Association of hepatitis C with posttransplant diabetes in renal transplant patients on tacrolimus

Management of the well renal transplant recipient: outpatient surveillance and treatment recommendations

Although renal transplantation offers survival and quality of life advantages as a renal replacement therapy, a substantial proportion of transplant recipients develop worsening of preexisting medical diseases or new complications, including sequelae of rejection, new onset diabetes after transplantation (NODAT), hyperlipidemia, opportunistic infections, cancer, and other systemic diseases secondary to immunosuppression. Management of these problems can be a complex endeavor due to medication interactions that often affect immunosuppression levels. However, successful management of the chronic medical problems associated with renal transplantation can prolong the life span of the graft and the patient.

Post-transplant diabetes mellitus and HCV seropositive status after renal transplantation: meta-analysis of clinical studies

Hepatitis C virus (HCV) infection has a detrimental role on patient and graft survival after renal transplantation (RT). Some studies have also implicated HCV in the development of post-transplant diabetes mellitus (PTDM). We conducted a systematic review of the published medical literature of the relationship between anti-HCV seropositive status and DM after RT. The risk of DM occurrence in anti-HCV-positive and -negative patients after RT was regarded as the most reliable outcome end-point. We used the random effects model of DerSimonian and Laird to generate a summary estimate of the Odds Ratio (OD) of new onset DM in HCV-positive and -negative patients after kidney transplantation. Ten studies involving 2502 unique RT recipients were identified. The incidence of PTDM after RT ranged between 7.9% and 50%. The summary estimate for adjusted OR was 3.97 with a 95% confidence interval (CI) of 1.83-8.61 (p-value for homogeneity <0.0473). Thus, pooling of study results demonstrated the presence of a significant link between anti-HCV seropositive status and DM after RT. This relationship provides one potential explanation for the adverse effects of HCV on patient and graft survival after RT.

New-Onset Diabetes after Kidney Transplantation: An Application of 2003 International Guidelines

BACKGROUND

The 2003 International Consensus Guidelines defined new-onset diabetes after transplantation. This study determined the risk of new-onset diabetes following kidney transplantation using these criteria.

METHODS

Consecutive nondiabetic patients who received kidney transplantation between August 2001 and March 2003 (recent, n=61) and before August 2001 (earlier, n=61) were retrospectively evaluated.

RESULTS

In all, 74% in the recent group and 56% in the earlier group developed diabetes by 1 year posttransplant. Median time to diabetes development was 23 days in the recent vs. 134 days in the earlier group (P=0.0304). Most patients developed diabetes within 60 days after transplantation. Immunosuppression was the strongest correlate of diabetes development; tacrolimus and cyclosporine A treatments were associated with increased risk. The rate of development was also greater when rapamycin was added to tacrolimus, compared to when it was not. The risk was double in African-Americans compared to whites. Age, body mass index, family history of diabetes, and etiology of renal failure did not predict diabetes; however, the mean age of patients was greater than previously reported.

CONCLUSIONS

The majority of patients are at risk of developing new-onset diabetes within a short time after kidney transplantation. The risk may be due to preexisting risk factors, immunosuppressive agents, or older age. The significance of these findings is not clear, but demands appropriate follow-up studies related to glycemia, end-organ complications, and graft function. It remains to be determined whether the 2003 International Consensus Guidelines are adequate to appropriately diagnose diabetes in the posttransplant time period, with special emphasis on the first 3 months.

Factors influencing the onset of diabetes mellitus after kidney transplantation: a single French center experience

Posttransplantation diabetes mellitus (PTDM) is a complication arising mostly during the first 6 months after kidney transplantation. Considering the serious outcomes of chronic hyperglycemia in kidney transplant patients, the recognition of factors that contribute to the onset of PTDM is of particular relevance. A retrospective analysis was performed to document the incidence of and the risk factors for diabetes mellitus occurring in the first year after kidney transplantation among 177 adult patients, without previously known diabetes transplanted between January 1998 and December 2000. PTDM, defined as fasting plasma glucose > or = 126 mg/dL confirmed by repeat testing on a different day, occurred in 48 (27.12%) patients of whom 36 showed transient changes during the first year after transplantation. Univariate analysis identified variables to be associated with the onset of PTDM: older recipient age (P = .05), male gender (P = .03), family history of diabetes (P = .04), advanced donor age (P = .008), absence of induction immunosuppression (P = .04), use of tacrolimus (vs cyclosporine; P = .01), one or more than one (steroid-treated) acute rejection episode(s) (P = .000001), cytomegalovirus infection (P = .02), and use of beta-blockers or diuretics (P = .05). By multivariate analysis, five factors were independently associated with the onset of PTDM: two episodes of rejection (odds ratio = 42.69, P = .000025), one episode of rejection (5.01, P = .007), older recipient age (1.06, P = .017), family history of diabetes (7.24, P = .011), and weight at transplantation (1.03, P = .048). Tacrolimus treatment remained of borderline significance (2.77, P = .05). In addition to traditional risk factors predisposing to the development of type 2 diabetes in the general population, episodes of acute rejection significantly influence the incidence of PTDM.

Hepatitis C is a predictor of poorer renal survival in diabetic patients

OBJECTIVE

Hepatitis C virus (HCV) is highly prevalent in the U.S. and worsens renal survival in some kidney diseases. We examined the effects of HCV on renal survival in diabetic patients with renal disease.

RESEARCH DESIGN AND METHODS

HCV and diabetes status were noted in patients seen in our nephrology clinic in 2001 and 2002. Charts of diabetic patients were reviewed for demographics, blood pressure, renal function, medicines, the presence of HCV, and other factors at the initial visit and over follow-up. The effect of HCV on renal survival was determined by Cox proportional hazards, using end-stage renal disease (ESRD) as an end point.

