Hepatitis C infection increases the risk of new-onset diabetes after transplantation in liver allograft recipients

Prediabetes and older age increase the risk of post-transplantation diabetes mellitus: Qatar experience

Post-transplantation diabetes mellitus (PTDM) is a major complication in kidney transplant recipients leading to reduced allograft and patient survival. Given the high prevalence of diabetes in Qatar, which is twice the global average, we were interested in determining the incidence of PTDM, identifying risk factors, and comparing clinical outcomes in kidney transplant recipients with and without diabetes. We retrospectively followed up 191 adult kidney allograft recipients transplanted between January 1, 2012, and December 31, 2016, for a median of 41 months. A total of 76 patients (40%) had pre-existing diabetes. A total of 39 patients developed PTDM during follow-up; they represent 34% of patients who did not have diabetes prior to transplantation. Two thirds of PTDM occurred within 3-6 months post-transplantation. Prediabetes before transplant [OR = 6.07 (1.24-29.74), P = .026] older recipient's age at the time of transplantation [OR = 1.10 (1.00-1.20), P = .039] and average fasting blood sugar during 3-6 months post-transplant [OR = 1.06 (1.01-1.11), P = .010] were independently associated with PTDM. Patient and kidney allograft survival rates exceeded 97% in all groups. The incidence of PTDM in kidney transplant recipients living in Qatar is high. Older age and prediabetes are independent risk factors for developing PTDM.

Cardiovascular and Metabolic Consequences of Liver Transplantation: A Review

Liver transplantation (LT) is considered the curative treatment option for selected patients who suffer from end-stage or acute liver disease or hepatic malignancy (primary). After LT, patients should be carefully monitored for complications that may appear, partially due to immunosuppressive therapy, but not entirely. Cardiovascular diseases are frequently encountered in patients with LT, being responsible for high morbidity and mortality. Patients with underlying cardiovascular and metabolic pathologies are prone to complications after the transplant, but these complications can also appear de novo, mostly associated with immunosuppressants. Metabolic syndrome, defined by obesity, hypertension, dyslipidemia, and hyperglycemia, is diagnosed among LT recipients and is aggravated after LT, influencing the long-term survival. In this review, our purpose was to summarize the current knowledge regarding cardiovascular (CV) diseases and the metabolic syndrome associated with LT and to assess their impact on short and long-term morbidity and mortality.

Post-Liver Transplantation Diabetes Mellitus: A Review of Relevance and Approach to Treatment

Post-liver transplantation diabetes mellitus (PLTDM) develops in up to 30% of liver transplant recipients and is associated with increased risk of mortality and multiple morbid outcomes. PLTDM is a multicausal disorder, but the main risk factor is the use of immunosuppressive agents of the calcineurin inhibitor (CNI) family (tacrolimus and cyclosporine). Additional factors, such as pre-transplant overweight, nonalcoholic steatohepatitis and hepatitis C virus infection, may further increase risk of developing PLTDM. A diagnosis of PLTDM should be established only after doses of CNI and steroids are stable and the post-operative stress has been overcome. The predominant defect induced by CNI is insulin secretory dysfunction. Plasma glucose control must start immediately after the transplant procedure in order to improve long-term results for both patient and transplant. Among the better known antidiabetics, metformin and DPP-4 inhibitors have a particularly benign profile in the PLTDM context and are the preferred oral agents for long-term management. Insulin therapy is also an effective approach that addresses the prevailing pathophysiological defect of the disorder. There is still insufficient evidence about the impact of newer families of antidiabetics (GLP-1 agonists, SGLT-2 inhibitors) on PLTDM. In this review, we summarize current knowledge on the epidemiology, pathogenesis, course of disease and medical management of PLTDM.

