Diabetes mellitus after renal transplantation: as deleterious as non-transplant-associated diabetes?

Post-renal transplant diabetes mellitus in korean subjects: superimposition of transplant-related immunosuppressant factors on genetic and type 2 diabetic risk factors

Postrenal transplantation diabetes mellitus (PTDM), or new-onset diabetes after organ transplantation, is an important chronic transplant-associated complication. Similar to type 2 diabetes, decreased insulin secretion and increased insulin resistance are important to the pathophysiologic mechanism behind the development of PTDM. However, β-cell dysfunction rather than insulin resistance seems to be a greater contributing factor in the development of PTDM. Increased age, family history of diabetes, ethnicity, genetic variation, obesity, and hepatitis C are partially accountable for an increased underlying risk of PTDM in renal allograft recipients. In addition, the use of and kinds of immunosuppressive agents are key transplant-associated risk factors. Recently, a number of genetic variants or polymorphisms susceptible to immunosuppressants have been reported to be associated with calcineurin inhibition-induced β-cell dysfunction. The identification of high risk factors of PTDM would help prevent PTDM and improve long-term patient outcomes by allowing for personalized immunosuppressant regimens and by managing cardiovascular risk factors.

New onset diabetes after kidney transplantation in autosomal dominant polycystic kidney disease: a retrospective cohort study

BACKGROUND

New onset diabetes after transplantation (NODAT) is a common adverse outcome of organ transplantation that increases the risk of cardiovascular disease, infection and graft rejection. In kidney transplantation, apart from traditional risk factors, autosomal dominant polycystic kidney disease (ADPKD) has also been reported by several authors as a predisposing factor to the development of NODAT, but any rationale for an association between ADPKD and NODAT is unclear. We examined the cumulative incidence of NODAT in or own transplant population comparing ADPKD patients with non-ADPKD controls.

METHODS

A retrospective cohort study to determine the cumulative incidence of patients developing NODAT (defined by World Health Organization-based criteria and/or use of hypoglycaemic medication) was conducted in 79 patients with ADPKD (79 transplants) and 423 non-ADPKD controls (426 transplants) selected from 613 sequential transplant recipients over 8 years. Patients with pre-existing diabetes as a primary disease or comorbidity and/or with minimal follow up or early graft loss/death were excluded.

RESULTS

Of the 502 patients (505 transplants) studied, 86 (17.0%) developed NODAT. There was no significant difference in the cumulative incidence of NODAT in the ADPKD (16.5%; CI 13.6-20.7%) compared with the non-ADPKD (17.1%; CI 8.3-24.6%) control group. Of the 13 patients in the ADPKD group with NODAT, three required treatment with insulin with or without oral hypoglycaemic agents. Among the 73 NODAT patients in the non-ADPKD group, eight received insulin with or without oral hypoglycaemics. Furthermore, of the patients that did develop NODAT, there was no difference in the time to its development in patients with and without ADPKD.

CONCLUSION

There was no evidence of an increased incidence of NODAT in ADPKD kidney transplant recipients.

Increased body mass index but not common vitamin D receptor, peroxisome proliferator-activated receptor γ, or cytokine polymorphisms confers predisposition to posttransplant diabetes

CONTEXT

Posttransplant diabetes mellitus (PTDM) is a major complication after solid organ transplantation. The use of corticosteroids and calcineurin inhibitors, especially tacrolimus, are significant risk factors. However, it is not clear what genetic factors modify the risk. Evidence suggests vitamin D deficiency, perturbed glucose homeostasis, and increased inflammation all play roles in the development of diabetes.

OBJECTIVE

To investigate whether common vitamin D receptor (VDR), cytokine, and peroxisome proliferator-activated receptor γ (PPARγ) polymorphisms are correlated with the development of PTDM.

DESIGN

DNA was isolated from the peripheral blood of 51 kidney transplant recipients with PTDM and 72 patients without diabetes pretransplant or posttransplant at the time of follow-up. The genotypes for 5 polymorphisms, 1 each in VDR, PPARγ, INFγ, TGFβ1, and TNF, were determined using direct sequencing. Age, sex, number of acute rejection episodes, follow-up length, ethnicity, body mass index, and the frequency of alleles and genotypes for each polymorphism were compared between the 2 groups.

RESULTS

Body mass index was the only factor that was statistically different between the 2 groups (P  =  .001). The frequency of different alleles and genotypes for each of the 5 polymorphisms did not differ between the 2 groups.

CONCLUSIONS

These results indicate that increased body mass index is a significant risk factor for the development of PTDM. However, none of the genetic polymorphisms studied confer predisposition to PTDM with the current sample size.

Complications associated with new-onset diabetes after kidney transplantation

New-onset diabetes mellitus after kidney transplantation (NODAT) is widely acknowledged to be associated with increased morbidity and mortality, as well as poor quality of life. Clear evidence links the occurrence of NODAT to accelerated progression of some macrovascular and/or microvascular complications. However, the evidence that some complications commonly attributed to diabetes mellitus occur in the context of transplantation lacks robustness. Certain complications are transplantation-specific and prevalent, but others are not frequently observed or documented. For this reason, it is essential that clinicians are aware of the array of potential complications associated with NODAT in kidney allograft recipients. Rather than simply translating evidence from the general population to the high-risk transplant recipient, this Review aims to provide specific guidance on diabetes-related complications in the context of a complex transplantation environment.

New-onset diabetes after renal transplantation: diagnosis, incidence, risk factors, impact on outcomes, and novel implications

OBJECTIVE

New-onset diabetes after transplantation (NODAT) is a multifactorial, complex metabolic disorder associated with impaired long-term graft function, reduced recipient survival, and increased risks of cardiovascular disease and infectious complications. The impact of NODAT is generally underestimated partly due to the inconsistent criteria that have been previously used for its diagnosis and to the generally short observation periods. The aim of this article was to review the recent literature on NODAT and to highlight the novel implications.

FINDINGS

The 2010 American Diabetes Association guidelines provide useful, simplified criteria to unify the diagnosis including application of hemoglobin A1C levels. We sought to establish the impact of various modifiable and nonmodifiable risk factors. A vast number of papers have examined the effects of immunosuppressive medications on the development of NODAT: Neither calcineurin inhibitor nor sirolimus (SRL) or steroids seems to be innocent of contributing to it. Immunosuppressants account for 74% of the occurrence of NODAT. Among modifiable risk factors, obesity is independent and significant, with great prevalence in the population. In additional to lifestyle modifications, the role of bariatric surgery (BS) either before or after transplantation is highlighted herein as a strategy to reduce disease in the view of the results among overweight, nontransplanted patients.

