1
|
Kurnikowski A, Werzowa J, Hödlmoser S, Krenn S, Paschen C, Mussnig S, Tura A, Harreiter J, Krebs M, Song PX, Eller K, Pascual J, Budde K, Hecking M, Schwaiger E. Continuous Insulin Therapy to Prevent Post-Transplant Diabetes Mellitus: A Randomized Controlled Trial. Kidney Med 2024; 6:100860. [PMID: 39157193 PMCID: PMC11326904 DOI: 10.1016/j.xkme.2024.100860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024] Open
Abstract
Rationale & Objectives Hyperglycemia is frequently observed early after transplantation and associated with development of post-transplant diabetes mellitus (PTDM). Here, we assessed continuous subcutaneous insulin infusion (CSII) targeting afternoon hyperglycemia. Study Design Open-label randomized parallel 3-arm design. Settings & Participants In total, 85 kidney transplant recipients without previous diabetes diagnosis were randomized to postoperative CSII therapy, basal insulin, or control. Interventions Insulin was to be initiated at afternoon capillary blood glucose level of ≥140 mg/dL (7.8 mmol/L; CSII and basal insulin) or fasting plasma glucose level of ≥200 mg/dL (11.1 mmol/L; control). Outcomes Hemoglobin A1c (HbA1c) levels at 3 months post-transplant (primary endpoint). PTDM assessed using oral glucose tolerance test at 12 and 24 months. Results CSII therapy lasted until median day 18 and maximum day 88. The median HbA1c value at month 3 was 5.6% (38 mmol/mol) in the CSII group versus 5.7% (39 mmol/mol) in the control group (P = 0.70) and 5.4% (36 mmol/mol) in the basal insulin group (P = 0.02). At months 12 and 24, the odds for PTDM were similar compared with the control group (odds ratios [95% confidence intervals], 0.80 [0.18-3.49] and 0.71 [0.15-3.16], respectively) and the basal insulin group (0.96 [0.18-5.68] and 1.51 [0.24-12.84], respectively). Mild hypoglycemia events occurred in the CSII and the basal insulin groups. Limitations This study is limited by outdated insulin pump technology, frequent discontinuations of CSII, a complex protocol, and concerns regarding reliability of HbA1c measurements. Conclusions CSII therapy was not superior at reducing HbA1c levels at month 3 or PTDM prevalence at months 12 and 24 compared with the control or basal insulin group.
Collapse
Affiliation(s)
- Amelie Kurnikowski
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, Vienna, Austria
- First Medical Department, Hanusch Hospital, Vienna, Austria
| | - Sebastian Hödlmoser
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Simon Krenn
- Center for Health & Bioresources, Medical Signal Analysis, Austrian Institute of Technology GmbH, Vienna, Austria
| | - Christopher Paschen
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sebastian Mussnig
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
| | - Jürgen Harreiter
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Medicine, Landesklinikum Scheibbs, Scheibbs, Austria
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter X.K. Song
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Julio Pascual
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Klemens Budde
- Medizinische Klinik m. S. Nephrologie, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Kuratorium for Dialysis and Kidney Transplantation (KfH) e.V., Germany
| | - Elisabeth Schwaiger
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Internal Medicine I: Cardiology and Nephrology, Hospital of the Brothers of St. John of God, Eisenstadt, Austria
| |
Collapse
|
2
|
Rossi MR, Mazzali M, de Sousa MV. Oral Glucose Tolerance Test as a Risk Marker for Developing Post-Transplant Diabetes Mellitus. Transplant Proc 2024; 56:1061-1065. [PMID: 38762406 DOI: 10.1016/j.transproceed.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION The incidence of post-transplant diabetes mellitus (PTDM) can reach 30% during the first 6 months after kidney transplantation (KT), increasing the risk of graft failure and mortality. There is no well-established biomarker for predicting PTDM occurrence. This study evaluated the association between the abnormal 2-hour oral glucose tolerance test (OGTT) and the PTDM incidence. METHODS A retrospective single-center study, including adult kidney transplant recipients from deceased donors, was performed between March 2021 and June 2022. EXCLUSION CRITERIA age <18 years; pretransplant diabetes mellitus (DM); death with a functioning graft; loss of follow-up and/or graft failure before 6 months post-transplant. The results of pretransplant OGTT, fasting (FPG), and afternoon plasma glucose levels at hospitalization and FPG in the first, second, and third months post-transplant were evaluated. For analysis, patients were grouped according to the PTDM diagnosis: PTDM and non-PTDM. RESULTS From 164 KT performed in the period, 50 (30%) were included, most male (n = 34, 68%), with a mean age of 48.3 ± 12.5 years. Nine patients (18%) developed PTDM, 44% between 3 and 6 months. General characteristics and immunosuppressive therapy were similar between the groups. The mean FPG in the pretransplant OGTT was significantly higher in the PTDM group compared with the non-PTDM group (85.7 ± 7.9 vs 79.1 ± 8.2, P = .03). The number of patients classified as impaired glucose tolerance (IGT) on the pre-transplant OGTT was significantly higher in the PTDM group. CONCLUSION IGT in the pretransplant OGTT was associated with PTDM cases in kidney transplant recipients without a previous diagnosis of DM.
Collapse
Affiliation(s)
- Matheus Rizzato Rossi
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas-UNICAMP, Campinas, São Paulo, Brazil.
| | - Marilda Mazzali
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Marcos Vinicius de Sousa
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas-UNICAMP, Campinas, São Paulo, Brazil
| |
Collapse
|
3
|
Jørgensen IF, Muse VP, Aguayo-Orozco A, Brunak S, Sørensen SS. Stratification of Kidney Transplant Recipients Into Five Subgroups Based on Temporal Disease Trajectories. Transplant Direct 2024; 10:e1576. [PMID: 38274475 PMCID: PMC10810574 DOI: 10.1097/txd.0000000000001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/02/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024] Open
Abstract
Background Kidney transplantation is the treatment of choice for patients with end-stage renal disease. Considerable clinical research has focused on improving graft survival and an increasing number of kidney recipients die with a functioning graft. There is a need to improve patient survival and to better understand the individualized risk of comorbidities and complications. Here, we developed a method to stratify recipients into similar subgroups based on previous comorbidities and subsequently identify complications and for a subpopulation, laboratory test values associated with survival. Methods First, we identified significant disease patterns based on all hospital diagnoses from the Danish National Patient Registry for 5752 kidney transplant recipients from 1977 to 2018. Using hierarchical clustering, these longitudinal patterns of diseases segregate into 3 main clusters of glomerulonephritis, hypertension, and diabetes. As some recipients are diagnosed with diseases from >1 cluster, recipients are further stratified into 5 more fine-grained trajectory subgroups for which survival, stratified complication patterns as well as laboratory test values are analyzed. Results The study replicated known associations indicating that diabetes and low levels of albumin are associated with worse survival when investigating all recipients. However, stratification of recipients by trajectory subgroup showed additional associations. For recipients with glomerulonephritis, higher levels of basophils are significantly associated with poor survival, and these patients are more often diagnosed with bacterial infections. Additional associations were also found. Conclusions This study demonstrates that disease trajectories can confirm known comorbidities and furthermore stratify kidney transplant recipients into clinical subgroups in which we can characterize stratified risk factors. We hope to motivate future studies to stratify recipients into more fine-grained, homogenous subgroups to better discover associations relevant for the individual patient and thereby enable more personalized disease-management and improve long-term outcomes and survival.
Collapse
Affiliation(s)
- Isabella F. Jørgensen
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N, Denmark
| | - Victorine P. Muse
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N, Denmark
| | - Alejandro Aguayo-Orozco
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen N, Denmark
| | - Søren S. Sørensen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| |
Collapse
|
4
|
Chew Sue Mei S, Pritchard N, Grayton H, Simonicova I, Park SM, Adler AI. Diabetes mellitus in Kabuki syndrome 1 on a background of post-transplant diabetes mellitus. Endocrinol Diabetes Metab Case Rep 2024; 2024:23-0133. [PMID: 38290219 PMCID: PMC10895327 DOI: 10.1530/edm-23-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Summary Kabuki syndrome is a genetic disorder characterised by distinctive facial features, developmental delays, and multisystem congenital anomalies. Endocrine complications such as premature thelarche and short stature are common, whereas disorders of glycaemic control are less frequent. We describe a 23-year-old white female referred to the diabetes clinic for hyperglycaemia during haemodialysis. She was subsequently diagnosed with Kabuki syndrome based on characteristic clinical features, confirmed by detecting a heterozygous pathogenic variant in KMT2D. She was known to have had multiple congenital anomalies at birth, including complex congenital heart disease and a single dysplastic ectopic kidney, and received a cadaveric transplanted kidney at the age of 13. She had hyperglycaemia consistent with post-transplant diabetes mellitus (DM) and was started on insulin. Examination at the time revealed truncal obesity. She developed acute graft rejection and graft failure 14 months post-transplant and she was started on haemodialysis. Her blood glucose levels normalised post-graft explant, but she was hyperglycaemic again during haemodialysis at the age of 23. Given her clinical phenotype, negative diabetes antibodies and normal pancreas on ultrasound, she was assumed to have type 2 DM and achieved good glycaemic control with gliclazide. Learning points Involve clinical genetics early in the investigative pathway of sick neonates born with multiple congenital anomalies to establish a diagnosis to direct medical care. Consider the possibility of Kabuki syndrome (KS) in the differential diagnoses in any neonate with normal karyotyping or microarray analysis and with multiple congenital anomalies (especially cardiac, renal, or skeletal), dysmorphic facial features, transient neonatal hypoglycaemia and failure to thrive. Consider the possibility of diabetes as an endocrine complication in KS patients who are obese or who have autoimmune disorders.
