251
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Driscoll CJ. Risk factors for posttransplant diabetes mellitus: a review of the literature. Prog Transplant 2008; 17:295-300; quiz 301. [PMID: 18240695 DOI: 10.1177/152692480701700407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The development of diabetes after solid organ transplantation is a known complication, and many published studies have examined prevalence rates and risk factors for specific categories of transplant recipients. However, fewer articles have compared rates of posttransplant diabetes and risk factors among different types of transplant recipients. This article provides an overview of the literature on this subject and compares similarities and differences related to posttransplant diabetes for different categories of organ transplant recipients. Awareness of the various risk factors for different organ transplant recipients will enhance transplant clinicians' knowledge related to this complication so that appropriate monitoring can be started.
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252
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Shirali AC, Bia MJ. Management of cardiovascular disease in renal transplant recipients. Clin J Am Soc Nephrol 2008; 3:491-504. [PMID: 18287250 PMCID: PMC6631091 DOI: 10.2215/cjn.05081107] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiovascular disease is a major cause of graft loss and the leading cause of death in renal transplant recipients. Although there are robust data on the frequency of risk factors and their contributions to cardiovascular disease in this population, few trials have demonstrated the benefit of modifying these risk factors to reduce cardiovascular events. Nevertheless, it is widely accepted that the clinical acumen filtered through the best available studies in the general population be used to treat individual renal transplant recipients given their high cardiovascular mortality. Transplant task forces and the Kidney Disease Outcomes Quality Initiative have created guidelines for this purpose. This review examines the data available for prevention and treatment of major risk factors contributing to cardiovascular disease in renal transplant recipients. The contribution of immunosuppressive agents to each risk factor and the evidence to support lifestyle modification as well as drug therapy are examined. Reducing cardiovascular risk factors requires an integrative approach that is best accomplished by a team of health care professionals. It creates a significant challenge but one that must be met if allograft survival is to improve.
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Affiliation(s)
- Anushree C Shirali
- Division of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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253
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Bloom RD, Crutchlow MF. New-onset diabetes mellitus in the kidney recipient: diagnosis and management strategies. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S38-48. [PMID: 18309002 PMCID: PMC3152270 DOI: 10.2215/cjn.02650707] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Advancing care has markedly improved survival after kidney transplantation, leaving patients susceptible to the effects of chronic transplant-associated morbidities. New-onset diabetes mellitus (NODM) is common in kidney recipients, threatening health and longevity by predisposing to microvascular and cardiovascular disease and by reducing graft survival. A strong rationale therefore exists for the aggressive treatment of NODM in kidney recipients to limit these complications. Screening for diabetes should be systematic and should span the pre- and posttransplantation periods. Once NODM is diagnosed in the kidney transplant patient, a comprehensive plan of therapy should be used to achieve treatment targets. As in the general population, treatment includes lifestyle modification and drug therapy as needed, but transplant-specific factors add complexity to the care of kidney recipients. Among these, minimizing immunosuppression-related toxicity without compromising graft outcomes is of paramount importance. Preexisting allograft functional impairment and the potential for significant interactions with immunosuppressive agents mandate that the expanding armamentarium of hypoglycemic agents be used with care. A team-oriented treatment approach that capitalizes on the collective expertise of transplant physicians, diabetologists, nurse-educators, and dieticians will optimize both glycemic control and the overall health of hyperglycemic kidney recipients.
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Affiliation(s)
- Roy D Bloom
- Renal Electrolyte and Hypertension Division, University of Pennsylvania, Founders Building, First Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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254
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Gill JS. Cardiovascular disease in transplant recipients: current and future treatment strategies. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S29-37. [PMID: 18309001 PMCID: PMC3152272 DOI: 10.2215/cjn.02690707] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A cardiovascular disease event in a transplant recipient may be the result of a pretransplantation disease process, a direct effect of immunosuppressant medications, or the result of exposure to a variety of traditional and nontraditional risk factors after transplantation. Although the understanding of posttransplantation cardiovascular disease remains incomplete, there is evidence that the impact of posttransplantation cardiovascular disease has been decreased, through increased attention to this problem. In the absence of controlled studies to guide therapy, this review summarizes treatment of cardiovascular disease risk factors for which there is strong evidence of benefit in the nontransplantation setting, observational evidence of a similar risk in transplant recipients, and evidence that treatment can be safely administered to transplant recipients. Putative risk factors for posttransplantation cardiovascular disease for which the current level of evidence is insufficient to support specific treatment recommendations are also discussed. Potential new strategies to decrease the risk for cardiovascular disease events after transplantation in the future, including aggressive pretransplantation risk reduction, individualized treatments to prevent different types of cardiovascular disease, dedicated efforts to reduce cardiovascular disease events during transitions between dialysis and transplantation, and manipulation of immunosuppressant protocols, are also introduced.
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Affiliation(s)
- John S Gill
- Division of Nephrology, University of British Columbia, St. Paul's Hospital, Providence Building, Ward 6a, 1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
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255
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Risk Profile for Cardiovascular Morbidity and Mortality After Lung Transplantation. Nurs Clin North Am 2008; 43:37-53; vi. [DOI: 10.1016/j.cnur.2007.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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256
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Krämer BK, Del Castillo D, Margreiter R, Sperschneider H, Olbricht CJ, Ortuño J, Sester U, Kunzendorf U, Dietl KH, Bonomini V, Rigotti P, Ronco C, Tabernero JM, Rivero M, Banas B, Mühlbacher F, Arias M, Montagnino G. Efficacy and safety of tacrolimus compared with ciclosporin A in renal transplantation: three-year observational results. Nephrol Dial Transplant 2008; 23:2386-92. [PMID: 18258740 DOI: 10.1093/ndt/gfn004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The European tacrolimus versus ciclosporin A microemulsion (CsA-ME) renal transplantation study showed that tacrolimus was significantly more effective in preventing acute rejection and had a superior cardiovascular risk profile at 6 months. METHODS The endpoints of this investigator-initiated, observational, 36-month follow-up were acute rejection incidence rates, rates of patient and graft survival and renal function. An additional analysis was performed using the combined endpoints BPAR, graft loss and patient death. Data available from the original ITT population (557 patients; 286 tacrolimus and 271 CsA-ME) were analysed. RESULTS A total of 231 tacrolimus and 217 CsA-ME patients participated. At 36 months, Kaplan-Meier-estimated BPAR-free survival rates were 78.8% in the tacrolimus group and 60.6% in the CsA-ME group, graft survival rates were 88.0% and 86.9% and patient survival rates were 96.6% and 96.7%, respectively. The estimated combined endpoint-free survival rate was 71.4% with tacrolimus and 55.4% with CsA-ME (P <or= 0.001, chi-square test). Significantly more CsA-ME patients crossed over to tacrolimus during the 3-year follow-up: 21.2% versus 2.6%, P <or= 0.0001, chi-square test. Most patients in the tacrolimus arm discontinued steroids and received monotherapy and fewer tacrolimus patients remained on a triple regimen. Mean serum creatinine concentration was 145.4 +/- 90.9 micromol/L with tacrolimus and 149.0 +/- 92.1 micromol/L with CsA-ME. Significantly more CsA-ME patients had a classified cholesterol value >6 mmol/L (26.3% versus 12.6%, P <or= 0.0003, chi-square test). CONCLUSIONS Patients treated with tacrolimus had significantly higher combined endpoint-free survival rates and lower acute rejection rates with less immunosuppressive medication at 36 months.
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Affiliation(s)
- Bernhard K Krämer
- Klinik und Poliklinik für Innere Medizin II--Nephrologie, Klinikum der Universität Regensburg, Germany.
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257
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Roland M, Gatault P, Doute C, Büchler M, Al-Najjar A, Barbet C, Chatelet V, Marlière JF, Nivet H, Lebranchu Y, Halimi JM. Immunosuppressive medications, clinical and metabolic parameters in new-onset diabetes mellitus after kidney transplantation. Transpl Int 2008; 21:523-30. [PMID: 18266773 DOI: 10.1111/j.1432-2277.2008.00640.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
New-onset diabetes after transplantation (NODAT) is a growing concern in transplantation. All modifiable risk factors are not yet identified. We assessed the relationship between baseline clinical and biochemical parameters and NODAT. Eight-hundred and fifty-seven in-Caucasian renal transplant recipients were included. Charts were individually reviewed. The follow-up was 5.3 years (ranges: 0.25-20.8; 5613 patient-years). The incidence of NODAT was 15.0%, 18.4% and 22.0% at 10, 15 and 20 years following transplantation. Age, body mass index (BMI), glucose (all P < 0.0001) and triglycerides [hazard ratio (HR) per 1 mmol/l: 1.44 [1.17-1.77], P = 0.0006] were potent risk factors whereas steroid withdrawal (HR: 0.69 [0.47-1.01], P = 0.0601) reduced the risk. As compared to cyclosporine, sirolimus (HR: 3.26 [1.63-6.49], P = 0.0008) and tacrolimus (HR: 3.04 [2.02-4.59], P < 0.0001) were risk factors for NODAT. The risk of NODAT was comparable for sirolimus (HR: 2.35 [1.06-5.19], P = 0.0350) and tacrolimus (HR: 2.34 [1.46-3.75], P = 0.0004) after adjustments on age, BMI, glucose and steroid withdrawal; however, unlike sirolimus, tacrolimus remained significant after adjustment on triglycerides. The risk of NODAT appeared similar, but its pathophysiology seemed different in sirolimus- and tacrolimus-treated patients; this observation needs confirmation. However, main independent risk factors were age, BMI, initial glucose and triglycerides.