SUMMARY

Because of the strong association between high glucose values in the early posttransplant period and the development of NODAT, the condition must be recognized early after (or even before) transplantation by intensive screening. Patients at risk for NODAT must modify appropriate risk factors and particularly undergo pretransplant planning and/or posttransplant adjustment individualizing immunosuppressive therapy to mitigate the risk of this serious complication.

The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine

Anti-rejection regimens for renal transplants have changed dramatically during the past 20 years, but there are few long-term studies relating cost, mortality, or graft failure simultaneously to disease-pharmacotherapy couplets. We analyzed US Renal Data System data on a matched-pair cohort of first, single organ kidney transplants from 1998 through 2002 over up to 5 years following transplantation for patients on tacrolimus or low-dose cyclosporine, stratifying by whether the recipient had pre-existing or new onset diabetes. Kaplan-Meier survival curves show mortality and survival differences associated with diabetes, but no additional incremental effects of immune suppression regimen. Significant cost increases are reported for patients receiving tacrolimus above and beyond the extra costs associated with diabetes.

The association of early post-transplant glucose levels with long-term mortality

AIMS/OBJECTIVE

We aimed to assess the long-term effects of post-transplant glycaemia on long-term survival after renal transplantation.

METHODS

Study participants were 1,410 consecutive transplant recipients without known diabetes who underwent an OGTT 10 weeks post-transplant and were observed for a median of 6.7 years (range 0.3-13.8 years). The HRs adjusted for age, sex, traditional risk factors and transplant-related risk factors were estimated.

RESULTS

Each 1 mmol/l increase in fasting plasma glucose (fPG) or 2 h plasma glucose (2hPG) was associated with 11% (95% CI -1%, 24%) and 5% (1%, 9%) increments in all-cause mortality risk and 19% (1%, 39%) and 6% (1%, 12%) increments in cardiovascular (CV) mortality risk, respectively. Including both fPG and 2hPG in the multi-adjusted model the HR for 2hPG remained unchanged, while the HR for fPG was attenuated (1.05 [1.00, 1.11] and 0.97 [0.84, 1.14]). Compared with recipients with normal glucose tolerance, patients with post-transplant diabetes mellitus had higher all-cause and CV mortality (1.54 [1.09, 2.17] and 1.80 [1.10, 2.96]), while patients with impaired glucose tolerance (IGT) had higher all-cause, but not CV mortality (1.39 [1.01, 1.91] and 1.04 [0.62, 1.74]). Conversely, impaired fasting glucose was not associated with increased all-cause or CV mortality (0.79 [0.52, 1.23] and 0.76 [0.39, 1.49]). Post-challenge hyperglycaemia predicted death from any cause and infectious disease in the multivariable analyses (1.49 [1.15, 1.95] and 1.91 [1.09, 3.33]).

CONCLUSIONS/INTERPRETATION

For predicting all-cause and CV mortality, 2hPG is superior to fPG after renal transplantation. Also, early post-transplant diabetes, IGT and post-challenge hyperglycaemia were significant predictors of death. Future studies should determine whether an OGTT helps identify renal transplant recipients at increased risk of premature death.

Incidence and Risk Factors for Development of New-onset Diabetes after Kidney Transplantation

Introduction: New-onset diabetes after transplantation (NODAT) is an increasingly recognised metabolic complication of kidney transplantation that is associated with increased morbidity and mortality. This study aimed to determine the incidence of NODAT and identify risk factors for development of NODAT among kidney allograft recipients in a single centre. Materials and Methods: We retrospectively reviewed all kidney allograft recipients in our centre between 1998 and 2007. NODAT were determined using criteria as per American Diabetes Association guidelines. Logistic regression analyses were performed to identify predictors of NODAT. Results: Among 388 patients included in the analysis, NODAT was reported in 94 patients (24.2%) after a median follow-up time of 52.1 months. The cumulative incidence of NODAT was 15.8%, 22.8% and 24.5% at 1, 3, and 5 years following transplantation. Seven clinical factors were independent predictors of NODAT: older age, HLA B13 and B15 phenotypes, use of sirolimus, acute rejections, higher pre-transplant and post-transplant (day 1) plasma glucose levels. Patients with NODAT had poorer outcomes in both graft and patient survival. Conclusion: Our study demonstrates a significant risk and burden of NODAT in an Asian transplant population. Risk stratification and aggressive monitoring of blood glucose early post-transplantation is necessary to identify high-risk patients so that appropriate tailoring of immunosuppression and early institution of lifestyle modifications can be implemented. Key words: Diabetes mellitus, Immunosuppression, Kidney transplantation, Metabolic complication, Sirolimus

Risk factors and consequences of post-transplant diabetes mellitus

BACKGROUND

The aim of this study is to investigate the clinical course as well as risk factors and prognosis of post-transplant diabetes mellitus (PTDM).

METHODS

Five hundred fifty-five kidney transplant recipients were retrospectively evaluated. PTDM was defined as fasting blood glucose ≥140 mg/dL on at least two consecutive measurements or requirement of oral antidiabetic drug or insulin. Patients with PTDM were divided into subgroups according to time of onset (early; <90 d vs. late, ≥90 d) and duration of diabetes (transient, <90 d vs. sustained ≥90 d).

RESULTS

The frequency of PTDM was 18.3%. In multivariate analysis age (p < 0.001), hepatitis C virus (HCV) infection (p < 0.05) and tacrolimus use (p < 0.001) were independent risk factors. Among 220 HCV+ patients, liver biopsy was performed in 158, the histological grade (3.3 ± 2.8 vs. 4.4 ± 3.1) and stage (0.9 ± 1.1 vs. 1.4 ± 1.2) were significantly more severe in patients with PTDM than in non-diabetics. Incidence of PTDM in patients with severe fibrosis was 46.7%; 19.2% in nil or mild fibrosis (p < 0.05). Patient and graft survival were significantly worse, and cardiovascular events and life-threatening infection episodes were more frequent in PTDM. Half of the patients had early PTDM, while 30.3% of patients with PTDM showed transient nature. Five- and 10-yr death censored graft survival rates were worse in transient subgroup compared with sustained patients with diabetes (log rank 0.025) whereas there was no difference in outcome between early and late subgroups.