Collapse
Affiliation(s)
- S Chew Sue Mei
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - N Pritchard
- Department of Renal Medicine, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - H Grayton
- Cambridge Genomics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - I Simonicova
- Cambridge Genomics Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S M Park
- Department of Clinical Genetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A I Adler
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- University of Oxford Diabetes Trials Unit, Oxford, UK
| |
Collapse
|
5
|
Laghrib Y, Massart A, de Fijter JW, Abramowicz D, De Block C, Hellemans R. Pre-transplant HbA1c and risk of diabetes mellitus after kidney transplantation: a single center retrospective analysis. J Nephrol 2023; 36:1921-1929. [PMID: 37039964 DOI: 10.1007/s40620-023-01623-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Post-transplant diabetes mellitus occurs in 10-40% of kidney transplant recipients and is associated with increased risk of developing cardiovascular diseases. Early identification of patients with a higher risk of developing diabetes could allow to take timely measures. However, no validated model exists to predict the risk of post-transplant diabetes mellitus. METHODS This retrospective study includes 267 adult patients who underwent kidney transplantation at the Antwerp University Hospital between January 2014 and August 2021. Post-transplant diabetes mellitus was diagnosed based on the American Diabetes Association definition at 3 months post-transplant. First, a logistic regression analysis was used to identify predictors for post-transplant diabetes mellitus. Second, criteria to identify patients with a high risk (> 35%) of developing post-transplant diabetes mellitus at 3 months were established. RESULTS At 3 months post-transplantation, 54 (20.2%) patients developed post-transplant diabetes mellitus. Univariable analysis showed that age, body mass index and HbA1c on the day of transplantation were associated with post-transplant diabetes mellitus. However, in a multivariable model with the same parameters, only HbA1c remained statistically significant. An absolute increase in HbA1c of 0.1% increases the odds for developing post-transplant diabetes mellitus by 28% (95% confidence interval 1.15-1.42). An HbA1c level ≥ 5.3% at transplantation, regardless of age or body mass index, is sufficient to identify patients with a post-transplant diabetes mellitus risk of ≥ 35% with a positive predictive value of 39% and a negative predictive value of 88%. CONCLUSIONS The HbA1c value at transplantation was the strongest predictor for post-transplant diabetes mellitus at 3 months post-transplant. Furthermore, at least in our population, a pre-transplant HbA1c of ≥ 5.3% can be used as an easy tool to identify patients at high risk of early post-transplant diabetes mellitus.
Collapse
Affiliation(s)
- Yassine Laghrib
- Department of Nephrology-Hypertension, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium.
| | - Annick Massart
- Department of Nephrology-Hypertension, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Johan Willem de Fijter
- Department of Nephrology-Hypertension, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Daniel Abramowicz
- Department of Nephrology-Hypertension, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Rachel Hellemans
- Department of Nephrology-Hypertension, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| |
Collapse
|
6
|
Bang JB, Oh CK, Kim YS, Kim SH, Yu HC, Kim CD, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Ahn HJ, Lee SH, Jeon JY. Changes in glucose metabolism among recipients with diabetes 1 year after kidney transplant: a multicenter 1-year prospective study. Front Endocrinol (Lausanne) 2023; 14:1197475. [PMID: 37424863 PMCID: PMC10325682 DOI: 10.3389/fendo.2023.1197475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Diabetes mellitus is a common and crucial metabolic complication in kidney transplantation. It is necessary to analyze the course of glucose metabolism in patients who already have diabetes after receiving a transplant. In this study, we investigated the changes in glucose metabolism after transplantation, and a detailed analysis was performed on some patients whose glycemic status improved. Methods The multicenter prospective cohort study was conducted between 1 April 2016 and 31 September 2018. Adult patients (aged 20 to 65 years) who received kidney allografts from living or deceased donors were included. Seventy-four subjects with pre-transplant diabetes were followed up for 1 year after kidney transplantation. Diabetes remission was defined as the results of the oral glucose tolerance test performed one year after transplantation and the presence or absence of diabetes medications. After 1-year post-transplant, 74 recipients were divided into the persistent diabetes group (n = 58) and the remission group (n = 16). Multivariable logistic regression was performed to identify clinical factors associated with diabetes remission. Results Of 74 recipients, 16 (21.6%) showed diabetes remission after 1-year post-transplant. The homeostatic model assessment for insulin resistance numerically increased in both groups throughout the first year after transplantation and significantly increased in the persistent diabetes group. The insulinogenic index (IGI30) value significantly increased only in the remission group, and the IGI30 value remained low in the persistent diabetes group. In univariate analysis, younger age, newly diagnosed diabetes before transplantation, low baseline hemoglobin A1c, and high baseline IGI30 were significantly associated with remission of diabetes. After multivariate analysis, only newly diagnosed diabetes before transplantation and IGI30 at baseline were associated with remission of diabetes (34.00 [1.192-969.84], P = 0.039, and 17.625 [1.412-220.001], P = 0.026, respectively). Conclusion In conclusion, some kidney recipients with pre-transplant diabetes have diabetes remission 1 year after transplantation. Our prospective study revealed that preserved insulin secretory function and newly diagnosed diabetes at the time of kidney transplantation were favorable factors for which glucose metabolism did not worsen or improve 1 year after kidney transplantation.
Collapse
Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery and Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University College of Medicine, Jeonju, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jun So
- Department of Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sang Ho Lee
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Republic of Korea
| | - Hyung Joon Ahn
- Department of Surgery, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
| |
Collapse
|
7
|
Fariña-Hernández A, Marrero-Miranda D, Perez-Carreño E, De Vera-Gonzalez A, González A, Acosta-Sorensen C, Rodríguez-Rodríguez AE, Collantes T, García MDP, Rodríguez-Muñoz AI, Rodriguez-Alvarez C, Rivero A, Macía M, Teran E, Sanchez-Dorta NV, Perez-Tamajón L, Alvarez-González A, González-Rinne A, Rodríguez-Hernández A, De Bonis-Redondo E, Rodriguez-Adanero C, Hernández D, Porrini E, Torres A. Pretransplant evaluation and the risk of glucose metabolic alterations after renal transplantation: a prospective study. Nephrol Dial Transplant 2023; 38:778-786. [PMID: 36083994 DOI: 10.1093/ndt/gfac256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Post-transplant prediabetes (PreDM) and diabetes (PTDM) are common and have an impact on cardiovascular events. We sought to investigate the pathogenesis and best approach for prediction. METHODS We prospectively studied 115 waitlisted patients from a single center without manifest diabetes. An oral glucose tolerance test (OGTT) was performed yearly until transplantation and 12 months later. Insulin secretion, insulin sensitivity (IS) and disposition index (DI) were derived from the OGTT. RESULTS PreDM and PTDM were observed in 27% and 28.6% of patients, respectively. Pretransplant age, body mass index (BMI), 120 min glucose, IS, DI, and prediabetes or undiagnosed diabetes were significantly associated with these alterations. In multivariate analysis, pretransplant age [odds ratio (OR) 1.5; 95% confidence interval (CI) 1.04-2.1], BMI (OR 1.16; 95% CI 1.04-1.3) and cumulative steroids (OR 1.5; 95% CI 1.02-2.2) were predictors of PreDM or PTDM. Receiver operating characteristic curve analysis showed that pretransplant BMI and 120 min glucose had the highest area under the curve (0.72; 95% CI 0.62-0.8; and 0.69; 95% CI 0.59-0.79, respectively). The highest discrimination cut-off for BMI (≥28.5 kg/m2) and 120 min glucose (≥123.5 mg/dL) yielded a similar number needed to diagnose (2.5). CONCLUSIONS PreDM or PTDM develops in waitlisted patients with an ineffective insulin secretion and BMI shows a similar diagnostic capacity to OGTT. Pretransplant interventions may reduce post-transplant glucose alterations.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Antonio Rivero
- Nephrology Service, Hospital Universitario NS de La Candelaria, Tenerife, Spain
| | - Manuel Macía
- Nephrology Service, Hospital Universitario NS de La Candelaria, Tenerife, Spain
| | - Elena Teran
- Nephrology Service, Hospital Universitario de Canarias, Tenerife, Spain
| | | | | | | | | | | | | | | | - Domingo Hernández
- Nephrology Service, Hospital Regional Universitario de Málaga, Universidad de Málaga, IBIMA
| | - Esteban Porrini
- Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Tenerife, Spain
| | - Armando Torres
- Nephrology Service, Hospital Universitario de Canarias, Tenerife, Spain.,Instituto de Tecnologías Biomédicas (ITB), Universidad de La Laguna, Tenerife, Spain
| |
Collapse
|
8
|
Schneditz D, Niemczyk L, Wojtecka A, Szamotulska K, Niemczyk S. Comparable Hemodilution with Hypertonic Glucose in Patients with and without Type-2 Diabetes Mellitus during Hemodialysis. Nutrients 2023; 15:nu15030536. [PMID: 36771243 PMCID: PMC9920628 DOI: 10.3390/nu15030536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
(1) Background: It was examined whether glucose-induced changes in the relative blood volume are suitable to identify subjects with and without type-2 diabetes mellitus (T2D) during hemodialysis. (2) Methods: The relative blood volume was continuously recorded during hemodialysis and perturbed by the infusion of glucose comparable to the dose used for intravenous glucose tolerance tests. Indices of glucose metabolism were determined by the homeostatic model assessment (HOMA). Body composition was measured by a bioimpedance analysis. The magnitude and the time course of hemodilution were described by a modified gamma variate model and five model parameters. (3) Results: A total of 34 subjects were studied, 14 with and 20 without T2D. The magnitude of the hemodilution and the selected model parameters correlated with measures of anthropometry, body mass index, absolute and relative fat mass, volume excess, baseline insulin concentration, and HOMA indices such as insulin resistance and glucose disposition in a continuous analysis, but were not different in a dichotomous analysis of patients with and without T2D. (4) Conclusions: Even though the parameters of the hemodilution curve were correlated with measures of impaired glucose metabolism and body composition, the distinction between subjects with and without T2D was not possible using glucose-induced changes in the relative blood volume during hemodialysis.