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Affiliation(s)
- Mélanie Roland
- Service de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, CHRU Tours, Tours, France
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258
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Reduced incidence of new-onset posttransplantation diabetes mellitus during the last decade. Transplantation 2008; 84:1125-30. [PMID: 17998867 DOI: 10.1097/01.tp.0000287191.45032.38] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND A previous study (1995-1996) of 173 nondiabetic renal transplant recipients (historical cohort; HC) revealed a 20% incidence of new-onset posttransplantation diabetes mellitus (PTDM) and 32% with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). We examined whether glucose tolerance has improved after recent changes in our immunosuppressive protocol and a switch from deferred to preemptive cytomegalovirus (CMV) therapy. METHODS A total of 321 consecutive, nondiabetic patients (new cohort; NC) were examined 10 weeks after kidney transplantation with an oral glucose tolerance test (n=301) between January 2004 and December 2005. RESULTS Although recipients in the NC were on average 3 years older [mean (SD): 50.3 (14.6) vs. 47.4 (16.0), P=0.038] and had a higher mean body mass index [24.5 (3.6) vs. 23.5 (3.8) kg/m(2), P=0.003], a significantly lower incidence of both PTDM (13%) and IGT/IFG (18%) was observed in the NC (P<0.001) as compared to the HC. The patients in the NC received a significantly lower mean daily oral prednisolone dose [13.2 (4.7) vs. 15.3 (6.6) mg/day, P<0.001], and had lower frequencies of rejections (36% vs. 57%, P<0.001) and CMV infection (54% vs. 63%, P=0.071). Patients in the NC had significantly lower odds of developing PTDM, even after adjustment for age, prednisolone dose, HLA-B27 status and CMV infection (odds ratio: 0.42, 95% CI: 0.23-0.77, P=0.005). CONCLUSIONS The odds of developing PTDM are more than halved over the last decade. Possible explanations are changes in immunosuppressive therapy, fewer rejections, and lower doses of steroids.
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259
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Pham PTT, Pham PCT, Lipshutz GS, Wilkinson AH. New onset diabetes mellitus after solid organ transplantation. Endocrinol Metab Clin North Am 2007; 36:873-90; vii. [PMID: 17983926 DOI: 10.1016/j.ecl.2007.07.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Phuong-Thu T Pham
- Kidney and Pancreas Transplantation, Department of Medicine, University of California, Los Angeles, CA 90095-1693, USA
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260
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Goldberg PA. Comprehensive management of post-transplant diabetes mellitus: from intensive care to home care. Endocrinol Metab Clin North Am 2007; 36:907-22; viii. [PMID: 17983928 DOI: 10.1016/j.ecl.2007.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Philip A Goldberg
- Department of Internal Medicine, Section of Endocrinology and Metabolism, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
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261
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Subramanian S, Trence DL. Immunosuppressive agents: effects on glucose and lipid metabolism. Endocrinol Metab Clin North Am 2007; 36:891-905; vii. [PMID: 17983927 DOI: 10.1016/j.ecl.2007.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Immunosuppressive therapies are critical elements in successful organ transplantation. Although immunosuppressant drugs are essential in preventing graft rejection and graft maintenance after transplantation, their use is complicated by adverse effects, many being detrimental to graft and even patient long-term survival. Commonly used agents are associated with dysregulated glucose metabolism and dyslipidemia. This article focuses on the effects of immunosuppressive agents on glucose and lipid metabolism. Adrenal effects of these drugs, where known, also are discussed.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Box 356426, 1959 NE Pacific Street, Seattle, WA 98195, USA
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262
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Abstract
Liver allograft recipients are at increased risk of death from cerebrovascular and cardiovascular disease. We propose the following strategy of risk-reduction, based on currently available literature. Lifestyle: standard advice should be given (avoidance of smoking, excess alcohol and obesity, adequate exercise, reduction of excess sodium intake). Hypertension: target blood pressure should be 140/90 mmHg or lower, but for those with diabetes or renal disease, 130/80 mmHg or lower. For patients without proteinuria, antihypertensive therapy should be initiated with a calcium channel blocker and for those with proteinuria, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. If monotherapy fails to achieve adequate response, calcium channel blockers and ACE-inhibitors or angiotensin II receptor blockers should be combined. If hypertension remains uncontrolled, an alpha-blocker may be added. Consideration should be given to changing immunosuppression and avoiding use of calcineurin inhibitors. Diabetes: recipients should be regularly screened for diabetes. For patients with new-onset diabetes after transplant, stepwise therapy should be guided by HbA1c concentrations, as with type II diabetes mellitus. Hyperlipidemia: annual screening of lipid profile should be undertaken, with treatment thresholds and targets based on those advocated for the high risk general population. Dietary intervention is appropriate for all patients. A statin should be considered as the first line treatment to achieve specified targets. In patients receiving a calcineurin inhibitor, Pravastatin should be commenced at a dose of 10 mg/day. In patients receiving other forms of immunosuppression, pravastatin may be commenced at a dose of 20 mg/day. Liver tests should be monitored and patients warned to report myalgia. If monotherapy is inadequate, ezetimibe or a fibrate may be added. Consideration may be given to change in immunosuppression if combination lipid-lowering therapy proves inadequate.
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Affiliation(s)
- George Mells
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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263
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Vincenti F, Friman S, Scheuermann E, Rostaing L, Jenssen T, Campistol JM, Uchida K, Pescovitz MD, Marchetti P, Tuncer M, Citterio F, Wiecek A, Chadban S, El-Shahawy M, Budde K, Goto N. Results of an international, randomized trial comparing glucose metabolism disorders and outcome with cyclosporine versus tacrolimus. Am J Transplant 2007; 7:1506-14. [PMID: 17359512 DOI: 10.1111/j.1600-6143.2007.01749.x] [Citation(s) in RCA: 439] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
DIRECT (Diabetes Incidence after Renal Transplantation: Neoral C(2) Monitoring Versus Tacrolimus) was a 6-month, open-label, randomized, multicenter study which used American Diabetes Association/World Health Organization criteria to define glucose abnormalities. De novo renal transplant patients were randomized to cyclosporine microemulsion (CsA-ME, using C(2) monitoring) or tacrolimus, with mycophenolic acid, steroids and basiliximab. The intent-to-treat population comprised 682 patients (336 CsA-ME, 346 tacrolimus): 567 were nondiabetic at baseline. Demographics, diabetes risk factors and steroid doses were similar between treatment groups. The primary safety endpoint, new-onset diabetes after transplant (NODAT) or impaired fasting glucose (IFG) at 6 months, occurred in 73 CsA-ME patients (26.0%) and 96 tacrolimus patients (33.6%, p = 0.046). The primary efficacy endpoint, biopsy-proven acute rejection, graft loss or death at 6 months, occurred in 43 CsA-ME patients (12.8%) and 34 tacrolimus patients (9.8%, p = 0.211). Mean glomerular filtration rate (Cockcroft-Gault) was 63.6 +/- 20.7 mL/min/1.73 m(2) in the CsA-ME cohort and 65.9 +/- 23.1 mL/min/1.73 m(2) with tacrolimus (p = 0.285); mean serum creatinine was 139 +/- 58 and 133 +/- 57 mumol/L, respectively (p = 0.005). Blood pressure was similar between treatment groups at month 6, but total cholesterol, LDL-cholesterol and triglyceride levels were significantly higher with CsA than with tacrolimus (total cholesterol:HDL remained unchanged). The profile and incidence of adverse events were similar between treatments. The incidence of NODAT or IFG at 6 months post-transplant is significantly lower with CsA-ME than with tacrolimus without a significant difference in short-term outcome.
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Affiliation(s)
- F Vincenti
- University of California San Francisco Kidney Transplant Service, San Francisco, CA, USA.
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264
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Moench C, Barreiros AP, Schuchmann M, Bittinger F, Thiesen J, Hommel G, Kraemer I, Otto G. Tacrolimus monotherapy without steroids after liver transplantation--a prospective randomized double-blinded placebo-controlled trial. Am J Transplant 2007; 7:1616-23. [PMID: 17511685 DOI: 10.1111/j.1600-6143.2007.01804.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Early steroid withdrawal after liver transplantation (LT) is desirable in order to reduce steroid side effects. Between February 2000 and August 2004, 110 patients after LT were included in this prospective, randomized, double-blind, placebo-controlled trial. Randomization was performed before LT. In all patients, tacrolimus was used without induction therapy. All patients received methylprednisolon for 14 days, thereafter a double-blinded medication containing either placebo (n = 56) or methylprednisolon (n = 54) for 6 months, which was completely stopped thereafter. End points were patient and graft survival, acute and chronic rejection, and incidence of steroid side effects during the first year after LT. One-year patient survival was 85.7% (placebo) and 88.8% (steroid) (p = 0.572). Twenty-seven (48.2%) and 19 (35.2%) patients experienced acute rejection (placebo versus steroid, respectively; p = 0.116). Two patients in the placebo group but none in the steroid group experienced chronic rejection (p = 0.257). The rates of side effects were (placebo versus steroid, respectively): CMV infection 25% versus 33% (p = 0.336), post-transplant diabetes 30% versus 53% (p = 0.024), hypertension 39% versus 52% (p = 0.248), hypercholesterolemia 10% versus 41% (p = 0.002) and hypertriglyceridemia 32% versus 54% (p = 0.046). In conclusion, early steroid withdrawal after LT is feasible under tacrolimus monotherapy without increased rejection rates and with a lower rate of side effects.