CONCLUSIONS

Age, tacrolimus, and HCV are independent risk factors for PTDM. PTDM has a negative impact on both patient and graft survival, irrespective of the time of onset and duration of diabetes.

New-onset diabetes after transplantation: risk factors and clinical impact

With improvements in patient and graft survival, increasing attention has been placed on complications that contribute to long-term patient morbidity and mortality. New-onset diabetes after transplantation (NODAT) is a common complication of solid-organ transplantation, and is a strong predictor of graft failure and cardiovascular mortality in the transplant population. Risk factors for NODAT in transplant recipients are similar to those in non-transplant patients, but transplant-specific risk factors such as hepatitis C (HCV) infection, corticosteroids and calcineurin inhibitors play a dominant role in NODAT pathogenesis. Management of NODAT is similar to type 2 diabetes management in the general population. However, adjusting the immunosuppressant regimen to improve glucose tolerance must be weighed against the risk of allograft rejection. Lifestyle modification is currently the strategy with the least risk and the most benefit.

Association of metabolic syndrome with development of new-onset diabetes after transplantation

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a major posttransplant complication associated with lower allograft and recipient survival. Our objective was to determine whether metabolic syndrome pretransplant is independently associated with NODAT development.

METHODS

We recruited 640 consecutive incident nondiabetic renal transplant recipients from three academic centers between 1999 and 2004. NODAT was defined as the use of hypoglycemic medication, a random plasma glucose level more than 200 mg/dL, or two fasting glucose levels more than or equal to 126 mg/dL beyond 30 days posttransplant.

RESULTS

Metabolic syndrome was common pretransplant (57.2%). NODAT developed in 31.4% of recipients 1 year posttransplant. Participants with metabolic syndrome were more likely to develop NODAT compared with recipients without metabolic syndrome (34.4% vs. 27.4%, P=0.057). Recipients with increasing number of positive metabolic syndrome components were more likely to develop NODAT (metabolic syndrome score prevalence at 1 year: 0 components-0.0%, 1-24.2%, 2-29.3%, 3-31.0%, 4-34.8%, and 5-73.7%, P=0.001). After adjustment for demographics, age by decade (hazard ratio [HR] 1.34 [1.20-1.50], P<0.0001), African American race (HR 1.35 [1.01-1.82], P=0.043), cumulative prednisone dosage (HR 1.18 [1.07-1.30], P=0.001), and metabolic syndrome (HR 1.34 [1.00-1.79], P=0.047) were independent predictors of development of NODAT at 1 year posttransplant. In a multivariable analysis incorporating the individual metabolic syndrome components themselves as covariates, the only pretransplant metabolic syndrome component to remain an independent predictor of NODAT was low high-density lipoprotein (hazard ratio [HR] 1.37 [1.01-1.85], P=0.042).

CONCLUSIONS

Metabolic syndrome is an independent predictor for NODAT and is a possible target for intervention to prevent NODAT. Future studies to evaluate whether modification of metabolic syndrome factors pretransplant reduces NODAT development are needed.

Risk factors and outcomes associated with posttransplant diabetes mellitus in kidney transplant recipients

BACKGROUND

Although our understanding of the risk factors involved in the occurrence of posttransplant diabetes mellitus (PTDM) as well as its outcomes has improved, it still remains incomplete. Our study attempts to analyze the risk factors as well as the outcomes associated with PTDM in the renal transplant patients at the Cleveland Clinic.

METHODS

Our study is a retrospective, case-control study. We screened 209 charts of 217 patients who received single-organ kidney transplant at the Cleveland Clinic between January 1996 and December 1998. PTDM was defined by the American Diabetes Association criteria of either a fasting blood glucose >or=126 mg/dL or random blood sugars >or=200 mg/dL confirmed on a second occasion. Kidney transplant recipients who developed PTDM (cases) were compared with kidney transplant recipients who did not develop diabetes but were matched for the time of transplant (controls).

RESULTS

Forty-nine patients (23%) developed PTDM. The data of 47 cases and 47 controls were analyzed. Age >or=40 years, body mass index >or=30, pretransplant triglyceride levels >150 mg/dL, and presence of graft rejection were significant risk factors for developing PTDM. Smoking was associated with increased risk of PTDM but failed to achieve statistical significance. Compared with controls, PTDM patients had higher risk of cardiovascular disease, infections, and graft rejection.

CONCLUSION

Our results show that PTDM is a significant problem after kidney transplantation, and those who have high risk should be closely monitored after transplant and aggressively treated if they develop diabetes to minimize the risk of complications.

Histamine inhibits adhesion molecule expression in human monocytes, induced by advanced glycation end products, during the mixed lymphocyte reaction

BACKGROUND AND PURPOSE

Post-transplant diabetes mellitus is a frequent complication among transplant recipients. Ligation of advanced glycation end products (AGEs) with their receptor on monocytes/macrophages plays important roles in the genesis of diabetic complications. The enhancement of adhesion molecule expression on monocytes/macrophages activates T-cells, reducing allograft survival. Out of four distinct AGE subtypes (AGE-2, AGE-3, AGE-4 and AGE-5), only AGE-2 and AGE-3 induced expression of intercellular adhesion molecules (ICAMs), output of cytokines and proliferation of lymphocytes, during the mixed lymphocyte reaction (MLR). Here we have assessed the role of histamine in the actions of AGEs during the MLR.

EXPERIMENTAL APPROACH

Human peripheral blood cells were used in these experiments. Flow cytometry was used to examine the expression of the ICAM-1, B7.1, B7.2 and CD40. Production of the cytokine interferon-gamma, and levels of cAMP were determined by elisa. Lymphocyte proliferation was determined by [(3)H]-thymidine uptake.

KEY RESULTS

Histamine concentration dependently inhibited the action of AGE-2 and AGE-3. The actions of histamine were antagonized by an H(2)-receptor antagonist, famotidine, and mimicked by H(2)/H(4)-receptor agonists, dimaprit and 4-methylhistamine. The effects of histamine were reversed by a protein kinase A (PKA) inhibitor, H89, and mimicked by dibutyryl cAMP and an adenylate cyclase activator, forskolin.

CONCLUSIONS AND IMPLICATIONS

Histamine down-regulated AGE-2- and AGE-3-induced expression of adhesion molecules, cytokine production and lymphocyte proliferation via histamine H(2) receptors and the cAMP/PKA pathway.