Hepatitis C Virus Infection and Diabetes Mellitus in End-Stage Renal Disease: Evidence of a Negative Association

Epidemiological studies have implicated hepatitis C virus (HCV) infection in the pathogenesis of diabetes mellitus (DM) both in the population as a whole and after solid organ transplantation. Whether this association exists in patients with end-stage renal disease (ESRD) undergoing dialysis is unclear. The aim of this study is to investigate the relationship between HCV and DM in a large group (n = 742) of patients with ESRD from Europe and North America. The presence of diabetes was ascertained by using American Diabetes Association guidelines based on fasting glucose measurement and medication history. Presence of HCV infection was assessed by serum testing for anti-HCV antibodies. The prevalence of anti-HCV antibody positive patients was 15% (112/742); the frequency of DM was higher among anti-HCV positive than -HCV negative patients but the difference did not approach statistical significance, 32% (36/112) vs 29.5% (186/630). The frequency of patients with diabetic nephropathy was not higher in anti-HCV positive than -negative patients; 21.4% (24/112) vs 23.3% (147/630), NS. Logistic regression model showed an independent and significant link between anti-HCV seropositive status and raised GPT (P = 0.032), male gender (P = 0.0462), positive history of prior renal transplant (P = 0.0006), and longer time on dialysis (P = 0.00001). In summary, no link between anti-HCV antibody and DM occurred in this ESRD population; there was no association between rate of anti-HCV antibody and diabetic nephropathy.

Prevalence, predictive factors, and survival outcome of new-onset diabetes after liver transplantation: A population-based cohort study

The aim of the present nationwide population-based cohort study was to explore the prevalence, risk factors, and survival outcome of new-onset diabetes (NOD) in recipients after liver transplantation.The National Health Insurance Research Database of Taiwan was searched for ICD-9-codes, 2248 patients who had received liver transplant without pretransplant diabetes from July 1, 1998 to December 31, 2012 were included in the study. The preoperative risks factors were considered and analyzed using logistic regression analysis, following adjustments for age and sex. All patients were followed up until the end of the study or death.The final dataset included 189 patients with NOD and 2059 without diabetes after liver transplantation. The prevalence of NOD was 8.4% and in 64% NOD appeared in the first year after liver transplantation. Preoperative clinical events, alcoholic liver cirrhosis, and hepatic encephalopathy were the most important risk factors for NOD after liver transplantation. The mortality rate was lower in NOD recipients than in non-NOD recipients within 5 years.In this study, we provide evidence that NOD recipients had better 5-year survival outcomes in this clinical population. The most important identifiable predictive factors for NOD after liver transplantation were alcoholic hepatitis, ascites, hepatic coma, and esophageal varices.

Characterization of Remitting and Relapsing Hyperglycemia in Post-Renal-Transplant Recipients

Background

Hyperglycemia following solid organ transplant is common among patients without pre-existing diabetes mellitus (DM). Post-transplant hyperglycemia can occur once or multiple times, which if continued, causes new-onset diabetes after transplantation (NODAT).

Objective

To study if the first and recurrent incidence of hyperglycemia are affected differently by immunosuppressive regimens, demographic and medical-related risk factors, and inpatient hyperglycemic conditions (i.e., an emphasis on the time course of post-transplant complications).

Methods

We conducted a retrospective analysis of 407 patients who underwent kidney transplantation at Mayo Clinic Arizona. Among these, there were 292 patients with no signs of DM prior to transplant. For this category of patients, we evaluated the impact of (1) immunosuppressive drugs (e.g., tacrolimus, sirolimus, and steroid), (2) demographic and medical-related risk factors, and (3) inpatient hyperglycemic conditions on the first and recurrent incidence of hyperglycemia in one year post-transplant. We employed two versions of Cox regression analyses: (1) a time-dependent model to analyze the recurrent cases of hyperglycemia and (2) a time-independent model to analyze the first incidence of hyperglycemia.

Results

Age (P = 0.018), HDL cholesterol (P = 0.010), and the average trough level of tacrolimus (P<0.0001) are significant risk factors associated with the first incidence of hyperglycemia, while age (P<0.0001), non-White race (P = 0.002), BMI (P = 0.002), HDL cholesterol (P = 0.003), uric acid (P = 0.012), and using steroid (P = 0.007) are the significant risk factors for the recurrent cases of hyperglycemia.