Collapse
Affiliation(s)
- Daniel Schneditz
- Otto Loewi Research Center, Division of Physiology, Medical University of Graz, 8010 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-7385
| | - Longin Niemczyk
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Anna Wojtecka
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, National Research Institute of Mother and Child, 01-211 Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine, 04-141 Warsaw, Poland
| |
Collapse
|
9
|
Vinson AJ, Thanamayooran A, Kiberd BA, West K, Siddiqi FS, Gunaratnam L, Tennankore KK. The Association of Pre-Transplant C-Peptide Level with the Development of Post-Transplant Diabetes: A Cohort Study. KIDNEY360 2022; 3:1738-1745. [PMID: 36514718 PMCID: PMC9717663 DOI: 10.34067/kid.0003742022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/28/2022] [Indexed: 01/12/2023]
Abstract
Background Post-transplant diabetes mellitus (PTDM) is an important complication after kidney transplantation that results in reduced patient and allograft survival. Although there are established risk factors for PTDM, whether pretransplant C-peptide levels associate with PTDM is unknown. Therefore, in this study, we aimed to examine the association of pretransplant C-peptide levels with PTDM. Methods This was a cohort study of nondiabetic adult patients who underwent kidney transplant in Nova Scotia, Canada, between January 1, 2016, and March 31, 2021, with fasting C-peptide levels measured before transplant. Multivariable logistic regression was used to determine the association of pretransplant C-peptide (dichotomized around the median) with PTDM at 1 year post transplant. Given the known association between pretransplant obesity and PTDM, we repeated our primary analysis in a cohort restricted to a BMI of 20-35 kg/m2. Results The median C-peptide value was 3251 (Q1 2480, Q3 4724); pretransplant C-peptide level was dichotomized at 3000 pmol/L. PTDM occurred in 25 (19%) individuals. Thirty percent of patients in the high and only 2% of patients in the low C-peptide groups developed PTDM (P<0.001). A C-peptide level ≥3000 pmol/L was strongly associated with PTDM in multivariable analysis (OR=18.9, 95% CI, 2.06 to 174.2). In a restricted cohort with a BMI of 20-35 kg/m2, an elevated pretransplant C-peptide remained independently associated with the risk of PTDM (OR=15.7, 95% CI, 1.64 to 150.3). C-peptide was the only factor independently associated with PTDM in this restricted BMI cohort. Conclusions A pretransplant C-peptide level ≥3000 pmol/L was associated with a nearly 20-fold increased odds of PTDM at 1 year post kidney transplantation. Identifying patients with high pretransplant C-peptide levels may therefore help identify those at risk for PTDM who may benefit from focused preventative and therapeutic interventions and support.
Collapse
Affiliation(s)
- Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Aran Thanamayooran
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Bryce A. Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Kenneth West
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Ferhan S. Siddiqi
- Division of Endocrinology and Metabolism, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Lakshman Gunaratnam
- Multiorgan Transplant Program, London Health Sciences Centre, London, Canada,Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| |
Collapse
|
10
|
Effect of Early Steroid Withdrawal on Posttransplant Diabetes Among Kidney Transplant Recipients Differs by Recipient Age. Transplant Direct 2021; 8:e1260. [PMID: 34912947 PMCID: PMC8670588 DOI: 10.1097/txd.0000000000001260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Posttransplant diabetes (PTD), a major complication after kidney transplantation (KT), is often attributable to immunosuppression. The risk of PTD may increase with more potent steroid maintenance and older recipient age. Methods. Using United States Renal Data System data, we studied 12 488 adult first-time KT recipients (2010–2015) with no known pre-KT diabetes. We compared the risk of PTD among recipients who underwent early steroid withdrawal (ESW) versus continued steroid maintenance (CSM) using Cox regression with inverse probability weighting to adjust for confounding. We tested whether the risk of PTD resulting from ESW differed by recipient age (18–29, 30–54, and ≥55 y). Results. Of 12 488, 28.3% recipients received ESW. The incidence rate for PTD was 13 per 100 person-y and lower among recipients who received ESW (11 per 100 person-y in ESW; 14 per 100 person-y in CSM). Overall, ESW was associated with lower risk of PTD compared with CSM (adjusted hazard ratio [aHR] = 0.720.790.86), but the risk differed by recipient age (Pinteraction = 0.09 for comparison between recipients aged 18–29 and those aged 30–54; Pinteraction = 0.01 for comparison between recipients aged 18–29 and those aged ≥55). ESW was associated with lower risk of PTD among recipients aged ≥55 (aHR = 0.620.710.81) and those aged 30–54 (aHR = 0.730.830.95), but not among recipients aged 18–29 (aHR = 0.811.181.72). Although recipients who received ESW had a higher risk of acute rejection across the age groups (adjusted odds ratio = 1.011.171.34), recipients with no PTD had a lower risk of mortality (aHR = 0.580.660.74). Conclusions. The beneficial association of ESW with decreased PTD was more pronounced among recipients aged ≥55, supporting an age-specific assessment of the risk-benefit balance regarding ESW.
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW Posttransplant diabetes mellitus (PTDM) is a prevalent complication in kidney transplant recipients, and has been associated with worse short-term and long-term outcomes. RECENT FINDINGS While hyperglycemia is frequently seen in the early posttransplant period because of surgical stress, infection, and use of high-dose steroids, the diagnosis of PTDM should be established after patients are clinically stable and on stable maintenance immunosuppression. In the early posttransplant period, hyperglycemia is typically treated with insulin, and pilot data have suggested potential benefit of lower vs. higher glycemic targets in this setting. Growing data indicate lifestyle modifications, including dietary interventions, physical activity, and mitigation of obesity, are associated with improved posttransplant outcomes. While there are limited data to support a first-line antidiabetic medication for PTDM, more established pharmacotherapies such as sulfonylureas, meglitinides, and dipetidyl peptidase IV inhibitors are commonly used. Given recent trials showing the benefits of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists upon kidney outcomes in nontransplant patients, further study of these agents specifically in kidney transplant recipients are urgently needed. SUMMARY Increasing evidence supports a multidisciplinary approach, including lifestyle modification, obesity treatment, judicious immunosuppression selection, and careful utilization of novel antidiabetic therapies in PTDM patients.
Collapse
|
12
|
Martinez Cantarin MP. Diabetes in Kidney Transplantation. Adv Chronic Kidney Dis 2021; 28:596-605. [PMID: 35367028 DOI: 10.1053/j.ackd.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
Diabetes mellitus (DM) is one of the most common complications after kidney transplantation and is associated with unfavorable outcomes including death. DM can be present before transplant but post-transplant DM (PTDM) refers to diabetes that is diagnosed after solid organ transplantation. Despite its high prevalence, optimal treatment to prevent complications of PTDM is unknown. Medical therapy of pre-existent DM or PTDM after transplant is challenging because of frequent interactions between antidiabetic and immunosuppressive agents. There is also frequent need for medication dose adjustments due to residual kidney disease and a higher risk of medication side effects in patients treated with immunosuppressive agents. Sodium-glucose cotransporter 2 inhibitors have demonstrated a favorable cardio-renal profile in patients with DM without a transplant and hence hold great promise in this patient population although there is concern about the higher risk of urinary tract infections. The significant gaps in our understanding of the pathophysiology, diagnosis, and management of DM after kidney transplantation need to be urgently addressed.
Collapse
|
13
|
Kotha S, Lawendy B, Asim S, Gomes C, Yu J, Orchanian-Cheff A, Tomlinson G, Bhat M. Impact of immunosuppression on incidence of post-transplant diabetes mellitus in solid organ transplant recipients: Systematic review and meta-analysis. World J Transplant 2021; 11:432-442. [PMID: 34722172 PMCID: PMC8529944 DOI: 10.5500/wjt.v11.i10.432] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/27/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Solid organ transplantation is a life-saving intervention for end-stage organ disease. Post-transplant diabetes mellitus (PTDM) is a common complication in solid organ transplant recipients, and significantly compromises long-term survival beyond a year.
AIM To perform a systematic review and meta-analysis to estimate incidence of PTDM and compare the effects of the 3 major immunosuppressants on incidence of PTDM.
METHODS Two hundred and six eligible studies identified 75595 patients on Tacrolimus, 51242 on Cyclosporine and 3020 on Sirolimus. Random effects meta-analyses was used to calculate incidence.
RESULTS Network meta-analysis estimated the overall risk of developing PTDM was higher with tacrolimus (OR = 1.4 95%CI: 1.0–2.0) and sirolimus (OR = 1.8; 95%CI: 1.5–2.2) than with Cyclosporine. The overall incidence of PTDM at years 2-3 was 17% for kidney, 19% for liver and 22% for heart. The risk factors for PTDM most frequently identified in the primary studies were age, body mass index, hepatitis C, and African American descent.
CONCLUSION Tacrolimus tends to exhibit higher diabetogenicity in the short-term (2-3 years post-transplant), whereas sirolimus exhibits higher diabetogenicity in the long-term (5-10 years post-transplant). This study will aid clinicians in recognition of risk factors for PTDM and encourage careful evaluation of the risk/benefit of different immunosuppressant regimens in transplant recipients.