Primary care of the renal transplant patient

There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60-65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP's perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.

Prostaglandin E2 inhibits advanced glycation end product-induced adhesion molecule expression on monocytes, cytokine production, and lymphocyte proliferation during human mixed lymphocyte reaction

Posttransplant diabetes mellitus is a frequent complication among transplant recipients. Ligation of advanced glycation end products (AGEs) with their receptor on monocytes/macrophages plays a role in diabetes complications. The enhancement of adhesion molecule expression on monocytes/macrophages activates T cells, reducing allograft survival. In previous work, we found that toxic AGEs, AGE-2 and AGE-3, induced the expression of intracellular adhesion molecule-1, B7.1, B7.2, and CD40 on monocytes, production of interferon-gamma and tumor necrosis factor alpha, and lymphocyte proliferation during human mixed lymphocyte reaction. AGE-induced up-regulation of adhesion molecule expression was involved in cytokine production and lymphocyte proliferation. Prostaglandin E2 (PGE2) concentration-dependently inhibited the actions of AGE-2 and AGE-3. The effects of PGE2 were mimicked by an EP2 receptor agonist, ONO-AE1-259-01 (11,15-O-dimethyl PGE2), and an EP4 receptor agonist, ONO-AE1-329 [16-(3-methoxymethyl)phenyl-omega-tetranor-3,7dithia PGE1]. An EP2 receptor antagonist, AH6809 (6-isopropoxy-9-oxaxanthene-2-carboxylic acid), and an EP4 receptor antagonist, AH23848 [(4Z)-7-[(rel-1S,2S,5R)-5-((1,1'-biphenyl-4-yl)methoxy)-2-(4-morpholinyl)-3-oxocyclopentyl]-4-heptenoic acid], inhibited the actions of PGE2. The stimulation of EP2 and EP4 receptors is reported to increase cAMP levels. The effects of PGE2 were reversed by protein kinase A (PKA) inhibitors and mimicked by dibutyryl cAMP and an adenylate cyclase activator, forskolin. These results as a whole indicate that PGE2 inhibited the actions of AGE-2 and AGE-3 via EP2/EP4 receptors and the cAMP/PKA pathway.

Pilot study: association of traditional and genetic risk factors and new-onset diabetes mellitus following kidney transplantation

INTRODUCTION

New-onset diabetes mellitus, which occurs after kidney transplant and type 2 diabetes mellitus (T2DM), shares common risk factors and antecedents in impaired insulin secretion and action. Several genetic polymorphisms have been shown to be associated with T2DM. We hypothesized that transplant recipients who carry risk alleles for T2DM are "tipped over" to develop diabetes mellitus in the posttransplant milieu.

METHODS

We investigated the association of genetic and traditional risk factors present before transplantation and the development of new-onset diabetes mellitus after kidney transplantation (NODAT). Markers in 8 known T2DM-linked genes were genotyped using either the iPLEX assay or allelic discrimination (AD)-PCR in the study cohort testing for association with NODAT. We used univariate and multivariate logistic regression models for the association of pretransplant nongenetic and genetic variables with the development of NODAT.

RESULTS

The study cohort included 91 kidney transplant recipients with at least 1 year posttransplant follow-up, including 22 who developed NODAT. We observed that increased age, family history of T2DM, pretransplant obesity, and triglyceridemia were associated with NODAT development. In addition, we observed positive trends, although statistically not significant, for association between T2DM-associated genes and NODAT.

CONCLUSIONS

These findings demonstrated an increased NODAT risk among patient with a positive family history for T2DM, which, in conjunction with the observed positive predictive trends of known T2DM-associated genetic polymorphisms with NODAT, was suggestive of a genetic predisposition to NODAT.

Post-transplant glucose status in 61 pediatric renal transplant recipients: preliminary results of five Turkish pediatric nephrology centers

To assess the incidence, risk factors and outcomes of PTDM, a total of 61 non-diabetic children (24 girls, 37 boys, age: 14.5 +/- 2.1 yr) were examined after their first kidney transplantation (37.3 +/- 21.6 months) with an OGTT. At baseline, 16 (26.2%) patients had IGT, 45 (73.8%) had NGT, and no patient had PTDM. No significant difference was shown between TAC- and CSA-treated patients in terms of IGT. Higher BMI z-scores (p = 0.011), LDL-cholesterol (p < 0.05) and triglyceride levels (p < 0.01), HOMA-IR (p = 0.013) and lower HOMA-%beta (p = 0.011) were significantly associated with IGT. Fifty-four patients were re-evaluated after six months; eight patients with baseline IGT (50%) improved to NGT, three (19%) developed PTDM requiring insulin therapy, five (31%) remained with IGT, and four patients progressed from NGT to either IGT (two) or PTDM (two). These 12 progressive patients had significantly higher total cholesterol (p < 0.05), triglycerides (p < 0.05), HOMA-IR (p < 0.01) and lower HOMA-%beta (p < 0.0) than non-progressive patients at baseline. We can conclude that post-transplantation glucose abnormalities are common in Turkish pediatric kidney recipients, and higher BMI z-scores and triglyceride concentrations are the main risk factors. Considering that the progressive patients are significantly more insulin resistant at baseline, we suggest that the utility of both HOMA-IR and HOMA-%beta in predicting future risk of PTDM and/or IGT should be evaluated in children.

Early hyperglycemia: a risk factor for posttransplant diabetes mellitus among renal transplant recipients

To ascertain the frequency, epidemiology, and risk factors of posttransplant diabetes mellitus (PTDM), a retrospective analysis of all first renal transplantations, without personal history of diabetes (DM) and with a follow up >or=6 months, was performed. All patients received methylprednisolone (0.5-1 g IV) immediately prior to surgery, followed by immunosuppression including steroids, cyclosporine, and azathioprine most frequently. Early hyperglycemia was defined as values >126 mg/dL during the first week after transplantation and DM by 2 blood glucose levels of >126 mg/dL after the first month of follow-up. Included were 163 patients, namely, 57.6% males and 66% recipients of a deceased donor and 12% with a first-degree family history of DM. Mean age at transplantation was 39 years (range, 17-70 years) with a mean follow-up of 64 months. Among the 163 total subjects, some developed PTDM with frequencies of 7.5%, 13%, and 23% at 1, 5, and 10 years, respectively. Among patients with a first-degree family history of DM, 37% developed PTDM compared with 14% of those without it (odds ratio [OR] = 3.6; P < .05). Early hyperglycemia was observed in 55/92 patients, 15 of whom developed PTDM. Among patients with PTDM, the frequency of early hyperglycemia was 87% compared with 54% among those who did not develop this complication (OR = 5.4; P < .05). We confirmed a high frequency of PTDM, identifying risk factors such as a first-degree family history of DM and the development of early hyperglycemia, which should be taken into account to increase our diagnostic sensitivity and improve therapeutic individualization among renal transplant patients.