Discussion

This study draws attention to the importance of analyzing the risk factors associated with a disease (specially a chronic one) with respect to both its first and recurrent incidence, as well as carefully differentiating these two perspectives: a fact that is currently overlooked in the literature.

Long-term outcome after liver transplantation

Liver transplantation is a life-saving therapy for patients with end-stage liver disease, acute liver failure, and liver tumors. Over the past 4 decades, improvements in surgical techniques, peritransplant intensive care, and immunosuppressive regimens have resulted in significant improvements in short-term survival. Focus has now shifted to addressing long-term complications and improving quality of life in liver recipients. These include adverse effects of immunosuppression; recurrence of the primary liver disease; and management of diabetes, hypertension, dyslipidemia, obesity, metabolic syndrome, cardiovascular disease, renal dysfunction, osteoporosis, and de novo malignancy. Issues such as posttransplant depression, employment, sexual function, fertility, and pregnancy must not be overlooked, as they have a direct impact on the liver recipient's quality of life. This review summarizes the latest data in long-term outcome after liver transplantation.

Prevention and management of transplant-associated diabetes

INTRODUCTION

New-onset diabetes after transplantation (NODAT) is considered to be a major cause of cardiovascular disease and death among patients with a functioning allograft. A major challenge is to reduce the incidence of NODAT and to treat it optimally once it has occurred.

AREAS COVERED

This review presents current data on how to prevent NODAT in patients at risk, with a focus on modifications in the immunosuppressive regimen. Current suggestions for detection and treatment of NODAT are also presented.

EXPERT OPINION

Prevention of NODAT is possible by assessing the patient's glycemic risk prior to transplantation and tailoring the treatment (e.g., choice and dosage of immunosuppressive agents) after transplantation. An oral glucose tolerance test is still the gold standard to detect NODAT in patients at risk (prediabetes) but algorithms can be used to select those who should be tested. The treatment of NODAT involves a broad approach on risk factors for cardiovascular events and graft loss. Future studies on the use of oral hypoglycemic agents in NODAT are still needed.

Regression of new-onset diabetes mellitus after conversion from tacrolimus to cyclosporine in liver transplant patients: results of a pilot study

INTRODUCTION

New-onset diabetes mellitus (NODM) has important implications for long-term outcome following liver transplantation.

AIM

To evaluate the impact of conversion from tacrolimus to cyclosporine in liver transplant patients presenting NODM.

METHOD

In a 12-month pilot study, 39 liver transplant patients with NODM were converted from tacrolimus to cyclosporine. Most patients (59%) were receiving antidiabetic therapy (18% insulin, 41% oral) and all patients had received dietary advice prior to the study.

RESULTS

At month 12, NODM had significantly resolved (FBG<7 mmol/L without treatment) in 36% of patients (95% CI 20.8-51.0%). In the 16 patients not receiving antidiabetic drugs at baseline, mean FBG decreased from 8.1 mmol/L to 6.6 mmol/L (P=0.008) and mean HbA(1c) decreased from 6.4 to 6.0% (P=0.05). Steroids were stopped rapidly in the nine patients receiving steroids at inclusion but NODM resolution was observed in only one of these nine patients. No significant factors were identified that could have affected NODM resolution. There were three episodes of biopsy-proven acute rejection (7.7%), no graft losses and one death. Overall, cyclosporine tolerance was good with no significant change in creatinine clearance at month 12. Total cholesterol increased from 4.6 mmol/L to 5.1 mmol/L (P<0.001).

CONCLUSIONS

These results suggest that liver transplant patients with NODM may benefit from conversion to cyclosporine from tacrolimus through improved glucose metabolism. Confirmation in a prospective, randomized comparative study is required.