Collapse
Affiliation(s)
- Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' Hospital, London SE1 7JD, United Kingdom
| | - Bishoy Lawendy
- Department of Multi-Organ Transplantation, Toronto General Hospital, Toronto M5G 2C4, Canada
| | - Saira Asim
- Multi Organ Transplant Program, Toronto General Hospital, Toronto M5G 2C4, Canada
| | - Charlene Gomes
- Department of Multi-Organ Transplantation, Toronto General Hospital, Toronto M5G 2C4, Canada
| | - Jeffrey Yu
- Department of Multi-Organ Transplantation, Toronto General Hospital, Toronto M5G 2C4, Canada
| | - Ani Orchanian-Cheff
- Department of Multi-Organ Transplantation, Toronto General Hospital, Toronto M5G 2C4, Canada
| | - George Tomlinson
- Dalla Lana School of Public Health, Department of Medicine, University Health Network - Toronto General Hospital, University of Toronto, Toronto M5G 2C4, Canada
| | - Mamatha Bhat
- Multi-organ Transplant, Toronto General Hospital, Toronto M5G 2C4, Canada
| |
Collapse
|
14
|
Rhee CM, Kalantar-Zadeh K, Moore LW. Medical Nutrition Therapy for Diabetic Kidney Disease. J Ren Nutr 2021; 31:229-232. [PMID: 33990265 DOI: 10.1053/j.jrn.2021.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/13/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Connie M Rhee
- University of California Irvine, Orange, California.
| | | | | |
Collapse
|
15
|
Rodríguez-Rodríguez AE, Porrini E, Hornum M, Donate-Correa J, Morales-Febles R, Khemlani Ramchand S, Molina Lima MX, Torres A. Post-Transplant Diabetes Mellitus and Prediabetes in Renal Transplant Recipients: An Update. Nephron Clin Pract 2021; 145:317-329. [PMID: 33902027 DOI: 10.1159/000514288] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent and relevant complication after renal transplantation: it affects 20-30% of renal transplant recipients and increases the risk for cardiovascular and infectious events. Thus, understanding pathogenesis of PTDM would help limiting its consequences. In this review, we analyse novel aspects of PTDM, based on studies of the last decade, such as the clinical evolution of PTDM, early and late, the reversibility rate, diagnostic criteria, risk factors, including pre-transplant metabolic syndrome and insulin resistance (IR) and the interaction between these factors and immunosuppressive medications. Also, we discuss novel pathogenic factors, in particular the role of β-cell function in an environment of IR and common pathways between pre-existing cell damage and tacrolimus-induced toxicity. The relevant role of prediabetes in the pathogenesis of PTDM and cardiovascular disease is also addressed. Finally, current evidence on PTDM treatment is discussed.
Collapse
Affiliation(s)
| | - Esteban Porrini
- Research Unit, Hospital Universitario de Canarias, Universidad de la Laguna, Tenerife, Spain.,Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Javier Donate-Correa
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | | | | | | | - Armando Torres
- Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Servicio de Nefrología, Hospital Universitario de Canarias, Tenerife, Spain
| |
Collapse
|
16
|
Madziarska K, Hap K, Mazanowska O, Sutkowska E. Comprehensive lifestyle modification as
complementary therapy to prevent and manage
post-transplant diabetes mellitus*. POSTEP HIG MED DOSW 2021. [DOI: 10.5604/01.3001.0014.8311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is one from the most common metabolic complications
after kidney transplantation. PTDM develops in the early period after transplantation.
The risk factors of PTDM are carbohydrate imbalances occurring in the patient prior to
transplantation, surgery and the inclusion of immunosuppressive treatment. Kidney transplant
patients tend to gain weight, which is associated with an increased risk of post-transplant
diabetes, cardiovascular diseases and abnormal transplanted kidney function.
Patients after kidney transplantation should be advised to adopt a lifestyle based on a proper
diet, exercise, weight control and smoking cessation. The strategy to reduce the risk factors
for PTDM development should start before transplantation and continue after kidney
transplantation. A targeted, non-pharmacological approach to patients already during the
dialysis period may have a significant impact on reducing post-transplantation diabetes.
Lifestyle interventions can effectively reduce the risk of development and inhibit the progression
of post-transplantation diabetes. The article describes elements of comprehensive
non-pharmacological management based on available knowledge of rehabilitation, dietetics
and psychology.
Collapse
Affiliation(s)
- Katarzyna Madziarska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Katarzyna Hap
- Department and Division of Medical Rehabilitation, Wroclaw Medical University, Poland
| | - Oktawia Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Poland
| | - Edyta Sutkowska
- Department and Division of Medical Rehabilitation, Wroclaw Medical University, Poland
| |
Collapse
|
17
|
Current Pharmacological Intervention and Medical Management for Diabetic Kidney Transplant Recipients. Pharmaceutics 2021; 13:pharmaceutics13030413. [PMID: 33808901 PMCID: PMC8003701 DOI: 10.3390/pharmaceutics13030413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 01/02/2023] Open
Abstract
Hyperglycemia after kidney transplantation is common in both diabetic and non-diabetic patients. Both pretransplant and post-transplant diabetes mellitus are associated with increased kidney allograft failure and mortality. Glucose management may be challenging for kidney transplant recipients. The pathophysiology and pattern of hyperglycemia in patients following kidney transplantation is different from those with type 2 diabetes mellitus. In patients with pre-existing and post-transplant diabetes mellitus, there is limited data on the management of hyperglycemia after kidney transplantation. The following article discusses the nomenclature and diagnosis of pre- and post-transplant diabetes mellitus, the impact of transplant-related hyperglycemia on patient and kidney allograft outcomes, risk factors and potential pathogenic mechanisms of hyperglycemia after kidney transplantation, glucose management before and after transplantation, and modalities for prevention of post-transplant diabetes mellitus.
Collapse
|
18
|
Nodular glomerulosclerosis in a kidney transplant recipient with impaired glucose tolerance: diabetic or idiopathic? A case report and literature review. CEN Case Rep 2021; 10:273-280. [PMID: 33393072 DOI: 10.1007/s13730-020-00546-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022] Open
Abstract
Nodular glomerulosclerosis, typically diagnosed in patients with diabetes mellitus, has been reported in native kidneys of pre-diabetic patients but similar cases in kidney transplant recipients are lacking. We describe a case of nodular glomerulosclerosis in a kidney transplant recipient who had not been found to be diabetic despite regular screening and discuss the implications for the pathogenesis and diagnosis of nodular glomerulosclerosis and screening of post-transplant diabetes mellitus.
Collapse
|
19
|
Jørgensen MB, Idorn T, Rydahl C, Hansen HP, Bressendorff I, Brandi L, Wewer Albrechtsen NJ, van Hall G, Hartmann B, Holst JJ, Knop FK, Hornum M, Feldt-Rasmussen B. Effect of the Incretin Hormones on the Endocrine Pancreas in End-Stage Renal Disease. J Clin Endocrinol Metab 2020; 105:5586894. [PMID: 31608934 DOI: 10.1210/clinem/dgz048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/25/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT The insulin-stimulating and glucagon-regulating effects of the 2 incretin hormones, glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), contribute to maintain normal glucose homeostasis. Impaired glucose tolerance occurs with high prevalence among patients with end-stage renal disease (ESRD). OBJECTIVE To evaluate the effect of the incretin hormones on endocrine pancreatic function in patients with ESRD. DESIGN AND SETTING Twelve ESRD patients on chronic hemodialysis and 12 matched healthy controls, all with normal oral glucose tolerance test, were included. On 3 separate days, a 2-hour euglycemic clamp followed by a 2-hour hyperglycemic clamp (3 mM above fasting level) was performed with concomitant infusion of GLP-1 (1 pmol/kg/min), GIP (2 pmol/kg/min), or saline administered in a randomized, double-blinded fashion. A 30% lower infusion rate was used in the ESRD group to obtain comparable incretin hormone plasma levels. RESULTS During clamps, comparable plasma glucose and intact incretin hormone concentrations were achieved. The effect of GLP-1 to increase insulin concentrations relative to placebo levels tended to be lower during euglycemia in ESRD and was significantly reduced during hyperglycemia (50 [8-72]%, P = 0.03). Similarly, the effect of GIP relative to placebo levels tended to be lower during euglycemia in ESRD and was significantly reduced during hyperglycemia (34 [13-50]%, P = 0.005). Glucagon was suppressed in both groups, with controls reaching lower concentrations than ESRD patients. CONCLUSIONS The effect of incretin hormones to increase insulin release is reduced in ESRD, which, together with elevated glucagon levels, could contribute to the high prevalence of impaired glucose tolerance among ESRD patients.