RESULTS

Of 1,127 patients, prevalence rates for HCV were higher in African Americans than non-African Americans (8.09 vs. 3.93%, respectively, P = 0.06), with African-American men having the highest prevalence rates (12.7%). The charts of 312 diabetic patients were reviewed. Over 80% were African American, as were 23 of 24 patients with HCV. Compared with non-HCV patients, HCV patients were younger, had higher diastolic blood pressure, and had lower BMI. HCV patients had significantly worse cumulative renal survival by Kaplan-Meier. On Cox proportional hazards analysis, HCV was a significant predictor of reaching ESRD independent of initial renal function, proteinuria, blood pressure, sex, race, presence of diabetic nephropathy, age, or duration of diabetes (odds ratio 3.49, 95% CI 1.27-9.57, P = 0.015).

CONCLUSIONS

HCV is common in African Americans with diabetes and renal disease and is an independent risk factor for renal survival in this population. Prospective studies are necessary to confirm these observations.

New-onset diabetes after transplantation

New-onset diabetes after transplantation (NODAT) is associated with significant morbidity and mortality. Given the availability of simple diagnostic methods and the known benefits of strict glycemic control, patients should be screened frequently after organ transplantation. The management of NODAT is multifaceted and aimed at both treatment and prevention of complications. Evaluation of patient risk for post-transplant diabetes mellitus and its complications is an important consideration in initial selection and subsequent modification of the immunosuppressive regimen.

Tacrolimus and Posttransplant Diabetes Mellitus in Renal Transplantation

The most prominent side effect of tacrolimus is the induction of posttransplant diabetes mellitus (PTDM). In this review, the authors discuss the incidence, mechanism, prevention, and treatment of tacrolimus-induced PTDM in renal patients.

Challenges in the diagnosis and management of new-onset diabetes after transplantation

With the availability of newer and more potent immunosuppressive agents, post-transplant survival has markedly improved. However, these agents, together with the rising age of transplant recipients, have been associated with a rise in the incidence of new-onset diabetes after transplantation (NODAT). Besides the traditional risk factors for diabetes mellitus, such as age, obesity, hypertension, and family history of diabetes, additional risk factors for NODAT are identified. These include immunosuppressive therapy, hepatitis C infection, acute rejection, and deceased donor kidney transplant. In this article, we discuss the epidemiology, risk factors, pathophysiology, clinical course, and therapeutic and diagnostic challenges of this emerging disease.

Management of hyperglycaemia after pancreas transplantation: are new immunosuppressants the answer?

Pancreas transplantation is considered the optimal therapy for patients with diabetes mellitus who reach end-stage renal disease. Despite achievement of euglycaemia after this procedure, the progression to impaired pancreatic function and metabolic exhaustion still represents one of the major concerns that increase the risk of graft loss. This paper reviews the possible mechanisms that can induce post-transplant hyperglycaemia, including those related to immunosuppression and those non-related, and the new strategies available for minimising or preventing this complication. Different aetiologies can induce pancreatic dysfunction. Technical complications, acute pancreatitis and delayed graft function, mostly related to impaired insulin secretion, are considered the early causes for abnormal glucose control. In general, acute rejection does not affect the endocrine portion of the pancreas graft because islet destruction occurs later than the inflammation of the exocrine components. Hyperinsulinaemia and insulin resistance represent the main concern for the progression of blood glucose intolerance. The anastomotic techniques of the exocrine portion of the pancreas and the immunosuppressive regimens are of critical importance for the development of impaired glucose metabolism. Hyperinsulinaemia, as a result of the fact that systemic-enteric or systemic-bladder drainages reducing the hepatic clearance of insulin, has led to the introduction of more physiological techniques using portal drainage of the endocrine secretions. Experimental and clinical data have shown that many of the current immunosuppressants account, to a large degree, for the increased risk of the development of post-transplant hyperglycaemia. The most common maintenance regimen in pancreatic transplantation still consists of triple therapy with a combination of corticosteroids, calcineurin inhibitors (either ciclosporin [cyclosporine] or tacrolimus), and mycophenolate mofetil (MMF).The diabetogenic effects of corticosteroids and calcineurin inhibitors have resulted in the need for protocols able to minimise their use. Recent studies have shown the safety and efficacy of steroid-sparing or -free regimens. Sirolimus has shown powerful immunosuppressive potency in absence of nephrotoxicity and diabetogenicity. Multicentre and single-centre reports have demonstrated that both calcineurin inhibitor withdrawal and avoidance were possible when sirolimus was used in a concentration-controlled fashion, with low-dose corticosteroids and MMF. Although the experience with sirolimus in pancreatic transplantation is still limited, the results are promising. Patients affected by diabetic gastroparesis seem to better tolerate a regimen with sirolimus and low-dose tacrolimus than one with tacrolimus in combination with MMF.For successful, long-term results of pancreatic transplantation, it is crucial to combine donor selection, technical aspects, modified anastomotic techniques and new therapeutic approaches designed to minimise the metabolic and non-metabolic adverse effects of the immunosuppressive regimens.