[Hepatitis C and metabolic syndrome]

Insulin resistance is a predictive factor of response to treatment with peginterferon and ribavirin in patients with hepatitis C. Insulin resistance impairs sensitivity to interferon and can block its intracellular signalling. Insulin resistance also induces the development of steatosis, progression of fibrosis and proinflammatory cytokine release and reduces the bioavailability of interferon. Suppressor of cytokine signalling 3 and protein tyrosine phosphatases are involved in blocking the intracellular signalling of interferon and insulin. Insulin resistance can be treated through diet, physical exercise and the use of insulin-sensitizing agents such as biguanides or glitazones. The TRIC-1 study demonstrated that adding metformin to routine treatment improves the possibilities of cure in women and in patients whose insulin sensitivity returns to normal during treatment.

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

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

Association of hepatitis C virus infection and diabetes in central Tunisia

AIM: To investigate hepatitis C virus (HCV) seroprevalence in Tunisian patients with diabetes mellitus and in a control group.

METHODS: A cross-sectional study was conducted to determine the HCV seroprevalence in 1269 patients with diabetes (452 male, 817 female) and 1315 non-diabetic patients, attending health centers in Sousse, Tunisia. HCV screening was performed in both groups using a fourth-generation enzyme immunoassay.

RESULTS: In the diabetic group, 17 (1.3%) were found to be HCV-infected compared with eight (0.6%) in the control group, although the difference was not significant (P = 0.057). Quantitative PCR was performed in 20 patients. Eleven patients were positive and showed HCV genotype 1b in all cases.

CONCLUSION: Frequency of HCV antibodies was low in patients with diabetes and in the control group in central Tunisia, with no significant difference between the groups.

Hepatitis C virus and type 2 diabetes

This review focuses on the relationship between hepatitis C virus (HCV) infection and glucose metabolism derangements. Cross-sectional and longitudinal studies have shown that the chronic HCV infection is associated with an increased risk of developing insulin resistance (IR) and type 2 diabetes (T2D). The direct effect of HCV on the insulin signaling has been analyzed in experimental models. Although currently available data should be considered as preliminary, HCV seems to affect glucose metabolism via mechanisms that involve cellular pathways that have been implicated in the host innate immune response. IR and T2D not only accelerate the histological and clinical progression of chronic hepatitis C, but also reduce the early and sustained virological response to interferon-alpha-based therapy. Thus, a detailed knowledge of the mechanisms underlying the HCV-associated glucose metabolism derangements is warranted, in order to improve the clinical management of chronic hepatitis C patients.

New onset diabetes mellitus after liver transplantation and hepatitis C virus infection: meta-analysis of clinical studies

New onset diabetes mellitus (NODM) postliver transplantation (LT) is very common and may negatively affect patient and graft survival, but its causative mechanism is still unclear. This study was to analyze the connection between Hepatitis C virus (HCV) infection and NODM after LT by systematically reviewing published medical literature. We electronically searched databases of MEDLINE, EMBASE and the Cochrane Library from January 1980 to January 2008. Only retrospective studies could be identified. Seven of them were subjected to the meta-analysis. Analysis was performed by using revman 4.2 software. We found that HCV increased the prevalence of NODM [OR 2.46; 95%CI (1.44, 4.19)]. Then, we further analyzed the association between HCV and persistent-NODM (P-NODM) after LT. The result showed that prevalence of P-NODM was higher in HCV-positive group than in HCV-negative group with marginally statistical significance [OR = 1.39; 95%CI (1.06, 1.83)]. The present meta-analysis based on retrospective studies suggested a significant relationship between HCV and NODM after LT, and it seems that HCV infection might also increase the prevalence of P-NODM. Multicenter, large sized prospective studies are still needed to further confirm these results.

Risk factors for posttransplant diabetes mellitus: a review of the literature

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.

Diabetes and Hepatic Oxidative Damage Are Associated With Hepatitis C Progression After Liver Transplantation

BACKGROUND

Posttransplant diabetes mellitus (PTDM) is common after liver transplantation and was recently identified as a risk factor for hepatitis C progression. Increased levels of oxidative stress have been identified in diabetes and hepatitis C. The aim of this study was to evaluate the relationship among PTDM, oxidative damage in liver biopsy specimens, and fibrosis progression posttransplant.