Collapse
Affiliation(s)
- Morten B Jørgensen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Idorn
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Casper Rydahl
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Henrik P Hansen
- Department of Nephrology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Iain Bressendorff
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark
| | - Lisbet Brandi
- Department of Cardiology, Endocrinology and Nephrology, Nordsjællands Hospital, University of Copenhagen, Hillerød, Denmark
| | | | - Gerrit van Hall
- Clinical Metabolomics Core Facility, Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- The Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
20
|
Riou M, Renaud-Picard B, Munch M, Lefebvre F, Baltzinger P, Porzio M, Hirschi S, Dégot T, Schuller A, Santelmo N, Reeb J, Olland A, Falcoz PE, Massard G, Kessler L, Kessler R. Organized Management of Diabetes Mellitus in Lung Transplantation: Study of Glycemic Control and Patient Survival in a Single Center. Transplant Proc 2019; 51:3375-3384. [DOI: 10.1016/j.transproceed.2019.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 05/31/2019] [Accepted: 07/09/2019] [Indexed: 12/27/2022]
|
21
|
Porrini E, Díaz JM, Moreso F, Lauzurrica R, Ibernon M, Torres IS, Ruiz RB, Rodríguez Rodríguez AE, Mallén PD, Bayés-Genís B, Gainza FJ, Osorio JM, Osuna A, Domínguez R, Ruiz JC, Sosa AJ, Rinne AG, Miranda DM, Macías M, Torres A. Prediabetes is a risk factor for cardiovascular disease following renal transplantation. Kidney Int 2019; 96:1374-1380. [PMID: 31611066 DOI: 10.1016/j.kint.2019.06.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/04/2019] [Accepted: 06/27/2019] [Indexed: 12/14/2022]
Abstract
Prediabetes and post-transplant diabetes mellitus affect about 20-30% of renal transplant patients. The latter is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. To study this we analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated oral glucose tests for up to five years and a long term survival evaluation. Prediabetes and post-transplant diabetes mellitus were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was significantly higher in patients with either prediabetes, (17%; 0.023 person/year) or post-transplant diabetes mellitus (20%; 0.028 person/year) than in normal individuals, (7%; 0.0095 person/year). The incidence of events was comparable between prediabetes and post-transplant diabetes mellitus. Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate Cox survival analyses (hazard ratio 2.24, 95% confidence interval 1.11-4.52). Prediabetes at three months and hemoglobin A1c at 12 months were not significantly associated with cardiovascular disease. Thus, prediabetes is a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Since prediabetes is potentially a reversible condition, there is an opportunity to prevent cardiovascular disease in this population.
Collapse
Affiliation(s)
- Esteban Porrini
- Instituto de Tecnologías Biomédicas, University of La Laguna, Tenerife, Spain.
| | | | | | | | | | | | | | | | | | | | | | - José Manuel Osorio
- Nephrology Section, Hospital Nuestra Señora Virgen de las Nieves, Granada, Spain
| | - Antonio Osuna
- Nephrology Section, Hospital Nuestra Señora Virgen de las Nieves, Granada, Spain
| | - Rosa Domínguez
- Nephrology Unit, Hospital Marqués de Valdecilla, Santander, Spain
| | - Juan Carlos Ruiz
- Nephrology Unit, Hospital Marqués de Valdecilla, Santander, Spain
| | | | | | | | - Manuel Macías
- Nephrology Unit, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, Spain
| | - Armando Torres
- Instituto de Tecnologías Biomédicas, University of La Laguna, Tenerife, Spain; Nephrology Unit, Hospital Universitario de Canarias, La Laguna, Spain
| |
Collapse
|
22
|
Abstract
Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10-20% of patients with kidney transplants and in 20-40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.
Collapse
Affiliation(s)
- Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
23
|
Ussif AM, Åsberg A, Halden TAS, Nordheim E, Hartmann A, Jenssen T. Validation of diagnostic utility of fasting plasma glucose and HbA1c in stable renal transplant recipients one year after transplantation. BMC Nephrol 2019; 20:12. [PMID: 30630438 PMCID: PMC6327477 DOI: 10.1186/s12882-018-1171-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 12/03/2018] [Indexed: 01/29/2023] Open
Abstract
Background The use of HbA1c ≥6.5% for diagnosis of diabetes has been challenged for post-transplantation diabetes mellitus (PTDM) also known as new onset diabetes after transplantation (NODAT) due to a low sensitivity early after renal transplantation. PTDM diagnosed with an oral glucose tolerance test (OGTT) is highly predictable for long-term patient mortality. HbA1c was introduced for diagnosis based on the risk of developing diabetic retinopathy. The utility of HbA1c measures versus glucose criteria has not been widely assessed in stable transplant patients but still HbA1c is widely used in this population. The aim of the present analyses was to validate the utility of fasting plasma glucose (FPG) together with HbA1c in diagnosing PTDM in stable renal transplant recipients (RTRs). Methods OGTT’s were performed one year after transplantation in 494 consecutive RTRs without diabetes. FPG and HbA1c were obtained the same day, before starting the OGTT. Validation was performed using C-statistics and logistic regression analyses. Results PTDM was diagnosed in 51 patients (10.3%) by glucose criteria, 38 (74%) patients were diagnosed by FPG ≥7.0 mmol/L [126.1 mg/dl], and 13 (26%) only by 2-h plasma glucose. Six of the latter had HbA1c ≥6.5%. Only seven patients out of the 51 (13.7%) PTDM patients remained undiagnosed when HbA1c ≥6.5% was used together with FPG, and five of these regressed to normal after a median follow-up of 14 months. ROC curves including FPG and HbA1c versus OGTT derived criteria revealed an AUC of 0.858. Conclusions Combining standard diagnostic FPG and HbA1c criteria captured almost all patients with persistent PTDM in stable RTRs. The combined use of the criteria appears to be an applicable diagnostic strategy for PTDM without the need of an OGTT one year post-transplant. Trial registration Retrospectively registered.
Collapse
Affiliation(s)
- Amin M Ussif
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway.
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway.,The Norwegian Renal Registry, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Thea Anine Strøm Halden
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway
| | - Espen Nordheim
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, P.O.Box 4950, 0424, Oslo, Nydalen, Norway.,Metabolic and Renal Research Group, Faculty of Health Sciences UiT, The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
24
|
Socioeconomic Inequalities of Undiagnosed Diabetes in a Resource-Poor Setting: Insights from the Cross-Sectional Bangladesh Demographic and Health Survey 2011. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16010115. [PMID: 30609855 PMCID: PMC6338882 DOI: 10.3390/ijerph16010115] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 12/22/2018] [Accepted: 12/27/2018] [Indexed: 01/21/2023]
Abstract
Diabetes mellitus is rising disproportionately but is not frequently diagnosed until complications appear, which results in adverse health consequences. We estimated the prevalence of undiagnosed diabetes among adult diabetic patients and associated socioeconomic inequalities in Bangladesh. We used nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) 2011 data. Among patients with diabetes, we identified undiagnosed cases as having fasting plasma glucose ≥ 7.0 mmol/L, never having taken prescribed medicine and being told by health professionals. Among 938 patients with diabetes, 53.4% remained undiagnosed. The poorest (75.9%) and rural (59.0%) patients had significantly higher undiagnosed cases than the richest (36.0%) and urban (42.5%), respectively. Multiple logistic regression analysis revealed that the likelihood of being undiagnosed was lower among patients with age ≥ 70 years vs. 35–39 years (adjusted odds ratio (AOR) = 0.35; 95% confidence interval (CI) 0.19, 0.64) and patients with higher education vs. no education (AOR = 0.36; 95% CI 0.21, 0.62). Conversely, a high level of physical activity and being in a poor socioeconomic quintile were associated with a higher risk of remaining undiagnosed for diabetes. The Concentration Index (C) also showed that undiagnosed diabetes was largely distributed among the socioeconomically worse-off group in Bangladesh (C = −0.35). Nationwide diabetes screening programs may reduce this problem in Bangladesh and other similar low-income settings.
Collapse
|
25
|
Torres A, Hernández D, Moreso F, Serón D, Burgos MD, Pallardó LM, Kanter J, Díaz Corte C, Rodríguez M, Diaz JM, Silva I, Valdes F, Fernández-Rivera C, Osuna A, Gracia Guindo MC, Gómez Alamillo C, Ruiz JC, Marrero Miranda D, Pérez-Tamajón L, Rodríguez A, González-Rinne A, Alvarez A, Perez-Carreño E, de la Vega Prieto MJ, Henriquez F, Gallego R, Salido E, Porrini E. Randomized Controlled Trial Assessing the Impact of Tacrolimus Versus Cyclosporine on the Incidence of Posttransplant Diabetes Mellitus. Kidney Int Rep 2018; 3:1304-1315. [PMID: 30450457 PMCID: PMC6224662 DOI: 10.1016/j.ekir.2018.07.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Despite the high incidence of posttransplant diabetes mellitus (PTDM) among high-risk recipients, no studies have investigated its prevention by immunosuppression optimization. METHODS We conducted an open-label, multicenter, randomized trial testing whether a tacrolimus-based immunosuppression and rapid steroid withdrawal (SW) within 1 week (Tac-SW) or cyclosporine A (CsA) with steroid minimization (SM) (CsA-SM), decreased the incidence of PTDM compared with tacrolimus with SM (Tac-SM). All arms received basiliximab and mycophenolate mofetil. High risk was defined by age >60 or >45 years plus metabolic criteria based on body mass index, triglycerides, and high-density lipoprotein-cholesterol levels. The primary endpoint was the incidence of PTDM after 12 months. RESULTS The study comprised 128 de novo renal transplant recipients without pretransplant diabetes (Tac-SW: 44, Tac-SM: 42, CsA-SM: 42). The 1-year incidence of PTDM in each arm was 37.8% for Tac-SW, 25.7% for Tac-SM, and 9.7% for CsA-SM (relative risk [RR] Tac-SW vs. CsA-SM 3.9 [1.2-12.4; P = 0.01]; RR Tac-SM vs. CsA-SM 2.7 [0.8-8.9; P = 0.1]). Antidiabetic therapy was required less commonly in the CsA-SM arm (P = 0.06); however, acute rejection rate was higher in CsA-SM arm (Tac-SW 11.4%, Tac-SM 4.8%, and CsA-SM 21.4% of patients; cumulative incidence P = 0.04). Graft and patient survival, and graft function were similar among arms. CONCLUSION In high-risk patients, tacrolimus-based immunosuppression with SM provides the best balance between PTDM and acute rejection incidence.