Advanced glycation end products enhance monocyte activation during human mixed lymphocyte reaction

Posttransplant diabetes mellitus (PTDM) is a frequent complication among transplant recipients. Ligation of advanced glycation end products (AGEs) with their receptor (RAGE) on monocytes/macrophages plays roles in the diabetes complications. The enhancement of adhesion molecule expression on monocytes/macrophages activates T-cells, leading to reduced allograft survival. We investigated the effect of four distinct AGE subtypes (AGE-2/AGE-3/AGE-4/AGE-5) on the expressions of intracellular adhesion molecule (ICAM)-1, B7.1, B7.2 and CD40 on monocytes, the production of interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha and the proliferation of T-cells during human mixed lymphocyte reaction (MLR). AGE-2 and AGE-3 selectively induced the adhesion molecule expression, cytokine production and T-cell proliferation. The AGE-induced up-regulation of adhesion molecule expression was involved in the cytokine production and T-cell proliferation. AGE-2 and AGE-3 up-regulated the expression of RAGE on monocytes; therefore, the AGEs may activate monocytes, leading to the up-regulation of adhesion molecule expression, cytokine production and T-cell proliferation.

Investigation of impaired carbohydrate metabolism in pediatric liver transplant recipients

OGTT was performed in 28 liver transplants maintained with tacrolimus to investigate carbohydrate metabolism and assess risk factors for development of PTDM. None had PTDM that was detected by OGTT. Early PTDM in four cases (14.3%) resolved in follow-up. Five new cases (17.9%) demonstrated DCM (DCM = IGT +/- hyperinsulinemia). Fasting measurements were normal in two hyperinsulinemic cases. With one (20%, p > 0.05) exception none of the children with DCM were overweight or had a family history of diabetes. All five (100%) children with DCM had been given high cumulative dosage of steroids 18 (78.3%)--without DCM (p > 0.05). The median age of children with DCM was greater [4.3 (12.7-18.0) vs. 7.0 (2.3-18.0) yr, p < 0.01] and duration of follow-up longer [5.3 (2.3-7.0) vs. 2.5 (0.7-7.3) yr, p < 0.05]. Four children (80%) with DCM were pubertal (p < 0.05). However, neither age nor duration of follow-up or pubertal stage had significant effect on DCM development. Early PTDM is a transient phenomenon and is not predictive for future development of diabetes. DCM is frequently observed in liver transplanted children. Albeit the children with DCM were given high cumulative dose of steroids, were older, mostly were pubertal, and had longer duration of follow-up, we cannot draw firm conclusions on effects of the risk factors on carbohydrate metabolism because of the small sample size and relatively short duration of follow-up. Unlike fasting measurements, OGTT can detect all children with DCM.

Glycemic control and organ transplantation

A discussion of hyperglycemia during organ transplantation is a broad topic that includes patients with a known history of diabetes pretransplant, those at risk for post-transplant diabetes, those with stress-induced hyperglycemia, those with hyperglycemia related to immunosuppressive therapy, and hyperglycemia in the deceased organ donor. In contrast to the plethora of articles and studies describing perioperative and critical care management of hyperglycemia in cardiac, trauma, and medical/surgical intensive care unit patients, relatively few published articles in the field of organ transplantation can be found. This article consists of a review of available literature in the form of publications and abstracts, and a preliminary report of the authors' work with liver transplantation and deceased organ donors.

Posttransplantation hypomagnesemia and its relation with immunosuppression as predictors of new-onset diabetes after transplantation

New-onset diabetes after transplantation (NODAT) is a frequent complication and has an impact on patient and graft survival. Hypomagnesemia is common in both renal transplant recipients and in diabetics. This study examines the relationship between hypomagnesemia, NODAT and the type of immunosuppression in renal transplant recipients. We conducted a retrospective single-center analysis (2002-2008) in order to assess NODAT the first year posttransplantation as defined by American Diabetes Association criteria. Serum magnesium (Mg) levels were defined as the median of all Mg levels registered during the first month posttransplantation. Patients with NODAT (N = 75; 29.5%) versus non-NODAT had lower Mg levels (p < 0.001). Patients with an Mg level < versus > or = 1.9 mg/dL showed a faster development of NODAT (log-rank p < 0.001). Mg levels were lower in patients on calcineurin inhibitors (CNI) versus no CNI patients (p < 0.001). Mg levels, albumin, BMI, triglycerides, posttransplantation hyperglycemia, tacrolimus levels and the use of sirolimus were predictors of NODAT in the multivariate analysis. Hypomagnesemia was an independent predictor of NODAT in renal transplant recipients. We confirm that the use of CNI is associated with NODAT, but, to a large extent, this effect seems attributable to the induction of hypomagnesemia. After adjustment for Mg, sirolimus was also associated with NODAT.

Post-transplant diabetes mellitus in pediatric liver transplantation

To determine the characteristics of pediatric liver transplant recipients who develop GI and/or PTDM, data on children undergoing their first liver transplant from the SPLIT database were analyzed (n = 1611). Recipient and donor characteristics that were evaluated included age at transplant, gender, race, primary disease, hospitalization status at transplant, BMI, recipient and donor CMV status, donor type, donor age, and primary immunosuppression. GI/PTDM was found in 214 individuals (13%) of whom 166 (78%) were diagnosed within 30 days of transplantation (early GI/PTDM). Multivariate analyses suggests that age >5 yr at transplant, hospitalization at transplant, a primary diagnosis other than BA, early steroid use, and tacrolimus use are associated with increased incidence of early GI. Routine monitoring for the development of GI and post-transplant diabetes is indicated in the short- and long-term care of children after liver transplantation.