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Affiliation(s)
- C Moench
- Department of Transplantation and Hepatobiliarypancreatic Surgery, Johannes Gutenberg University Mainz Hospital, Mainz, Germany.
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265
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Burroughs TE, Swindle J, Takemoto S, Lentine KL, Machnicki G, Irish WD, Brennan DC, Schnitzler MA. Diabetic Complications Associated With New-Onset Diabetes Mellitus in Renal Transplant Recipients. Transplantation 2007; 83:1027-34. [PMID: 17452891 DOI: 10.1097/01.tp.0000259617.21741.95] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Data are scarce regarding the incidence and risk factors for complications of new-onset diabetes mellitus (NODM) in renal transplant patients. METHODS United States Renal Data System (USRDS) data from primary renal transplant recipients during 1995-2001 who developed NODM was used to examine diabetic complications over the first three years posttransplant. Prognostic models were used to evaluate patient characteristics and treatment choices associated with risk of each class of complications. Propensity scores for choice of calcineurin inhibitor were included in multivariate analyses. RESULTS The analysis included 21,489 patients, of whom 4,105 developed NODM by 3 years posttransplant. One or more NODM complications developed in 2,393 patients (58.3% of all patients with NODM), comprising ketoacidosis (334, 8.1%), hyperosmolarity (131, 3.2%), renal complications (1,286, 31.3%), ophthalmic complications (340, 8.3%), neurological complications (665, 16.2%), peripheral circulatory disorders (170, 4.1%) and hypoglycemia/shock (301, 7.3%). Complications developed within a mean of 500 to 600 days from diagnosis of NODM. Multivariate analysis showed that increased recipient age, higher body mass index, African-American race, hepatitis C infection, hypertension as cause of end-stage renal disease, cold ischemia >or=30 hours, and use of tacrolimus each increased risk of complications. CONCLUSION NODM is associated with similar complications to those seen in the general population, but these appear to develop at an accelerated rate. Obesity and use of tacrolimus are the only modifiable factors that appear to affect risk of NODM or its complications.
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Affiliation(s)
- Thomas E Burroughs
- Center for Outcomes Research, Department of Internal Medicine, Saint Louis University, St. Louis, MO 63104, USA.
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266
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Abstract
New-onset diabetes after transplantation is a serious complication of organ transplantation that is becoming increasingly more common. New-onset diabetes after transplantation has implications for graft and patient survival. This article reviews the pathogenesis, diagnosis and management of new-onset diabetes after transplantation.
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Affiliation(s)
- David C Wheeler
- Centre for Nephrology, Royal Free and University College Medical School, London
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267
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Burroughs TE, Lentine KL, Takemoto SK, Swindle J, Machnicki G, Hardinger K, Brennan DC, Irish WD, Schnitzler MA. Influence of early posttransplantation prednisone and calcineurin inhibitor dosages on the incidence of new-onset diabetes. Clin J Am Soc Nephrol 2007; 2:517-23. [PMID: 17699459 DOI: 10.2215/cjn.00620206] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Risk for new-onset diabetes (NOD) after renal transplantation is higher with tacrolimus (Tac) than with cyclosporine (CsA), but the extent to which the diabetogenic effect of Tac is dosage dependent or steroid dependent remains uncertain. Patients who received a transplant between 1995 and 2002 were drawn from the United Network for Organ Sharing registry and prescription records and NOD diagnoses from Medicare claims, both provided by the United States Renal Data System. Patients were divided into six groups of steroid and Tac doses at 30 d after transplantation and referenced against CsA. Relative hazards of NOD with Cox proportional hazards regression were estimated incorporating propensity scores for Tac and nonimmunosuppressive factors related to NOD. A total of 8839 patients with valid immunosuppression records and without pretransplantation evidence of diabetes were included in the study. Unadjusted, cumulative, NOD incidence 1 yr after transplantation was 14.6% with CsA and 22.2% with Tac and at 3 yr after transplantation was 23.4% with CsA and 32.9% with Tac (P < 0.0001). Neither higher CsA nor higher steroid dosages were associated with NOD in CsA-treated patients. However, NOD hazard was significantly higher with Tac than with CsA in all six steroid/Tac dosing groups, including the cohort with the lowest dosages of Tac (dosage thresholds at 30 d after transplantation <0.12 mg/kg per d [mean 0.07 mg/kg per d] and steroids (<0.75 mg/kg per d; hazard ratio 1.28; 95% confidence interval 1.10 to 1.48; P = 0.0012). Whereas the incidence of NOD is greatest with high Tac dosages, the increased risk versus CsA is sustained with lower Tac dosages. Higher steroid dosages increase the early diabetogenic effect of Tac but not of CsA.
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Affiliation(s)
- Thomas E Burroughs
- Center for Outcomes Research, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA.
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268
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Dumler F, Kilates C. Metabolic and nutritional complications of renal transplantation. J Ren Nutr 2007; 17:97-102. [PMID: 17198943 DOI: 10.1053/j.jrn.2006.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Renal transplantation is the gold standard therapy for patients with end-stage renal disease. However, renal transplantation is associated with various metabolic and nutritional complications. This review focuses primarily on factors that have a significant impact on cardiovascular disease, namely, hyperlipidemia, posttransplant diabetes mellitus, and hyperhomocysteinemia. The prevalence of hyperlipidemia in renal transplant patients is estimated at 80% to 90%. Corticosteroids, cyclosporine, and sirolimus are commonly associated with hyperlipidemia. The incidence of posttransplant diabetes mellitus is estimated to be 24% at 36 months post transplant. Glucocorticoids induce metabolic changes that result in hyperglycemia. Calcineurin inhibitors have direct islet cell toxicity and induced alterations in the transcriptional regulation of insulin. Hyperhomocysteinemia is common in renal transplant recipients and is an independent risk factor for cardiovascular disease.
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Affiliation(s)
- Francis Dumler
- Division of Nephrology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA.
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269
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Hur KY, Kim MS, Kim YS, Kang ES, Nam JH, Kim SH, Nam CM, Ahn CW, Cha BS, Kim SI, Lee HC. Risk factors associated with the onset and progression of posttransplantation diabetes in renal allograft recipients. Diabetes Care 2007; 30:609-15. [PMID: 17327329 DOI: 10.2337/dc06-1277] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to assess the incidence of posttransplantation diabetes mellitus (PTDM) in renal allograft recipients and to investigate factors contributing to the onset and progression of PTDM and its underlying pathogenic mechanism(s). RESEARCH DESIGN AND METHODS A total of 77 patients with normal glucose tolerance (NGT) were enrolled in this study. An oral glucose tolerance test was performed 1 week before transplantation and repeated at 1 and 7 years after transplantation. RESULTS The overall incidence of PTDM was 39% at 1 year and 35.1% at 7 years posttransplantation. The incidence for each category of PTDM was as follows: persistent PTDM (P-PTDM) (patients who developed diabetes mellitus within 1 year of transplantation and remained diabetic during 7 years), 23.4%; transient PTDM (T-PTDM) (patients who developed diabetes mellitus during the 1st year after transplantation but eventually recovered to have NGT), 15.6%; late PTDM (L-PTDM) (patients who developed diabetes mellitus later than 1 year after transplantation), 11.7%; and non-PTDM during 7 years (N-PTDM7) (patients who did not develop diabetes mellitus during 7 years), 49.3%. Older age (> or = 40 years) at transplantation was a higher risk factor for P-PTDM, whereas a high BMI (> or = 25 kg/m2) and impaired fasting glucose (IFG) at 1 year posttransplantation were higher risk factors for L-PTDM. Impaired insulin secretion rather than insulin resistance was significantly associated with the development of P- and L-PTDM. CONCLUSIONS Impaired insulin secretion may be the main mechanism for the development of PTDM. Older age at transplantation seems to be associated with P-PTDM, whereas a high BMI and IFG at 1 year after transplantation were associated with L-PTDM.