METHODS

Subjects consisted of 27 hepatitis C-infected liver transplant recipients who had liver biopsy specimens available from 49 protocol liver biopsies. Paraffin embedded liver tissue sections were stained for 8-hydroxy-2' deoxyguanosine (8-OHdG), an indicator of hydroxyl radical mediated tissue damage. The percentage of cells staining for 8-OHdG in a histologic section was categorized as high (>66%) versus low score (< or =66%). Fibrosis index was calculated as fibrosis score (0-4)/ years posttransplant. Time to bridging fibrosis or cirrhosis (F3-4) was compared as a function of PTDM and 8-OHdG score.

RESULTS

Considering all 49 biopsies, fibrosis index was higher in cases with PTDM (P<0.001) and high 8-OHdG score (P=0.004). High 8-OHdG score was associated with PTDM (P=0.012). In time to event analyses, time to F3-4 was more rapid in patients with PTDM (P=0.02) and in those with high 8-OHdG scores (P<0.001).

CONCLUSIONS

This study confirmed a relationship between PTDM and hepatitis C fibrosis progression and found that oxidative damage in liver biopsy specimens was associated with PTDM and more rapid development of advanced fibrosis.

The dynamics of glucose metabolism under calcineurin inhibitors in the first year after renal transplantation in nonobese patients

BACKGROUND

The incidence of glucose metabolism disturbances after transplantation often is based on the use of hypoglycemic agents and not on the results of glucose tolerance tests (GTTs), which may camouflage the real incidence. A lack of information also exists regarding the profile of glucose metabolism during the first year after transplant.

METHODS

Oral GTT along with insulin measurements and drugs pharmacokinetics were prospectively performed at days 30, 60, 180, and 360 after transplant to diagnose disturbances of glucose metabolism after renal transplantation, in nonobese patients receiving either tacrolimus (n=55) or cyclosporine (n=29), along with mycophenolate mofetil and steroids.

RESULTS

The incidence of impaired glucose tolerance or diabetes mellitus reached a peak at 60 days and decreased at 1 year. It could not be adequately diagnosed using fasting plasma glucose in a decreased abnormal (>99 ng/mL) range. In both groups, insulin secretion, evaluated by the Homeostasis Model Assesment (HoMA-beta), decreased (P<0.005) from the condition of normal GTT (101+/-56%) to impaired glucose tolerance (72+/-35%) and diabetes mellitus (54+/-25%). In the cyclosporine group, insulin secretion was normal and stable throughout the study period, but in the tacrolimus group, insulin secretion recovered over time and was inversely correlated with tacrolimus exposure. Insulin resistance (HoMA-IR) did not change.

CONCLUSIONS

This study shows the need to perform an oral GTT at 60 days and at the end of the first year of renal transplantation to adequately diagnose impaired glucose metabolism.

Differences and similarities in early atherosclerosis between patients with non-alcoholic steatohepatitis and chronic hepatitis B and C

BACKGROUND/AIMS

To compare carotid intima-media thickness (IMT) - an index of early atherosclerosis - among patients with non-alcoholic steatohepatitis (NASH), patients with chronic hepatitis B (HBV) or C (HCV) and control subjects.

METHODS

We studied 60 consecutive patients with biopsy-proven NASH, 60 patients with HCV, 35 patients with HBV, and 60 healthy controls who were comparable for age and sex. Common carotid IMT was measured with ultrasonography in all participants by a single operator blinded to subjects' characteristics.

RESULTS

Carotid IMT measurements were markedly different among the groups; the lowest values were in controls, intermediate in patients with HBV or HCV, and highest in those with NASH (0.84+/-0.1 vs. 0.97+/-0.1 vs. 1.09+/-0.2 vs. 1.23+/-0.2mm, respectively; p<0.001). The marked differences in carotid IMT that were observed among the groups were little affected by adjustment for age, sex, body mass index, smoking, LDL cholesterol, insulin resistance (by homeostasis model assessment) and components of the Adult Treatment Panel III-defined metabolic syndrome. Concordantly, in logistic regression analysis, NASH, HBV and HCV predicted carotid IMT independent of potential confounders.

