Diabetes mellitus after kidney transplantation in Japanese patients: The Japan Academic Consortium of Kidney Transplantation study

Pulse wave parameters as a predictor of the development of post-transplant diabetes mellitus after kidney transplantation

BACKGROUND

Kidney transplantation is the preferred treatment for patients with end-stage renal disease, significantly preserving kidney function and patient quality of life. However, post-transplant diabetes mellitus (PTDM) is a common complication, occurring in approximately one-third of renal transplant recipients. This study aims to evaluate the role of pulse wave parameters in predicting PTDM and to identify other pre-transplant risk factors.

METHODS

This prospective cohort study included 105 patients on the kidney transplant waiting list from 2017 to 2022. Exclusion criteria included any pre-existing diabetes mellitus. Patients underwent physical examinations, laboratory analyses, and pulse wave analysis before transplantation and one year post-transplant. PTDM diagnosis followed International Consensus Guidelines. Data were analyzed using Wilcox test, Bonferroni correction, May-Whitney U-test, and Fisher's exact test, with p < 0.05 considered statistically significant.

RESULTS

Post-transplant, 21% of patients were diagnosed with PTDM, increasing to 35% 3months post-transplant and 43% at one year post-transplant. Significant findings included: Pre-transplat risk factors for developing PTDM: Proteinuria (p = 0.037, OR = 3.942) and perioperative hyperglycemia (p = 0.003, OR = 4.219 at 3 months; p = 0.001, OR = 4.571 at 1 year). Pulse wave parameters for developing PTDM: Pre-transplant Aortic PP > 45 mmHg (AUC = 0.757) and PWV > 8.5 m/s (AUC = 0.730) were strong predictors of the development of PTDM after 3 months (p < 0.0001). Moreover, we found significant improvements in aortic pulse pressure (Aortic PP) and pulse wave velocity (PWV) post-transplant (p < 0.0001).

CONCLUSION

Our study confirms that pulse wave parameters, such as Aortic PP and PWV, are significant predictors of PTDM in kidney transplant recipients (KTR). These findings support incorporating pulse wave analysis into routine pre-transplant evaluations to identify high-risk patients. Additionally, monitoring these parameters post-transplant may aid in early intervention and prevention of PTDM, ultimately improving patient outcomes.

TRIAL REGISTRATION

Ethical approval was obtained from the Ethics Committee of Medical faculty and University Hospital Olomouc (approval no. 94/15).

Managing Post-Transplant Diabetes Mellitus after Kidney Transplantation: Challenges and Advances in Treatment

Kidney transplantation is the most effective treatment for end-stage renal failure but is associated with complications, including post-transplant diabetes mellitus (PTDM). It affects the quality of life and survival of patients and the transplanted organ. It can cause complications, including infections and episodes of acute rejection, further threatening graft survival. The prevalence of PTDM, depending on the source, can range from 4 to 30% in transplant patients. This article aims to discuss issues related to diabetes in kidney transplant patients and the latest treatments. Knowledge of the mechanisms of action of immunosuppressive drugs used after transplantation and their effect on carbohydrate metabolism is key to the rapid and effective detection of PTDM. Patient therapy should not only include standard management such as lifestyle modification, insulin therapy or pharmacotherapy based on well-known oral and injection drugs. New opportunities are offered by hypoglycemic drugs still in clinical trials, including glucokinase activators, such as dorzagliatin, ADV-1002401, LY2608204, TMG-123, imeglimine, amycretin and pramlintide. Although many therapeutic options are currently available, PTDM often creates uncertainty about the most appropriate treatment strategy. Therefore, more research is needed to individualize therapeutic plans and monitor these patients.

Importance of Management of Lifestyle-Related Diseases After Kidney Donation to Living Donors

BACKGROUND

Living kidney transplant donors are classified as stage 3 chronic kidney disease after kidney donation. For this reason, we provide daily lifestyle guidance, such as blood pressure and weight management before surgery, and dietary counseling focused on salt restriction. We emphasize providing lifestyle guidance after kidney donation.

METHOD

At Osaka Medical and Pharmaceutical University Hospital, living kidney donors are scheduled for their first postoperative visit 1 month after kidney donation, followed by regular checkups every 6 months after that, starting 3 months after the initial visit. When living kidney donors come to the Renal Replacement Therapy Selection Outpatient Clinic before kidney transplantation, we provide sufficient explanations of the potential risks that may arise after kidney donation and ensure that they understand the importance of regular postoperative checkups. Apart from cases where patients reside far away, and we ask another hospital to provide postoperative follow-up, we can achieve regular checkups for almost all cases.