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Affiliation(s)
- Kyu Yeon Hur
- Department of Internal Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong Seodaemun-Gu, Seoul, 120-752, Korea
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270
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271
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Crutchlow MF, Bloom RD. Transplant-associated hyperglycemia: a new look at an old problem. Clin J Am Soc Nephrol 2007; 2:343-55. [PMID: 17699434 DOI: 10.2215/cjn.03671106] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
New-onset diabetes has long been recognized as a common complication of kidney transplantation, promoting cardiovascular disease, death, and graft failure. Studies in recent years have begun to highlight the very high posttransplantation prevalence of the prediabetic states of impaired fasting glucose and impaired glucose tolerance and the significant repercussions of these states on cardiovascular health. Therefore, the overall burden of transplant-associated hyperglycemia (TAH), which encompasses new-onset diabetes and the prediabetic states, is far greater than previously appreciated. The kidney transplant population is predisposed to insulin resistance and to additional insults of hypertension and hyperlipidemia that, together with hyperglycemia, compose the metabolic syndrome and promote atherosclerosis. When recipients with an underlying, frequently nonmodifiable predisposition to glucose dysregulation encounter transplant-specific, often modifiable, diabetogenic exposures, TAH manifests. Aggressive screening will effectively detect TAH, whereas risk factor modification, lifestyle intervention, and, when appropriate, drug therapy may decrease its impact. Topics of future investigation should include the use of emerging diabetes therapies and avenues for the prevention and reversal of TAH.
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Affiliation(s)
- Michael F Crutchlow
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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272
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Bayés B, Granada ML, Pastor MC, Lauzurica R, Salinas I, Sanmartí A, Espinal A, Serra A, Navarro M, Bonal J, Romero R. Obesity, adiponectin and inflammation as predictors of new-onset diabetes mellitus after kidney transplantation. Am J Transplant 2007; 7:416-22. [PMID: 17229078 DOI: 10.1111/j.1600-6143.2006.01646.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The high incidence of new-onset diabetes mellitus after transplantation (NODAT) suggests the need to find new factors to explain the pathogenesis. Our objectives were (1) to confirm that low levels of pre-transplant adiponectin are an independent risk factor for the development of NODAT in a larger transplanted population; (2) to analyze whether adiponectin is a better predictor of NODAT than other inflammatory markers (C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) and pregnancy-associated plasma protein A (PAPP-A)) and (3) to assess the relationship between obesity, inflammatory markers and NODAT. One hundred ninety-nine non-diabetic patients (128 men; age: 53 +/- 11 years; body mass index (BMI) 24.98 +/- 3.76 kg/m2) were included. Pre-transplant plasma glucose, insulin, adiponectin, CRP, TNF-alpha, IL-6 and PAPP-A were measured. Forty-five patients developed NODAT. Patients with NODAT had a greater BMI (p = 0.005). Adiponectin was lower (p < 0.001) and CRP higher (p = 0.032) in patients with NODAT. Multivariate logistic regression and Cox analysis showed that the calcineurin inhibitor used, pre-transplant BMI and adiponectin were predictors of NODAT. ROC analysis showed that an adiponectin concentration of 11.4 microg/mL had a significant negative prediction for NODAT risk (sensitivity: 81% and specificity: 70%). Of the inflammatory markers studied, adiponectin proved to be an independent predictor of NODAT.
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Affiliation(s)
- B Bayés
- Nephrology Department, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona (Barcelona), Spain.
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273
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Affiliation(s)
- Matthew Jose
- Department of Nephrology, Royal Hobart Hospital, Hobart TAS 7000, Australia.
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274
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Abstract
The clinical impact of new-onset diabetes mellitus (NODM) is frequently underestimated by clinicians. NODM occurs in approximately 15-20% of renal transplant patients and 15% of liver transplant recipients. Diabetes after transplantation is a leading risk factor for cardiovascular events, with a higher prognostic value than in the non-transplant population. NODM also appears to have a negative influence on graft function, and graft survival rates after renal transplantation are significantly lower in patients who develop diabetes than in controls. Patient mortality following renal transplantation is generally found to be higher in patients with NODM, due to increased cardiovascular and peripheral vascular disease, accelerated graft deterioration and diabetes-related complications, notably infection. A renal registry analysis has reported an increase of 87% in risk of death following onset of NODM. There is also limited evidence that NODM is associated with increased risk of death in liver transplant patients. The relative incidence and severity of diabetic complications in transplant recipients have not been assessed rigorously in a clinical trial but registry data indicate that 20% of renal transplant patients with NODM experience at least one clinically significant diabetic complication within three years. Financially, the additional healthcare costs incurred over the first two years following onset of NODM amount to 21,500 dollars. Routine pre-transplant assessment of diabetic risk, with requisite modification of lifestyle, glycaemic monitoring and immunosuppressive regimens, and coupled with standardized, aggressive hypoglycaemic management as necessary, offers an important opportunity to alleviate the burden of NODM for transplant patients.
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Affiliation(s)
- Richard Moore
- Renal Unit, University Hospital of Wales, Cardiff, UK.
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275
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Navas de Solís MS, Merino Torres JF, Mascarell Martínez I, Piñón Sellés F. Importancia del trasplante pulmonar en la aparición de diabetes mellitus en pacientes adultos con fibrosis quística. Arch Bronconeumol 2007. [DOI: 10.1157/13098419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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276
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Cosio FG, Amer H, Grande JP, Larson TS, Stegall MD, Griffin MD. Comparison of Low Versus High Tacrolimus Levels in Kidney Transplantation: Assessment of Efficacy by Protocol Biopsies. Transplantation 2007; 83:411-6. [PMID: 17318073 DOI: 10.1097/01.tp.0000251807.72246.7d] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of calcineurin inhibitors is generally guided by drug blood levels. However, those levels are chosen based on clinical experience, lacking adequate titration studies. METHODS In these analyses, we compared clinical and histologic endpoints in two groups of kidney transplant recipients: in the first (HiTAC, January 2000 to June 2002, n=245) tacrolimus levels were significantly higher than in the second (LoTAC, July 2002 to September 2004, n=330). This change in drug levels (15% reduction) was made in an attempt to reduce the incidence of polyoma virus nephropathy (PVAN). Other immunosuppressive medications were unchanged during these two time periods. RESULTS The recipient and donor demographics were not statistically different between the two groups. Compared to HiTAC, at one year posttransplant LoTAC had: 1) lower incidence of PVAN (10.5% vs. 2.5%, P<0.0001); 2) lower fasting glucose levels; 3) higher iothalamate glomerular filtration rate (52+/-19 vs. 59+/-17 ml/min/m, P<0.0001); and 4) on protocol one-year biopsies, lower incidence and severity of interstitial fibrosis (67% vs. 45%, P=0.003) and tubular atrophy (82% vs., 66%, P=0.01). The incidence and severity of acute rejection episodes was similar between both groups (7.8% versus 7.6%). CONCLUSIONS Modest reductions in tacrolimus exposure early posttransplant are associated with significant beneficial effects for the patient and the allograft without an increased immunologic risk.
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Affiliation(s)
- Fernando G Cosio
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
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277
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Navas de Solís MS, Merino Torres JF, Martínez IM, Sellés FP. Lung Transplantation and the Development of Diabetes Mellitus in Adult Patients With Cystic Fibrosis. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1579-2129(07)60029-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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278
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González-Posada JM, Hernández D, Genís BB, Tamajón LP, Pérez JG, Maceira B, Sánchez MR, Serón D. Increased cardiovascular risk profile and mortality in kidney allograft recipients with post-transplant diabetes mellitus in Spain. Clin Transplant 2007; 20:650-8. [PMID: 16968493 DOI: 10.1111/j.1399-0012.2006.00532.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is associated with poorer outcomes in kidney transplantation (KT) but little information exists about the evolution of traditional cardiovascular risk (CVR) factors under this disorder. METHODS We retrospectively analysed CVR factors at 3, 12 and 24 months of follow-up and mortality at three yr in 3365 KT performed in Spain during the years 1990, 1994 and 1998 with a functioning graft after the first year. Three groups were considered: (i) (PTDM, n, 251), (ii) diabetes mellitus as primary disease (DM, n = 156) and (iii) the remaining patients (controls, n = 2958). RESULTS Recipient age, weight and body mass index (BMI) were higher in PTDM than in the other groups (p < 0.0001), with a lower increase of body weight during follow-up (p < 0.003). PTDM patients showed higher total-cholesterol levels than controls at one (p < 0.01) and two yr (p < 0.0009), and higher triglyceride levels than the other groups during follow-up (p < 0.002). Compared with Controls, PTDM patients had significantly higher systolic blood pressure at one (p < 0.001) and two yr (p < 0.005). Diastolic blood pressure was higher in PTDM and controls (p < 0.001), while pulse pressure was higher in PTDM and DM patients (p < 0.0001) during follow-up. Using Cox proportional hazards analysis, PTDM correlated with total mortality (RR = 1.55; range 1.05-2.3; p < 0.02) but not with cardiovascular mortality. CONCLUSIONS In Spanish KT recipients with graft function after one yr, PTDM is associated with a worse traditional CVR profile and a higher overall mortality. Although short-term cardiovascular mortality remains similar, better control of CVR factors is mandatory to prevent long-term cardiovascular mortality inherent to this population.