Collapse
Affiliation(s)
- Armando Torres
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Domingo Hernández
- Hospital Regional Universitario de Málaga, Universidad de Málaga, IBIMA, Málaga, Spain
| | - Francesc Moreso
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Serón
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Dolores Burgos
- Hospital Regional Universitario de Málaga, Universidad de Málaga, IBIMA, Málaga, Spain
| | | | - Julia Kanter
- Hospital Universitario Dr Peset, Valencia, Spain
| | | | | | | | | | - Francisco Valdes
- Complexo Hospitalario Universitario Juan Canalejo, A Coruña, Spain
| | | | - Antonio Osuna
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | - Juan C. Ruiz
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Domingo Marrero Miranda
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Lourdes Pérez-Tamajón
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Aurelio Rodríguez
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Ana González-Rinne
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Alejandra Alvarez
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Estefanía Perez-Carreño
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - María José de la Vega Prieto
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Fernando Henriquez
- Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de GC, Spain
| | - Roberto Gallego
- Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de GC, Spain
| | - Eduardo Salido
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Esteban Porrini
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| |
Collapse
|
26
|
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: 43] [Impact Index Per Article: 7.2] [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
|
27
|
Piotti G, Gandolfini I, Palmisano A, Maggiore U. Metabolic risk profile in kidney transplant candidates and recipients. Nephrol Dial Transplant 2018; 34:388-400. [DOI: 10.1093/ndt/gfy151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/01/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Giovanni Piotti
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Ilaria Gandolfini
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alessandra Palmisano
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| |
Collapse
|
28
|
Diabetes Mellitus Following Renal Transplantation: Clinical and Pharmacological Considerations for the Elderly Patient. Drugs Aging 2017; 34:589-601. [PMID: 28718072 DOI: 10.1007/s40266-017-0478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Post-transplant diabetes mellitus occurs in 30-50% of cases during the first year post-renal transplantation. It is associated with increased morbidity, mortality and healthcare costs. Risk factors include age and specific immunosuppression regimens. At the same time, renal transplantation is increasingly indicated in elderly (aged >65 years) patients as this proportion of older patients in the prevalent dialysis population has increased. The immune system and β cells undergo senescence and this impacts on the risk for developing post-transplant diabetes and our ability to prevent such development. It may, however, be possible to identify patients at risk of developing post-transplant diabetes, enabling treatment protocols that prevent or reduce the impact of post-transplant diabetes. Much work remains to be completed in this area and is facilitated by the growing base of knowledge regarding the pathophysiology of post-transplant diabetes. Should post-transplant diabetes develop, there are a range of treatment options available. There is increasing interest in using newer agents, although their safety and efficacy in transplant recipients remains to be conclusively established.
Collapse
|
29
|
Dubois-Laforgue D. [Post-transplantation diabetes mellitus in kidney recipients]. Nephrol Ther 2017; 13 Suppl 1:S137-S146. [PMID: 28577736 DOI: 10.1016/j.nephro.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 10/19/2022]
Abstract
Post-transplantation diabetes mellitus is defined as diabetes that is diagnosed in grafted patients. It affects 20 to 30 % of kidney transplant recipients, with a high incidence in the first year. The increasing age at transplantation and the rising incidence of obesity may increase its prevalence in the next years. Post-transplantation diabetes mellitus is associated with poor outcomes, such as mortality, cardiovascular events or graft dysfunction. Its occurrence is mainly related to immunosuppressive agents, affecting both insulin secretion and sensibility. Immunosuppressants may be iatrogenic, and as such, induce an early and transient diabetes. They may also precociously determine a permanent diabetes, acting here as a promoting factor in patients proned to the development of type 2 diabetes. Lastly, they may behave, far from transplantation, as an additional risk factor for type 2 diabetes. The screening, management and prognosis of these different subtypes of post-transplantation diabetes mellitus will be different.
Collapse
Affiliation(s)
- Danièle Dubois-Laforgue
- Service de diabétologie, hôpital Cochin-Port Royal, 123, boulevard Port-Royal, 75014 Paris, France; Inserm U1016, institut Cochin, 22, rue Méchain, 75014 Paris, France.
| |
Collapse
|
30
|
Jørgensen MB, Hornum M, van Hall G, Bistrup C, Hansen JM, Mathiesen ER, Feldt-Rasmussen B. The impact of kidney transplantation on insulin sensitivity. Transpl Int 2017; 30:295-304. [DOI: 10.1111/tri.12907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Morten B. Jørgensen
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Mads Hornum
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Gerrit van Hall
- Clinical Metabolomics Core Facility; Clinical Biochemistry, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Claus Bistrup
- Department of Nephrology; Odense University Hospital; Odense Denmark
| | - Jesper M. Hansen
- Department of Nephrology; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - Elisabeth R. Mathiesen
- Department of Endocrinology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| |
Collapse
|
31
|
A Prospective Study of Renal Transplant Recipients: A Fall in Insulin Secretion Underpins Dysglycemia After Renal Transplantation. Transplant Direct 2016; 2:e107. [PMID: 27826600 PMCID: PMC5096434 DOI: 10.1097/txd.0000000000000618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 07/25/2016] [Indexed: 02/06/2023] Open
Abstract
Background Dysglycemia (encompassing impaired glucose tolerance and diabetes mellitus) arising after renal transplantation is common and confers a significant cardiovascular mortality risk. Nonetheless, the pathophysiology of posttransplant dysglycemia is not well described. The aim of this study was to prospectively and comprehensively assess glucose handling in renal transplant recipients from before to 12 months after transplantation to determine the underpinning pathophysiology. Materials and Methods Intravenous and oral glucose tolerance testing was conducted before and at 3 and 12 months posttransplantation. An intravenous glucose tolerance test was also performed on day 7 posttransplantation. We followed up 16 transplant recipients for 3 months and 14 recipients for 12 months. Insulin secretion, resistance and a disposition index (DI (IV)), a measure of β cell responsiveness in the context of prevailing insulin resistance, were also determined. Results At 12 months, 50% of renal transplant recipients had dysglycemia. Dysglycemia was associated with a dramatic fall in DI (IV) and this loss in β cell function was evident as early as 3 months posttransplantation (23.5 pretransplant; 6.4 at 3 months and 12.2 at 12 months posttransplant). Differences in the β cell response to oral glucose challenge were evident pretransplant in those destined to develop dysglycemia posttransplant (2-hour blood glucose level 5.6 mmol/L versus 6.8 mmol/L; P < 0.01). Conclusions Dysglycemia after renal transplantation is common, and the loss of insulin secretion is a major contributor. Subclinical differences in glucose handling are evident pretransplant in those destined to develop dysglycemia potentially heralding a susceptible β cell which under the stressors associated with transplantation fails.
Collapse
|
32
|
Sharif A, Cohney S. Post-transplantation diabetes-state of the art. Lancet Diabetes Endocrinol 2016; 4:337-49. [PMID: 26632096 DOI: 10.1016/s2213-8587(15)00387-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 01/14/2023]
Abstract
With increasing success in overcoming the immunological and infectious challenges accompanying solid organ transplantation, susceptibility to post-transplant diabetes and cardiovascular disease has assumed increasing importance. Although some guidance is available from diabetes-related literature pertaining to the general population, some aspects are unique to solid organ allograft recipients. Both insulin resistance and β-cell dysfunction are generally agreed to contribute to development and manifestation of post-transplant diabetes, but controversy continues about which is most important and to what extent post-transplant diabetes is a distinct entity or simply a variant of type 2 diabetes with transplant-specific components. The optimum method and timing for detection and diagnosis of post-transplant diabetes remains an area of uncertainty. However, the greatest needs are to: address the absence of contemporary data for incidence and clinical outcomes associated with post-transplant diabetes; establish the role of glycaemic control; and assess the role of new diabetic therapies in prevention and management of post-transplant diabetes. We place the present knowledge base in the context of other advances in transplantation, challenge some existing ideas, and examine the potential role of emerging diabetes therapies. In highlighting existing deficiencies, we hope to provide direction for future research that will ultimately reduce incidence and improve management of post-transplant diabetes.
Collapse
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK.
| | - Solomon Cohney
- Department of Nephrology, Western & Royal Melbourne Hospitals, Melbourne, VIC, Australia
| |
Collapse
|
33
|
Chand S, McKnight AJ, Shabir S, Chan W, McCaughan JA, Maxwell AP, Harper L, Borrows R. Analysis of single nucleotide polymorphisms implicate mTOR signalling in the development of new-onset diabetes after transplantation. BBA CLINICAL 2016; 5:41-5. [PMID: 27051588 PMCID: PMC4802392 DOI: 10.1016/j.bbacli.2015.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/07/2015] [Accepted: 12/17/2015] [Indexed: 12/13/2022]
Abstract
Introduction Despite excellent first year outcomes in kidney transplantation, there remain significant long-term complications related to new-onset diabetes after transplantation (NODAT). The purpose of this study was to validate the findings of previous investigations of candidate gene variants in patients undergoing a protocolised, contemporary immunosuppression regimen, using detailed serial biochemical testing to identify NODAT development. Methods One hundred twelve live and deceased donor renal transplant recipients were prospectively followed-up for NODAT onset, biochemical testing at days 7, 90, and 365 after transplantation. Sixty-eight patients were included after exclusion for non-white ethnicity and pre-transplant diabetes. Literature review to identify candidate gene variants was undertaken as described previously. Results Over 25% of patients developed NODAT. In an adjusted model for age, sex, BMI, and BMI change over 12 months, five out of the studied 37 single nucleotide polymorphisms (SNPs) were significantly associated with NODAT: rs16936667:PRDM14 OR 10.57;95% CI 1.8–63.0;p = 0.01, rs1801282:PPARG OR 8.5; 95% CI 1.4–52.7; p = 0.02, rs8192678:PPARGC1A OR 0.26; 95% CI 0.08–0.91; p = 0.03, rs2144908:HNF4A OR 7.0; 95% CI 1.1–45.0;p = 0.04 and rs2340721:ATF6 OR 0.21; 95%CI 0.04–1.0; p = 0.05. Conclusion This study represents a replication study of candidate SNPs associated with developing NODAT and implicates mTOR as the central regulator via altered insulin sensitivity, pancreatic β cell, and mitochondrial survival and dysfunction as evidenced by the five SNPs. General significance Highlights the importance of careful biochemical phenotyping with oral glucose tolerance tests to diagnose NODAT in reducing time to diagnosis and missed cases. This alters potential genotype:phenotype association. The replication study generates the hypothesis that mTOR signalling pathway may be involved in NODAT development.
