, P<0.0001). New insulin use occurred sooner and with less total glucocorticoid dose for tacrolimus patients. If PTDM is defined as all cases of new hyperglycemia, then no immunosuppressive drug group demonstrated an increased risk. CONCLUSION.: The risk for developing PTDM is greatest among older recipients, and those obese at the time of transplant; those given steroid pulse therapy were at exceptionally high-risk. PTDM risk reduction should focus on weight loss in the obese end-stage renal disease population prior to transplant.

Drug-induced diabetes mellitus

AIMS

To review the medications that influence glucose metabolism with a focus on hypertensive, transplant and HIV-infected patient populations.

METHODS

Literature obtained from a MEDLINE search from 1970 to present, including studies published in the English language. The search strategy linked drugs, hyperglycaemia and diabetes mellitus, HIV, transplantation, hypertension and psychiatric patients.

RESULTS

Many common therapeutic agents influence glucose metabolism. Multiple mechanisms of action on glucose metabolism exist through pancreatic, hepatic and peripheral effects. The prevalence of hyperglycaemia was higher with the use of thiazide diuretic, beta-blocker, calcineurin, protease inhibitors and atypical antipsychotic drugs.

CONCLUSIONS

Patients treated with those drugs appear to be at increased risk for developing diabetes. It is prudent to monitor plasma glucose values when it is not possible to avoid prescription of medication with known effects on carbohydrate metabolism.

The impact of overweight on the development of diabetes after heart transplantation

BACKGROUND

Overweight is defined with a body mass index (BMI) >25. A BMI >25 is known as an independent risk factor for increased morbidity and mortality. The influence of an increased BMI on the development of diabetes and on survival after heart transplantation (HTX) was investigated.

METHODS

A total of 137 patients (116 men, 21 women), who underwent HTX at our Department from 1986 to 2002, were included in the study. For group stratification, the pre-operative BMI values were taken (group I: BMI </or=25; group II: BMI > 25). Groups were compared for primary disease, age and sex, development of renal failure, development of diabetes, and survival. The probability of survival and the freedom-from-diabetes interval were calculated by the use of Kaplan-Meier method.

RESULTS

No significant differences between groups I and II were found concerning primary disease, age and sex, and occurrence of renal failure. There was a tendency towards increased survival (p = 0.18) in group I. Patients of group II developed diabetes after HTX more frequently than those of group I (p < 0.001). Cox regression revealed that pre-operative BMI >25 is a highly significant independent risk factor for post-operative development of diabetes mellitus (DM) (p < 0.001).

CONCLUSION

Overweight prior to HTX appears to negatively influence long-term survival after HTX, although this difference did not reach statistical significance. Pre-operative overweight is a significant and independent risk factor for the development of post-transplant diabetes.

Cardiovascular risk profile with the new immunosuppressive combinations after renal transplantation

Cardiovascular disease remains the main cause of death among kidney transplant patients. Cardiovascular risk burden already present at the moment of transplantation is substantially worsened by chronic use of immunosuppressants. On the other hand, chronic allograft nephropathy, a clinical-pathological result of immunological and non-immunological damage of the graft, is the main cause of graft loss in the long-term. Among the non-immunological factors contributing to the development of chronic allograft nephropathy, cardiovascular risk factors also seem to play a role. In the present review, we analyse the impact of the different immunosuppressive medications on cardiovascular risk factors after renal transplantation, including renal function.

Posttransplantation Diabetes Mellitus: Prevalence and Risk Factors

BACKGROUND

Prevalence of diabetes mellitus (DM) type 2 in Asturias is 10%. The associations between age, family history of diabetes, hypertension, obesity, hypertriglyceridemia, and development of type 2 diabetes are well established. The aim of this study was to evaluate the prevalence of and risk factors for posttransplantation diabetes mellitus (PTDM).

METHODS

We retrospectively studied 500 patients who had received a cadaveric renal transplant. Subjects with pretransplantation diabetes (5.6% type 1 and 7% type 2) and nondiabetics (78.2%) were excluded. We only evaluated 46 (9.2%) patients with PTDM. The follow-up period was 6 months to 15 years. We reviewed gender, age, family history of diabetes, body weight, hypertension, cardiovascular events, serum creatinine, hepatitis C virus infection, triglycerides, hyperuricemia, high-density lipoprotein and low-density lipoprotein cholesterol, and immunosuppressive therapies.

RESULTS

The median time to diagnosis of PTDM was 3 months (range 1-56 months) after transplantation, a period in which 47% patients developed this complication. Compared with nondiabetics, PTDM patients were significantly older (P = .000), more obese (P = .002), received tacrolimus (P = .027), and had hypertension (P = .014) or cardiovascular events (P = .000). Serum creatinine and hepatitis C virus infection rated were similar in both groups. On multivariate analyses, the risk factors significantly associated with the development of PTDM were greater age (P = .0024), obesity (P = .0032), and hypertension (P = .0516).

CONCLUSIONS

Half of the patients with PTDM developed new-onset diabetes within the first 3 months. Age, obesity, and hypertension were among the risk factors for diabetes posttransplantation. After the transplantation, the modifiable risk factors are control of body weight and control of hypertension.

New-Onset Diabetes after Kidney Transplantation: An Application of 2003 International Guidelines

BACKGROUND

The 2003 International Consensus Guidelines defined new-onset diabetes after transplantation. This study determined the risk of new-onset diabetes following kidney transplantation using these criteria.

METHODS

Consecutive nondiabetic patients who received kidney transplantation between August 2001 and March 2003 (recent, n=61) and before August 2001 (earlier, n=61) were retrospectively evaluated.

RESULTS

In all, 74% in the recent group and 56% in the earlier group developed diabetes by 1 year posttransplant. Median time to diabetes development was 23 days in the recent vs. 134 days in the earlier group (P=0.0304). Most patients developed diabetes within 60 days after transplantation. Immunosuppression was the strongest correlate of diabetes development; tacrolimus and cyclosporine A treatments were associated with increased risk. The rate of development was also greater when rapamycin was added to tacrolimus, compared to when it was not. The risk was double in African-Americans compared to whites. Age, body mass index, family history of diabetes, and etiology of renal failure did not predict diabetes; however, the mean age of patients was greater than previously reported.

CONCLUSIONS

The majority of patients are at risk of developing new-onset diabetes within a short time after kidney transplantation. The risk may be due to preexisting risk factors, immunosuppressive agents, or older age. The significance of these findings is not clear, but demands appropriate follow-up studies related to glycemia, end-organ complications, and graft function. It remains to be determined whether the 2003 International Consensus Guidelines are adequate to appropriately diagnose diabetes in the posttransplant time period, with special emphasis on the first 3 months.