New-onset diabetes mellitus in transplant patients: pathogenesis, complications, and management

New-onset diabetes mellitus after transplantation is characterized by decreased insulin secretion and increased insulin resistance secondary to the effects of immunosuppression. Although impaired beta cell function appears to be the primary mechanism of calcineurin inhibitor-induced new-onset diabetes, impaired peripheral glucose utilization also appears to contribute to insulin resistance and abnormal glucose metabolism. Because transplant recipients who develop new-onset diabetes mellitus after transplantation are at increased risk for infections, cardiovascular disease, and poor patient and graft survival, all patients should undergo careful assessment of risk for diabetes prior to transplantation and regular screening for the development of hyperglycemia thereafter. For patients in high-risk groups, including certain ethnic backgrounds, older adults, and the very young, and patients with hepatitis C, consideration should be given to initiating immunosuppressive therapy with agents that are less diabetogenic. Recent guidelines include more stringent criteria for diagnosis and stress the importance of strict glycemic control. Diet, exercise, and weight management are core components of treatment with addition of oral hypoglycemic agents and/or insulin as needed to achieve control. Concomitant measures include aggressive control of lipids and blood pressure to reduce the risk of cardiovascular disease. New-onset diabetes after transplantation is a serious issue affecting patient and graft outcomes and warrants the attention of all health care professionals involved in assessing and managing the transplant recipient.

Review article: hepatitis C virus infection and type-2 diabetes mellitus in renal diseases and transplantation

A link between hepatitis C virus infection and development of diabetes mellitus has been suggested by many investigators; however, this remains controversial. The mechanisms underlying the association between hepatitis C virus and diabetes mellitus are unclear but a great majority of clinical surveys have found a significant and independent relationship between hepatitis C virus and diabetes mellitus after renal transplantation and orthotopic liver transplantation. We have systematically reviewed the scientific literature to explore the association between hepatitis C virus and diabetes mellitus in end-stage renal disease; in addition, data on patients undergoing orthotopic liver transplantation were also analysed. The unadjusted odds ratio for developing post-transplant diabetes mellitus in hepatitis C virus-infected renal transplant recipients ranged between 1.58 and 16.5 across the published studies. The rate of anti-hepatitis C virus antibody in serum was higher among dialysis patients having diabetes mellitus (odds ratio 9.9; 95% confidence interval 2.663-32.924). Patients with type-2 diabetes-related glomerulonephritis had the highest anti-hepatitis C virus prevalence [19.5% (24/123) vs. 3.2% (73/2247); P < 0.001] in a large cohort of Japanese patients who underwent renal biopsy. The link between hepatitis C virus and diabetes mellitus may explain, in part, the detrimental role of hepatitis C virus on patient and graft survival after orthotopic liver transplantation and/or renal transplantation. Preliminary evidence suggests that anti-viral therapies prior to renal transplantation and novel immunosuppressive regimens may lower the occurrence of diabetes mellitus in hepatitis C virus-infected patients after renal transplantation. Clinical trials are under way to assess if the hepatitis C virus-linked predisposition to new onset diabetes mellitus after renal transplantation may be reduced by newer immunosuppressive medications.

Outcome of hepatitis C virus-infected kidney transplant candidates who remain on the waiting list

The management of patients awaiting transplantation is a growing concern. This retrospective cohort study examined outcomes of hepatitis C virus (HCV)-infected kidney candidates who remain waitlisted. Records from 315 HCV+ kidney candidates evaluated between 1992 and 2002, were reviewed. A total of 300 (95.1%) patients were receiving renal replacement therapy at evaluation, median duration 48.2 + 4.3 months. The diabetes prevalence was 42.9% in HCV+ candidates, compared to 35.9% among 602 currently listed HCV- patients (p = 0.023). Liver disease, defined by abnormal hepatic biochemistry or histology, was observed in 59% patients. Median post-evaluation follow-up was 1440 +/- 75 days; 138 candidates were transplanted. Kaplan-Meier survival was higher among transplanted than non-transplanted patients (p = 0.003). Of 177 patients not transplanted, 76 were delisted, mostly due to death (45%) and non-compliance (28%), infrequently because of liver disease (8.8%). A Cox regression model was fit to examine risk factors for waitlist death; only diabetes was associated (HR: 2.17, 95% CI: 1.1-4.1, p = 0.02), while liver disease was not. This study demonstrates that, in waitlisted HCV+ kidney patients, diabetes occurs with increased prevalence and is a major mortality determinant. Diabetic HCV+ kidney candidates are therefore a patient subgroup that requires frequent and careful reevaluation to ensure ongoing transplantability.

Challenges facing islet transplantation for the treatment of type 1 diabetes mellitus

Islet transplantation represents a most impressive recent advance in the search for a type 1 diabetes mellitus cure. While several hundred patients have achieved at least temporary insulin independence after receiving the islet "mini-organs" (containing insulin-producing beta cells), very few patients remain insulin independent beyond 4 years after transplantation. In this review, we describe historic as well as technical details about the procedure and provide insight into clinical and basic research efforts to overcome existing hurdles for this promising therapy.

Challenges facing islet transplantation for the treatment of type 1 diabetes mellitus

Islet transplantation represents a most impressive recent advance in the search for a type 1 diabetes mellitus cure. While several hundred patients have achieved at least temporary insulin independence after receiving the islet "mini-organs" (containing insulin-producing beta cells), very few patients remain insulin independent beyond 4 years after transplantation. In this review, we describe historic as well as technical details about the procedure and provide insight into clinical and basic research efforts to overcome existing hurdles for this promising therapy.

