1
|
Van Laecke S. Thiazides in kidney transplant recipients: skin in the game. Nat Rev Nephrol 2024; 20:351-352. [PMID: 38632382 DOI: 10.1038/s41581-024-00839-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Steven Van Laecke
- Renal Division, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium.
| |
Collapse
|
2
|
Rahbari-Oskoui FF. Management of Hypertension and Associated Cardiovascular Disease in Autosomal Dominant Polycystic Kidney Disease. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:417-428. [PMID: 38097332 DOI: 10.1053/j.akdh.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 12/18/2023]
Abstract
Autosomal dominant polycystic kidney disease is the most commonly inherited disease of the kidneys affecting an estimated 12,000,000 people in the world. Autosomal dominant polycystic kidney disease is a systemic disease, with a wide range of associated features that includes hypertension, valvular heart diseases, cerebral aneurysms, aortic aneurysms, liver cysts, abdominal hernias, diverticulosis, gross hematuria, urinary tract infections, nephrolithiasis, pancreatic cysts, and seminal vesicle cysts. The cardiovascular anomalies are somewhat different than in the general population and also chronic kidney disease population, with higher morbidity and mortality rates. This review will focus on cardiovascular diseases associated with autosomal dominant polycystic kidney disease and their management.
Collapse
Affiliation(s)
- Frederic F Rahbari-Oskoui
- Director of the PKD Center of Excellence, Department of Medicine-Renal Division, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA.
| |
Collapse
|
3
|
Zhang Z, Sun J, Guo M, Yuan X. Progress of new-onset diabetes after liver and kidney transplantation. Front Endocrinol (Lausanne) 2023; 14:1091843. [PMID: 36843576 PMCID: PMC9944581 DOI: 10.3389/fendo.2023.1091843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Zhen Zhang
- Department of Urology, The People's Hospital of Linyi, Linyi, Shandong, China
| | - Jianyun Sun
- Department of Gastroenterology, The People's Hospital of Linyi, Linyi, Shandong, China
| | - Meng Guo
- National Key Laboratory of Medical Immunology &Institute of Immunology, Navy Medical University, Shanghai, China
| | - Xuemin Yuan
- Department of Gastroenterology, The People's Hospital of Linyi, Linyi, Shandong, China
| |
Collapse
|
4
|
Dachy A, Decuypere JP, Vennekens R, Jouret F, Mekahli D. Is autosomal dominant polycystic kidney disease an early sweet disease? Pediatr Nephrol 2022; 37:1945-1955. [PMID: 34988697 DOI: 10.1007/s00467-021-05406-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
The clinical course of autosomal dominant polycystic kidney disease (ADPKD) starts in childhood. Evidence of the beneficial impact of early nephron-protective strategies and lifestyle modifications on ADPKD prognosis is accumulating. Recent studies have described the association of overweight and obesity with rapid disease progression in adults with ADPKD. Moreover, defective glucose metabolism and metabolic reprogramming have been reported in distinct ADPKD models highlighting these pathways as potential therapeutic targets in ADPKD. Several "metabolic" approaches are currently under evaluation in adults, including ketogenic diet, food restriction, and metformin therapy. No data are available on the impact of these approaches in childhood thus far. Yet, according to World Health Organization (WHO), we are currently facing a childhood obesity crisis with an increased prevalence of overweight/obesity in the pediatric population associated with a cardio-metabolic risk profile. The present review summarizes the knowledge about the role of glucose metabolism in the pathophysiology of ADPKD and underscores the possible harm of overweight and obesity in ADPKD especially in terms of long-term cardiovascular outcomes and renal prognosis.
Collapse
Affiliation(s)
- Angélique Dachy
- PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatrics, ULiège Academic Hospital, Liège, Belgium.,Laboratory of Translational Research in Nephrology (LTRN), GIGA Cardiovascular Sciences, ULiège, Liège, Belgium
| | - Jean-Paul Decuypere
- PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Rudi Vennekens
- Laboratory of Ion Channel Research, Department of Cellular and Molecular Medicine, VIB Center for Brain and Disease Research, KU Leuven, Leuven, Belgium
| | - François Jouret
- Laboratory of Translational Research in Nephrology (LTRN), GIGA Cardiovascular Sciences, ULiège, Liège, Belgium.,Division of Nephrology, Department of Internal Medicine, ULiège Academic Hospital, Liège, Belgium
| | - Djalila Mekahli
- PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium. .,Department of Pediatric Nephrology, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| |
Collapse
|
5
|
Attallah N, Yassine L. Linagliptin in the Management of Type 2 Diabetes Mellitus After Kidney Transplant. Transplant Proc 2021; 53:2234-2237. [PMID: 34376312 DOI: 10.1016/j.transproceed.2021.07.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence and prevalence of end-stage renal disease (ESRD) is increasing. The most common cause of ESRD is diabetes mellitus (DM). Kidney transplantation offers better quality of life and survival for patients with ESRD. Because of the use of immunosuppressive therapy and steroids post-kidney transplantation, the patients are at an increased risk for the development of posttransplant DM (PTDM). Management of DM after transplantation (whether pre-existing or transplant related) remains a challenge. Multiple treatment options are currently available to manage PTDM. Those medications have good safety and efficacy record in the general population and in patients with mild degrees of kidney disease. METHODS We conducted a retrospective single center analysis of safety and efficacy of linagliptin post-kidney transplantation. The study was approved by the institutional review board. We collected data (demographics, laboratory tests, and any symptoms or hospitalizations) for 42 patients for a period of 12 months. RESULTS All 42 patients received linagliptin throughout the study period. Patients' average age was 62 years. Twenty-three were women and all were of Middle Eastern descent and had kidney transplants on average of 25 months when they were included in the study. Nineteen patients had DM before the transplant, and the rest had PTDM. Eighteen patients were on metformin and 15 were on insulin, whereas the rest were not on any other medications at the start of the study. Baseline average creatinine was 1.5 mg/dL (132.9 mmol/L) and glycated hemoglobin (HbA1c) was 8.2 g/dL at the start of the study, whereas creatinine was 1.6 mg/dL (138.5 mmol/L) and HbA1c was 7.4 g/dL at the end. HbA1c dropped 0.8 on average within 3 months of starting linagliptin and remained at the same level for the rest of the study. Urine protein did not change significantly throughout the study. Three patients developed acute myocardial infarction during the study, and a fourth one was hospitalized with an opportunistic infection. Two patients had urinary tract infections. Adverse effects were minimal. No allergic reactions, hypoglycemia, or acute pancreatitis episodes were reported. The average weight and body mass index did not change throughout the study. None of the patients stopped the medication. CONCLUSIONS In this retrospective analysis, linagliptin seems to be safe and efficacious after kidney transplantation. It can be considered as a treatment option to manage DM after transplantation.
Collapse
Affiliation(s)
- Nizar Attallah
- Department of Nephrology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
| | - Lina Yassine
- Imperial College of London Diabetes Center, Abu Dhabi, United Arab Emirates
| |
Collapse
|
6
|
Schwaiger E, Krenn S, Kurnikowski A, Bergfeld L, Pérez-Sáez MJ, Frey A, Topitz D, Bergmann M, Hödlmoser S, Bachmann F, Halleck F, Kron S, Hafner-Giessauf H, Eller K, Rosenkranz AR, Crespo M, Faura A, Tura A, Song PXK, Port FK, Pascual J, Budde K, Ristl R, Werzowa J, Hecking M. Early Postoperative Basal Insulin Therapy versus Standard of Care for the Prevention of Diabetes Mellitus after Kidney Transplantation: A Multicenter Randomized Trial. J Am Soc Nephrol 2021; 32:2083-2098. [PMID: 34330770 PMCID: PMC8455276 DOI: 10.1681/asn.2021010127] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/03/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Post-transplantation diabetes mellitus (PTDM) might be preventable. METHODS This open-label, multicenter randomized trial compared 133 kidney transplant recipients given intermediate-acting insulin isophane for postoperative afternoon glucose ≥140 mg/dl with 130 patients given short-acting insulin for fasting glucose ≥200 mg/dl (control). The primary end point was PTDM (antidiabetic treatment or oral glucose tolerance test-derived 2 hour glucose ≥200 mg/dl) at month 12 post-transplant. RESULTS In the intention-to-treat population, PTDM rates at 12 months were 12.2% and 14.7% in treatment versus control groups, respectively (odds ratio [OR], 0.82; 95% confidence interval [95% CI], 0.39 to 1.76) and 13.4% versus 17.4%, respectively, at 24 months (OR, 0.71; 95% CI, 0.34 to 1.49). In the per-protocol population, treatment resulted in reduced odds for PTDM at 12 months (OR, 0.40; 95% CI, 0.16 to 1.01) and 24 months (OR, 0.54; 95% CI, 0.24 to 1.20). After adjustment for polycystic kidney disease, per-protocol ORs for PTDM (treatment versus controls) were 0.21 (95% CI, 0.07 to 0.62) at 12 months and 0.35 (95% CI, 0.14 to 0.87) at 24 months. Significantly more hypoglycemic events (mostly asymptomatic or mildly symptomatic) occurred in the treatment group versus the control group. Within the treatment group, nonadherence to the insulin initiation protocol was associated with significantly higher odds for PTDM at months 12 and 24. CONCLUSIONS At low overt PTDM incidence, the primary end point in the intention-to-treat population did not differ significantly between treatment and control groups. In the per-protocol analysis, early basal insulin therapy resulted in significantly higher hypoglycemia rates but reduced odds for overt PTDM-a significant reduction after adjustment for baseline differences-suggesting the intervention merits further study.Clinical Trial registration number: NCT03507829.