CONCLUSIONS

These data suggest that NASH, HCV and HBV are strongly associated with early atherosclerosis independent of classical risk factors, insulin resistance and metabolic syndrome components.

Hepatitis C viremia increases the association with type 2 diabetes mellitus in a hepatitis B and C endemic area: an epidemiological link with virological implication

OBJECTIVES

There is growing evidence with regard to the association between hepatitis C virus (HCV) infection and type 2 diabetes mellitus (T2DM). However, the mutual link and related virological implication have not been fully clarified. The impact of hepatitis B virus (HBV) infection on the epidemiological link remains unclear. This study aimed to elucidate the link between T2DM and viral hepatitis infections, especially HCV infection. It also aimed to analyze the associated virological characteristics and implication.

METHODS

Cross-sectional analysis of a computer-sampling survey among 10,975 participants (aged 40-65 yr) was performed in an area endemic for HBV and HCV infections in Taiwan. Outcome measures included prevalence of T2DM among different groups of viral hepatitis infection, and comparison of related biochemical and virological profiles.

RESULTS

Of 10,975 participants studied, 9,932 eligible participants were analyzed. The prevalence of T2DM, seropositivity for HBV surface antigen (HBsAg) and HCV antibodies (anti-HCV), and HCV viremia was 12.5%, 13.1%, 6.5%, and 4.8%, respectively. Prevalence of HCV viremia showed significant difference between T2DM and non-T2DM subjects (6.9% vs 4.5%, P<0.001), whereas anti-HCV seropositivity showed borderline significance (7.8% vs 6.3%, P=0.047). There was no HCV genotype-specific difference between HCV genotype 1 and 2 in the association with T2DM. On the other side, the prevalence of HBsAg (+) did not differ between T2DM and non-T2DM subjects (12.5% vs 13.9%, P=0.19). The prevalence of T2DM among HCV viremic subjects (18.0%, 86/478) was significantly higher than HBsAg (+) subjects (11.4%, 155/1,363, P=0.001) and those negative for both viral hepatitis markers (12.5%, 997/8,004, P=0.001). Multivariate logistic regression analyses showed that HCV viremia was the leading significant factor associated with T2DM, followed by male gender, hypertension, body mass index, and age.

CONCLUSIONS

HBV infection did not increase the association with T2DM. A significant mutual link between T2DM and HCV viremia existed in this HBV/HCV endemic area. There was no HCV genotype-specific difference between HCV genotype 1 and 2 in the association with T2DM.

Long-term care of the liver transplant recipient

As survival increases after liver transplantation, common issues that arise involve immunosuppression-related complications and primary health care. Proper emphasis on the prevention and treatment of post-liver transplant complications, such as diabetes mellitus, dyslipidemia, renal dysfunction, osteoporosis, and obesity, requires careful screening and long-term surveillance to minimize the progression of these complications. Active involvement by internists and subspecialists is necessary and a multidisciplinary approach should be undertaken. Liver transplantation should be viewed as a lifelong commitment by both patient and physician.

Blood gene expression profiling in liver transplant recipients with hepatitis C virus and posttransplantation diabetes mellitus

BACKGROUND

Hepatitis C virus (HCV) is a risk factor for developing posttransplantation diabetes mellitus (PTDM) after liver transplantation; little is known about the biological mechanisms involved with this risk. This study investigated gene expression differences to provide insight into potential mechanisms.

PATIENTS AND METHODS

Gene expression profiles of blood samples obtained from 6 HCV+ liver transplant recipients were determined using Affymetrix U133 Plus 2.0 microarrays. Differential gene expression was assessed between HCV+ recipients with PTDM (n = 3) and without PTDM (n = 3) using the GeneSpring 7.3 software package. The Welch t test was used to identify significant differences (P < .05) between groups. Gene expression profiles for 6 HCV- liver transplant recipients (with PTDM = 3, without PTDM = 3) were used as a blind test set to evaluate a subset of genes to predict PTDM.