Development of diabetes mellitus following kidney transplantation: a Canadian experience

The onset of diabetes mellitus following kidney transplantation or post-transplant diabetes mellitus (PTDM) is now recognized as being an increasingly common complication that is associated with poor graft and patient survival. The incidence and clinical correlates of PTDM in a Canadian kidney transplant population has not been examined and may vary based on differences in demographics (i.e. race). Furthermore, little information exists on the association of variables such as cumulative dose of corticosteroids and trough calcineurin inhibitor levels and PTDM. We examined all recipients of a kidney transplant in our center between 1995 and 2001 and found an overall PTDM rate of 9.8%. Five clinical factors were independently associated with PTDM: older recipient age, deceased donor, hepatitis C antibody status, rejection episode and use of tacrolimus (vs. cyclosporine). Furthermore, cumulative corticosteroid dose and calcineurin inhibitor trough level were not associated with PTDM. This study demonstrates that in a Canadian kidney transplant population that there is a significant risk of PTDM following kidney transplantation, and it is therefore advisable to minimize this risk.

Reduced incidence of new-onset diabetes mellitus after renal transplantation with 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibitors (statins)

Statins have anti-inflammatory effects, modify endothelial function and improve peripheral insulin resistance. We hypothesized that statins influence the development of new-onset diabetes mellitus in renal transplant recipients. The records of all previously non-diabetic adults who received an allograft in Toronto between January 1, 1999 and December 31, 2001 were reviewed with follow-up through December 31, 2002. All patients receiving cyclosporine or tacrolimus, mycophenolate mofetil and prednisone were included. New-onset diabetes was diagnosed by the Canadian Diabetic Association criteria: fasting plasma glucose > or =7.0 mmol/L or 2-h postprandial glucose > or =11.1 mmol/L on more than two occasions. Statin use prior to diabetes development was recorded along with other variables. Cox proportional hazards models analyzing statin use as a time-dependent covariate were performed. Three hundred fourteen recipients met study criteria, of whom 129 received statins. New-onset diabetes incidence was 16% (n = 49). Statins (p = 0.0004, HR 0.238[0.109-0.524]) and ACE inhibitors/ARB (p = 0.01, HR 0.309[0.127-0.750]) were associated with decreased risk. Prednisone dose (p = 0.0001, HR 1.007[1.003-1.010] per 1 mg/d at 3 months), weight at transplant (p = 0.02, HR 1.022[1.003-1.042] per 1 kg), black ethnicity (p = 0.02, HR 1.230[1.023-1.480]) and age > or =45 years (p = 0.01, HR 2.226[1.162-4.261]) were associated with increased diabetes. Statin use is associated with reduced new-onset diabetes development after renal transplantation.

Rapid steroid withdrawal in hepatitis C virus-positive kidney transplant recipients

The effects of rapid steroid withdrawal (SW) on kidney transplantation (KT) outcome were investigated in 12 HCV+ patients in a prospective cohort study. These results were compared with 17 HCV+ patients who received KT in the prior 2 yr and treated with a standard prednisone taper protocol. SW patients received only 6 d of steroid treatment after transplantation. Eleven received Thymoglobulin and one Basiliximab induction treatment along with a calcineurin inhibitor and mycophenolate mofetil. Patient and graft survival was 92% in SW group (median follow-up 12 months, range 6-17), and 92 and 82% in the historic control group respectively (median follow-up 21 months, range 11-27). In the SW and control group, acute rejection rates were 9 and 18%, and mean creatinine levels at last follow-up 1.30 +/- 0.36 and 1.68 +/- 0.58 mg/dL respectively. Only two SW patients had an increase in liver function tests during follow-up (18%), compared with six patients in the control group (43%). This study demonstrates that rapid SW is safe for HCV+ KT recipients, without an increase in acute rejection episodes or liver function abnormalities in the short term.

Hepatitis C Infection, Time in Renal-Replacement Therapy, and Outcome after Kidney Transplantation

BACKGROUND

Hepatitis C virus (HCV) infection is common in kidney transplantation and is known to affect long-term patient and graft survival, as is time in renal-replacement therapy (RRT). The aim of this study was to investigate HCV in relation to time in RRT and its impact on outcome after transplantation.

METHODS

A follow-up cohort study using Kaplan-Meier analysis and Cox proportional hazards model was performed in 545 kidney and 26 kidney-pancreas transplant recipients receiving transplants between 1989 and 1997, with last follow-up on December 31, 2002. HCV status at transplantation and time in RRT were analyzed.

RESULTS

Time in RRT was significantly longer (P<0.0001), and previous transplantations were more common (P=0.04) in the HCV-positive group. HCV significantly reduced patient (P=0.0012) and graft survival (P=0.0003) after transplantation. Adjustment for age, sex, diabetes, previous transplantations, type of transplant, and time in RRT resulted in a relative risk (RR) for death of 2.23, 1.92, and 1.07 for HCV, diabetes, and age, respectively. The RR for graft loss was 1.96 and 1.03 for HCV and age. Sex, previous transplants, and time in RRT did not affect HCV as an independent risk factor for patient or graft survival. The leading cause of death was cardiovascular disease in both groups.

CONCLUSIONS

HCV was, in our series, more important than time in RRT for patient death and graft loss posttransplant. Successful pretransplant antiviral therapy could be more beneficial for HCV-infected patients rather than early transplantation for long-term outcome, but this needs to be studied prospectively.