Collapse
Affiliation(s)
- Elisabeth Schwaiger
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Kepler University Hospital, Linz, Austria
| | | | - Amelie Kurnikowski
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Leon Bergfeld
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alexander Frey
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine and Gastroenterology, Hospital Vienna North, Vienna, Austria
| | - David Topitz
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Pediatrics and Adolescent Medicine, Clinic Ottakring, Vienna, Austria
| | - Michael Bergmann
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Pneumology, Clinic Ottakring, Vienna, Austria
| | - Sebastian Hödlmoser
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Kron
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | - Anna Faura
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Andrea Tura
- Metabolic Unit, CNR Institute of Neuroscience, Padova, Italy
| | - Peter X K Song
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Vienna, Austria
| | - Johannes Werzowa
- 1st Medical Department, Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Center Meidling, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Mpratsiakou A, Papasotiriou M, Ntrinias T, Tsiotsios K, Papachristou E, Goumenos DS. Safety and Efficacy of Long-Term Administration of Dipeptidyl peptidase IV Inhibitors in Patients With New Onset Diabetes After Kidney Transplant. EXP CLIN TRANSPLANT 2021; 19:411-419. [PMID: 34053420 DOI: 10.6002/ect.2020.0519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The appearance of new onset diabetes is common after kidney transplant. Treatment options are limited because of renal function-related contraindications, interactions with immunosuppressive drugs, and side effects. We investigated the long-term safety and efficacy of dipeptidyl peptidase IV inhibitors in renal transplant recipients with new onset diabetes. MATERIALS AND METHODS We treated 12 patients with dipeptidyl peptidase IV inhibitors, and 5 patients received insulin monotherapy as initial treatment of new onset diabetes after kidney transplant. All patients were followed for 12 months after diagnosis. Glycosylated hemoglobin A1c, estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration equation), plasma immunosuppressive trough levels, serum lipids, blood pressure, and body weight were measured during outpatient visits. Effects of dipeptidyl peptidase IV inhibitors and insulin on the aforementioned parameters were measured to compare values at time of diagnosis versus mean values of the last 6 months of follow-up. RESULTS Patients were treated with linagliptin (4 patients), sitagliptin (4 patients), vildagliptin (2 patients), and alogliptin (2 patients). Patients had a mean age of 59.4 ± 12 years and a mean glycosylated hemoglobin A1c of 6.6% at diagnosis, which was decreased to 6.1% (P = .03) at 1 year of follow-up. Renal function remained stable, and plasma tacrolimus levels did not appear to be affected. No significant differences were shown in serum total, low-density lipoprotein, and high-density lipoprotein cholesterol levels aftertreatment. Nevertheless,triglyceride levels were significantly reduced (from 214.4 to 174.9 mg/dL; P = .0039). A decrease in body weight was also observed. Finally, patients treated with dipeptidyl peptidase V inhibitors achieved better glycosylated hemoglobin A1c levels than those treated with insulin. CONCLUSIONS Dipeptidyl peptidase IV inhibitors appear to be a safe, effective, and hypoglycemia-free option fortreatment of new onset diabetes in renaltransplant recipients and possibly provide better diabetes control than insulin therapy.
Collapse
Affiliation(s)
- Adamantia Mpratsiakou
- From the Department of Nephrology and Renal Transplantation, University Hospital of Patras, Patras, Greece
| | | | | | | | | | | |
Collapse
|
8
|
Autosomal Dominant Polycystic Kidney Disease Is a Risk Factor for Posttransplantation Diabetes Mellitus: An Updated Systematic Review and Meta-analysis. Transplant Direct 2020; 6:e553. [PMID: 32548247 PMCID: PMC7213605 DOI: 10.1097/txd.0000000000000989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 12/12/2022] Open
Abstract
Supplemental Digital Content is available in the text. Autosomal dominant polycystic kidney disease (ADPKD) is linked with risk for posttransplantation diabetes mellitus (PTDM), but this association has methodologic limitations like diagnostic criteria. The aim of this study was to use contemporary diagnostic criteria for PTDM and explore any risk association for kidney transplant recipients with ADPKD.
Collapse
|
9
|
|
10
|
Yang B, Wang Q, Wang R, Xu T. Clinical Manifestation, Management and Prognosis of Acute Myocardial Infarction in Autosomal Dominant Polycystic Kidney Disease. Kidney Blood Press Res 2018; 43:1806-1812. [PMID: 30504716 DOI: 10.1159/000495638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Cardiovascular complications are the most common cause of death in individuals with autosomal dominant polycystic kidney disease (ADPKD), yet there is no substantial data concerning the clinical characteristics of acute myocardial infarction (AMI) in this population. This study thus aimed to investigate AMI in persons with ADPKD. METHODS A retrospective analysis of ADPKD patients admitted to our hospital over a 13 year period was conducted. Age and gender-matched control patients without ADPKD were also selected at a ratio of 1: 10. RESULTS A total of 52 ADPKD and 520 non-ADPKD patients were enrolled in the present study, with those in the former group exhibiting significantly poorer kidney function. The distribution of AMI types differed significantly between these two groups. The incidence of ST-segment elevation myocardial infarction (STEMI) was higher (75.0%) and the incidence of non-ST segment elevation myocardial infarction (NSTEMI) was lower (25.0%) in the ADPKD group. At the onset of AMI, sudden cardiac death (SCD) was more common in ADPKD patients (11.5% vs. 4.6%). In terms of risk factors, the occurrence of hypertension was greater in ADPKD patients (78.8% vs. 39.6%). With regard to subsequent management, ADPKD patients had a higher prevalence of triple-branch coronary lesions (21.1% vs. 11.2%), undergoing more coronary artery bypass grafting (CABG) (7.7% vs. 5.4%) and fewer percutaneous coronary interventions (PCI) (73.1% vs. 84.6%). Overall, ADPKD patients had higher rates of mortality (13.5% vs. 6.2%). CONCLUSION ADPKD patients with AMI suffer from more severe conditions and difficult therapies, resulting in a poorer prognosis.
Collapse
Affiliation(s)
- Bo Yang
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Qi Wang
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Rui Wang
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Tao Xu
- Department of Urology, Peking University People's Hospital, Beijing, China,
| |
Collapse
|
11
|
Kumar S, Sanyal D, Das P, Bhattacharjee K, Rungta R. An observational Prospective Study to Evaluate the Preoperative Risk Factors of New-onset Diabetes Mellitus after Renal Transplantation in a Tertiary Care Centre in Eastern India. Indian J Endocrinol Metab 2018; 22:610-615. [PMID: 30294568 PMCID: PMC6166566 DOI: 10.4103/ijem.ijem_121_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES This study aimed to determine the pre-transplant risk factors as independent predictors on the new-onset of diabetes mellitus after renal transplants (NODATs). MATERIALS AND METHODS A single-centred prospective real-world observational study of 100 subjects who underwent renal transplantation over a period of 2 years. All known patients with diabetes were excluded from the study. NODAT was defined according to the American Diabetes Association definition. In addition to pre-transplant workup 2 days prior to transplant, post-transplant follow-up done on weekly basis for 1st month, every 15th day from 1st month to 3rd month, monthly from 3rd month to 12th month. Each transplant patient followed up for 1 year post-transplant or for 6 months post-development of NODAT, whichever was later. All the pre-transplant variables namely body mass index (BMI), family history of diabetes mellitus (DM), HbA1c, fasting insulin level, fasting c-peptide level, serology for hepatitis B, C, serum magnesium level and pre-operative insulin ressistance were further compared between NODAT and non-NODAT groups at the end of the study to assess their strength of associations. RESULTS Among the 100 subjects included in the study, 24 developed NODAT. Risk factors namely age, family history of DM, BMI, hepatitis B and C infection, total cholesterol, triglyceride level, pre-operative HbA1c, pre-operative insulin resistance and pre-diabetes were significantly higher, whereas beta-cell function, ABO compatibility and magnesium levels being significantly lower in NODAT cohort. CONCLUSION The incidence of NODAT is quite high (24%). Risk of development of NODAT was related to traditional as well as novel risk factors. Key aspects lies in identifying patients at risk of developing NODAT, using traditional risk factors for early diagnosis and introducing interventions on modifiable risk factors for prevention and timely intervention.
Collapse
Affiliation(s)
- Santosh Kumar
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, EM Bypass, Kolkata, West Bengal, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College, Jadavpur, Kolkata, West Bengal, India
| | - Pratik Das
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, EM Bypass, Kolkata, West Bengal, India
| | | | - Rohit Rungta
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, EM Bypass, Kolkata, West Bengal, India
| |
Collapse
|
12
|
Conte C, Secchi A. Post-transplantation diabetes in kidney transplant recipients: an update on management and prevention. Acta Diabetol 2018; 55:763-779. [PMID: 29619563 DOI: 10.1007/s00592-018-1137-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022]
Abstract
Post-transplantation diabetes mellitus (PTDM) may severely impact both short- and long-term outcomes of kidney transplant recipients in terms of graft and patient survival. However, PTDM often goes undiagnosed is underestimated or poorly managed. A diagnosis of PTDM should be delayed until the patient is on stable maintenance doses of immunosuppressive drugs, with stable kidney graft function and in the absence of acute infections. Risk factors for PTDM should be assessed during the pre-transplant evaluation period, in order to reduce the likelihood of developing diabetes. The oral glucose tolerance test is considered as the gold standard for diagnosing PTDM, whereas HbA1c is not reliable during the first months after transplantation. Glycaemic targets should be individualised, and comorbidities such as dyslipidaemia and hypertension should be treated with drugs that have the least possible impact on glucose metabolism, at doses that do not interact with immunosuppressants. While insulin is the preferred agent for treating inpatient hyperglycaemia in the immediate post-transplantation period, little evidence is available to guide therapeutic choices in the management of PTDM. Metformin and incretins may offer some advantage over other glucose-lowering agents, particularly with respect to risk of hypoglycaemia and weight gain. Tailoring immunosuppressive regimens may be of help, although maintenance of good kidney function should be prioritised over prevention/treatment of PTDM. The aim of this narrative review is to provide an overview of the available evidence on management and prevention of PTDM, with a focus on the available therapeutic options.