Oral glucose tolerance tests reduce time to NODAT diagnosis and missed cases Biochemical testing changes genotype:phenotype association mTOR signalling pathway may be involved in NODAT development
Collapse
Key Words
- ATF6, Activated transcription factor
- BMI, Body mass index
- GWAS, Genome-wide association study
- HLA, Human leucocyte antigen
- HNF4, Hepatocyte nuclear factor 4
- NODAT, New-onset diabetes after transplantation
- New-onset diabetes after transplantation
- PI3, Phospho-inositide 3-kinase
- PPARGC1α, Peroxisome proliferator-activated receptor gamma co-activator 1 alpha
- PPARy, Peroxisome proliferator-activated receptor gamma
- PRDM14, PR domain zinc protein 14
- SNP, Single nucleotide polymorphism
- mTOR
- mTOR, Mammalian target of rapamycin
- single nucleotide polymorphisms
Collapse
Affiliation(s)
- S Chand
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham B15 2WB, United Kingdom; Centre for Translational Inflammation Research, University of Birmingham, Birmingham B15 2WB, United Kingdom
| | - A J McKnight
- Regional Nephrology Unit, Belfast City Hospital, Belfast BT9 7AB, Northern Ireland
| | - S Shabir
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham B15 2WB, United Kingdom; Centre for Translational Inflammation Research, University of Birmingham, Birmingham B15 2WB, United Kingdom
| | - W Chan
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham B15 2WB, United Kingdom
| | - J A McCaughan
- Regional Nephrology Unit, Belfast City Hospital, Belfast BT9 7AB, Northern Ireland
| | - A P Maxwell
- Regional Nephrology Unit, Belfast City Hospital, Belfast BT9 7AB, Northern Ireland
| | - L Harper
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham B15 2WB, United Kingdom; Centre for Translational Inflammation Research, University of Birmingham, Birmingham B15 2WB, United Kingdom
| | - R Borrows
- Department of Nephrology and Kidney Transplantation, Queen Elizabeth Hospital, Birmingham B15 2WB, United Kingdom; Centre for Translational Inflammation Research, University of Birmingham, Birmingham B15 2WB, United Kingdom
| |
Collapse
|
34
|
Porrini EL, Díaz JM, Moreso F, Delgado Mallén PI, Silva Torres I, Ibernon M, Bayés-Genís B, Benitez-Ruiz R, Lampreabe I, Lauzurrica R, Osorio JM, Osuna A, Domínguez-Rollán R, Ruiz JC, Jiménez-Sosa A, González-Rinne A, Marrero-Miranda D, Macía M, García J, Torres A. Clinical evolution of post-transplant diabetes mellitus. Nephrol Dial Transplant 2015; 31:495-505. [DOI: 10.1093/ndt/gfv368] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/22/2015] [Indexed: 12/11/2022] Open
|
35
|
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
|
36
|
Werzowa J, Hecking M, Haidinger M, Döller D, Sharif A, Tura A, Säemann MD. The diagnosis of posttransplantation diabetes mellitus: meeting the challenges. Curr Diab Rep 2015; 15:27. [PMID: 25777999 DOI: 10.1007/s11892-015-0601-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Posttransplantation diabetes mellitus (PTDM) is a major complication after renal transplantation due to its negative impact on patient and graft survival, and affects up to 40% of renal transplant recipients. The generation of evidence regarding its optimal treatment is now progressing with some emphasis on early postoperative insulin treatment that targets β-cell failure. This therapy seems to benefit renal transplant patients but contrasts with previous PTDM guidelines that were following treatment of type 2 diabetes mellitus (DM): oral antidiabetics first, insulin last. Similarly, in the current PTDM consensus recommendations, diagnostic procedures are in accordance with the American Diabetes Association (ADA) recommendations for diagnosis of DM. PTDM and type 2 DM, however, are distinct disease entities with different pathophysiological backgrounds. This review will discuss the significance of the standard diagnostic criteria for DM in patients after renal transplantation without prior DM. In particular, the role of glycated hemoglobin (HbA1c) and oral glucose tolerance testing (OGTT) will be reviewed. In addition, the potential role of other glycated proteins and continuous glucose monitoring will be covered, although these parameters are not yet part of the consensus recommendations.
Collapse
Affiliation(s)
- J Werzowa
- Department of Internal Medicine III, Section of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria,
| | | | | | | | | | | | | |
Collapse
|
37
|
Pérez-Sáez MJ, Marín-Casino M, Pascual J. Treating posttransplantation diabetes mellitus. Expert Opin Pharmacother 2015; 16:1435-48. [DOI: 10.1517/14656566.2015.1039983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
38
|
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
|
39
|
|
40
|
Tufton N, Ahmad S, Rolfe C, Rajkariar R, Byrne C, Chowdhury TA. New-onset diabetes after renal transplantation. Diabet Med 2014; 31:1284-92. [PMID: 24975051 DOI: 10.1111/dme.12534] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/08/2014] [Accepted: 06/24/2014] [Indexed: 12/12/2022]
Abstract
Renal transplantation has important benefits in people with end-stage renal disease, with improvements in mortality, morbidity and quality of life. Whilst significant advances in transplantation techniques and immunosuppressive regimens have led to improvements in short-term outcomes, longer-term outcomes have not improved dramatically. New-onset diabetes after transplantation appears to be a major factor in morbidity and cardiovascular mortality in renal transplant recipients. The diagnosis of new-onset diabetes after renal transplantation has been hampered by a lack of clarity over diagnostic tests in early studies, although the use of the WHO criteria is now generally accepted. HbA1c may be useful diagnostically, but should probably be avoided in the first 3 months after transplantation. The pathogenesis of new-onset diabetes after renal transplantation is likely to be related to standard pathogenic factors in Type 2 diabetes (e.g. insulin resistance, β-cell failure, inflammation and genetic factors) as well as other factors, such as hepatitis C infection, and could be exacerbated by the use of immunosuppression (glucocorticoids and calcineurin inhibitors). Pre-transplant risk scores may help identify those people at risk of new-onset diabetes after renal transplantation. There are no randomized trials of treatment of new-onset diabetes after renal transplantation to determine whether intensive glucose control has an impact on cardiovascular or renal morbidity, therefore, treatment is guided by guidelines used in non-transplant diabetes. Many areas of uncertainty in the pathogenesis, diagnosis and management of new-onset diabetes after renal transplantation require further research.
Collapse
Affiliation(s)
- N Tufton
- Department of Diabetes and Metabolism, Barts and the London School of Medicine and Dentistry, London, UK
| | | | | | | | | | | |
Collapse
|
41
|
Jorgensen MB, Idorn T, Knop FK, Holst JJ, Hornum M, Feldt-Rasmussen B. Clearance of glucoregulatory peptide hormones during haemodialysis and haemodiafiltration in non-diabetic end-stage renal disease patients. Nephrol Dial Transplant 2014; 30:513-20. [DOI: 10.1093/ndt/gfu327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
|
42
|
Sharif A, Hecking M, de Vries APJ, Porrini E, Hornum M, Rasoul-Rockenschaub S, Krebs G, Berlakovich M, Kautzky-Willer A, Schernthaner G, Marchetti P, Pacini G, Ojo A, Takahara S, Larsen JL, Budde K, Eller K, Pascual J, Jardine A, Bakker SJL, Valderhaug TG, Jenssen TG, Cohney S, Säemann MD. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014; 14:1992-2000. [PMID: 25307034 PMCID: PMC4374739 DOI: 10.1111/ajt.12850] [Citation(s) in RCA: 359] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/21/2014] [Accepted: 05/26/2014] [Indexed: 01/25/2023]
Abstract
A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.