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279
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Tedesco-Silva H, Vitko S, Pascual J, Eris J, Magee JC, Whelchel J, Civati G, Campbell S, Alves-Filho G, Bourbigot B, Garcia VD, Leone J, Esmeraldo R, Rigotti P, Cambi V, Haas T. 12-month safety and efficacy of everolimus with reduced exposure cyclosporine in de novo renal transplant recipients. Transpl Int 2007; 20:27-36. [PMID: 17181650 DOI: 10.1111/j.1432-2277.2006.00414.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The proliferation signal inhibitor everolimus (Certican), has demonstrated efficacy with full-dose cyclosporine (CsA) (Neoral). Two multicenter randomized controlled studies were performed to compare 12-month efficacy and safety of everolimus 1.5 and 3.0 mg/day with reduced-dose CsA. Study 1 enrolled 237 de novo renal allograft recipients, randomizing 222 nonblack patients to either everolimus 1.5 or 3.0 mg/day, with the Neoral) dose guided by C(2) (monitoring of CsA concentration 2 h after dosing). Study 2 had a similar protocol, with basiliximab included, enrolling 256 recipients and randomizing 243 nonblack patients. In Study 1, there was a lower incidence of acute rejection in nonblack patients on 3 mg/day (16.4%) compared with 1.5 mg/day (25.9%), P = 0.08. In Study 2, the inclusion of basiliximab lowered the overall incidence of acute rejection; 14.3% of nonblack patients (3 mg/day) and 13.6% of nonblack patients (1.5 mg/day) had acute rejection by 12 months (P =0.891). Renal function was preserved throughout the study, with no differences observed between groups within studies. Everolimus was well tolerated with no significant differences between doses. Everolimus, in combination with reduced-dose Neoral), demonstrated efficacy and was well tolerated. Basiliximab allows for utilization of lower doses of everolimus with reduced dosing of Neoral).
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280
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Saliba F, Lakehal M, Pageaux GP, Roche B, Vanlemmens C, Duvoux C, Dumortier J, Salamé E, Calmus Y, Maugendre D. Risk factors for new-onset diabetes mellitus following liver transplantation and impact of hepatitis C infection : an observational multicenter study. Liver Transpl 2007; 13:136-44. [PMID: 17192854 DOI: 10.1002/lt.21010] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
New-onset diabetes mellitus (NODM) remains a common complication of liver transplantation (LT). We studied incidence and risk factors in 211 French patients who had undergone a primary LT between 6 and 24 months previously. This is a cross-sectional and retrospective multicenter study. Data were collected on consecutive patients at a single routine post-LT consultation. Demographic details, immunosuppressive regimens, familial and personal histories, hepatitis status, and cardiovascular risk were analyzed to compare those who developed NODM (American Diabetes Association/World Health Organization criteria) with the others. The overall incidence of NODM was 22.7%: 24% in tacrolimus (Tac)-treated patients (n = 175; 82.9%) and 16.7% in cyclosporine-treated patients (n = 36; 17.1%). A total of 81% of the cases were diagnosed within 3 months of LT (M3). Among hepatitis C virus (HCV)-infected (HCV(+)) patients, NODM incidence was 41.7% whereas among those patients negative for this virus (HCV(-)), the incidence was only 18.9% (P = 0.008). In Tac-treated patients, the incidence of NODM in the HCV(+) patients was significantly higher than in the HCV(-) patients (46.7% and 19.3%, respectively, P = 0.0014). Only 1 of 6 (16.7%) of the HCV(+) patients developed NODM on cyclosporine. Other independent pretransplantation risk factors for NODM included impaired fasting glucose (IFG) and a maximum lifetime body-mass index (BMI) over 25 kg/m2. In conclusion, emergence of NODM after LT is related to risk factors that can be detected prior to the graft, like maximum lifetime BMI, IFG, and HCV status. Tac induced a significantly higher incidence of NODM in the HCV(+) compared to the HCV(-) patients. The treatment should therefore be tailored to the patient's risk especially in case of HCV infection.
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Affiliation(s)
- Faouzi Saliba
- Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Centre hépato-biliaire, Villejuif, France.
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281
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Mathier MA, Murali S. Cardiac Transplantation and Circulatory Support Devices. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50024-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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282
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de Solís MSN, Torres JFM, Martínez IM, Sellés FP. Lung Transplantation and the Development of Diabetes Mellitus in Adult Patients With Cystic Fibrosis. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1579-2129(07)60035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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283
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Hor T, Baldwin D. Urinary albumin excretion in patients with diabetes after renal transplantation. Transplant Proc 2006; 38:2879-82. [PMID: 17112854 DOI: 10.1016/j.transproceed.2006.08.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many studies support microalbuminuria screening as the cornerstone of early detection of nephropathy in patients with diabetes mellitus (DM), but there are no studies that address its utility in the follow-up of renal transplant recipients with DM. MATERIALS AND METHODS We retrospectively studied 104 subjects with DM who had undergone renal transplantation. Sixty three had a history of preexisting DM and 41 developed posttransplant diabetes (PTDM). We collected data on random urine albumin/creatinine (A/C) ratio, systolic blood pressure (SBP), serum creatinine concentration (Cr), and HBA1C. RESULTS Mean subject age was 58 +/- 9.8 years; 63% received cadaveric grafts while 37% received living donor grafts. Mean follow-up was 7 years (range 1.6 to 15.6). Seventy percentage developed proteinuria over time; of these 62% developed microalbuminuria (A/C ratio 30 to 300 microg albumin/mg creatinine) and 38% developed macroalbuminuria (A/C ratio >300 microg/mg). Subjects with preexisting DM were as likely to develop an elevated A/C ratio as those with PTDM. Higher A/C ratios correlated with higher SBP (P < .01), with higher HBA1C (P < .036), and with higher Cr (P < .01). Lower A/C ratios correlated with more stable Cr over time (P < .01). CONCLUSIONS Strict SBP and glycemic control are associated with a significantly lower A/C ratio in patients with DM after renal transplantation. Annual monitoring of A/C ratio in patients with DM after renal transplantation can identify candidates for stricter glycemic and blood pressure control, similar to current recommendations for all other patients with DM.
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Affiliation(s)
- T Hor
- Section of Endocrinology, Rush University Medical Center, Chicago, Illinois 60612, USA
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284
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Bloom RD, Lake JR. Emerging issues in hepatitis C virus-positive liver and kidney transplant recipients. Am J Transplant 2006; 6:2232-7. [PMID: 16869798 DOI: 10.1111/j.1600-6143.2006.01457.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatitis C virus (HCV) infection is a major health care issue in liver and kidney transplantation. Besides negatively affecting both patient and graft survival, HCV is associated with a heightened risk for new onset diabetes mellitus (NODM). The mechanisms underlying the diabetogenicity of HCV are complex but are likely to involve insulin resistance caused by inhibitory actions of the virus on insulin regulatory pathways in the liver. The resultant glucose dysregulation is an important determinant of increased morbidity and mortality in liver and kidney recipients. This review highlights the concerns for outcomes in HCV-positive liver and kidney transplant patients with particular focus on the interrelationship between hepatitis C and diabetes. Data about the potential role of calcineurin inhibitors, corticosteroids and mycophenolate mofetil in HCV infection and HCV-associated NODM will also be discussed.
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Affiliation(s)
- R D Bloom
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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285
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Haririan A, Sillix DH, Morawski K, El-Amm JM, Garnick J, Doshi MD, West MS, Gruber SA. Short-term experience with early steroid withdrawal in African-American renal transplant recipients. Am J Transplant 2006; 6:2396-402. [PMID: 16869806 DOI: 10.1111/j.1600-6143.2006.01477.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
There are limited data on the results of early steroid withdrawal (ESW) in African-American (AA) renal allograft recipients. We examined short-term transplant outcomes in a retrospective, non-concurrent cohort study of 40 AAs who did not (ESW group), and 33 who did [steroid maintenance (SM) group] receive maintenance steroids after day 4 post-transplant. Patients received thymoglobulin (ATG) induction, mycophenolate mofetil, and tacrolimus or sirolimus. Data were analyzed using survival analysis methods and regression models. Patients in the ESW group were older, had lower current panel reactive antibody and fewer re-transplants, and received fewer doses of ATG. One-year graft survival and acute rejection (AR) rates were 100% and 13% in the ESW group and 97% and 15% in the SM group. After controlling for confounders, at 1 year, ESW was not associated with higher risk of graft loss, AR, or worse graft function, but was associated with less weight gain. The SM group had higher cholesterol levels at 3 months and higher risk of post-transplant diabetes mellitus. We did not observe any cases of subclinical rejection. This study suggests that ESW under modern immunosuppression is safe over the short term in at least a subset of AA recipients with risk profiles similar to those studied herein, and could be associated with improved outcomes.
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Affiliation(s)
- A Haririan
- Division of Nephrology, Department of Medicine, Wayne State University School of Medicine, Detroit, MI, USA.