Collapse
Affiliation(s)
- Caterina Conte
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Antonio Secchi
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| |
Collapse
|
13
|
Jankowska M, Qureshi AR, Barany P, Heimburger O, Stenvinkel P, Lindholm B. Do metabolic derangements in end-stage polycystic kidney disease differ versus other primary kidney diseases? Nephrology (Carlton) 2017; 23:31-36. [DOI: 10.1111/nep.12927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Magdalena Jankowska
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
- Department of Nephrology, Transplantology and Internal Medicine; Medical University of Gdansk; Poland
| | - Abdul Rashid Qureshi
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
| | - Peter Barany
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
| | - Olof Heimburger
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum; Karolinska Institutet; Stockholm Sweden
| |
Collapse
|
14
|
Illesy L, Kovács D, Szabó R, Asztalos A, Nemes B. Autosomal Dominant Polycystic Kidney Disease Transplant Recipients After Kidney Transplantation: A Single-center Experience. Transplant Proc 2017; 49:1522-1525. [DOI: 10.1016/j.transproceed.2017.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
15
|
Magistroni R, Boletta A. Defective glycolysis and the use of 2-deoxy-D-glucose in polycystic kidney disease: from animal models to humans. J Nephrol 2017; 30:511-519. [PMID: 28390001 DOI: 10.1007/s40620-017-0395-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/27/2017] [Indexed: 02/06/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is an inherited renal disease characterized by bilateral renal cyst formation. ADPKD is one of the most common rare disorders, accounting for ~10% of all patients with end-stage renal disease (ESRD). ADPKD is a chronic disorder in which the gradual expansion of cysts that form in a minority of nephrons eventually causes loss of renal function due to the compression and degeneration of the surrounding normal parenchyma. Numerous deranged pathways have been identified in the cyst-lining epithelia, prompting the design of potential therapies. Several of these potential treatments have proved effective in slowing down disease progression in pre-clinical animal studies, while only one has subsequently been proven to effectively slow down disease progression in patients, and it has recently been approved for therapy in Europe, Canada and Japan. Among the affected cellular functions and pathways, recent investigations have described metabolic derangement in ADPKD as a major trait offering additional opportunities for targeted therapies. In particular, increased aerobic glycolysis (the Warburg effect) has been described as a prominent feature of ADPKD kidneys and its inhibition using the glucose analogue 2-deoxy-D-glucose (2DG) proved effective in slowing down disease progression in preclinical models of the disease. At the same time, previous clinical experiences have been reported with 2DG, showing that this compound is well tolerated in humans with minimal and reversible side effects. In this work, we review the literature and speculate that 2DG could be a good candidate for a clinical trial in humans affected by ADPKD.
Collapse
Affiliation(s)
- Riccardo Magistroni
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Via Olgettina, 58, 20132, Milan, Italy
- Division of Nephrology and Hypertension, San Raffaele Hospital, Milan, Italy
- Division of Nephrology and Dialysis, AOU Policlinico di Modena, Università di Modena e Reggio Emilia, Modena, Italy
| | - Alessandra Boletta
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Via Olgettina, 58, 20132, Milan, Italy.
| |
Collapse
|
16
|
Cheungpasitporn W, Thongprayoon C, Vijayvargiya P, Anthanont P, Erickson SB. The Risk for New-Onset Diabetes Mellitus after Kidney Transplantation in Patients with Autosomal Dominant Polycystic Kidney Disease: A Systematic Review and Meta-Analysis. Can J Diabetes 2016; 40:521-528. [PMID: 27184299 DOI: 10.1016/j.jcjd.2016.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/09/2016] [Accepted: 03/01/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES New-onset diabetes after kidney transplantation (NODAT) is associated with both renal allograft failure and increased rates of mortality. The objective of this meta-analysis was to evaluate the risk for NODAT in patients with autosomal dominant polycystic kidney disease (ADPKD). METHODS A literature search was performed using MEDLINE, EMBASE and Cochrane Database of Systematic Reviews from inception through July 2015. Studies that reported relative risks, odd ratios or hazard ratios comparing the risk for NODAT in patients with ADPKD were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method. RESULTS Included in the analysis were 12 cohort studies, which comprised 1379 patients with ADPKD of a total of 9849 patients who had undergone kidney transplants. The pooled RRs of NODAT in patients with ADPKD were 1.92 (95% CI, 1.36 to 2.70). When meta-analysis was limited only to studies with confounder-adjusted analysis, the pooled RRs for NODAT were 1.98 (95% CI, 1.33 to 2.94). However, the association between NODAT requiring insulin treatment was insignificant, with pooled RRs of 1.57 (95% CI, 0.75 to 3.27). CONCLUSIONS Our meta-analysis demonstrates a significant association between ADPKD and NODAT in recipients of kidney transplants. The findings of this study may impact clinical management and follow up for patients with ADPKD after kidney transplantation.
Collapse
Affiliation(s)
- Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States.
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| | - Priya Vijayvargiya
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Pimjai Anthanont
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, United States; Faculty of Medicine, Thammasat University Hospital, Bangkok, Thailand
| | - Stephen B Erickson
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
17
|
Goldmannova D, Karasek D, Krystynik O, Zadrazil J. New-onset diabetes mellitus after renal transplantation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:195-200. [PMID: 26927467 DOI: 10.5507/bp.2016.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/02/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND AIM Diabetes mellitus is a very common metabolic disease with a rising incidence. It is both a leading cause of chronic renal disease and one of the most serious comorbidities in renal transplant recipients. New-onset diabetes after renal transplantation (NODAT) is associated with poor graft function, higher rates of cardiovascular complications and a poor prognosis. The aim of this paper is to review current knowledge of NODAT including risk factors, diagnosis and management. METHODS A MEDLINE search was performed to retrieve both original and review articles addressing the epidemiology, risk factors, screening and management of NODAT. We also focused on microRNAs as potential biomarkers of NODAT. RESULTS AND CONCLUSION Understanding the risk factors (both modifiable-e.g. obesity, viruses, and unmodifiable-e.g. age, genetics) may help reduce the incidence and impact of NODAT using pre- and post-transplant management. This can lead to better long-term graft function and general transplant success.
Collapse
Affiliation(s)
- Dominika Goldmannova
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - David Karasek
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Ondrej Krystynik
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Josef Zadrazil
- Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| |
Collapse
|
18
|
Shivaswamy V, Boerner B, Larsen J. Post-Transplant Diabetes Mellitus: Causes, Treatment, and Impact on Outcomes. Endocr Rev 2016; 37:37-61. [PMID: 26650437 PMCID: PMC4740345 DOI: 10.1210/er.2015-1084] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent consequence of solid organ transplantation. PTDM has been associated with greater mortality and increased infections in different transplant groups using different diagnostic criteria. An international consensus panel recommended a consistent set of guidelines in 2003 based on American Diabetes Association glucose criteria but did not exclude the immediate post-transplant hospitalization when many patients receive large doses of corticosteroids. Greater glucose monitoring during all hospitalizations has revealed significant glucose intolerance in the majority of recipients immediately after transplant. As a result, the international consensus panel reviewed its earlier guidelines and recommended delaying screening and diagnosis of PTDM until the recipient is on stable doses of immunosuppression after discharge from initial transplant hospitalization. The group cautioned that whereas hemoglobin A1C has been adopted as a diagnostic criterion by many, it is not reliable as the sole diabetes screening method during the first year after transplant. Risk factors for PTDM include many of the immunosuppressant medications themselves as well as those for type 2 diabetes. The provider managing diabetes and associated dyslipidemia and hypertension after transplant must be careful of the greater risk for drug-drug interactions and infections with immunosuppressant medications. Treatment goals and therapies must consider the greater risk for fluctuating and reduced kidney function, which can cause hypoglycemia. Research is actively focused on strategies to prevent PTDM, but until strategies are found, it is imperative that immunosuppression regimens are chosen based on their evidence to prolong graft survival, not to avoid PTDM.