Collapse
Affiliation(s)
- A. Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK,Corresponding author: Adnan Sharif,
| | - M. Hecking
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - A. P. J. de Vries
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - E. Porrini
- Center for Biomedical Research of the Canary Islands, CIBICAN, University of La Laguna, Tenerife, Spain
| | - M. Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - G Krebs
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - M. Berlakovich
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - A. Kautzky-Willer
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - G. Schernthaner
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - P. Marchetti
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | - G. Pacini
- Metabolic Unit, Institute of Biomedical Engineering, National Research Council, Padova, Italy
| | - A. Ojo
- Division of Nephrology, University of Michigan Health System, Ann Arbor, MI
| | - S. Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Osaka, Japan
| | - J. L. Larsen
- Department of Internal Medicine, Nebraska Medical Center, Omaha, NE
| | - K. Budde
- Department of Nephrology, Charité University, Berlin, Germany
| | - K. Eller
- Clinical Division of Nephrology, Medical University of Graz, Graz, Austria
| | - J. Pascual
- Servicio de Nefrología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - A. Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - S. J. L. Bakker
- Department of Internal Medicine, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - T. G. Valderhaug
- Department of Endocrinology, Akershus University Hospital, Lorenskog, Norway
| | - T. G. Jenssen
- Department of Organ Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - S. Cohney
- Department of Nephrology, Royal Melbourne and Western Hospitals, Melbourne, Australia
| | - M. D. Säemann
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
43
|
β Cell Glucotoxic-Associated Single Nucleotide Polymorphisms in Impaired Glucose Tolerance and New-Onset Diabetes After Transplantation. Transplantation 2014; 98:e19-20. [DOI: 10.1097/tp.0000000000000268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
44
|
Hornum M, Lindahl JP, von Zur-Mühlen B, Jenssen T, Feldt-Rasmussen B. Diagnosis, management and treatment of glucometabolic disorders emerging after kidney transplantation: a position statement from the Nordic Transplantation Societies. Transpl Int 2013; 26:1049-60. [PMID: 23634804 DOI: 10.1111/tri.12112] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 02/11/2013] [Accepted: 04/06/2013] [Indexed: 12/16/2022]
Abstract
After successful solid organ transplantation, new-onset diabetes (NODAT) is reported to develop in about 15-40% of the patients. The variation in incidence may partly depend on differences in the populations that have been studied and partly depend on the different definitions of NODAT that have been used. The diagnosis was often based on 'the use of insulin postoperatively', 'oral agents used', random glucose monitoring and a fasting glucose value between 7 and 13 mmol/l (126-234 mg/dl). Only few have used a 2-h glucose tolerance test performed before transplantation. There is a huge variation in the literature regarding risk factors for developing NODAT. They can be divided into factors related to glucose metabolism or to patient demographics and the latter into modifiable and nonmodifiable. Screening for risk factors should start early and be re-evaluated while being on the waitlist. Patients on the waiting list for renal transplantation and transplanted patients share many characteristics in having hyperglycaemia, disturbed insulin secretion and increased insulin resistance. We present guidelines for early risk factor assessment and a screening/treatment strategy for disturbed glucose metabolism, both before and after transplantation. The aim was to avoid the increased cardiovascular disease and mortality rates associated with NODAT.
Collapse
Affiliation(s)
- Mads Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | | | | |
Collapse
|
45
|
Abstract
PURPOSE OF REVIEW New onset diabetes after kidney transplantation (NODAT) remains a common complication after transplantation and is associated with significant morbidity and mortality. The review will examine recent advances in our knowledge of this metabolic disorder and speculate upon future development. RECENT FINDINGS Research continues to broaden the horizon of existing and emerging risk factors that contribute to development of NODAT. Attempts to use this knowledge to develop quantitative risk scoring composites have been made, utilizing either pretransplant or 1-year posttransplantation variables, with variable success. Reassuringly a number of clinical trials have been published, or are currently in progress, that utilize pharmacological intervention for both prevention and management of NODAT. These are both in the form of differential immunosuppressant regimens or use of antiglycemic agents. Upcoming results will prove crucial in developing a genuine evidence-base for NODAT management. SUMMARY Rather than simple translation of data from the general to kidney transplant population, clinicians must appreciate that NODAT constitutes a distinct metabolic entity with unique pathophysiology. As such targeted strategies to prevent and manage NODAT require focused investigation to deal with this common complication.
Collapse
|
46
|
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
|
47
|
Shabir S, Jham S, Harper L, Ball S, Borrows R, Sharif A. Validity of glycated haemoglobin to diagnose new onset diabetes after transplantation. Transpl Int 2013; 26:315-21. [PMID: 23279163 DOI: 10.1111/tri.12042] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 10/07/2012] [Accepted: 11/18/2012] [Indexed: 12/21/2022]
Abstract
Diagnosing new onset diabetes after transplantation (NODAT) by glycated haemoglobin (HbA1c) has not been validated against the gold-standard oral glucose tolerance test (OGTT). We analysed the predictive and optimum value of HbA1c to diagnose NODAT amongst nondiabetic renal transplant recipients. Assessment of glucose metabolism (OGTT and HbA1c) was prospectively undertaken at 3 and 12 months post-transplantation in 71 nondiabetic renal transplant recipients. Receiver operator characteristic (ROC) curve analyses were performed to determine accuracy, sensitivity, specificity and area under curve (c-statistic). Incidence of NODAT at 3 and 12 months post-transplantation was 14.3% and 9.5% respectively. At 3 months, optimum HbA1c cut-off value for predicting NODAT based on fasting glucose was 7.35 [AUC 1.00 (sensitivity 100.0%, specificity 100.0%, P = 0.004)] and for postprandial glucose-defined NODAT was 6.20 [AUC 0.98 (sensitivity 100.0%, specificity 88.9%, P < 0.001)]. At 12 months, optimum HbA1c cut-off value for both fasting- and postprandial glucose-defined NODAT was 6.45 [AUC 0.92 (sensitivity 100.0%, specificity 87.5%, P = 0.048) and AUC 0.84 (sensitivity 75.0%, specificity 89.5%, P = 0.026) respectively]. Concordance between diagnosis of NODAT (OGTT+, HbA1c+) and nondiagnosis of NODAT (OGTT-, HbA1c-) was 88.9% and 98.7% respectively. To conclude, HbA1c (≥6.5%) can be utilized to diagnose NODAT beyond 3 months post-transplantation but the OGTT remains the gold-standard tool.
Collapse
Affiliation(s)
- Shazia Shabir
- Renal Institute of Birmingham, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | | | | | | | | | | |
Collapse
|
48
|
Early posttransplantation hyperglycemia in kidney transplant recipients is associated with overall long-term graft losses. Transplantation 2012; 94:714-20. [PMID: 22965263 DOI: 10.1097/tp.0b013e31825f4434] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The association of early-onset posttransplantation hyperglycemia with long-term renal allograft survival is unknown. METHODS Seventy-one (SD 9) days after transplantation, 1410 first-time kidney transplant recipients without diabetes underwent an oral glucose tolerance test and were observed until primary outcome (graft loss) or December 31, 2008 (median [range], 6.0 years [0.3-13.8 years]). We used multivariable Cox regression analysis adjusted for age, gender, body mass index, creatinine level, donor age, preemptive transplantation, deceased donor, early rejection, and early cytomegalovirus infection to estimate hazard ratios for overall and death-censored allograft survival. RESULTS A total of 392 (28%) recipients experienced graft failure, and 235 (60%) were induced by death. Each 1 mmol/L increase in 2-hr plasma glucose (2hPG) was associated with 7% and 3% increased risk of unadjusted and adjusted overall graft failure (hazard ratio [95% confidence interval], 1.07 [1.04-1.10] and 1.03 [1.00-1.07]). Fasting plasma glucose was associated with unadjusted but not adjusted overall graft failure (1.09 [1.01-1.18] and 1.07 [0.98-1.17]). Neither 2hPG nor fasting plasma glucose was associated with death-censored graft loss (P=0.578 and P=0.896). Compared with recipients with normal glucose tolerance, recipients with posttransplantation diabetes mellitus showed a tendency toward increased overall multiadjusted graft failure (1.30 [0.98-1.73]). This was not observed in patients with impaired fasting glucose or impaired glucose tolerance. CONCLUSIONS In this study, 2hPG was associated with overall graft failure but not death-censored graft failure. The link between 2hPG and graft failure may be explained by the association with mortality.
Collapse
|
49
|
Tatar E, Kircelli F, Demirci MS, Turan MN, Gungor O, Asci G, Ozkahya M, Ok E, Hoscoskun C, Toz H. Pre-transplant HbA1c level as an early marker for new-onset diabetes after renal transplantation. Int Urol Nephrol 2012; 45:251-8. [PMID: 23054321 DOI: 10.1007/s11255-012-0304-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/17/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a common complication in renal transplant (RT) patients. The clinical significance of pre-transplant HbA1c level remains unclear in RT patients. Thus, we investigated the predictive role of pre-transplant HbA1c levels for the NODAT diagnosed in 1 year after renal transplantation. METHODS Two hundred and four RT patients older than 18 years were analyzed. NODAT diagnosis during the 1-year follow-up after RT was based on the 2003 modified criteria of the ADA. HbA1c level was measured at pre-transplantation period and every 3 months after RT. RESULTS Mean age was 39.3 ± 10.7 (20-73) years and 36 % were female. Mean pre-transplant HbA1c level was 4.9 ± 0.5 % (4.0-6.4 %). Pre-transplant HbA1c level was positively correlated with age, pre-transplant body mass index (BMI) and cholesterol level. Fifty-four patients (25.9 %) developed NODAT and 33.8 % had impaired fasting blood glucose levels. Patients with NODAT were significantly older and had higher pre-transplant BMI and HbA1c than those without. Use of Tacrolimus was also higher in patients with NODAT. In stepwise logistic regression analysis, pre-transplant HbA1c level was an independent predictor for the development on NODAT (OR = 4.63, 95 % CI: 2.09-10.2, p < 0.001) together with age, Tacrolimus-based regimen and pre-transplant fasting blood glucose level. CONCLUSIONS Assessment of pre-transplant HbA1c levels may be a valuable tool for early diagnosis of NODAT in RT recipients.
Collapse
Affiliation(s)
- Erhan Tatar
- Division of Nephrology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Spain L, Iser P, Steinberg A, Dwyer KM. Hypertensive crisis precipitated by insulin-induced hypoglycemia with end-stage renal failure. Clin Kidney J 2012; 5:362-3. [PMID: 25874100 PMCID: PMC4393465 DOI: 10.1093/ckj/sfs053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 04/20/2012] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lavinia Spain
- Department of Nephrology , St. Vincent's Hospital Melbourne , Fitzroy, Victoria , Australia
| | - Peter Iser
- Department of Nephrology , St. Vincent's Hospital Melbourne , Fitzroy, Victoria , Australia
| | - Adam Steinberg
- Department of Nephrology , St. Vincent's Hospital Melbourne , Fitzroy, Victoria , Australia
| | - Karen M Dwyer
- Department of Nephrology , St. Vincent's Hospital Melbourne , Fitzroy, Victoria , Australia
| |
Collapse
|