New-onset diabetes after transplantation

For many years new-onset diabetes after transplantation has been recognized as a complication of solid-organ transplantation, although its importance has been greatly underestimated. Studies have shown that the cumulative incidence of this condition in heart transplant recipients may reach 32% at 5 years, similar to that reported in kidney and liver transplant patients. Several factors predispose to increased risk for developing new-onset diabetes after transplantation, including age, ethnicity, family history of diabetes, obesity and immunosuppressive therapy. Corticosteroids are associated with the greatest risk of developing the condition. Tacrolimus is more diabetogenic than cyclosporine in kidney and liver transplant patients, but there are few data reporting the effects of these agents in heart transplant patients. In kidney transplant patients, diabetes is known to be a significant risk factor for cardiovascular disease post-transplant. Although this has yet to be demonstrated clearly in heart transplant patients, evidence suggests that new-onset diabetes after transplantation may play a role in the development of cardiac allograft vasculopathy (CAV). Because CAV is the major limitation to long-term survival in this population, it is clear that efforts should be made to reduce the risk of diabetes and treat this condition appropriately. Management of transplant recipients with new-onset diabetes after transplantation has been assisted by the recent publication of International Consensus Guidelines. The guidelines were developed to establish a standard definition and describe risk factors for new-onset diabetes after transplantation. Use of these guidelines will help to prospectively identify those at risk of developing new-onset diabetes after transplantation so that therapeutic strategies can be individualized early in the treatment regimen. These management approaches should help to lower the risk of new-onset diabetes after heart transplantation and reduce the possible long-term consequences of the condition.

Risk factors and incidence of posttransplant diabetes mellitus in renal transplant recipients

OBJECTIVE

This study reviewed the incidence of post-transplantation diabetes mellitus (PTDM) and risk factors for its development among renal transplant recipients in Malaysia.

METHODS

Records of all kidney recipients with no known diabetes mellitus prior to transplantation and followed for at least 6 months posttransplant were selected for this retrospective study. PTDM was diagnosed according to American Diabetic Association/WHO criteria or the need to start insulin or an oral hypoglycemic agent. The data set included recipient age, gender, race, weight, donor type, duration of transplant, HCV antibody status, and immunosuppressive medication.

RESULTS

Of the 316 patients who fulfilled the selection criteria, 13.3% had PTDM. Gender, race, type of donor, HCV serologic status, and use of tacrolimus did not differ significantly between recipients with versus without PTDM. However, recipients who developed PTDM were significantly older (median age 50.5 versus 42.0 years, P < 0.0001), had significantly longer posttransplant follow-up (median duration 125.5 versus 85.0 months, P = .0030) and weighed more at transplantation/first follow-up (median weight 57.6 versus 52.3 kg, P = .0103).

CONCLUSION

The overall cumulative incidence of PTDM in this study was similar to the published reports. Older age, longer posttransplant duration, and heavier weight were the only variables significantly associated with PTDM.

Asymptomatic cytomegalovirus infection is associated with increased risk of new-onset diabetes mellitus and impaired insulin release after renal transplantation

AIMS/HYPOTHESIS

The human cytomegalovirus (CMV) may increase the risk of diabetes mellitus, but the literature is scarce. The present study was designed to test the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset diabetes after renal transplantation, and to assess the impact of asymptomatic CMV infection on OGTT-derived estimates of insulin release and insulin action.

METHODS

A total of 160 consecutive non-diabetic renal transplant recipients on cyclosporine (Sandimmun Neoral)-based immunosuppression were closely monitored for CMV infection during the first 3 months after transplantation. All patients underwent a 75-g OGTT at 10 weeks. Excluded from the analyses were 36 patients with symptomatic CMV infection (disease).

RESULTS

The incidence of new-onset diabetes was 6% in a control group of recipients without CMV infection (4/63) and 26% in the group with asymptomatic CMV infection (16/61). Asymptomatic CMV infection was associated with a significantly increased risk of new-onset diabetes (adjusted odds ratio: 4.00; 95% CI: 1.19 to 13.43, p=0.025). The group of patients with CMV infection had a significantly lower median insulin release than controls.

CONCLUSIONS/INTERPRETATION

Our findings support the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset post-transplant diabetes mellitus, and suggest that impaired insulin release may involve one pathogenetic mechanism.

Improved detection of HCV Infection in hemodialysis patients using a new HCV RNA qualitative assay: experience of a transplant center

BACKGROUND

Hepatitis C virus (HCV) is frequently a silent infection in hemodialysis (HD) patients with a prevalence of 8-10%. Improving HCV detection in this population prior to transplantation is critical both for infection control and optimal patient care.

OBJECTIVES

To assess the current HCV testing practice of the National Institute for Transplantation (PCR testing of enzyme immunoassay (EIA) positive HD patients) by evaluating a subset of EIA positive and EIA negative samples with the VERSANT HCV RNA Qualitative Assay based on transcription mediated amplification (HCV Qual (TMA)) (sensitivity < or = 9.6 IU/ml) and in-house PCR (HCV Qual (PCR)) (sensitivity approximately 149 IU/ml).

STUDY DESIGN

2321 HD patients were screened by Abbott HCV EIA 2.0. A subset of 80/169 E IA positive samples and 100/2152 EIA negative samples were tested by both assays. TMA/PCR discordant samples were genotyped.

RESULTS

PCR and TMA gave concordant results in 67/80 (83.8%) of EIA positive samples. 11/80 (14.7%) were reactive by HCV Qual (TMA), but not by HCV Qual (PCR); 2/80 (2.7%) were reactive by HCV Qual (PCR), but not by HCV Qual (TMA). 2/100 (2%) EIA negative samples were reactive and 95/100 (95%) were non-reactive by both assays. Three (3%) were only HCV Qual (TMA) reactive. 11/14 TMA+/PCR-samples with sufficient volume were genotyped.

CONCLUSIONS

HCV Qual (TMA) identified active HCV infection in more EIA positive and EIA negative patients than HCV Qual (PCR) and should be part of our testing algorithm.

Is hepatitis C a risk factor to posttransplant diabetes mellitus after renal transplantation in patients using tacrolimus?