Collapse
Affiliation(s)
- Vijay Shivaswamy
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Brian Boerner
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Jennifer Larsen
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| |
Collapse
|
19
|
Lee VW, Tunnicliffe DJ, Rangan GK. KHA-CARI Autosomal Dominant Polycystic Kidney Disease Guideline: Management of End-Stage Kidney Disease. Semin Nephrol 2016; 35:595-602.e12. [PMID: 26718164 DOI: 10.1016/j.semnephrol.2015.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Vincent W Lee
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia.
| | - David J Tunnicliffe
- KHA-CARI Guidelines, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia; Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Gopala K Rangan
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Millennium Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia
| |
Collapse
|
20
|
Yang B, Chen S, Yang G, Mei C, Ong A, Mao Z. New onset diabetes after kidney transplantation in patients with autosomal dominant polycystic kidney disease: systematic review protocol. BMJ Open 2015; 5:e008440. [PMID: 26546139 PMCID: PMC4636618 DOI: 10.1136/bmjopen-2015-008440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disorder with numerous cysts developing in bilateral kidneys. Meanwhile, ADPKD can also be regarded as a systemic disease because the cystic and non-cystic abnormalities could be identified in multiple organs in patients with ADPKD. Several lines of evidence suggest the risk of post-transplant diabetes mellitus or new-onset diabetes after transplantation (NODAT) is higher in patients with ADPKD compared with non-ADPKD renal recipients, but the available results are conflicting. We describe the protocol of a systematic review and meta-analysis for investigating the risk of NODAT in patients with ADPKD. METHODS AND ANALYSIS PubMed, EMBASE and The Cochrane Library will be searched. Cohort studies irrespective of language and publication status, comparing the incidence of NODAT in renal recipients with ADPKD and other kidney disease will be eligible. We will assess heterogeneity among studies. Along with 95% CIs, dichotomous data will be summarised as risk ratios; numbers needed to treat/harm and continuous data will be given as standard mean differences. Excluding outliers and testing small sample size studies if our results are robust, sensitivity analysis will be carried out. ETHICS AND DISSEMINATION Ethical approval is not required because this study includes no confidential personal data or patient interventions. The review findings will be helpful in designing and implementing future studies and will be of interest to a wide range of readers, including healthcare professionals, researchers, health service managers and policymakers. The systematic review will be published in a peer-reviewed journal and disseminated electronically and in print. TRIAL REGISTRATION NUMBER The study protocol has been registered in PROSPERO (http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42014009677.
Collapse
Affiliation(s)
- Bo Yang
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Sixiu Chen
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Guang Yang
- No. 1 Cadets Company, Second Military Medical University, Shanghai, People's Republic of China
| | - Changlin Mei
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Albert Ong
- Kidney Genetics Group, Academic Nephrology Unit, The Henry Wellcome Laboratories for Medical Research, University of Sheffield Medical School, Sheffield, UK
| | - Zhiguo Mao
- Division of Nephrology, Kidney Institute of CPLA, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| |
Collapse
|
21
|
Lim SW, Jin JZ, Jin L, Jin J, Li C. Role of dipeptidyl peptidase-4 inhibitors in new-onset diabetes after transplantation. Korean J Intern Med 2015; 30:759-70. [PMID: 26552451 PMCID: PMC4642005 DOI: 10.3904/kjim.2015.30.6.759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/14/2015] [Indexed: 02/06/2023] Open
Abstract
Despite strict pre- and post-transplantation screening, the incidence of new-onset diabetes after transplantation (NODAT) remains as high as 60%. This complication affects the risk of cardiovascular events and patient and graft survival rates. Thus, reducing the impact of NODAT could improve overall transplant success. The pathogenesis of NODAT is multifactorial, and both modifiable and nonmodifiable risk factors have been implicated. Monitoring and controlling the blood glucose profile, implementing multidisciplinary care, performing lifestyle modifications, using a modified immunosuppressive regimen, administering anti-metabolite agents, and taking a conventional antidiabetic approach may diminish the incidence of NODAT. In addition to these preventive strategies, inhibition of dipeptidyl peptidase-4 (DPP4) by the gliptin family of drugs has recently gained considerable interest as therapy for type 2 diabetes mellitus and NODAT. This review focuses on the role of DPP4 inhibitors and discusses recent literature regarding management of NODAT.
Collapse
Affiliation(s)
- Sun Woo Lim
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Zhe Jin
- Division of Nephrology, Department of Internal Medicine, Yanbian University Hospital, Yanji, China
| | - Long Jin
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jian Jin
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Convergent Research Consortium for Immunologic Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Yanbian University Hospital, Yanji, China
| | - Can Li
- Division of Nephrology, Department of Internal Medicine, Yanbian University Hospital, Yanji, China
- Correspondence to Can Li, M.D. Division of Nephrology, Department of Internal Medicine, Yanbian University Hospital, #1327 JuZi St., Yanji 133000, China Tel: +86-433-266-0065 Fax: +86-433-251-3610 E-mail:
| |
Collapse
|
22
|
EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.2014.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
23
|
Pinheiro Buarque MNA, de Francesco Daher E, de Matos Esmeraldo R, Lima Macedo RB, Martins Costa MC, Morais de Alencar CH, Magalhães Montenegro Júnior R. Historical cohort with diabetes mellitus after kidney transplantation and associated factors of its development in adult patients of a transplantation reference center in the State of Ceará, Brazil. Transplant Proc 2015; 46:1698-704. [PMID: 25131016 DOI: 10.1016/j.transproceed.2014.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Post-transplantation diabetes mellitus (PTDM) is an important complication related to kidney transplantation (KT), and its occurrence is associated with increased morbidity and mortality. Nevertheless, KT is considered to be the most effective treatment option that offers better quality of life for patients with end-stage kidney disease. This study aimed to describe the occurrence of PTDM and the risk factors associated with its development in kidney transplant patients of a transplantation reference center in the State of Ceará (Brazil). This historical cohort study, based on medical records data, included adult patients undergoing KT from January 2006 to December 2010 in a public tertiary hospital. Multivariate analysis was performed with the use of a logistic regression model, with PTDM presence as dependent variable and the possible risk factors under study as independent variables. Throughout the evaluated period, 430 KTs were performed; 92 patients were excluded. Diabetes mellitus was already present in 9.2% of patients before KT. Hyperglycemia during the 1st month after transplantation occurred in 34.5% of recipients, and the occurrence of PTDM to the end of study was 19.9%. Factors associated with PTDM development were: fasting plasma glucose 1 month after KT (P < .001; odds ratio [OR] 1.05), deceased-donor KT (P = .015; OR 3.53), impaired fasting glucose before transplantation (P = .014; OR 4.10), and acute rejection occurrence (P = .003; OR 6.43). High PTDM occurrence was found, in accordance with the literature. Identification of factors associated with PTDM development, as well as its early diagnosis, could result in long-term improvement in patient and graft survivals.
Collapse
Affiliation(s)
- M N A Pinheiro Buarque
- Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil; Serviço de Transplante de Órgãos, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil.
| | | | - R de Matos Esmeraldo
- Serviço de Transplante de Órgãos, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
| | - R B Lima Macedo
- Serviço de Endocrinologia e Metabologia, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
| | - M C Martins Costa
- Serviço de Transplante de Órgãos, Hospital Geral de Fortaleza, Fortaleza, Ceará, Brazil
| | | | | |
Collapse
|
24
|
Langsford D, Dwyer K. Dysglycemia after renal transplantation: Definition, pathogenesis, outcomes and implications for management. World J Diabetes 2015; 6:1132-51. [PMID: 26322159 PMCID: PMC4549664 DOI: 10.4239/wjd.v6.i10.1132] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 07/06/2015] [Accepted: 08/16/2015] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
|
25
|
Noël N, Rieu P. [Pathophysiology, epidemiology, clinical presentation, diagnosis and treatment options for autosomal dominant polycystic kidney disease]. Nephrol Ther 2015; 11:213-25. [PMID: 26113401 DOI: 10.1016/j.nephro.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/07/2015] [Accepted: 04/08/2015] [Indexed: 01/12/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the leading genetic cause of end-stage renal disease (ESRD) worldwide. Its prevalence is evaluated according to studies and population between 1/1000 and 1/4000 live births and it accounts for 6 to 8% of incident ESRD patients in developed countries. ADPKD is characterized by numerous cysts in both kidneys and various extrarenal manifestations that are detailed in this review. Clinico-radiological and genetic diagnosis are also discussed. Mutations in the PKD1 and PKD2 codifying for polycystin-1 (PC-1) and polycystin-2 (PC-2) are responsible for the 85 and 15% of ADPKD cases, respectively. In primary cilia of normal kidney epithelial cells, PC-1 and PC-2 interact forming a complex involved in flow- and cilia-dependant signalling pathways where intracellular calcium and cAMP play a central role. Alteration of these multiple signal transduction pathways leads to cystogenesis accompanied by dysregulated planar cell polarity, excessive cell proliferation and fluid secretion, and pathogenic interactions of epithelial cells with an abnormal extracellular matrix. The mass effect of expanding cyst is responsible for the decline in glomerular filtration rate that occurs late in the course of the disease. For many decades, the treatment for ADPKD aims to lessen the condition's symptoms, limit kidney damage, and prevent complications. Recently, the development of promising specific treatment raises the hope to slow the growth of cysts and delay the disease. Treatment strategies targeting cAMP signalling such as vasopressin receptor antagonists or somatostatin analogs have been tested successfully in clinical trials with relative safety. Newer treatments supported by preclinical trials will become available in the next future. Recognizing early markers of renal progression (clinical, imaging, and genetic markers) to identify high-risk patients and multidrug approaches with synergistic effects may provide new opportunities for the treatment of ADPKD.