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286
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Kamar N, Mariat C, Delahousse M, Lefrançois N, Dantal J, Benhamou P. New Onset Diabetes Mellitus Incidence and Risk Factors in Kidney Transplantation: Results of the Observational Cross-Sectional Study Diapason. Transplant Proc 2006; 38:2295-7. [PMID: 16980069 DOI: 10.1016/j.transproceed.2006.06.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND New-onset diabetes mellitus (NODM) is a frequent complication of kidney transplantation. Data on NODM are mainly available in the United States. A study was implemented in a French population of kidney transplants. The incidence and risk factors of NODM were analysed. Diabetes was defined according to American Diabetes/World Health Organization guidelines. METHODS Diapason is an observational cross-sectional study of 527 kidney transplant patients from 17 units based on data collected at a single routine visit 6 to 24 months after kidney transplantation. RESULTS The mean age of the patients was 47.2 years, and 61.1% were men; 49.5% were receiving cyclosporine microemulsion and 50.5% tacrolimus. NODM developed in 7.0% after a median interval of 1.6 months. Univariate analysis identified six pretransplantation risk factors: advanced age, impaired fasting glucose, at least two cardiovascular risk factors, hepatitis C status, maximums lifetime body mass index above 25, and tacrolimus or cyclosporine therapy. Four independent factors were identified by multivariate analysis: body mass index above 25 (OR = 5.1), pretransplantation impaired fasting glucose (OR = 4.7), hepatitis C status (OR = 4.7), and tacrolimus versus cyclosporine treatment (OR = 3.0). CONCLUSIONS NODM is associated with risk factors present prior to kidney transplantation and with treatment with tacrolimus as opposed to cyclosporine. Therefore, the choice of calcineurin inhibitor should be based on the patient's overall risk profile.
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Affiliation(s)
- N Kamar
- Department of Nephrology, Dialysis and Transplantation, CHU Rangueil, 1 avenue Jean Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
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287
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Hoitsma AJ, Hilbrands LB. Relative risk of new-onset diabetes during the first year after renal transplantation in patients receiving tacrolimus or cyclosporine immunosuppression. Clin Transplant 2006; 20:659-64. [PMID: 16968494 DOI: 10.1111/j.1399-0012.2006.00535.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Clinical trials have consistently shown a higher incidence of new-onset diabetes mellitus with tacrolimus than cyclosporine. However, in protocol-driven studies steroid doses are comparable in both treatment arms, while in clinical practice steroid dose used in conjunction with tacrolimus or cyclosporine may differ. This retrospective study analysed renal transplant recipients without pre-existing diabetes receiving tacrolimus (n = 100) or cyclosporine (n = 100) for whom one-year follow-up data were available. Diabetes was defined as use of insulin or oral hypoglycemic agents; fasting glucose >6.9 mmol/L; or non-fasting glucose >11 mmol/L on three consecutive occasions. Tacrolimus-treated patients were significantly older than cyclosporine-treated patients (49 +/- 14 vs. 44 +/- 13 yr, p < 0.05) and received a significantly lower cumulative dose of corticosteroids over the first three months post-transplant (1284 +/- 379 vs. 1714 +/- 486 mg, p < 0.0001). At 3, 6, 9 and 12 months significantly more tacrolimus-treated patients had new-onset diabetes than cyclosporine- treated patients. At 12 months, 18 patients receiving tacrolimus and two receiving cyclosporine had diabetes (p < 0.0001). There was a clear relationship between age and incidence of new-onset diabetes at three months in the tacrolimus cohort. After stratifying patients by age group, the frequency of diabetes was significantly higher with tacrolimus than with cyclosporine in patients aged 40-60 yr [8/46 (17.4%) vs. 2/48 (4.2%), p < 0.05] and >60 yr [9/28 (32.1%) vs. 0/14 (0%), p < 0.05]. The mean tacrolimus trough level during the first three months was similar in patients with diabetes (13.1 +/- 2.3 ng/mL) or without diabetes (13.0 +/- 2.8 ng/mL, n.s.). These results indicate that new-onset diabetes is strongly and significantly associated with tacrolimus vs. cyclosporine in renal transplant recipients, even when steroid dosing is lower with tacrolimus.
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Affiliation(s)
- Andries J Hoitsma
- Division of Nephrology, Radboud University Nijmegen, Medical Centre, Nijmegen, The Netherlands.
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288
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Abstract
The study explores the prevalence of unrecognized diabetes mellitus (DM), the incidence and risk factors new onset diabetes mellitus (NODM) and determines whether patient survival differs between patients with transient (NODM that resolves) compared with those with fixed NODM. This is a single center review of solitary kidney recipients transplanted from 1993 to 2003. Of the 381 patients without DM pre-transplant, 111 met criteria for DM post. Of these 17 were unrecognized to have DM, 31 had transient (resolved) NODM and 64 had fixed NODM. In a multivariate analysis, age, body mass index, repeat transplant and rejection were risk factors for NODM. In a separate analysis of only fixed NODM, tacrolimus use showed a trend for an independent association (HR 1.7 95% CI 0.95-2.9). NODM patient survival was comparable to non-diabetic recipients even up to 10 yr; however, excess mortality started to be seen in the fixed NODM subgroup at late follow up. Use of more stringent DM criteria results in a population with relatively good intermediate term survival and allows detection and treatment of early disease. Transient NODM represents approximately one third of NODM and has a relatively good prognosis.
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Affiliation(s)
- Mathew Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax Nova Scotia, Canada
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289
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Bamoulid J, Courivaud C, Deschamps M, Mercier P, Ferrand C, Penfornis A, Tiberghien P, Chalopin JM, Saas P, Ducloux D. IL-6 Promoter Polymorphism −174 Is Associated with New-Onset Diabetes after Transplantation. J Am Soc Nephrol 2006; 17:2333-40. [PMID: 16837641 DOI: 10.1681/asn.2006010066] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
New-onset diabetes after transplantation (NODAT) is a serious complication of transplantation. This study tested whether IL-6 production capacity may influence the development of NODAT in two different groups of patients. The occurrence of NODAT was analyzed with respect to IL-6 gene promoter polymorphism at position -174 (G-->C) and other relevant risk factors retrospectively in 217 renal transplant recipients and prospectively in 132. A linear increase in both circulating IL-6 (P = 0.09) and C-reactive protein (an indicator of basal IL-6 secretion; P = 0.03) concentrations from the CC genotype to the GG genotype was observed. In the multivariate model, the CC genotype was associated with a decreased risk for NODAT compared with the GG genotype in the two cohorts. Homeostasis Model Assessment for Insulin Resistance also revealed lesser insulin sensitivity in the GG carriers than in the CC carriers (2.15 +/- 2 versus 1.32 +/- 1.03; P = 0.03). Subgroup analysis showed that the influence of IL-6 gene promoter polymorphism on the development of NODAT was restricted mostly to overweight patients. These results highly suggest that IL-6 production capacity influences the development of NODAT and that diabetes-inducing drug administration should be limited in overweight patients who carry the GG genotype.
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Affiliation(s)
- Jamal Bamoulid
- INSERM, U645, University Besançon, and IFR133, Besançon, France
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290
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Lansang MC, Ma L, Schold JD, Meier-Kriesche HU, Kaplan B. The relationship between diabetes and infectious hospitalizations in renal transplant recipients. Diabetes Care 2006; 29:1659-60. [PMID: 16801596 DOI: 10.2337/dc05-2412] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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291
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Romagnoli J, Citterio F, Nanni G, Favi E, Tondolo V, Spagnoletti G, Salerno MP, Castagneto M. Incidence of Posttransplant Diabetes Mellitus in Kidney Transplant Recipients Immunosuppressed With Sirolimus in Combination With Cyclosporine. Transplant Proc 2006; 38:1034-6. [PMID: 16757255 DOI: 10.1016/j.transproceed.2006.03.072] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Sirolimus (SRL) in combination with Cyclosporine A (CsA) and steroids has been shown to lower the incidence of acute renal allograft rejection episodes, allowing CsA sparing. We retrospectively compared the incidence of posttransplant diabetes mellitus (PTDM) among kidney transplant recipients (KTx) immunosuppressed with SRL + CsA versus CsA alone. Patients were divided into two groups: SRL + CsA (n = 38) versus CsA (n = 48). Mean follow-up was 53.9 +/- 17.1 months. Seventeen/86 subjects (19.8%) developed diabetes after transplantation (7 IFG, 8.1%; 10 PTDM, 11.6%). The incidence was significantly higher in SRL + CsA (12/38 patients, 31.6%) compared with CsA (5/43 patients, 10.4%) (P = .0144, odds ratio 3.97). More patients required treatment in the SRL + CsA compared to CsA alone cohort (13.2% vs 2.1%, P = .051): 4 pts (10.5%) became insulin- dependent among SRL+CsA, vs none in the CsA group. Use of OHD was similar in both groups (2.6% SRL + CsA vs 2.1% CsA). There were no significant differences between the two groups in terms of age, sex distribution, BMI, or serum creatinine at 1 to 3 and 5 years from transplantation. All PTDM patients are alive at follow-up, while two grafts were lost due to chronic renal allograft dysfunction. Within the limits of a small retrospective study, we observed that SRL in combination with CsA increased the diabetogenic potential of CsA. A possible explanation of our findings is that higher CsA doses were used in the early experience with SRL + CsA; therefore the higher incidence of PTDM that we observed in the SRL + CsA combination may be a sign of toxicity. Careful monitoring of blood levels is mandatory in the SRL + CsA combination to avoid pleiotropic toxicity.