The objective of this study was to evaluate the association between previous hepatitis C virus (HCV) infection and the occurrence of posttransplant diabetes mellitus (PTDM) among patients undergoing kidney transplants using tacrolimus (FK). From August 1999 to January 2003, 66 patients (36.4 +/- 15.5 years) underwent kidney transplantation using an immunosuppressive regimen of tacrolimus, mycophenolate mofetil, or azathioprine and steroids. Thirty-four patients (52%) received kidneys from living donors and 32 (48%) from cadaveric donors. The diagnosis of diabetes mellitus was established after two consecutive ambulatory measurements of fasting glycemia > or = 126 mg/dL. Thirty-five percent of the patients (23/66) were HCV+ and 65% (43/66) HCV-. Of the 66 patients, 33% (22) developed PTDM, 19 (82%) from the HCV+ group and only 3 (7%) from the HCV- group. Among those who developed PDTM, the diagnosis was established in the first 2 posttransplant months in most cases (68.2%). The results showed a significant association between HCV and PTDM (P < or = .0001). In this group of patients HCV infection was strongly associated with the development of PTDM. Therefore, additional care is required regarding the immunosuppressive regimen among patients with chronic HCV infection.

Posttransplant diabetes mellitus in renal transplant patients with hepatitis C virus

The aim of this study was to assess the possible association between posttransplant diabetes mellitus (DM) and hepatitis C virus (HCV) infection in renal transplant recipients. This study included 124 patients who underwent renal transplantation between 1997 and 2002. Inclusion criteria were patients who were not diabetic prior to transplantation and posttransplant follow-up longer than 6 months. DM was defined as fasting blood glucose levels higher than 126 mg/dL on at least two occasions. HCV infection was detected using second- or third-generation ELISA methods and/or polymerase chain reactions for HCV-RNA. Twenty-five HCV positive (HCV+) patients were compared with 25 consecutive HCV negative (HCV-) transplant patients. Demographic and clinical data of the groups were compared. Posttransplantation DM was observed in 24% of the HCV+ patients. There were no statistical differences in age, gender, race, family history of DM, follow-up, or body mass index between the two groups. There was a higher prevalence of posttransplantation DM in HCV+ patients, but the difference did not reach statistical significance (24% vs 12%, P = NS). Alternatively, comparing patients of the two groups (n = 50) who did versus not develop DM, the incidence of posttransplantation DM was higher among HCV+ patients, but the difference did not reach statistical significance (66.6% vs 46.3%, P = NS). In conclusion, there was no association between HCV infection and the development of posttransplantation DM in this cohort of renal transplant recipients. However, there was a trend that suggested an association.

Hepatitis C virus is independently associated with increased insulin resistance after liver transplantation

BACKGROUND AND AIMS

There is a strong epidemiologic association between diabetes mellitus (DM) and hepatitis C virus (HCV) infection. However, the pathogenetic basis for this association has not been established. We sought to evaluate the association between insulin resistance (IR), beta-cell dysfunction, and HCV among orthotopic liver transplant (OLT) recipients.

METHODS

We performed a cross sectional analysis comparing 39 HCV(+) with 60 HCV(-) OLT recipients. IR and beta-cell function were calculated using validated measures and were correlated with clinical variables.

RESULTS

By multivariate analysis of the entire cohort, HCV infection and body mass index (BMI) were independent predictors of IR (P =0.04 and 0.0006, respectively). HCV infection was associated with 35% increase in IR. Because the model used to calculate IR was derived from nondiabetic subjects, we performed additional analysis of patients who did not meet criteria for diabetes at the time of their study evaluation. In this analysis, HCV(+) subjects had greater fasting insulin and homeostasis model assessment (HOMA) IR (15.3 mu U/mL and 3.8) compared with HCV(-) patients (10.7 mu U/mL and 2.5) (P =0.03, 0.03). There was no difference in beta-cell function or hepatic insulin extraction between the HCV (+) and (-) groups. HCV (P =0.0005), BMI (P <0.0001), and high high-density lipoprotein (P =0.039) were the only independent predictors of IR. The presence of HCV infection and a 10-fold increase in HCV RNA were associated with a 62% and 8% increase in IR, respectively.

CONCLUSIONS

HCV is independently associated with increased IR after OLT. These findings provide a possible pathogenetic basis for the association of DM with HCV.

New onset diabetes mellitus in patients receiving calcineurin inhibitors: a systematic review and meta-analysis

New onset diabetes mellitus (NODM) is a serious complication of transplantation. This meta-analysis evaluates the reported incidence of NODM after solid organ transplantation in patients receiving CNI treatment. Databases from January 1992 to April 2002 were searched. Fifty-six publications providing NODM incidence data were reviewed. Sixteen prospective, randomized comparative studies providing information on incidence of insulin-dependent diabetes mellitus (IDDM) were subjected to meta-analysis. New onset diabetes mellitus was reported in 13.4% of patients after solid organ transplantation, with a higher incidence in patients receiving tacrolimus than cyclosporine (16.6% vs. 9.8%). This trend was observed across renal, liver, heart and lung transplant groups. Meta-analysis of 16 studies included patients receiving either tacrolimus (n=1636) or cyclosporine (n=1407). The incidence of IDDM was significantly higher among tacrolimus-treated patients (10.4% vs. 4.5%, p<0.00001), an effect observed in renal (9.8% vs. 2.7% p<0.00001) and nonrenal (11.1% vs. 6.2%; p<0.003) groups, and among patients receiving equal doses of concomitant medication in both treatment arms (12.0% vs. 3.0%; p<0.00001). The reported incidence of NODM during the past decade was significantly higher among patients receiving tacrolimus than cyclosporine. These data provide a quantitative foundation for studies designed to reduce the rates of NODM following solid organ transplantation.