Collapse
Affiliation(s)
- Natacha Noël
- Service de néphrologie, centre hospitalier universitaire de Reims, 51100 Reims, France
| | - Philippe Rieu
- Service de néphrologie, centre hospitalier universitaire de Reims, 51100 Reims, France.
| |
Collapse
|
26
|
Wallace IR, Waters NH, Pilmore H, Drury PL, Wu F. New onset diabetes after transplantation: Not another acronym! JRSM Open 2015; 6:2054270414567166. [PMID: 25780593 PMCID: PMC4349758 DOI: 10.1177/2054270414567166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
New onset diabetes after transplantation is the onset of diabetes in previously non-diabetic individuals extending beyond the first month post-transplantation.
Collapse
Affiliation(s)
- I R Wallace
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - N H Waters
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - H Pilmore
- Department of Transplant Nephrology, Auckland City Hospital, Auckland 1023, New Zealand
| | - P L Drury
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - F Wu
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| |
Collapse
|
27
|
New-onset diabetes after kidney transplant in children. Pediatr Nephrol 2015; 30:405-16. [PMID: 24894384 DOI: 10.1007/s00467-014-2830-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 04/01/2014] [Accepted: 04/11/2014] [Indexed: 02/08/2023]
Abstract
The development of new-onset diabetes after kidney transplantation (NODAT) is associated with reduced graft function, increased cardiovascular morbidity and lower patient survival among adult recipients. In the pediatric population, however, the few studies examining NODAT have yielded inconsistent results. Therefore, the true incidence of NODAT in the pediatric population has been difficult to establish. The identification of children and adolescents at risk for NODAT requires appropriate screening questions and tests pre- and post-kidney transplant. Several risk factors have been implicated in the pathogenesis of NODAT and post-transplant glucose intolerance, including African American race, obesity, family history of diabetes and the type of immunosuppressant regimen. Moreover, uremia per se results in a state of insulin resistance that increases the risk of developing diabetes post-transplant. When an individual becomes glucose intolerant, early lifestyle modification and antihyperglycemic measures with tailoring of the immunosuppressant regimen should be implemented to prevent the development of NODAT. For the child or adolescent with NODAT, antihyperglycemic therapy should be prescribed in order to achieve optimal glycemic control, ultimately reducing complications and improving overall allograft and patient survival. In this article, we review the risk factors, screening methods, diagnosis, management and outcome of children and adolescents with NODAT and post-kidney transplant glucose intolerance.
Collapse
|
28
|
Relation between pretransplant magnesemia and the risk of new onset diabetes after transplantation within the first year of kidney transplantation. Transplantation 2014; 97:1155-60. [PMID: 24686469 DOI: 10.1097/01.tp.0000440950.22133.a1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a frequent condition associated with a poor outcome. In kidney transplantation, hypomagnesemia is a frequent posttransplant complication and has been associated with calcineurin inhibitors use. Previous studies have analyzed the relationship between posttransplant hypomagnesemia and the risk of NODAT and provided conflicting conclusions. We conducted an observational study to analyze the relationship between pretransplant magnesemia (Mg) and the risk of NODAT within the first year of kidney transplantation. METHODS A cohort study was conducted to determine the risk conferred by pretransplant magnesium level on development of NODAT within 1 year posttransplant. First time kidney transplant recipients between January 2005 and December 2010 with more than 6 months of follow-up were included. Mg was measured within the 24 hours preceding kidney transplantation. NODAT was defined according to the American Diabetes Association criteria. RESULTS Among the 154 patients analyzed, 28 (18.2%) developed NODAT at year 1. NODAT patients had lower levels of pretransplant Mg as compared with non-NODAT patients (P<0.02). When patients were divided into tertiles of Mg level, NODAT developed more frequently in patients in the lower tertile (Mg <2 mg/dL) as compared with patients in the higher tertile (Mg >2.3 mg/dL) (log rank, P<0.05). A multivariate analysis after adjustment to several variables demonstrated pretransplant Mg to be an independent risk factor of NODAT. CONCLUSION This study supports that a low pretransplant Mg level is an independent risk factor of NODAT in kidney transplant recipients.
Collapse
|
29
|
Kanaan N, Devuyst O, Pirson Y. Renal transplantation in autosomal dominant polycystic kidney disease. Nat Rev Nephrol 2014; 10:455-65. [PMID: 24935705 DOI: 10.1038/nrneph.2014.104] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In patients with autosomal dominant polycystic kidney disease (ADPKD) evaluated for kidney transplantation, issues related to native nephrectomy, cystic liver involvement, screening for intracranial aneurysms and living-related kidney donation deserve special consideration. Prophylactic native nephrectomy is restricted to patients with a history of cyst infection or recurrent haemorrhage or to those in whom space must be made to implant the graft. Patients with liver involvement require pretransplant imaging. Selection of patients for pretransplant screening of intracranial aneurysms should follow the general recommendations for patients with ADPKD. In living related-donor candidates aged <30 years and at-risk of ADPKD, molecular genetic testing should be carried out when ultrasonography and MRI findings are normal or equivocal. After kidney transplantation, patient and graft survival rates are excellent and the volume of native kidneys decreases. However, liver cysts continue to grow and treatment with a somatostatin analogue should be considered in patients with massive cyst involvement. Cerebrovascular events have a marginal effect on post-transplant morbidity and mortality. An increased risk of new-onset diabetes mellitus and nonmelanoma skin cancers has been reported, but several studies have challenged these findings. Finally, no data currently support the preferential use of mammalian target of rapamycin inhibitors as immunosuppressive agents in transplant recipients with ADPKD.
Collapse
Affiliation(s)
- Nada Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, B-1200 Brussels, Belgium
| | - Olivier Devuyst
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, B-1200 Brussels, Belgium
| | - Yves Pirson
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, B-1200 Brussels, Belgium
| |
Collapse
|
30
|
Schweer T, Gwinner W, Scheffner I, Schwarz A, Haller H, Blume C. High impact of rejection therapy on the incidence of post-transplant diabetes mellitus after kidney transplantation. Clin Transplant 2014; 28:512-9. [PMID: 24649873 DOI: 10.1111/ctr.12329] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although major risk factors for post-transplant diabetes (PTDM) after kidney transplantation have been identified, a systematic study on the impact of rejection and rejection therapy is missing so far. METHODS Five hundred and twenty-six kidney transplant recipients transplanted in the years 2000-2007 were included. PTDM was defined according to WHO guidelines, and patients' data were compared with special attention to protocol and for cause biopsies and rejection therapies. Survival analyses were made for graft loss and patient death. RESULTS 16.7% of all patients developed PTDM. Among common risk factors as higher age, body mass index (BMI), and others, the factor "acute cellular rejections" was comparably most relevant with a hazard ratio of 3.7. Consequently, antirejective treatment with steroid pulses and conversion to tacrolimus was the factor with the highest relative risk for the onset of PTDM (RR 3.5). PTDM itself had no impact on graft or patients' survival, but the decreased graft survival in PTDM patients was dominantly influenced by the higher frequency of acute cellular rejections, and patients' survival was reduced due to higher age. CONCLUSION Based upon a higher rate of acute rejections (AR), the necessity of frequent antirejective treatments was more relevant for the induction of PTDM than age or BMI.
Collapse
Affiliation(s)
- Torben Schweer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | |
Collapse
|
31
|
Mao Z, Xie G, Ong ACM. Metabolic abnormalities in autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2014; 30:197-203. [DOI: 10.1093/ndt/gfu044] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
|
32
|
Abstract
The epidemic of obesity and metabolic syndrome (MS) contributes to the rapid growth of chronic kidney disease (CKD) and end-stage renal disease (ESRD). There is a reverse epidemiology, known as the "obesity paradox," in ESRD patients receiving maintenance dialysis. Obese patients are routinely referred for kidney transplant, and they have more surgical and medical complications than non-obese patients. However, compared to dialysis, kidney transplant provides a survival benefit for obese patients. After kidney transplant, obese patients tend to gain more body weight, and non-obese patients can develop new-onset obesity/MS. Obesity/MS is not only associated with serious morbidities, but also compromises the long-term graft and patient survival. The immunosuppressive drugs commonly used as maintenance therapy, including corticosteroids, calcineurin inhibitors and mammalian target-of-rapamycin inhibitors, contribute to obesity/MS. Development of novel immunosuppressive drugs free of metabolic adverse effects is needed, so that the full potential and benefits of kidney transplantation can be realized.
Collapse
|
33
|
New onset of diabetes after transplantation - an overview of epidemiology, mechanism of development and diagnosis. Transpl Immunol 2013; 30:52-8. [PMID: 24184293 DOI: 10.1016/j.trim.2013.10.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 10/21/2013] [Accepted: 10/21/2013] [Indexed: 12/12/2022]
Abstract
New onset of diabetes after transplantation (NODAT) is a serious and common complication following solid organ transplantation. NODAT has been reported to occur in 2% to 53% of renal transplant recipients. Several risk factors are associated with NODAT, however the mechanisms underlying were unclear. Renal transplant recipients who develop NODAT are reported to be at increased risk of infections, cardiovascular events, graft loss and patient loss. It has been reported that the incidence of NODAT is high in the early transplant period due to the exposure to the high doses of corticosteroids, calcineurin inhibitors and the physical inactivity during that period. In addition to these risk factors the traditional risk factors also play a major role in developing NODAT. Early detection is crucial in the management and control of NODAT which can be achieved through pretransplant screening there by identifying high risk patients and implementing the measures to reduce the development of NODAT. In the present article we reviewed the literature on the epidemiology, risk factors, mechanisms involved and the diagnostic criteria in the development of NODAT. Development of diagnostic tools for the assessment of β-cell function and determination of the role of glycemic control would include future area of research.