Diagnosis and approach to posttransplant diabetes

The availability of new immunosuppressive drugs has led to improvement in outcome for transplanted patients, but these drugs have also led to the increase of metabolic abnormalities, such as dyslipidemia and hyperglycemia, which can affect graft and patient outcome. Posttransplant diabetes mellitus (PTDM) or new-onset diabetes after transplantation is defined as the onset of diabetes in previously nondiabetic transplant recipients. Several clinical studies have demonstrated the involvement of PTDM in death due to infectious and cardiovascular disease. This article reviews recent concepts on pathophysiology, diagnosis, and treatment of PTDM.

Mammalian target of rapamycin and diabetes: what does the current evidence tell us?

New-onset diabetes mellitus after transplantation (NODAT) is a serious complication in organ transplantation; not only does it enhance the risk of graft dysfunction, it also increases cardiovascular morbidity and mortality. The mammalian target of rapamycin (mTOR) is regulated independently by insulin, amino acids, and energy sufficiency. It integrates signal from growth factors, hormones, nutrients, and cellular energy levels to regulate protein translation and cell growth, proliferation, and survival. In addition, mTOR generates an inhibitory feedback loop on insulin receptor substrate (IRS) proteins. Therefore, it was suggested that mTOR might link nutrient excess with both obesity and insulin resistance. In this review, we summarize the role of mTOR and its inhibitor sirolimus (SRL) on chronic hyperglycemia and insulin resistance in beta cells, adipose tissue, liver, and muscle. We further hypothesize, based on data from the literature and generated in our laboratory, that SRL could counteract the development of NODAT in stable glucose homeostasis due to its positive effects on insulin-stimulated glucose uptake, whereas in conditions that require an adaptive beta cell proliferation (such as pregnancy and weight increase), the administration of SRL might have effects that would promote the development of NODAT. Therefore, it seems crucial for patient outcome to consider these potentially contrasting effects of SRL.

Long-term treatment of sirolimus but not cyclosporine ameliorates diabetic nephropathy in the rat

BACKGROUND

Not just de novo induction of diabetes mellitus, but also the progression of diabetic nephropathy may be enhanced under immunosuppressive therapy after organ transplantation. We evaluated whether sirolimus (SRL) or cyclosporine A (CsA) therapy would be a superior immunosuppressant in streptozotocin-induced diabetic nephropathy.

METHODS

Diabetes was induced by intravenous injection of streptozotozin (60 mg/kg body weight) in 26 male Sprague-Dawley rats. Eight days after diabetes induction, animals were divided into three groups, which were treated with placebo (n=8), SRL (n=9), or CsA (n=9). Six nondiabetic placebo-treated rats were included as controls.

RESULTS

After 19 weeks of diabetes, SRL significantly decreased fibrosis as assessed by periodic acid Schiff staining and by specific extracellular matrix proteins such as fibronectin and laminin at messenger RNA and protein level compared with the diabetic placebo group. SRL ameliorated renal inflammation, glomerular hypertrophy, and podocyte loss as indicated by morphometric and immunohistological analysis. SRL lowered expression and activity of glomerular transforming growth factor-beta1/2 and vascular endothelial growth factor, all of which are considered central cytokines in the pathogenesis of diabetic nephropathy. In contrast, calcineurin phosphatase inhibition through CsA did not ameliorate any of the features of diabetic nephropathy compared with placebo treatment but slightly aggravated glomerular fibrosis without affecting transforming growth factor-beta1/2 or vascular endothelial growth factor.

CONCLUSION

Compared with CsA, SRL by anti-inflammatory, antifibrotic, and podocyte-protective effects clearly seems to be the superior treatment of prevention or amelioration of diabetic nephropathy in the rat.

Skin-autofluorescence is an independent predictor of graft loss in renal transplant recipients

BACKGROUND

Skin-autofluorescence (skin-AF) noninvasively measures the tissue accumulation of advanced glycation end products (AGEs). AGEs are nephrotoxic and potential effectors of cardiovascular mortality. We investigated whether skin-AF predicted graft loss after kidney transplantation.

METHODS

A total of 302 renal transplant recipients were enrolled at a median time of 6.1 (2.6-12.1) years after transplantation and were subsequently followed up for first occurrence of graft loss (i.e., graft failure or all-cause mortality) for 5.2 (4.6-5.4) years. The association of baseline skin-AF with graft loss was investigated with univariable and multivariable Cox-regression and receiver-operator-characteristic curve analyses.

RESULTS

Baseline skin-AF was 2.7+/-0.8 arbitrary units. Skin-AF predicted graft loss in a univariable Cox regression analysis (Hazard ratios 2.40 [1.75-3.29], P<0.001) and in a multivariable model (Hazard ratios 1.83 [1.22-2.75], P=0.003), adjusted for other identified risk-factors, including patient age, creatinine clearance, protein excretion, high sensitivity C-reactive protein (hsCRP), and human leukocyte antigen-DR mismatching. The area under the receiver-operator-characteristic curve for skin-AF as predictor of graft loss was significantly different from 0.5. Skin-AF was also a significant predictor of graft failure and mortality as separate end points.

CONCLUSIONS

We conclude that skin-AF is an independent predictor of graft loss in kidney transplant recipients. Although skin-AF is not a direct measurement for AGEs, we believe that our results do support the hypothesis that accumulation of AGEs in renal transplant recipients contributes to the development of graft loss.

Review article: New-onset diabetes after transplantation

SUMMARY

This article reviews the clinical aspects and epidemiological links between diabetes mellitus and renal transplantation, and emphasizes areas that warrant further clarification. In particular, we summarize the data for various immunosuppression medications on the risk of new-onset diabetes after transplantation (NODAT). An increased mechanistic understanding of new-onset diabetes might provide new insights into the pathophysiology of this complication after solid organ transplantation. Claims that selecting immunosuppression regimen to minimize the risk of NODAT, nevertheless, are currently not supported by the scientific published work. Intuitively, strategies that aim to change the underlying biology of the disease process of NODAT are desirable; among them, lifestyle modification is currently the most promising in terms of real benefit with the least risk.