RESULTS

Eighty-four living kidney transplant donors are being followed up at Osaka Medical and Pharmaceutical University Hospital. The average age is 59.8 ± 11.8 years, showing a trend of aging. Among the donors under follow-up, 7 developed hyperlipidemia, 2 developed hypertension, and 1 developed diabetes as new-onset lifestyle diseases after kidney donation.

CONCLUSION

The ability to empathize with and support the anxieties associated with kidney donation and build a strong relationship of trust with the donors has become a significant factor in achieving a high rate of regular checkups after kidney donation. As a result, it has led to early detection and intervention for donor diseases, contributing to the maintenance of their health. Managing lifestyle-related diseases after kidney donation is essential for living kidney donors.

Myosteatosis as a novel predictor of new-onset diabetes mellitus after kidney transplantation

OBJECTIVES

We evaluate the effect of myosteatosis on new-onset diabetes mellitus after kidney transplantation.

METHODS

Consecutive patients who had renal transplant between 2006 and 2021 were reviewed, and 219 patients were finally included. Psoas muscle index was used to evaluate sarcopenia and average total psoas density (calculated by computed tomography before surgery) for myosteatosis. We used Cox proportional regression analyses in investigation of whether skeletal muscle depletion before surgery inclusive of sarcopenia and myosteatosis is a new additional predictor of new-onset diabetes mellitus.

RESULTS

Median recipient age and body mass index were 45 years and 21.1 kg/m2 , respectively, and 123 patients (56%) were male. Preoperative impaired glucose tolerance was present in 58 patients (27%) and new-onset diabetes mellitus in 30 patients (14%), with median psoas muscle index of 6 cm2 /m2 and average total psoas density of 41 Hounsfield Unit. In multivariate analysis, significant risk factors were body mass index ≥25 kg/m2 (p < 0.01), impaired glucose tolerance (p < 0.01), and average total psoas density < 41.9 Hounsfield Unit (p = 0.03). New-onset diabetes mellitus had incidence rates of 3.7% without risk factors, 10% with a single risk factor, 33% with two, and 60% with three. Patients with new-onset diabetes mellitus were effectively stratified by the number of risk factors (p < 0.01).

CONCLUSIONS

Myosteatosis could be a new risk factor used to predict new-onset diabetes mellitus.

Low dose tacrolimus exposure and early steroid withdrawal with strict body weight control can improve post kidney transplant glucose tolerance in Japanese patients

The development of diabetes mellitus (DM) after living donor kidney transplantation (KT) is a risk factor for worsening transplant kidney function, cardiac disease, and cerebrovascular disease, which may affect prognosis after KT. At our institution, all patients' glucose tolerance is evaluated perioperatively by oral glucose tolerance tests (OGTTs) at pre-KT, and 3, 6, and 12 month (mo.) after KT. We analyzed the insulinogenic index (ISI) and homeostasis model assessment beta cell (HOMA-β) based on the immunoreactive insulin (IRI) levels to determine how glucose tolerance changed after KT in 214 patients who had not been diagnosed with DM before KT. In addition, we analyzed the body mass index (BMI) which may also influence glucose tolerance after KT. The concentration of tacrolimus (TAC) in blood was also measured as the area under the curve (AUC) to examine its effects at each sampling point. The preoperative-OGTTs showed that DM was newly diagnosed in 22 of 214 patients (10.3%) who had not been given a diagnosis of DM by the pre-KT fasting blood sugar (FBS) tests. The glucose tolerance was improved in 15 of 22 DM patients at 12 mo. after KT. ISI and IRI deteriorated only at 3 mo. after KT but improved over time. There was a trend of an inverse correlation between HOMA-β and TAC-AUC. We also found inverse correlations between IRI and an increase in BMI from 3 to 12 mo. after KT. Early corticosteroid withdrawal or the steroid minimization protocol with tacrolimus to maintain a low level of diabetogenic tacrolimus and BMI decrease after KT used by our hospital individualizes lifestyle interventions for each patient might contribute to an improvement in post-KT glucose tolerance.

Long-term prolonged-release tacrolimus outcomes in living donor kidney transplantation: The Japan Academic Consortium of Kidney Transplantation study-II

OBJECTIVES

To evaluate the 10-year efficacy and safety of a prolonged-release tacrolimus-based combination immunosuppressive regimen on longer-term outcomes in living donor kidney transplantation.

METHODS

Data from Japanese living donor kidney transplant recipients (n = 410) maintained on continuous prolonged-release tacrolimus-based immunosuppression from 2009-2013 were analyzed with a median follow-up of 9.9 years.