Collapse
|
34
|
New-onset diabetes after kidney transplantation: prevalence, risk factors, and management. Transplantation 2013; 93:1189-95. [PMID: 22475764 DOI: 10.1097/tp.0b013e31824db97d] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
New-Onset Diabetes After Transplantation (NODAT) is an increasingly recognized severe metabolic complication of kidney transplantation causing lower graft function and survival and reduced long-term patient survival mainly due to cardiovascular events. The real incidence of NODAT after kidney transplantation is difficult to establish, because different classification systems and definitions have been employed over the years. Several risk factors, already present before or arising after transplantation, in particular the employed immunosuppressive regimens, have been related to the development of NODAT. However the responsible pathogenic mechanisms are still far to be perfectly known. Awareness of NODAT and of the NODAT-related factors is of paramount importance for the clinicians in order to individuate higher risk patients and arrange screening strategies. The risk of NODAT can be reduced by planning preventive measures and by tailoring immunosuppressive regimens according to the patient characteristics. Once NODAT has been diagnosed, the administration of specific anti-hyperglycemic therapy is mandatory to reach a tight glycemic control, which contributes to significantly reduce posttransplant mortality and morbidity.
Collapse
|
35
|
Hecking M, Werzowa J, Haidinger M, Hörl WH, Pascual J, Budde K, Luan FL, Ojo A, de Vries APJ, Porrini E, Pacini G, Port FK, Sharif A, Säemann MD. Novel views on new-onset diabetes after transplantation: development, prevention and treatment. Nephrol Dial Transplant 2013; 28:550-66. [PMID: 23328712 DOI: 10.1093/ndt/gfs583] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
New-onset diabetes after transplantation (NODAT) is associated with increased risk of allograft failure, cardiovascular disease and mortality, and therefore, jeopardizes the success of renal transplantation. Increased awareness of NODAT and the prediabetic states (impaired fasting glucose and impaired glucose tolerance, IGT) has fostered previous and present recommendations, based on the management of type 2 diabetes mellitus (T2DM). Unfortunately, the idea that NODAT merely resembles T2DM is potentially misleading, because the opportunity to initiate adequate anti-hyperglycaemic treatment early after transplantation might be given away for 'tailored' immunosuppression in patients who have developed NODAT or carry personal risk factors. Risk factor-independent mechanisms, however, seem to render postoperative hyperglycaemia with subsequent development of overt or 'full-blown' NODAT, the unavoidable consequence of the transplant and immunosuppressive process itself, at least in many cases. A proof of the concept that timely preventive intervention with exogenous insulin against post-transplant hyperglycaemia may decrease NODAT was recently provided by a small clinical trial, which is awaiting confirmation from a multicentre study. However, because early insulin therapy aimed at beta-cell protection seems to contrast the currently recommended, stepwise approach of 'watchful waiting' prior to pancreatic decompensation, we here aim at reviewing recent concepts regarding the development, prevention and treatment of NODAT, some of which seem to challenge the traditional view on T2DM and NODAT. In summary, we suggest a novel, risk factor-independent management approach to NODAT, which includes glycaemic monitoring and anti-hyperglycaemic treatment in virtually everybody after transplantation. This approach has widespread implications for future research and is intended to tackle NODAT and also ultimately cardiovascular disease.
Collapse
Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is associated with high cardiovascular (CV) risk and reduced patient survival. It is unclear whether this risk is newly acquired or represents preexisting CV disease in patients with this complication. METHODS Included are 1146 adults, recipients of first kidney transplants from 1984 to 2008 treated with modern immunosuppressants. RESULTS One year after transplantation, 29.8% of patients experienced impaired fasting glycemia and 13.4% NODAT. The risk of NODAT related to recipient variables include the following: older age, male gender, higher body mass index, higher pretransplantation glucose and triglyceride levels, and lower high-density lipoprotein level. Increasing fasting glucose levels at 1, 4, or 12 months after transplantation, independent of other factors, related to reduced patient survival (12 months hazard ratio [HR]=1.146 [1.132-1.161], P<0.0001 for 10mg/dL increase in glucose), and this was primarily because of an increase in CV deaths. Hyperglycemia related to all major CV events (MCVE), cardiac (HR=1.113 [1.094-1.132], P<0.0001), vascular (HR=1.168 [1.140-1.197], P<0.0001), and strokes (HR=1.156 [1.123-1.191], P=0.003). These relations were statistically independent of other risk factors. The increased risk of MCVE was noted particularly in patients without MCVE before transplantation (HR=1.145 [1.126-1.165], P<0.0001). Furthermore, among patients with after transplantation MCVE (n=123, 11%), hyperglycemia increases the risk of death (NODAT: HR=2.410 [1.125-5.162], P=0.024). CONCLUSIONS After transplantation hyperglycemia is a strong independent risk factor for MCVE and death, mainly from CV causes. This risk is independent of the presence of CV disease identified before transplantation.
Collapse
|
37
|
Cardiovascular consequences of new-onset hyperglycemia after kidney transplantation. Transplantation 2012. [PMID: 22820698 DOI: 10.1097/tp.0b013e318258483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is associated with high cardiovascular (CV) risk and reduced patient survival. It is unclear whether this risk is newly acquired or represents preexisting CV disease in patients with this complication. METHODS Included are 1146 adults, recipients of first kidney transplants from 1984 to 2008 treated with modern immunosuppressants. RESULTS One year after transplantation, 29.8% of patients experienced impaired fasting glycemia and 13.4% NODAT. The risk of NODAT related to recipient variables include the following: older age, male gender, higher body mass index, higher pretransplantation glucose and triglyceride levels, and lower high-density lipoprotein level. Increasing fasting glucose levels at 1, 4, or 12 months after transplantation, independent of other factors, related to reduced patient survival (12 months hazard ratio [HR]=1.146 [1.132-1.161], P<0.0001 for 10mg/dL increase in glucose), and this was primarily because of an increase in CV deaths. Hyperglycemia related to all major CV events (MCVE), cardiac (HR=1.113 [1.094-1.132], P<0.0001), vascular (HR=1.168 [1.140-1.197], P<0.0001), and strokes (HR=1.156 [1.123-1.191], P=0.003). These relations were statistically independent of other risk factors. The increased risk of MCVE was noted particularly in patients without MCVE before transplantation (HR=1.145 [1.126-1.165], P<0.0001). Furthermore, among patients with after transplantation MCVE (n=123, 11%), hyperglycemia increases the risk of death (NODAT: HR=2.410 [1.125-5.162], P=0.024). CONCLUSIONS After transplantation hyperglycemia is a strong independent risk factor for MCVE and death, mainly from CV causes. This risk is independent of the presence of CV disease identified before transplantation.
Collapse
|
38
|
Ruderman I, Masterson R, Yates C, Gorelik A, Cohney SJ, Walker RG. New onset diabetes after kidney transplantation in autosomal dominant polycystic kidney disease: a retrospective cohort study. Nephrology (Carlton) 2012; 17:89-96. [PMID: 21854501 DOI: 10.1111/j.1440-1797.2011.01507.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND New onset diabetes after transplantation (NODAT) is a common adverse outcome of organ transplantation that increases the risk of cardiovascular disease, infection and graft rejection. In kidney transplantation, apart from traditional risk factors, autosomal dominant polycystic kidney disease (ADPKD) has also been reported by several authors as a predisposing factor to the development of NODAT, but any rationale for an association between ADPKD and NODAT is unclear. We examined the cumulative incidence of NODAT in or own transplant population comparing ADPKD patients with non-ADPKD controls. METHODS A retrospective cohort study to determine the cumulative incidence of patients developing NODAT (defined by World Health Organization-based criteria and/or use of hypoglycaemic medication) was conducted in 79 patients with ADPKD (79 transplants) and 423 non-ADPKD controls (426 transplants) selected from 613 sequential transplant recipients over 8 years. Patients with pre-existing diabetes as a primary disease or comorbidity and/or with minimal follow up or early graft loss/death were excluded. RESULTS Of the 502 patients (505 transplants) studied, 86 (17.0%) developed NODAT. There was no significant difference in the cumulative incidence of NODAT in the ADPKD (16.5%; CI 13.6-20.7%) compared with the non-ADPKD (17.1%; CI 8.3-24.6%) control group. Of the 13 patients in the ADPKD group with NODAT, three required treatment with insulin with or without oral hypoglycaemic agents. Among the 73 NODAT patients in the non-ADPKD group, eight received insulin with or without oral hypoglycaemics. Furthermore, of the patients that did develop NODAT, there was no difference in the time to its development in patients with and without ADPKD. CONCLUSION There was no evidence of an increased incidence of NODAT in ADPKD kidney transplant recipients.
