Hyperparathyroidism and new onset diabetes after renal transplantation

Systematic Review of the Treatment of Persistent Hyperparathyroidism Following Kidney Transplantation

Chronic kidney disease-mineral and bone disorder is one of the complications associated with chronic kidney disease. About 10-50% of patients following kidney transplantation have persistent hyperparathyroidism. Hypercalcaemic hyperparathyroidism has a negative impact on the kidney transplant outcome; therefore, it requires treatment. The data regarding the treatment of persistent hyperparathyroidism provided in scientific publications are divergent and contradictory. Therefore, the aim of our systematic review was to evaluate the efficacy of persistent hyperparathyroidism treatment in patients following kidney transplantation. The Cochrane, PubMed, and Scopus databases were browsed independently by two authors. The search strategy included controlled vocabulary and keywords. The effectiveness of calcitriol, paricalcitol, cinacalcet, and parathyroidectomy was compared and analysed. The mean calcium and parathormone (PTH) concentrations per patient in the group of paricalcitol increased by 1.27% and decreased by 35.14% (n = 248); in the group of cinacalcet decreased by 12.09% and 32.16% (n = 368); and in the group of parathyroidectomy decreased by 19.06% and 86.49% (n = 15) at the end of the study compared to the baseline (n = 244, n = 342 and n = 15), respectively. Paricalcitol, cinacalcet, and parathyroidectomy decreased the intact PTH level. Cinacalcet and parathyroidectomy lowered calcium levels in renal transplant patients with hypercalcaemia. Conversely, paricalcitol increased the serum calcium concentration. Cinacalcet seems to be a good candidate in the treatment of post-transplant hyperparathyroidism.

Prevalence and Risk Factors of New-Onset Diabetes After Transplantation (NODAT)

Background

New-onset diabetes after transplantation (NODAT) is a serious complication after a solid organ transplant. NODAT occurs in 2% to 53% of all solid organ transplant recipients. The identification of high-risk patients and the implementation of measures to limit the development of NODAT can improve the long-term patient prognosis.

Material/Methods

Our study group consisted of 336 patients undergoing heart transplant. Patients with prior diabetes (60 patients) were excluded from analysis. The remaining 276 patients were divided in 2 groups: with NODAT (n=109) and without NODAT (n=167). Logistic regression analysis was used for NODAT risk factor assessment.

Results

NODAT occurred in 109 (32%) out of 336 patients without diagnosed diabetes before heart transplantation. Risk factors for post-transplant diabetes mellitus, which was shown by the analysis of the collected data, were BMI at discharge (OR=1.082, CI 1.011–1.158, p=0.0233), history of diagnosed CMV infection (OR=1.464, CI 1.068–2.007, p=0.0179), and age over 51 years (OR=1.634, CI 1.274–2.095, p=0.0001).

Conclusions

1. New-onset diabetes after transplantation (NODAT) or long-lasting hypoglycemia (over 2 years after transplantation) was diagnosed in 32% patients after heart transplantation developed. 2. The risk factors of NODAT were BMI at discharge and history of diagnosed CMV infection, and age over 51 years was an independent risk factor.

Insights into the Association of Vitamin D Deficiency with Parathyroid Hormone Levels with Relevance to Renal Function and Insulin Resistance

Objective:

The rationale of the current study was to investigate whether this inverse association is agedependent and whether it has any role in modulating renal function and insulin resistance.

Methods:

To test this hypothesis, we have carried out a hospital based study enrolling 848 subjects (558 men and 290 women) with the mean age of 50.9 ± 15.9 y. Chemiluminometric competitive immune assays were performed using commercial kits to determine 25-OH vitamin D and Parathyroid Hormone (PTH) levels. Fasting glucose levels and serum creatinine were used to evaluate diabetes and renal function.

Results:

Vitamin D deficiency was predominant irrespective of age group (p = 0.21) and gender (p = 0.12). An inverse association between vitamin D and PTH was observed (r = -0.24) in middle age subjects (p = 0.02). The data segregation based on plasma vitamin D levels which were <20 ng/ml, 20.1- 30 ng/ml and >30 ng/ml confirmed the inverse association between vitamin D and PTH levels (ptrend: 0.007). Subjects with low plasma vitamin D and increased PTH exhibited elevated blood urea, serum creatinine and blood glucose. Subjects with 25-OHD deficiency showed a 3.03-folds (95% CI: 2.26- 4.07) and 2.09-fold (1.41-3.10) increased risk for diabetes and renal disease, respectively.

Conclusion:

Based on the results of the present study, it is suggested that those with vitamin D deficiency need to be evaluated for possible presence of renal dysfunction, diabetes/insulin resistance in addition to assessing their PTH status.