RESULTS

A prolonged-release, tacrolimus-based combination regimen provided death-censored graft failure and all-cause death rates at 10 years of 7.0% and 6.8%, respectively. In multivariable analyses, acute and chronic rejection and 'throughout' (new-onset plus preexisting) diabetes mellitus were risk factors for death-censored graft failure. Recipient age ≥ 65 years, throughout diabetes mellitus and malignancy were common risk factors for all-cause death. Throughout diabetes mellitus was the most common risk factor for both death-censored graft failure and all-cause death. Additional analyses showed 10-year cumulative rates of death-censored graft failure were 14.0% and 5.4% for recipients with or without preexisting diabetes mellitus, respectively (log-rank test: p = 0.009). All-cause death rates were 12.7% and 5.4% in the preexisting and non-diabetes mellitus groups, respectively (log-rank test: p = 0.023).

CONCLUSIONS

In this real-world, retrospective, living donor kidney transplantation study, a prolonged-release tacrolimus-based immunosuppressive combination regimen provided 10-year death-censored graft failure rates of 14.0% and 5.4% in diabetes mellitus and non-diabetes mellitus patients, respectively; Similarly, 10-year all-cause death rates were 12.7% and 5.4% in diabetes mellitus and non-diabetes mellitus patients, respectively. To our knowledge, the data in this study are the first to provide 10-year transplant outcomes in living donor kidney transplant recipients under prolonged-release tacrolimus-based regimen.

Progress of new-onset diabetes after liver and kidney transplantation

Organ transplantation is currently the most effective treatment for end-stage organ failure. Post transplantation diabetes mellitus (PTDM) is a severe complication after organ transplantation that seriously affects the short-term and long-term survival of recipients. However, PTDM is often overlooked or poorly managed in its early stage. This article provides an overview of the incidence, and pathogenesis of and risk factors for PTDM, aiming to gain a deeper understanding of PTDM and improve the quality of life of recipients.

Pretransplant BMI Should Be <25 in Japanese Kidney Transplant Recipients: A Single-Center Experience

BACKGROUND

The aim of this study was to determine the appropriate body mass index (BMI) in Japanese kidney transplant (KTx) recipients. We analyzed the effects of pre- and post-transplant (Tx) obesity on graft and patient survival, perioperative complications, post-transplant diabetes mellitus (PTDM), and cardiovascular disease (CVD) in Japanese KTx recipients.

METHODS

This retrospective study included 269 recipients who underwent KTx from 2008 through 2020 at Niigata University Hospital. Obesity was defined as a body mass index (BMI) ≥25 kg/m². We examined the association between pre- and post-Tx obesity and graft survival, patient survival, the incidence of PTDM and CVD, and perioperative surgical complications.

RESULTS

The graft survival rate was lower in the pre-Tx BMI ≥25 kg/m² group, although there was no significant difference in patient survival. There was no difference in graft and patient survival between the post-Tx BMI ≥25 kg/m² group and the <25 kg/m² group. A pre-Tx BMI ≥25 kg/m² was an independent risk factor for biopsy-proven allograft rejection. New-onset DM after transplantation was significantly more common in the BMI ≥25 kg/m² group than in the BMI <25 kg/m² group (36% vs 13%; P = .002). The incidence of CVD was significantly higher in the post-Tx BMI ≥30 kg/m² group than in the BMI <30 kg/m² group (50% vs 11%; P = .023). There were no differences in surgical operating time, intraoperative blood loss, or perioperative complications between the obese and non-obese groups.

CONCLUSION

Pre-Tx BMI ≥25 kg/m² may be a risk factor for allograft rejection and graft loss. Post-Tx BMI should be <25 kg/m² to reduce the risk for PTDM.

Clinical outcomes of posttransplantation diabetes mellitus in kidney transplantation recipients: a nationwide population-based cohort study in Korea

Posttransplantation diabetes mellitus (PTDM) is an important metabolic complication after KT that causes graft failure and cardiovascular complications in kidney transplantation (KT) recipients. Using the national claim data of South Korea, 7612 KT recipients between 2009 and 2017 were analyzed. PTDM was defined as a consecutive 30-day prescription history of antidiabetic medication after KT. Among these patients, 24.7% were diagnosed with PTDM, and 51.9% were diagnosed within 6 months after KT. Compared to patients without PTDM, those with PTDM were older, more likely to be men, more likely to be diagnosed with hypertension and cardio-cerebrovascular disease, and experienced more rejection episodes requiring high-dose steroid treatment after KT. During the follow-up, 607 DCGFs, 230 DWGFs, 244 MACEs, and 260 all-cause mortality events occurred. Patients with PTDM showed a higher risk of DCGF (adjusted hazard ratio [aHR] 1.49; 95% confidence interval [CI] 1.22-1.82; P < 0.001) and MACEs (aHR 1.76; 95% CI 1.33-2.31; P < 0.001) than patients without PTDM. The risks for all clinical outcomes were higher in the insulin group than in the non-use insulin group. PTDM in KT recipients resulted in both worse allograft and patient outcomes represented by DCGF and MACE, especially in patients needing insulin treatment.