Collapse
Affiliation(s)
- Irene Ruderman
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | | | | | | | | |
Collapse
|
39
|
Stevens KK, Patel RK, Jardine AG. HOW TO IDENTIFY AND MANAGE DIABETES MELLITUS AFTER RENAL TRANSPLANTATION. J Ren Care 2012; 38 Suppl 1:125-37. [DOI: 10.1111/j.1755-6686.2012.00282.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
40
|
Incidence and risk factors of glucose metabolism disorders in kidney transplant recipients: role of systematic screening by oral glucose tolerance test. Transplantation 2011; 91:757-64. [PMID: 21336240 DOI: 10.1097/tp.0b013e31820f0877] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) increases infectious and cardiovascular complications and reduces patient and graft survival. We assessed the incidence and the risk factors for glucose metabolism abnormalities before and after kidney transplantation using an oral glucose tolerance test (OGTT). The purpose of the study was to better identify patients at risk for NODAT to adapt their immunosuppressive treatment and their management after transplantation. METHODS OGTT was performed before transplantation in 243 patients placed on the kidney waiting list between January 1, 2005, and December 31, 2008. Of these 243 patients, 120 received a kidney transplant and also had an OGTT after transplantation. RESULTS Impaired glucose tolerance (IGT) was identified in 22 of 120 patients (18%) before transplantation. After transplantation, diabetes developed in 31 patients and 16 patients had IGT. According to univariate analyses, risk factors for NODAT were age more than 50 years, body mass index more than 25 kg/m, pretransplant IGT, autosomal dominant polycystic kidney disease, and acute rejection. According to multivariate analyses, pretransplant IGT (relative risk=2.4), autosomal dominant polycystic kidney disease (relative risk=3), and acute rejection (RR, 2.8) remained significantly associated with NODAT. Patients were stratified by age, primary kidney disease, and pretransplant OGTT. The risk of developing NODAT increased 2.4-, 5-, and 14-fold, depending on the number of risk factors. CONCLUSION Pretransplant OGTT, together with age and nephropathy, is a helpful tool for identifying patients at risk for NODAT. For patients with two or three of these risk factors, the adjustment of immunosuppression may be recommended.
Collapse
|
41
|
Pham PTT, Pham PMT, Pham SV, Pham PAT, Pham PCT. New onset diabetes after transplantation (NODAT): an overview. Diabetes Metab Syndr Obes 2011; 4:175-86. [PMID: 21760734 PMCID: PMC3131798 DOI: 10.2147/dmso.s19027] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Although renal transplantation ameliorates cardiovascular risk factors by restoring renal function, it introduces new cardiovascular risks including impaired glucose tolerance or diabetes mellitus, hypertension, and dyslipidemia that are derived, in part, from immunosuppressive medications such as calcineurin inhibitors, corticosteroids, or mammalian target of rapamycin inhibitors. New onset diabetes mellitus after transplantation (NODAT) is a serious and common complication following solid organ transplantation. NODAT has been reported to occur in 2% to 53% of all solid organ transplants. Kidney transplant recipients who develop NODAT have variably been reported to be at increased risk of fatal and nonfatal cardiovascular events and other adverse outcomes including infection, reduced patient survival, graft rejection, and accelerated graft loss compared with those who do not develop diabetes. Identification of high-risk patients and implementation of measures to reduce the development of NODAT may improve long-term patient and graft outcome. The following article presents an overview of the literature on the current diagnostic criteria for NODAT, its incidence after solid organ transplantation, suggested risk factors and potential pathogenic mechanisms. The impact of NODAT on patient and allograft outcomes and suggested guidelines for early identification and management of NODAT will also be discussed.
Collapse
Affiliation(s)
- Phuong-Thu T Pham
- Nephrology Division, Kidney Transplant Program, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Phuong-Mai T Pham
- David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Medicine, Greater Los Angeles VA Medical Center, Los Angeles, CA
| | - Son V Pham
- Division of Cardiology, Bay Pines VA Medical Center, Bay Pines, FL
| | | | - Phuong-Chi T Pham
- David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Medicine, Nephrology Division, UCLA Olive View Medical Center, Los Angeles, CA, USA
| |
Collapse
|
42
|
Kuypers DRJ, de Jonge H, Naesens M, Vanrenterghem Y. A prospective, open-label, observational clinical cohort study of the association between delayed renal allograft function, tacrolimus exposure, and CYP3A5 genotype in adult recipients. Clin Ther 2011; 32:2012-23. [PMID: 21118736 DOI: 10.1016/j.clinthera.2010.11.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tacrolimus, a calcineurin inhibitor with a macrolide lactone structure, is currently used as a cornerstone immunosuppressive drug in solid organ transplantation. It is metabolized by hepatic and intestinal cytochrome P450 (CYP) 3A4/3A5 enzymes and is a substrate for P-glycoprotein (ABCB1). The disposition of tacrolimus might be influenced by severe renal allograft dysfunction (eg, in cases of delayed graft function [DGF]). New-onset diabetes after transplantation (NODAT) is a known adverse effect of tacrolimus therapy and has been associated with DGF. OBJECTIVES The impact of DGF on tacrolimus C(min) and dose requirements was evaluated in renal transplant recipients in the first postoperative week. The effects of the CYP3A5*3 A6986G polymorphism on initial mean tacrolimus C(min) and dose requirements in the presence and absence of DGF were assessed. This study also tested the hypothesis that if DGF influences early tacrolimus exposure, this would lead to a higher risk for NODAT (defined as the need for glucose-lowering medication for an uninterrupted period of ≥ 26 weeks). METHODS This prospective, open-label, observational clinical cohort study enrolled renal allograft recipients aged ≥ 18 years. Tacrolimus was administered as an oral loading dose of 0.2 mg/kg/d and adjusted to achieve a target mean daily tacrolimus C(min) between 12 and 15 ng/mL. C(min) values and oral dose requirements in the first postoperative week were compared between patients with and without DGF. Patients were genotyped for the CYP3A4*1B -290A>G, CYP3A5*3 A6986G, ABCB1 Exon26 C3435T, ABCB1 Exon21 G2677T, and ABCB1 Exon21 G2677A single nucleotide polymorphisms. NODAT that occurred within the first 12 weeks after transplantation was confirmed using an oral glucose tolerance test. RESULTS A total of 304 patients were enrolled (184 men, 120 women; mean [SD] age, 52.9 [14.1] years). Through day 3 after transplantation, mean (SD) 12-hour tacrolimus C(min) values were significantly higher in recipients experiencing DGF despite identical loading doses of 0.2 mg/kg. Mean tacrolimus dose requirements were significantly lower in patients with DGF during the first week. After recovery of DGF, mean tacrolimus dose requirements were not significantly different between recipients with and without DGF. In homozygous CYP3A5*3 carriers (n = 252), mean (SD) tacrolimus dose requirements remained significantly lower during DGF, while in CYP3A5*1 carriers with DGF (n = 52), lower mean dose requirements were observed only after postoperative day 4. The proportion of patients in whom NODAT developed was significantly greater in patients with DGF and tacrolimus C(min) >15 ng/mL on the first day after transplantation (27.2%) compared with recipients who remained free of DGF and had C(min) ≤15 ng/mL on day 1 (6.5%) (P = 0.016). On logistic regression analysis, greater recipient age (odds ratio [OR] = 1.044; 95% CI, 1.009-1.080), higher tacrolimus C(min) on day 1 (OR = 1.048; 95% CI, 1.017-1.080), and DGF (OR = 2.968; 95% CI, 1.107-7.959) were associated with an increased risk for NODAT. CONCLUSION In this open-label, observational study, DGF was associated with higher initial mean tacrolimus C(min) values and lower daily dose requirements predominantly in CYP3A5 nonexpressers.
Collapse
Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
| | | | | | | |
Collapse
|
43
|
Jacquet A, Pallet N, Kessler M, Hourmant M, Garrigue V, Rostaing L, Kreis H, Legendre C, Mamzer-Bruneel MF. Outcomes of renal transplantation in patients with autosomal dominant polycystic kidney disease: a nationwide longitudinal study. Transpl Int 2011; 24:582-7. [PMID: 21352383 DOI: 10.1111/j.1432-2277.2011.01237.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Renal transplantation in patients with autosomal dominant polycystic kidney disease (ADPKD) is a medical and surgical challenge. Detailed longitudinal epidemiological studies on large populations are lacking and it is mandatory to care better for these patients. The success of such a project requires the development of a validated epidemiological database. Herein, we present the results of the largest longitudinal study to date on renal transplant in patients with ADPKD. The 15-year outcomes following renal transplantation of 534 ADPKD patients were compared with 4779 non-ADPKD patients. This comprehensive, longitudinal, multicenter French study was performed using the validated database, DIVAT (Données Informatisées et VAlidées en Transplantaion). We demonstrate that renal transplantation in ADPKD is associated with better graft survival, more thromboembolic complications, more metabolic complications, and increased incidence of hypertension, whereas the prevalence of infections is not increased. This study provides important new insights that could lead to a better care for renal transplant patients with ADPKD.
Collapse
Affiliation(s)
- Antoine Jacquet
- Nephrology and Renal Transplantation Department, Bicetre Hospital, Paris, France
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Räkel A, Karelis AD. New-onset diabetes after transplantation: risk factors and clinical impact. DIABETES & METABOLISM 2011; 37:1-14. [PMID: 21295510 DOI: 10.1016/j.diabet.2010.09.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 09/17/2010] [Accepted: 09/21/2010] [Indexed: 02/06/2023]
Abstract
With improvements in patient and graft survival, increasing attention has been placed on complications that contribute to long-term patient morbidity and mortality. New-onset diabetes after transplantation (NODAT) is a common complication of solid-organ transplantation, and is a strong predictor of graft failure and cardiovascular mortality in the transplant population. Risk factors for NODAT in transplant recipients are similar to those in non-transplant patients, but transplant-specific risk factors such as hepatitis C (HCV) infection, corticosteroids and calcineurin inhibitors play a dominant role in NODAT pathogenesis. Management of NODAT is similar to type 2 diabetes management in the general population. However, adjusting the immunosuppressant regimen to improve glucose tolerance must be weighed against the risk of allograft rejection. Lifestyle modification is currently the strategy with the least risk and the most benefit.