Hepatitis C and renal disease: an update

Hepatitis C is both a cause and a complication of chronic renal disease. Chronic infection with hepatitis C virus (HCV) can lead to the immune complex syndromes of cryoglobulinemia and membranoproliferative glomerulonephritis (MPGN). The pathogenetic mechanisms for these conditions have not been defined, although they are clearly caused by the chronic viral infection. Management of HCV-related cryoglobulinemia and MPGN is difficult; antiviral therapy is effective in clearing HCV infection in a proportion of patients, but these conditions can be severe and resistant to antiviral therapy. Hepatitis C also is a complicating factor among patients with end-stage renal disease and renal transplants. The source of HCV infection in these patients can be nosocomial. Screening and careful attention to infection control precautions are mandatory for dialysis units to prevent the spread of hepatitis C. Prevention of spread is particularly important in these patients because HCV infection is associated with significant worsening of survival on dialysis therapy, as well as after kidney transplantation. Furthermore, therapy for hepatitis C is problematic, only partially effective, and associated with significant side effects in this population. There are significant needs in both basic and clinical research in the pathogenesis, natural history, prevention, and therapy for hepatitis C in patients with renal disease.

Tacrolimus: a further update of its use in the management of organ transplantation

Extensive clinical use has confirmed that tacrolimus (Prograf) is a key option for immunosuppression after transplantation. In large, prospective, randomised, multicentre trials in adults and children receiving solid organ transplants, tacrolimus was at least as effective or provided better efficacy than cyclosporin microemulsion in terms of patient and graft survival, treatment failure rates and the incidence of biopsy-proven acute and corticosteroid-resistant rejection episodes. Notably, the lower incidence of rejection episodes after renal transplantation in tacrolimus recipients was reflected in improved cost effectiveness. In bone marrow transplant (BMT) recipients, the incidence of tacrolimus grade II-IV graft-versus-host disease was significantly lower with tacrolimus than cyclosporin treatment. Efficacy was maintained in renal and liver transplant recipients after total withdrawal of corticosteroid therapy from tacrolimus-based immunosuppression, with the incidence of acute rejection episodes at up to 2 years' follow-up being similar with or without corticosteroids. Tacrolimus provided effective rescue therapy in transplant recipients with persistent acute or chronic allograft rejection or drug-related toxicity associated with cyclosporin treatment. Typically, conversion to tacrolimus reversed rejection episodes and/or improved the tolerability profile, particularly in terms of reduced hyperlipidaemia. In lung transplant recipients with obliterative bronchiolitis, conversion to tacrolimus reduced the decline in and/or improved lung function in terms of forced expiratory volume in 1 second. Tolerability issues may be a factor when choosing a calcineurin inhibitor. Cyclosporin tends to be associated with a higher incidence of significant hypertension, hyperlipidaemia, hirsutism, gingivitis and gum hyperplasia, whereas the incidence of some types of neurotoxicity, disturbances in glucose metabolism, diarrhoea, pruritus and alopecia may be higher with tacrolimus treatment. Renal function, as assessed by serum creatinine levels and glomerular filtration rates, was better in tacrolimus than cyclosporin recipients at up to 5 years' follow-up.

CONCLUSION

Recent well designed trials have consolidated the place of tacrolimus as an important choice for primary immunosuppression in solid organ transplantation and in BMT. Notably, in adults and children receiving transplants, tacrolimus-based primary immunosuppression was at least as effective or provided better efficacy than cyclosporin microemulsion treatment in terms of patient and graft survival, treatment failure and the incidence of acute and corticosteroid-resistant rejection episodes. The reduced incidence of rejection episodes in renal transplant recipients receiving tacrolimus translated into a better cost effectiveness relative to cyclosporin microemulsion treatment. The optimal immunosuppression regimen is ultimately dependent on balancing such factors as the efficacy of the individual drugs, their tolerability, potential for drug interactions and pharmacoeconomic issues.

Early renal insufficiency and hospitalized heart disease after renal transplantation in the era of modern immunosuppression

Renal insufficiency has been identified as a risk factor for graft loss and death after renal transplantation but has not been consistently linked to early, nonfatal, hospitalized heart disease (HHD). With the United States Renal Data System database, 29,597 patients who received a kidney transplant between January 1, 1996, and July 31, 2000, with Medicare as the primary payer, and were monitored until December 31, 2000, were studied. Cox proportional-hazards regression models were used to calculate the association of recipient estimated GFR (eGFR) at 1 yr after renal transplantation, as determined with the Modification of Diet in Renal Disease formula, with hospitalization for treatment of acute coronary syndromes (ACS) (International Classification of Diseases, version 9, code 410.x or 411.x) or congestive heart failure (CHF) (code 428.x) 1 to 3 yr after renal transplantation. Rates of ACS and CHF were 2.2 and 4.9%, respectively, for patients with eGFR of <44.8 ml/min per 1.73 m(2), compared with 1.2 and 1.4% for patients with eGFR of >69.7 ml/min per 1.73 m(2). Reduced eGFR (<44.8 ml/min per 1.73 m(2), compared with >69.7 ml/min per 1.73 m(2)) at the end of the first 1 yr after transplantation was independently associated with increased risks of both ACS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.39 to 3.35) and CHF (adjusted hazard ratio, 2.95; 95% confidence interval, 2.24 to 3.90). It was concluded that early renal insufficiency (approximately stage 3 chronic kidney disease) was associated with higher rates of HHD 1 to 3 yr after kidney transplantation. Preservation of renal function after renal transplantation may reduce the rates of HHD, and renal transplant recipients with reduced eGFR should be considered at high risk of developing cardiovascular disease.