Post-transplant Diabetes Mellitus in Kidney Transplant Recipients in Sudan: A Comparison Between Tacrolimus and Cyclosporine-Based Immunosuppression

Hyperglycemia is a common complication among transplant patients without a history of diabetes mellitus (DM). Although new and potent immunosuppressants have improved short and long-term outcomes after transplantation, these drugs themselves may be associated with a greater risk of hyperglycemia. The present study aimed to determine the prevalence of post-transplant diabetes mellitus (PTDM) in post renal transplant patients in Sudan, and compare the effect of cyclosporine and tacrolimus-based immunosuppressive regimens. All adult kidney transplant recipients without pre-transplant diabetes who attended the transplant clinic at Ahmed Gasim Cardiac Surgery and Renal Transplant Center in Sudan were included. A total of 100 cases with functioning kidney allografts were enrolled in this study. The majority of cases were in the age range between 20 and 60 years (92%). Males and females were nearly equally distributed (56% vs 44%). Fifty-two percent of patients were on cyclosporine and 48% on tacrolimus. Overall, 18% of patients suffered from post-transplant diabetes mellitus. There was no statistically significant difference between tacrolimus and cyclosporine with regards to the prevalence of hyperglycemia (16.6% versus 13.4%; p>0.05).

Nonlinear relationship between body mass index and clinical outcomes after kidney transplantation: A dose-response meta-analysis of 50 observational studies

BACKGROUND

Exact dose-response relationship between body mass index at transplantation and clinical outcomes after kidney transplantation remained unclear, and no specific body mass index threshold and pretransplant weight loss aim were recommended for kidney transplantation candidates among transplant centers.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for literature published up to December 31, 2019. The two-stage, random effect meta-analysis was performed to estimate the dose-response relationship between body mass index and clinical outcomes after kidney transplantation.

RESULTS

Ninety-four studies were included for qualitative assessment and 50 for dose-response meta-analyses. There was a U-shaped relationship between graft loss, patient death, and body mass index. Body mass index with the lowest risk of graft loss was 25.2 kg/m², and preferred body mass index range was 22-28 kg/m². Referring to a body mass index of 22 kg/m², the risk of graft loss was 1.088, 0.981, 1.003, and 1.685 for a body mass index of 18, 24, 28, and 40 kg/m², respectively. Body mass index with the lowest risk of patient death was 24.7 kg/m², and preferred body mass index range was 22-27 kg/m². Referring to a body mass index of 22 kg/m², the patient death risk was 1.115, 0.981, 1.032, and 2.634 for a body mass index of 18, 24, 28, and 40 kg/m², respectively. J-shaped relationships were observed between body mass index and acute rejection, delayed graft function, primary graft nonfunction, and de novo diabetes. Pair-wise comparisons showed that higher body mass index was also a risk factor for cardiovascular diseases, hypertension, infection, longer length of hospital stay, and lower estimated glomerular filtration rate level.

CONCLUSION

Underweight and severe obesity at transplantation are associated with a significantly increased risk of graft loss and patient death. A target body mass index at kidney transplantation is 22-27 kg/m².

Serum hs-CRP measured prior transplantation predicts of new-onset diabetes after transplantation in renal transplant recipients

BACKGROUND

To assess the incidence of new-onset diabetes after transplantation (NODAT) for the first year post-transplantation and the predictive value of high-sensitivity C-reactive Protein (hs-CRP) before transplantation for NODAT prediction in kidney transplantation patients.

MATERIAL AND METHODS

A study of 251 consecutive adult end-stage kidney disease patients transplanted kidneys from living donors, follow-up during the first year to find NODAT. We diagnosed NODAT based on blood glucose or HbA1c following to the criteria of the American Diabetes Association.

RESULTS

The ratio of NODAT was 12.4%. The mean age, mean BMI, the proportion of arteriosclerosis, and the median hs-CRP level in NODAT group were significantly higher than those of non-NODAT group with p < 0.05. Age, BMI and serum hs-CRP had a predictive value for NODAT (Age: AUC = 0.62, p < 0.05, BMI: AUC = 0.626, hs-CRP: AUC = 0.748, p < 0.001).

CONCLUSION

Serum hs-CRP level measured prior transplantation is a good predictor for NODAT in renal transplant recipients.