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Affiliation(s)
- J Romagnoli
- Department of Surgery, Organ Transplantation, Catholic University, Policlinico Gemelli, Rome, Italy.
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292
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Alexander JW, Goodman HR, Cardi M, Austin J, Goel S, Safdar S, Huang S, Munda R, Fidler JP, Buell JF, Hanaway M, Susskind B, Roy-Chaudhury P, Trofe J, Alloway R, Woodle ES. Simultaneous corticosteroid avoidance and calcineurin inhibitor minimization in renal transplantation. Transpl Int 2006; 19:295-302. [PMID: 16573545 DOI: 10.1111/j.1432-2277.2006.00280.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Steroids and calcineurin inhibitors (CNI) have been mainstays of immunosuppression but both have numerous side effects that are associated with substantial morbidity and mortality. This study was carried out to determine if steroids can be eliminated with early discontinuation of cyclosporine A (CsA) and later discontinuation of mycophenolate mofetil (MMF). Ninety-six patients with kidney transplants were entered into four subgroups of two pilot studies. All patients received Thymoglobulin induction, rapamycin (RAPA), and the immunonutrients arginine and an oil containing omega-3 fatty acids. Mycophenolate mofetil was started in standard doses and discontinued by 2 years. CsA was given in reduced doses for either 4, 6, or 12 months. Follow-up was 12-36 months. Thirteen first rejection episodes occurred during the first year (14%). Combining all patients, 86% were rejection-free at 1 year, 80% at 2 years and 79% at 3 years. No kidney has been lost to acute rejection. Ninety percent of the 84 patients at risk at the end of the study were steroid-free and 87% were off CNI. Fifty-seven percent of 54 patients with a functioning kidney at 3 years were receiving monotherapy with RAPA. We conclude that this therapeutic strategy is worthy of a prospective multi-center clinical trial.
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Affiliation(s)
- J Wesley Alexander
- Department of Surgery, Transplantation Division, University of Cincinnati College of Medicine, OH 45267, USA
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293
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Giordano M, Colella V, Dammacco A, Torelli C, Grandaliano G, Teutonico A, Depalo T, Caringella DA, Di Paolo S. A study on glucose metabolism in a small cohort of children and adolescents with kidney transplant. J Endocrinol Invest 2006; 29:330-6. [PMID: 16699299 DOI: 10.1007/bf03344104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) and impaired glucose tolerance are now considered among the major adverse events following organ transplantation. The present study was aimed at investigating the regulation of glucose metabolism in pediatric recipients of a kidney transplant (KT), receiving tacrolimus or cyclosporine A-based immunosuppression. Twelve subjects, eight males and four females, aged 12.1+/-3.8 yr, and with a mean time from KT of 45.6 months were enrolled in the study. All patients had a basal evaluation of fasting glucose (GF), fasting insulin (IF), C-peptide and glycated hemoglobin (HbA1c) levels. They then underwent oral glucose tolerance test (OGTT), with measurement of blood glucose and insulin concentration. Two children had impaired GF, associated with supernormal HbA1c levels, one patient showed impaired glucose tolerance, none had PTDM. Peripheral insulin resistance, as measured by quantitative insulin sensitivity check index (QUICKI) and homeostasis model assessment estimate of insulin sensitivity (HOMA-IR) index, was enhanced in 3 patients. Subsequently, GF significantly increased with time from transplant (p=0.01), while fasting C-peptide and the area under the curve of insulin correlated with creatinine clearance. In conclusion, our results, although generated in a small sample size, would suggest that long-term follow-up of children receiving a KT should extend to explore the response to oral glucose load and at least the basal measure of insulin response.
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Affiliation(s)
- M Giordano
- Pediatric Nephrology and Dialysis Unit, Children's Hospital Giovanni XXIII, University of Bari, 70126 Bari, Italy.
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294
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Djamali A, Samaniego M, Muth B, Muehrer R, Hofmann RM, Pirsch J, Howard A, Mourad G, Becker BN. Medical Care of Kidney Transplant Recipients after the First Posttransplant Year. Clin J Am Soc Nephrol 2006; 1:623-40. [PMID: 17699268 DOI: 10.2215/cjn.01371005] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Kidney transplantation is the treatment of choice for patients with ESRD. Despite improvements in short-term patient and graft outcomes, there has been no major improvement in long-term outcomes. The use of kidney allografts from expanded-criteria donors, polyoma virus nephropathy, underimmunosuppression, and incomplete functional recovery after rejection episodes may play a role in the lack of improvement in long-term outcomes. Other factors, including cardiovascular disease, infections, and malignancies, also shorten patient survival and therefore reduce the functional life of an allograft. There is a need for interventions that improve long-term outcomes in kidney transplant recipients. These patients are a unique subset of patients with chronic kidney disease. Therefore, interventions need to address disease progression, comorbid conditions, and patient mortality through a multifaceted approach. The Kidney Disease Outcomes Quality Initiative from the National Kidney Foundation, the European Best Practice Guidelines, and the forthcoming Kidney Disease: Improving Global Outcomes clinical practice guidelines can serve as a cornerstone of this approach. The unique aspects of chronic kidney disease in the transplant recipient require the integration of specific transplant-oriented problems into this care schema and a concrete partnership among transplant centers, community nephrologists, and primary care physicians. This article reviews the contemporary aspects of care for these patients.
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Affiliation(s)
- Arjang Djamali
- Department of Medicine, Nephrology Section, University of Wisconsin Madison, School of Medicine, 3034 Fish Hatchery Road, Suite B, Madison, WI 53713, USA.
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295
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Sezer S, Bilgic A, Uyar M, Arat Z, Ozdemir FN, Haberal M. Risk Factors for Development of Posttransplant Diabetes Mellitus in Renal Transplant Recipients. Transplant Proc 2006; 38:529-32. [PMID: 16549166 DOI: 10.1016/j.transproceed.2005.12.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Diabetes mellitus appearing after kidney transplantation--posttransplant diabetes mellitus (PTDM)--is a common complication associated with poor graft and patient survival. The purpose of the current study was to determine the risk factors for developing PTDM in 204 renal transplant recipients who had been followed for at least 30 months. Posttransplant diabetes mellitus was diagnosed according to the American Diabetic Association/WHO criteria, or a requirement for insulin, an oral hypoglycemic agent, or both. Analyses of possible risk factors for PTDM included demographic features, dialysis and posttransplantation duration, smoking, body mass index, medications, co-morbid diseases, HLA mismatches, as well as laboratory metrics of serum creatinine, albumin, calcium, phosphorus, C-reactive protein, parathyroid hormone, and lipid profiles. Twenty-six patients displayed PTDM. Univariate analysis showed that older age, greater body mass index, presence of hepatitis C virus (HCV) infection, and smoking at the time of renal transplantation were associated with PTDM development. In a multivariate analysis, HCV infection, smoking, and patient age at the time of transplantation were independent risk factors for PTDM. In conclusion, the presence of HCV infection or a smoking habit in addition to older age at the time of transplantation were the main predictors for developing PTDM. Patients should be closely followed regarding their smoking habit and weight gain as modifiable risk factors for PTDM.
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Affiliation(s)
- S Sezer
- Department of Nephrology, Baskent University Hospital, Ankara, Turkey
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296
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Sezer S, Akgul A, Altunoglu A, Altinoglu A, Arat Z, Ozdemir FN, Haberal M. Posttransplant Diabetes Mellitus: Impact of Good Blood Glucose Regulation on Renal Transplant Recipient Outcome. Transplant Proc 2006; 38:533-6. [PMID: 16549167 DOI: 10.1016/j.transproceed.2005.12.106] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Posttransplant diabetes mellitus (PTDM) is a frequent complication among renal transplant recipients. This study sought to compare clinical outcomes of patients with PTDM who had strict glucose control with nondiabetic patients and to identify risk factors for atherosclerotic disease in both groups. We retrospectively examined 204 renal allograft recipients transplanted at our center between 1996 and 2002. Demographic features, dialysis and posttransplantation duration, smoking, body mass index, medications, comorbid diseases, number of HLA mismatches, and laboratory parameters including serum levels of creatinine, albumin, calcium, phosphorus, C-reactive protein, lipid parameters, and parathyroid hormone were analyzed as possible risk factors for atherosclerotic disease. Patients were followed for a mean of 59.7 +/- 23.6 months. PTDM was diagnosed according to the American Diabetic Association criteria or the need for an insulin/oral hypoglycemic agent. Twenty-six patients developed PTDM, and these patients had very good diabetes control. One patient with poorly regulated PTDM was excluded. Adverse events which were documented in 24 patients were more frequent among patients with PTDM. Mean age was found to be an independent risk factor for atherosclerotic disease, whereas PTDM was not. There were no differences regarding other atherosclerosis-related or other risk factors (including serum C-reactive protein levels and lipid profiles) between the groups. Nondiabetic subjects tended to have longer graft survival than patients with PTDM, but this finding was not statistically significant. PTDM is an important risk factor for developing atherosclerotic disease. Good control of blood glucose levels can decrease the high morbidity rates and negative influence of PTDM on patient and graft survival rates in this population.