Collapse
Affiliation(s)
- A Räkel
- Department of Medicine, hôpital Saint-Luc, centre de recherche, centre hospitalier, University of Montreal, René-Lévesque-Est, Québec, Canada.
| | | |
Collapse
|
45
|
Pietrzak-Nowacka M, Safranow K, Nowosiad M, Dębska-Ślizień A, Dziewanowski K, Głyda M, Jankowska M, Rutkowski B, Ciechanowski K. HLA-B27 is a potential risk factor for posttransplantation diabetes mellitus in autosomal dominant polycystic kidney disease patients. Transplant Proc 2010; 42:3465-70. [PMID: 21094798 DOI: 10.1016/j.transproceed.2010.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 07/07/2010] [Accepted: 08/19/2010] [Indexed: 10/18/2022]
Abstract
The aim of this work was to investigate HLA phenotype predisposition to posttransplantation diabetes mellitus (PTDM) in kidney transplant recipients stratified according to kidney failure etiology. Ninety-eight transplant recipient pairs with kidney grafts from the same cadaveric donor were qualified for the study. In each pair, 1 kidney was grafted to an individual with autosomal dominant polycystic kidney disease (ADPKD group) and 1 to recipient with a different cause of kidney failure (non-ADPKD group). All class II HLA antigens were determined with the PCR-SSP molecular method. To identify class I HLA molecules we used both molecular and serologic methods. Diabetes was diagnosed according to the American Diabetes Association criteria. The posttransplantation observation period was 12 months. In the ADPKD group, HLA-B27 was more common in PTDM than non-PTDM patients; 31.6% versus 11.4% (P = .069). The difference achieved significance when comparing insulin-treated with non-insulin-treated patients (44.4% vs 12.4%; P = .029). In the non-ADPKD group, HLA-A28 and HLA-B13 were observed more frequently in patients with PTDM than in recipients without diabetes (22.2% vs 2.5% [P = .0099] and 22.2% vs 3.8% [P = .020]). All of these associations were significant upon multivariate analysis. HLA-B27 allele is a factor predisposing ADPKD patients to insulin-dependent PTDM. Antigens predisposing to PTDM among kidney graft recipients without ADPKD include HLA-A28 and B13.
Collapse
Affiliation(s)
- M Pietrzak-Nowacka
- Department of Nephrology, Transplantology, and Internal Medicine, Pomeranian Medical University, Szczecin, Poland.
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Association of metabolic syndrome with development of new-onset diabetes after transplantation. Transplantation 2010; 90:861-6. [PMID: 20724958 DOI: 10.1097/tp.0b013e3181f1543c] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a major posttransplant complication associated with lower allograft and recipient survival. Our objective was to determine whether metabolic syndrome pretransplant is independently associated with NODAT development. METHODS We recruited 640 consecutive incident nondiabetic renal transplant recipients from three academic centers between 1999 and 2004. NODAT was defined as the use of hypoglycemic medication, a random plasma glucose level more than 200 mg/dL, or two fasting glucose levels more than or equal to 126 mg/dL beyond 30 days posttransplant. RESULTS Metabolic syndrome was common pretransplant (57.2%). NODAT developed in 31.4% of recipients 1 year posttransplant. Participants with metabolic syndrome were more likely to develop NODAT compared with recipients without metabolic syndrome (34.4% vs. 27.4%, P=0.057). Recipients with increasing number of positive metabolic syndrome components were more likely to develop NODAT (metabolic syndrome score prevalence at 1 year: 0 components-0.0%, 1-24.2%, 2-29.3%, 3-31.0%, 4-34.8%, and 5-73.7%, P=0.001). After adjustment for demographics, age by decade (hazard ratio [HR] 1.34 [1.20-1.50], P<0.0001), African American race (HR 1.35 [1.01-1.82], P=0.043), cumulative prednisone dosage (HR 1.18 [1.07-1.30], P=0.001), and metabolic syndrome (HR 1.34 [1.00-1.79], P=0.047) were independent predictors of development of NODAT at 1 year posttransplant. In a multivariable analysis incorporating the individual metabolic syndrome components themselves as covariates, the only pretransplant metabolic syndrome component to remain an independent predictor of NODAT was low high-density lipoprotein (hazard ratio [HR] 1.37 [1.01-1.85], P=0.042). CONCLUSIONS Metabolic syndrome is an independent predictor for NODAT and is a possible target for intervention to prevent NODAT. Future studies to evaluate whether modification of metabolic syndrome factors pretransplant reduces NODAT development are needed.
Collapse
|
47
|
Pietrzak-Nowacka M, Safranow K, Byra E, Nowosiad M, Marchelek-Myśliwiec M, Ciechanowski K. Glucose metabolism parameters during an oral glucose tolerance test in patients with autosomal dominant polycystic kidney disease. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 70:561-7. [DOI: 10.3109/00365513.2010.527012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
48
|
Sharif A, Baboolal K. Risk factors for new-onset diabetes after kidney transplantation. Nat Rev Nephrol 2010; 6:415-23. [PMID: 20498675 DOI: 10.1038/nrneph.2010.66] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
New-onset diabetes after transplantation, a common complication following kidney transplantation, is associated with adverse patient and graft outcomes. Our understanding of the risk factors associated with this metabolic disorder is improving and both transplantation-specific and nonspecific factors are clearly involved. Knowledge of these risk factors is important so that clinicians can implement pre-emptive risk stratification strategies and to guide therapeutic, risk-attenuation approaches in patients who develop transplant-associated hyperglycemia. In this Review, we explore the current understanding of the diverse range of risk factors that contribute to abnormal glucose metabolism after transplantation, with the aim of helping to guide clinical decision-making using appropriate risk stratification.
Collapse
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, Renal Institute of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK.
| | | |
Collapse
|
49
|
Bretagnol A, Halimi JM, Roland M, Barbet C, Machet L, Al Najjar A, Marlière JF, Badin J, Nivet H, Lebranchu Y, Büchler M. Autosomal dominant polycystic kidney disease: risk factor for nonmelanoma skin cancer following kidney transplantation. Transpl Int 2010; 23:878-86. [PMID: 20230542 DOI: 10.1111/j.1432-2277.2010.01070.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Nonmelanoma skin cancers (NMSC) are the most common malignant tumors following solid organ transplantation. Risk factors for NMSC mainly include immunosuppression, age, sun exposure and patient phototype. Recent findings have suggested that autosomal dominant polycystic kidney disease (ADPKD) may increase the risk of developing NMSC. We performed a monocenter retrospective study including all kidney recipients between 1985 and 2006 (n = 1019). We studied the incidence of NMSC, solid cancers and post-transplantation lymphoproliferative disease (PTLD), and analyzed the following parameters: age, gender, phototype, time on dialysis, graft rank, immunosuppressive regimen, history of cancer and kidney disease (ADPKD versus others). Median follow-up was 5.5 years (range: 0.02-20.6; 79 838 patient-years). The cumulated incidence of NMSC 10 years after transplantation was 12.7% (9.3% for solid cancers and 3.5% for PTLD). Autosomal dominant polycystic kidney disease and age were risk factors for NMSC (HR 2.63; P < 0.0001 and HR 2.21; P < 0.001, respectively) using univariate analysis. The association between ADPKD and NMSC remained significant after adjustments for age, gender and phototype using multivariate analysis (HR 1.71; P = 0.0145) and for immunosuppressive regimens (P < 0.0001). Autosomal dominant polycystic kidney disease was not a risk factor for the occurrence of solid cancers after transplantation (HR 0.96; P = 0.89). Our findings suggest that ADPKD is an independent risk factor for developing NMSC after kidney transplantation.
Collapse
Affiliation(s)
- Anne Bretagnol
- Department of Nephrology and Clinical Immunology, CHRU Tours, Université François Rabelais, Tours, France
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Alam A, Perrone RD. Management of ESRD in patients with autosomal dominant polycystic kidney disease. Adv Chronic Kidney Dis 2010; 17:164-72. [PMID: 20219619 DOI: 10.1053/j.ackd.2009.12.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 12/24/2009] [Accepted: 12/26/2009] [Indexed: 01/13/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the leading hereditary cause of ESRD in the United States. Because of the renal and extrarenal manifestations of ADPKD, specific challenges exist caring for these patients once they reach ESRD. In this article, we report the overall outcomes of individuals with ADPKD after ESRD as compared with non-ADPKD patients. We also review the available literature concerning issues specific to dialysis or kidney transplantation. For the ADPKD patient on dialysis, we address the use of peritoneal dialysis, the management of renal cystic, and extrarenal complications, and we discuss the significance of the relative polycythemia often observed in this population. For the ADPKD patient undergoing kidney transplantation, we highlight issues of anemia management and aneurysm screening pretransplant, the indications for nephrectomy of the native ADPKD kidneys, the potential benefits of select immunosuppressive agents, the role for combined kidney-liver transplantation, and renal and extrarenal complications of ADPKD postkidney transplantation. In general, patients with ADPKD have more favorable outcomes after ESRD as compared with those with other causes of kidney failure. Most of our knowledge, however, is based on case series and observational studies. Although these reports have certainly been valuable to our understanding, there still remains considerable uncertainty and ambiguity in many aspects of ADPKD patient care as it relates to ESRD. Particular focus needs to be placed on performing clinical trials with the goal of enhancing outcomes and quality of life of patients with ADPKD.
Collapse
|