Risk Factors in and Long-Term Survival of Patients with Post-Transplantation Diabetes Mellitus: A Retrospective Cohort Study

Post-transplant diabetes mellitus (PTDM) is associated with infection, cardiovascular morbidity, and mortality. A retrospective cohort study involving patients who underwent renal transplantation in a transplantation center in Taiwan from January 2000 to December 2018 was conducted to investigate the incidence and risk factors of PTDM and long-term patient and graft survival rates. High age (45-65 vs. <45 years, adjusted odds ratio (aOR) = 2.90, 95% confidence interval (CI) = 1.64-5.13, p < 0.001), high body mass index (>27 vs. <24 kg/m², aOR = 5.35, 95% CI = 2.75-10.42, p < 0.001), and deceased organ donor (cadaveric vs. living, aOR = 2.01, 95% CI = 1.03-3.93, p = 0.04) were the three most important risk factors for the development of PTDM. The cumulative survival rate of patients and allografts was higher in patients without PTDM than in those with PTDM (p = 0.007 and 0.041, respectively). Concurrent use of calcineurin inhibitors and mammalian target of rapamycin inhibitors (mTORis) decreased the risk of PTDM (tacrolimus vs. tacrolimus with mTORi, aOR = 0.28, 95% CI = 0.14-0.55, p < 0.001). Investigating PTDM risk factors before and modifying immunosuppressant regimens after transplantation may effectively prevent PTDM development.

Post-transplant diabetes mellitus in patients with solid organ transplants

Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10-20% of patients with kidney transplants and in 20-40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.

Once-daily vs twice-daily tacrolimus for de novo living kidney transplantation patients including ABO/HLA compatible and incompatible: A randomized trial

Tacrolimus (TAC) is available as a twice-daily capsule (TAC-BID), once-daily capsule (TAC-QD), and once-daily tablet. Recipients with ABO-incompatible/anti-human leukocyte antigen (HLA)-incompatible transplantation were excluded in previous trials and have thus not been evaluated. We conducted a 5-year trial to determine whether TAC-QD is noninferior to TAC-BID for transplant outcomes. Adults who underwent de novo living kidney transplantation were randomly assigned (62 TAC-QD; 63 TAC-BID). We did not exclude ABO-/HLA- incompatible transplantation. TAC was initiated 7 days preoperatively (0.10 mg/kg/d). Mycophenolate mofetil, methylprednisolone, and basiliximab were administered. The primary endpoint was graft failure (non-censored for death). We performed a noninferiority test. The noninferiority margin was 10% in risk difference. Five-year graft failure rates were 6.5% and 9.5% for TAC-QD and TAC-BID, respectively (noninferiority, P = 0.009). The estimated glomerular filtration rates were similar between the groups (noninferiority, P < 0.001). TAC-QD did not have point estimates of risk difference above the inferiority margin in any assessed endpoints. However, a tendency of interaction was observed between biopsy-proven acute rejection and the follow-up period. In a living kidney transplant population with 40% of patients with ABO/HLA incompatibility, the effect of TAC-QD was not appreciably worse on various clinical transplant outcomes than that of TAC-BID over 5 years.

Elderly living donor kidney transplantation allows worthwhile outcomes: The Japan Academic Consortium of Kidney Transplantation study

OBJECTIVE

To compare transplant outcomes among elderly (aged ≥60 years) and non-elderly recipients, and to evaluate the acceptability of elderly living donor kidney transplantation in practice after consideration of living donor type.

METHODS

We included 830 adult patients with living donor kidney transplantation between 2000 and 2011 in this retrospective cohort study. We compared death-censored graft survival, patient survival, biopsy-proven rejection, complications, and renal function in elderly (n = 119) and non-elderly recipients (n = 278).

RESULTS

There was no significant difference in 10-year death-censored graft survival (P = 0.980). Corresponding patient survival rates in the elderly and non-elderly groups were 84.1% and 98.1%, respectively (hazard ratio 6.15, 95% confidence interval 2.12-17.82, P < 0.001). Elderly patients had more complications and chronic T-cell-mediated rejection. Factors associated with death in elderly recipients with functioning grafts were residual advanced recipient age (hazard ratio 1.39), decreased hemoglobin (hazard ratio 4.10), hepatitis B virus (hazard ratio 7.89), hepatitis C virus (hazard ratio 13.12) and elevated alanine aminotransferase (hazard ratio 1.13).

CONCLUSIONS

Elderly living donor kidney transplantation seems to provide adequate acceptable outcomes. However, physicians should be cautious when evaluating elderly patients with hepatitis, and further studies are required to improve long-term outcomes.