New-onset diabetes mellitus after solid organ transplantation

New-onset diabetes mellitus is a common complication of solid organ transplantation and is likely to become even more common with the current epidemic of obesity in some countries. It has become clear that both new-onset diabetes and prediabetic states (impaired fasting glucose and impaired glucose tolerance) negatively influence graft and patient survival after transplantation. This observation forms the basis for recommending meticulous screening for glucose intolerance before and after transplantation. Although a number of clinical factors including age, weight, ethnicity, family history, and infection with hepatitis C are closely associated with the new-onset diabetes mellitus, immunosuppression with corticosteroids, calcineurin inhibitors and possibly sirolimus plays a dominant role in its pathogenesis. Management of new-onset diabetes after transplantation generally conforms to the guidelines for treatment of type 2 diabetes mellitus in the general population. However, further studies are needed to determine the optimal immunosuppressive regimens for patients with this disorder.

Management of new-onset diabetes mellitus after transplantation

Solid organ transplantation is now the standard of care for end-stage organ failure, and primary care physicians are frequently involved in the follow-up care of transplant recipients. New-onset diabetes mellitus after solid organ transplantation (NODAT) has emerged as an increasingly important determinant of outcomes and survival in transplant recipients. Transplant recipients are at high risk for developing prediabetes and overt diabetes mellitus due to a number of factors, including immunosuppressive therapies. This article presents an algorithmic approach with supporting evidence to provide a rational framework for selecting the appropriate therapy among numerous treatment options. Patient education and self-management are crucial for ensuring a successful outcome post transplantation.

Comparative risk of impaired glucose metabolism associated with cyclosporine versus tacrolimus in the late posttransplant period

New onset diabetes after transplantation (NODAT) and impaired fasting glucose (IFG) are common in kidney transplant recipients (KTRs). Calcinuerin inhibitor (CNI) therapy is a causal risk factor. NODAT is associated with increased mortality and diminished graft survival. We studied the incidence of NODAT and IFG in KTRs before and after a medically indicated switch of CNI therapy from cyclosporine (CsA) to tacrolimus (Tac). The study population consisted of 704 nondiabetic KTRs. Of them, 171 underwent conversion from CsA to Tac (group I) and 533 remained on the CsA since transplantation (Group II). Time-dependent Cox regression and generalized estimating equations were used to account for sequential CNI exposure. NODAT and IFG occurred in 15.2% and 22.1% of group I subjects and 15.6% and 25.8% of group II subjects, respectively (p = 0.90 for NODAT and p = 0.38 for IFG). Accounting for equal follow-up time since conversion from CsA to Tac, the adjusted 5-year NODAT-free survival was 87.4% and 91.4% in group I and group II, respectively (p = 0.90). In conclusion, conversion to Tac, compared to continuous exposure to CsA, carries quantitatively similar risk of impaired glucose metabolism in KTRs in the late posttransplant period.

The impact of new-onset diabetes on arterial stiffness after renal transplantation

New-onset diabetes after renal transplantation (NODAT) is known to be a potent risk factor for cardiovascular events. We therefore investigated the incidence and risk factors for NODAT, and evaluated surrogate endpoints of atherosclerosis in Japanese patients with stable renal function after renal transplantation. Seventy-nine patients were enrolled in the study, and a 75 g oral glucose tolerance test (OGTT) was performed in subjects excluding patients with known NODAT. We evaluated the risk factors for NODAT and the degree of atherosclerosis, determined by brachial-ankle pulse wave velocity (baPWV), ankle-brachial blood pressure index (ABPI) and intima-media thickness (IMT) of the carotid artery. Eleven patients diagnosed as NODAT had significantly higher fasting plasma glucose before transplantation, blood pressure, and incidence of hepatitis C virus (HCV) infection than patients without NODAT. Multivariate regression analysis revealed that the independent determinant of NODAT was fasting plasma glucose pre-transplantation, HCV infection and systolic blood pressure. The baPWV in patients with NODAT was significantly higher compared to that in patients without NODAT. In addition, the independent determinant of baPWV evaluated by multivariate regression analysis was an increase in systolic blood pressure and age, and a decrease of adiponectin levels. In conclusion, we found that high fasting plasma glucose prior to transplantation, HCV infection and high blood pressure are risk factors for NODAT in Japanese patients after renal transplantation. Since NODAT patients have advanced arterial stiffness probably due to high blood pressure, strict control of blood pressure will be important for preventing the development of cardiovascular disease in NODAT.

Sirolimus is associated with new-onset diabetes in kidney transplant recipients

New-onset diabetes (NOD) is associated with transplant failure. A few single-center studies have suggested that sirolimus is associated with NOD, but this is not well established. With the use of data from the United States Renal Data System, this study evaluated the association between sirolimus use at the time of transplantation and NOD among 20,124 adult recipients of a first kidney transplant without diabetes. Compared with patients treated with cyclosporine and either mycophenolate mofetil orazathioprine, sirolimus-treated patients were at increased risk for NOD, whether it was used in combination with cyclosporine (adjusted hazard ratio [HR] 1.61; 95% confidence interval [CI] 1.36 to 1.90),tacrolimus (adjusted HR 1.66; 95% CI 1.42 to 1.93), or an antimetabolite (mycophenolate mofetil orazathioprine; adjusted HR 1.36; 95% CI 1.09 to 1.69). Similar results were obtained in a subgroup analysis that included the 16,861 patients who did not have their immunosuppressive regimen changed throughout the first posttransplantation year. In conclusion, sirolimus is independently associated with NOD. Given the negative impact of NOD on posttransplantation outcomes, these findings should be confirmed in prospective studies or in meta-analyses of existing trials that involved sirolimus.

Unmasking glucose metabolism alterations in stable renal transplant recipients: a multicenter study

BACKGROUND AND OBJECTIVES

Emerging information indicates that glucose metabolism alterations are common after renal transplantation and are associated with carotid atheromatosis. The aims of this study were to investigate the prevalence of different glucose metabolism alterations in stable recipients as well as the factors related to the condition.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A multicenter, cross-sectional study was conducted of 374 renal transplant recipients without pre- or posttransplantation diabetes. A standard 75-g oral glucose tolerance test was performed.

RESULTS

Glucose metabolism alterations were present in 119 (31.8%) recipients: 92 (24.6%) with an abnormal oral glucose tolerance test and 27 (7.2%) with isolated impaired fasting glucose. The most common disorder was impaired glucose tolerance (17.9%), and an abnormal oral glucose tolerance test was observed for 21.5% of recipients with a normal fasting glucose. By multivariate analysis, age, prednisone dosage, triglyceride/high-density lipoprotein cholesterol ratio, and beta blocker use were shown to be factors related to glucose metabolism alterations. Remarkably, triglyceride levels, triglyceride/high-density lipoprotein cholesterol ratio, and the proportion of recipients with impaired fasting glucose were already higher throughout the first posttransplantation year in recipients with a current glucose metabolism alteration as compared with those without the condition.