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Affiliation(s)
- S Sezer
- Department of Nephrology, Baskent University School of Medicine, Ankara, Turkey.
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297
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Rodrigo E, de Cos MA, Fernández-Fresnedo G, Sánchez B, Ruiz JC, Piñera C, Palomar R, Cotorruelo JG, Gómez-Alamillo C, de Castro SS, de Francisco ALM, Arias M. Higher initial tacrolimus blood levels and concentration-dose ratios in kidney transplant recipients who develop diabetes mellitus. Transplant Proc 2006; 37:3819-20. [PMID: 16386549 DOI: 10.1016/j.transproceed.2005.09.196] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Posttransplantation diabetes mellitus (PTDM) is a common complication of kidney transplantation, associated with poorer graft and patient outcomes. Tacrolimus is a strong immunosuppressive drug associated with low acute rejection rates, but a higher risk for PTDM. High trough levels of tacrolimus during the first month after transplantation have been found to be a significant risk factor for the development of PTDM. The aim of this single-center study was to identify the risk factors for the development of PTDM among kidney transplant recipients under tacrolimus therapy. We examined 73 cadaveric kidney transplant recipients receiving tacrolimus between 1994 and 2003. Age, donor and recipient gender, dialysis method, body mass index (BMI), first year weight gain, mismatches, incidence of acute rejection and delayed graft function, hepatitis C serology, first year cumulative steroid dose, first tacrolimus blood level, first tacrolimus blood level <15 ng/mL, and corresponding tacrolimus daily doses and concentration/dose ratios (CDR) were also collected. PTDM was defined as at least 2 fasting blood glucose values > or =126 mg/dL, according to the World Health Organization criteria. Incidence of first year PTDM was 27.4%. Patients with PTDM showed significantly higher age, BMI, first tacrolimus blood level, first tacrolimus CDR, and CDR with tacrolimus blood level <15 ng/mL as well as less 1-year weight gain. After logistic regression, age (relative risk [RR] 1.060, confidence interval [CI] 95%, 1.001-1.122; P = .043) and first tacrolimus blood level (RR 1.154; CI 95%, 1.038-1.283; P = .008) remain significant risk factors for developing PTDM. Older age and initial tacrolimus blood levels were the main risk factors for PTDM among our group of patients. Kidney transplant recipients who develop PTDM maintain a high CDR of tacrolimus.
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Affiliation(s)
- E Rodrigo
- Service of Nephrology, Hospital Valdecilla, University of Cantabria, Santander, Spain.
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298
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Bayés B, Granada ML, Lauzurica R, Pastor MC, Navarro M, Bonet J, Llopis MA, Romero R. Effect of low doses of atorvastatin on adiponectin, glucose homeostasis, and clinical inflammatory markers in kidney transplant recipients. Transplant Proc 2006; 37:3808-12. [PMID: 16386546 DOI: 10.1016/j.transproceed.2005.08.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Various studies describe the pleiotropic antiinflammatory and antioxidant effects of atorvastatin, in addition to its hypolipemic effects. It has been suggested that statins modify glucose homeostasis via their antiinflammatory effects. A further hypothesis suggests that the incidence of posttransplantation diabetes is lower in statin-treated patients. This study sought to ascertain whether atorvastatin modifies glucose homeostasis, adiponectin, and inflammatory markers in kidney transplant recipients. PATIENTS AND METHODS Sixty-eight kidney transplant recipients (41 men, 27 women; mean age, 53 +/- 12 years) with stable renal function and dyslipidemia were treated with atorvastatin (10 mg/d) for 12 weeks. Glucose, insulin, homeostasis model assessment (HOMA-IR) index, adiponectin, tumor necrosis factor (TNF)-alpha, and serum C-reactive protein (CRP) concentrations were determined at baseline and at 3 months. The lipid profile, renal function parameters (creatinine, creatinine clearance, and proteinuria), as well as GOT, GPT, and CK were determined at baseline and at 3 months. RESULTS Treatment with atorvastatin achieved a statistically significant decrease in lipid profile. After 3 months of treatment, 74.6% of patients had total cholesterol and 78.7% low-density lipoprotein (LDL) cholesterol concentrations within reference range (<5.2 and 3.3 mmol/L, respectively). Furthermore, 47.5% of patients attained an LDL concentration <2.59 mmol/L. A greater reduction in total cholesterol (P = .05) and LDL cholesterol (P = .04) was achieved in patients with creatinine clearance <60 mL/min. Atorvastatin did not modify glucose homeostasis parameters, adiponectin, TNF-alpha, or CRP. At baseline and after 3 months of treatment, an inverse correlation was found between adiponectin and glucose, insulin, HOMA- IR index, and creatinine clearance, and a positive correlation was found between adiponectin and high-density lipoprotein (HDL) cholesterol. CONCLUSION Atorvastatin at a dose of 10 mg/d in kidney transplant recipients does not modify glucose homeostasis or alter inflammatory markers, despite its hypolipemic effects. Its efficacy to reduce total cholesterol and LDL cholesterol was greater in patients with worse renal function.
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Affiliation(s)
- B Bayés
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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299
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Hoban R, Gielda B, Temkit M, Saha C, Book BK, Baker E, Pescovitz MD. Utility of HbA1c in the Detection of Subclinical Post Renal Transplant Diabetes. Transplantation 2006; 81:379-83. [PMID: 16477224 DOI: 10.1097/01.tp.0000188622.00840.13] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We hypothesized that the use of HbA1c testing would help identify postrenal transplant diabetes (PTDM). METHODS In all, 199 adult kidney transplant recipients at least 3 months posttransplant without previous history of diabetes or elevated fasting blood sugar were studied. Medical history, a fasting blood glucose, calcineurin inhibitor blood level, and HbA1c were obtained. Primary outcome was the incidence of subjects with HbA1c > or =6.1%. The covariates were use of cyclosporine or tacrolimus, time posttransplant, body mass index (BMI) at transplant and change since transplant, current steroid dose, history of graft rejection, current fasting glucose, age, and race. Proportions were compared between HbA1c <6 and > or =6.1% using Fisher's exact test. Means were compared using Student's t test. Logistic regression was used to identify risk factors associated with elevated HbA1c. RESULTS Twenty subjects (10.1%) had an elevated HbA1c. High normal fasting glucose (P=0.003) and African American race (P=0.08, marginally significant) were found to be associated with an elevated HbA1c. Subjects with normal and abnormal HbA1c levels were otherwise similar. There was no difference in HbA1c in tacrolimus versus cyclosporine treated subjects or in the percent of subjects with elevated HbA1c between these groups. CONCLUSIONS HbA1c levels were found to be more a more sensitive test than fasting blood glucose levels in PTDM, with 10.1% of all patients and 19.4% of blacks found to have an elevated HbA1c. HbA1c testing should be considered as a screening test for PTDM, especially in African Americans.
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Affiliation(s)
- Rebecca Hoban
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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300
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Mirabella S, Brunati A, Ricchiuti A, Pierini A, Franchello A, Salizzoni M. New-onset diabetes after liver transplantation. Transplant Proc 2006; 37:2636-7. [PMID: 16182771 DOI: 10.1016/j.transproceed.2005.06.084] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM The impact of new-onset diabetes (NOD) posttransplantation has been underestimated in the past. The aim of this study was to evaluate the incidence of diabetes after liver transplantation. METHODS We retrospectively analyzed the incidence of NOD in 899 patients transplanted in our center. According to International Consensus 2003 Guidelines, criteria for diagnosis of diabetes were: fasting plasma glucose > or =126 mg/dL, symptoms of diabetes plus casual plasma glucose concentrations > or =200 mg/dL, and 2-hour plasma glucose levels > or =200 mg/dL during an oral glucose tolerance test. We considered only patients with follow-up over 10 months. We evaluated the risk factors correlated with NOD (age, hepatitis C virus [HCV] positivity, tacrolimus vs cyclosporine, steatosic graft), and the outcomes of diabetic patient and their grafts. RESULTS The incidence of NOD was 10.8% (90/830 patients). Sixty nine patients were diabetic before transplantation. Recipient age >45 years (14.7% vs 6.8%, P = .002, OR = 2.4) and HCV positivity (15.5% vs 7.8%, P = .001, OR = 2.2) significantly correlated with NOD. Multivariate analysis confirmed these variables to be independently associated with diabetic risk. Tacrolimus was associated with an increased risk of NOD (16.2% in HCV-negative patients, 25% in HCV-positive patients), but this difference was not statistically significant. Steatotic grafts (>10%) were associated with an increased risk of NOD (28.6% vs 10%, P = .001, OR = 3.6). The outcome of patients and grafts in the group of diabetic patients was not significantly different from all other patients. CONCLUSIONS The incidence of NOD was more relevant in patients older than 45 years and/or HCV-positive. A steatotic graft was an important risk factor, and the match with high-risk patients should be avoided.
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Affiliation(s)
- S Mirabella
- Centro Trapianti di Fegato-Azienda Ospedaliera S. Giovanni Battista di Torino, Torino, Italy
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