A SEVERE CASE OF HYPERGLYCEMIA IN A KIDNEY TRANSPLANT RECIPIENT UNDERGOING INTERFERON-FREE THERAPY FOR CHRONIC HEPATITIS C

CONTEXT

Hepatitis C and diabetes represent important health problems globally. The new-onset diabetes after transplantation is a particular entity that appears due to the use of immunosuppression among transplanted patients.

OBJECTIVE

We aim to describe the clinical and biological aspects of severe hyperglycemia in a kidney transplant recipient undergoing Interferon-free therapy for chronic hepatitis C, discussing the interference of different factors with the glucose metabolism.

DESIGN

The occurrence of diabetes in a patient with history of renal transplantation and Interferon-free treated hepatitis C was studied from both clinical and paraclinical points of view.

SUBJECTS AND METHODS

When presenting to the hospital, extensive blood tests were performed on the patient, revealing significant hyperglycemia and an elevated level of blood tacrolimus. Creatinine clearance was calculated. ECG presented T-wave alterations. Intensive insulin protocol was applied, the case being managed in a multidisciplinary approach.

RESULTS

Blood glucose and tacrolimus were slowly normalized, under therapy. The antiviral treatment was continued, with the achievement of sustained virologic response.

CONCLUSIONS

Diabetes mellitus can have many causes, hepatitis C and transplantation both having an impact on glucose metabolism. The association of the three entities should be carefully managed, due to its enhancing effect on morbidity and mortality.

The incidence of new onset diabetes after transplantation and related factors: Single center experience

AIM

New-onset diabetes after transplantation (NODAT) is a frequent metabolic complication and is considered a risk factor for patients undergoing renal transplant. The aim of this study was to evaluate the incidence and developing duration of new-onset diabetes after transplant (NODAT) and influencing factors.

METHODS

All patients' data was investigated retrospectively. Diabetics, follow-up period<6 months, age<18years were excluded. Demographic, clinical and laboratory data was recorded. Patients were divided into two groups: with/without NODAT. NODAT group was divided into four subgroups according to the time of developing NODAT, which were 0-3, 3-6, 6-12 and 12 months later. Two groups were compared, to investigate the incidence of NODAT and risk factors associated with the occurrence of NODAT.

RESULTS

We retrospectively analyzed the records of 570 patients, of which 420 patients were included. Seventy (16.6%) patients had NODAT (36 female, mean age 51.7±8.2 years, mean follow-up 41.6±21.5 months), 52.8% of patients developed NODAT within the first three months of being diagnosed. 350 patients (116 female, mean age 43.2±12.5 years, mean follow-up 41.6±21.5 months) were without NODAT. The incidence of impaired fasting glucose (IFG) during the first week after transplant was found to be higher in the patients with NODAT (p<0.001). There was positive correlation between NODAT and older age, obesity, family history of diabetes, presence of IFG, fasting plasma glucose, total and LDL-cholesterol, triglycerides, parathormone. Old age, obesity, presence of IFG, pretransplant hypertriglyceridemia and hyperparathyroidism were predictors of development of NODAT.

CONCLUSION

Incidence of NODAT, especially the first six months, was high. All patients should be screened for IFG within the first week. Patients with dyslipidemia, elderly and obese patients should be closely monitored for the risk of development of NODAT.

Dysglycemia after renal transplantation: Definition, pathogenesis, outcomes and implications for management

New-onset diabetes after transplantation (NODAT) is major complication following renal transplantation. It commonly develops within 3-6 mo post-transplantation. The development of NODAT is associated with significant increase in risk of major cardiovascular events and cardiovascular death. Other dysglycemic states, such as impaired glucose tolerance are also associated with increasing risk of cardiovascular events. The pathogenesis of these dysglycemic states is complex. Older recipient age is a consistent major risk factor and the impact of calcineurin inhibitors and glucocorticoids has been well described. Glucocorticoids likely cause insulin resistance and calcineurin inhibitors likely cause β-cell toxicity. The impact of transplantation in incretin hormones remains to be clarified. The oral glucose tolerance test remains the best diagnostic test but other tests may be validated as screening tests. Possibly, NODAT can be prevented by administering insulin early in patients identified as high risk for NODAT. Once NODAT has been diagnosed altering immunosuppression may be acceptable, but creates the difficulty of balancing immunological with metabolic risk. With regard to hypoglycemic use, metformin may be the best option. Further research is needed to better understand the pathogenesis, identify high risk patients and to improve management options given the significant increased risk of major cardiovascular events and death.