Hepatitis C and the incidence of diabetes mellitus after renal transplant: influence of new immunosuppression protocols

BACKGROUND

Hepatitis C has been associated with an increased incidence of diabetes mellitus (DM) following renal transplantation (RT).

METHODS

Patients who underwent RT between 1985 and 2001 were excluded if they showed DM prior to RT, graft survival of less than 90 days, and unknown anti-HCV status (n=15). Two groups (G1 and G2) were distinguished according to the immunosuppressive regimen: G1 (transplanted 1985-1996) received steroids, azathioprine, and cyclosporine (n=330), whereas G2 (1997-2000) received new drugs in several combinations (MMF in 87% and/or tacrolimus in 35% [n=240]). Patients with HCV antibodies pre- and/or post-RT were considered HCV-positive. Post-RT DM requiring prolonged treatment with oral antidiabetics or insulin (>1 month) was assessed using Kaplan-Meier curves and Cox analysis.

RESULTS

G2 patients were significantly older, had a greater body mass index (BMI), and suffered significantly less from acute rejection episodes during the first year than G1 patients. Furthermore, fewer required maintenance steroids. HCV-positivity was more common in G1 than in G2 (n=96, 29.1% vs n=27, 11.3%). Six G2 patients were successfully treated with interferon pre-RT, achieving negative PCR-HCV status (maintained post-RT). DM incidence at 4 years was similar in G1 and G2 (8.8% and 8.2%). G1 HCV-positive patients showed a greater risk of developing DM than HCV-negative patients (28.0% vs 6.2% at 10 years; P=001). In G1, multivariate analysis showed that age, BMI, and HCV-positivity were significant risk factors predicting DM (relative risk, 5.7; 95% confidence interval 2.7-12). In G2 patients, HCV was not associated with an increased risk of DM; in the multivariate analysis only age appeared to be a risk factor.

CONCLUSIONS

The reported relationship between hepatitis C and post-RT DM was not observed among patients receiving new immunosuppressive treatments. Confirmation of this finding requires extended follow up. The reduced use of steroids and effective pre-RT use of interferon may also be responsible for the benefit.

Determinants of insulin secretion after renal transplantation

The high prevalence of post-transplant glucose intolerance and insulin resistance (IR) is associated with older age, family history of diabetes, immunosuppressive drugs, and antihypertensive therapy. However, the potential determinants of post-transplant beta-cell dysfunction are largely unknown. The objective of the present study was to address this issue in detail. A total of 167 previously nondiabetic renal transplant recipients underwent a 75-g oral glucose tolerance test (OGTT)10 weeks after transplantation. Serum glucose and insulin were measured at 0, 1, and 2 hours. Three insulin release indices (Secr(AUC), Secr(1.phase), and Secr(2.phase)) were calculated to assess the insulin secretory response as the dependent variable. To account for variations in insulin sensitivity (IS), beta-cell function was also estimated as the disposition index (DI); the product of the IS index (ISI(TX)) and Secr(1.phase). Increasing age was strongly and independently associated with a blunted insulin secretory response even after adjustment for IS (P =.001). An 80-year-old recipient had an approximately 50% lower insulin release than a 20-year-old individual, based on the linear regression model. Cytomegalovirus (CMV) disease and treatment with furosemide were both independently associated with beta-cell dysfunction (DI; P <.001 and P =.008). Patients treated with angiotensin-converting enzyme (ACE)-inhibitors had an enhanced absolute insulin release, but the DI was similar in both treated and untreated recipients. We conclude that older age is an important determinant of beta-cell dysfunction after renal transplantation. CMV disease and treatment with furosemide may also negatively influence pancreatic insulin release in renal transplant recipients.

Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome after renal transplantation in the United States

BACKGROUND: The incidence and risk factors for diabetic ketoacidosis (diabetic ketoacidosis) and hyperglycemic hyperosmolar syndrome (hyperglycemic hyperosmolar syndrome, previously called non-ketotic hyperosmolar coma) have not been reported in a national population of renal transplant (renal transplantation) recipients. METHODS: We performed a historical cohort study of 39,628 renal transplantation recipients in the United States Renal Data System between 1 July 1994 and 30 June 1998, followed until 31 Dec 1999. Outcomes were hospitalizations for a primary diagnosis of diabetic ketoacidosis (ICD-9 code 250.1x) and hyperglycemic hyperosmolar syndrome (code 250.2x). Cox Regression analysis was used to calculate adjusted hazard ratios for time to hospitalization for diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome. RESULTS: The incidence of diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome were 33.2/1000 person years (PY) and 2.7/1000 PY respectively for recipients with a prior diagnosis of diabetes mellitus (DM), and 2.0/1000 PY and 1.1/1000 PY in patients without DM. In Cox Regression analysis, African Americans (AHR, 2.71, 95 %CI, 1.96-3.75), females, recipients of cadaver kidneys, patients age 33-44 (vs. >55), more recent year of transplant, and patients with maintenance TAC (tacrolimus, vs. cyclosporine) had significantly higher risk of diabetic ketoacidosis. However, the rate of diabetic ketoacidosis decreased more over time in TAC users than overall. Risk factors for hyperglycemic hyperosmolar syndrome were similar except for the significance of positive recipient hepatitis C serology and non-significance of female gender. Both diabetic ketoacidosis (AHR, 2.44, 95% CI, 2.10-2.85, p < 0.0001) and hyperglycemic hyperosmolar syndrome (AHR 1.87, 95% CI, 1.22-2.88, p = 0.004) were independently associated with increased mortality. CONCLUSIONS: We conclude that diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome were associated with increased risk of mortality and were not uncommon after renal transplantation. High-risk groups were identified.