CONCLUSIONS

Glucose metabolism alterations are common in stable renal transplant recipients, and an oral glucose tolerance test is required for its detection. They are associated with a worse metabolic profile, which is already present during the first posttransplantation year. These findings may help planning strategies for early detection and intervention.

Unmasking glucose metabolism alterations in stable renal transplant recipients: a multicenter study

BACKGROUND AND OBJECTIVES

Emerging information indicates that glucose metabolism alterations are common after renal transplantation and are associated with carotid atheromatosis. The aims of this study were to investigate the prevalence of different glucose metabolism alterations in stable recipients as well as the factors related to the condition.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A multicenter, cross-sectional study was conducted of 374 renal transplant recipients without pre- or posttransplantation diabetes. A standard 75-g oral glucose tolerance test was performed.

RESULTS

Glucose metabolism alterations were present in 119 (31.8%) recipients: 92 (24.6%) with an abnormal oral glucose tolerance test and 27 (7.2%) with isolated impaired fasting glucose. The most common disorder was impaired glucose tolerance (17.9%), and an abnormal oral glucose tolerance test was observed for 21.5% of recipients with a normal fasting glucose. By multivariate analysis, age, prednisone dosage, triglyceride/high-density lipoprotein cholesterol ratio, and beta blocker use were shown to be factors related to glucose metabolism alterations. Remarkably, triglyceride levels, triglyceride/high-density lipoprotein cholesterol ratio, and the proportion of recipients with impaired fasting glucose were already higher throughout the first posttransplantation year in recipients with a current glucose metabolism alteration as compared with those without the condition.

CONCLUSIONS

Glucose metabolism alterations are common in stable renal transplant recipients, and an oral glucose tolerance test is required for its detection. They are associated with a worse metabolic profile, which is already present during the first posttransplantation year. These findings may help planning strategies for early detection and intervention.

Impact of acute rejection and new-onset diabetes on long-term transplant graft and patient survival

BACKGROUND AND OBJECTIVES

Development of new therapeutic strategies to improve long-term transplant outcomes requires improved understanding of the mechanisms by which these complications limit long-term transplant survival.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The association of acute rejection and new-onset diabetes was determined in the first posttransplantation year with the outcomes of transplant failure from any cause, death-censored graft loss, and death with a functioning graft in 27,707 adult recipients of first kidney-only transplants, with graft survival of at least 1 yr, performed between 1995 and 2002 in the United States.

RESULTS

In multivariate analyses, patients who developed acute rejection or new-onset diabetes had a similar risk for transplant failure from any cause, but the mechanisms of transplant failure were different: Acute rejection was associated with death-censored graft loss but only weakly associated with death with a functioning graft. In contrast new-onset diabetes was not associated with death-censored graft loss but was associated with an increased risk for death with a functioning graft.

CONCLUSIONS

Acute rejection and new-onset diabetes have a similar impact on long-term transplant survival but lead to transplant failure through different mechanisms. The mechanisms by which new-onset diabetes leads to transplant failure should be prospectively studied. Targeted therapeutic strategies to minimize the impact of various early posttransplantation complications may lead to improved long-term outcomes.

New-onset diabetes after kidney transplantation: risk factors

New-onset diabetes after transplantation (NODAT) contributes to the risk for cardiovascular disease and infection, reducing graft and patient survival. For improvement of the outcome of kidney transplant recipients, it is of great interest to know precisely the risk factors that contribute to NODAT development. Nonmodifiable risk factors for development of NODAT are age, race, genetic background, family history of diabetes, and previous glucose intolerance. Modifiable risk factors are obesity and overweight, hepatitis C virus and cytomegalovirus infections, and immunosuppressive drugs. Both steroids and calcineurin inhibitors influence the appearance of NODAT, whereas the role of sirolimus in glucose metabolism currently is controversial.

New onset diabetes mellitus after solid organ transplantation

This article presents an overview of the literature on the current diagnostic criteria for new onset diabetes mellitus after transplantation (NODAT) and discusses suggested risk factors for the development of NODAT, its potential pathogenic mechanisms, and its impact on post-transplant outcomes after solid organ transplantation. Suggested guidelines for early identification and management of NODAT are also discussed.

Comprehensive management of post-transplant diabetes mellitus: from intensive care to home care

Post-transplant diabetes mellitus (PTDM) is a common complication of solid organ and hematopoietic transplantation. This clinically oriented review article briefly summarizes the pathophysiology of PTDM, then presents a comprehensive clinical approach to diagnosis and therapy. Topics include the key clinical aspects of PTDM screening, diagnosis, and management during all phases following transplantation from the intensive care unit, to the inpatient ward, to the outpatient arena.

Risk factors for glucose metabolism disorders after kidney transplantation with uneventful course

A wide range of glucose metabolic disorders (GMDs) often arise after renal transplantation that predispose to graft dysfunction, infections, and cardiovascular disease. This study evaluated the risk factors for GMDs among 50 patients including 30 males and overall mean age 44.9 +/- 12.1 years. All 50 subjects displayed normal glucose tolerance tests pretransplantation and no family history of diabetes. They were selected from the 99 consecutive patients transplanted from April 2005 to January 2006 based upon uneventful posttransplantation course, without rejection episodes or hepatitis C virus (HCV) infections. The study concentrated on risk factors originating during the dialysis period. Even in this selected group, the risk of posttransplant GMD development was high (28%). Patients with GMDs showed significantly worse renal function at 1 month after transplantation (serum creatinine concentration: 1.70 +/- 1.67 mg/dL in the GMD group vs. 1.44 +/- 0.96 mg/dL in the group without GMDs [P = .027] and eGFR, 56.68 +/- 22.70 mL/min/1.73 m(2) versus 71.29 +/- 27.37 mL/min/1.73 m(2), respectively, [(P = .099)]. In a logistic regression model, a statistically significant difference between the groups was shown only for cold ischemia time (P = .037). In the logistic regression model with two independent variables, statistical significance was observed (P = .038) for body mass index at the time of transplantation. In this model, a lower pretransplant serum insulin concentration showed an influence that bordered on significance (P = .074). This study confirmed that the etiology of GMD after kidney transplantation is multifactorial, and at least in part connected with the pre-transplantation period.