RESULTS

Expression levels of 347 genes were significantly different between recipients with PTDM and those without PTDM. Seventy-four genes were up-regulated and 270 were down-regulated in PTDM. Genes were categorized into functional classes: apoptosis (n = 69 genes); immune function (n = 110); diabetes (n = 17); hepatitis C (n = 12); liver transplant (n = 69). The expression profile of a subset of genes was evaluated for predicting PTDM in 6 HCV- transplant recipients. We accurately predicted the presence or absence of PTDM in 5/6 recipients.

CONCLUSIONS

PTDM in HCV+ liver transplant recipients was associated with down-regulated expression of a large number of genes. A subset of these genes was useful to predict PTDM in HCV- recipients. Most genes were associated with apoptosis and immune function. HCV may act as a primer by affecting a group of genes involved in developing diabetes.

New-onset diabetes mellitus after living donor liver transplantation: possible association with hepatitis C

BACKGROUND

The relationship between hepatitis C virus (HCV) infection and new-onset diabetes mellitus (NODM) after liver transplantation is a controversial issue.

METHODS

A total of 223 adult living donor liver transplantation (LDLT) recipients followed for more than 6 months were analyzed for the prevalence of NODM. The prevalence was compared between 62 HCV-positive and 161 HCV-negative patients. All the HCV-positive patients underwent preemptive antiviral treatment with interferon alpha2b and ribavirin.

RESULTS

Preoperative diabetes mellitus was more frequently observed in HCV-positive patients (18% vs 4%, P = .001). NODM occurred more frequently in HCV-positive patients (41% vs 22%, P = .003). Multivariate analysis, however, revealed that HCV was not a predictor for NODM. A comparison of 14 HCV-positive patients with persistent NODM and 48 patients without persistent NODM indicated that there was no significant difference in the frequency of the viral response to antiviral therapy nor in HCV-RNA levels. Impaired glucose tolerance did not impact postoperative survival after LDLT.

CONCLUSIONS

HCV was not associated with the prevalence of NODM after LDLT. NODM did not influence patient survival.

Syndemics, sex and the city: understanding sexually transmitted diseases in social and cultural context

This paper employs syndemics theory to explain high rates of sexually transmitted disease among inner city African American and Puerto Rican heterosexual young adults in Hartford, CT, USA. Syndemic theory helps to elucidate the tendency for multiple co-terminus and interacting epidemics to develop under conditions of health and social disparity. Based on enhanced focus group and in-depth interview data, the paper argues that respondents employed a cultural logic of risk assessment which put them at high risk for STD infection. This cultural logic was shaped by their experiences of growing up in the inner city which included: coming of age in an impoverished family, living in a broken home, experiencing domestic violence, limited expectations of the future, limited exposure to positive role models, lack of expectation of the dependency of others, and fear of intimacy.

Posttransplant diabetes mellitus in liver transplant recipients

CONTEXT

Approximately 20% of liver transplant recipients develop posttransplant diabetes mellitus. Hepatitis C, a leading indication for liver transplantation, has been identified as a risk factor for posttransplant diabetes mellitus and is an observation that is not well described.

OBJECTIVE

To evaluate the incidence of posttransplant diabetes mellitus and risk factors associated with this condition.

DESIGN

A retrospective chart review.

SETTING

A large urban transplant center.

PATIENTS

One hundred fifteen liver transplant recipients who received a transplant between January 1, 1998, and August 31, 2001.

RESULTS

The rate of posttransplant diabetes mellitus, calculated at 3-month intervals in the first year after liver transplantation, ranged from 19.4% to 24.6%, which is similar to the averages reported in most published studies. The cumulative rate of posttransplant diabetes mellitus, which includes all patients who developed this condition during the time studied, was 31.3%. Clinical and demographic factors, including immunosuppression regimens, were similar between patients with and without posttransplant diabetes mellitus. Two risk factors for posttransplant diabetes mellitus were identified: hepatitis C, which was the leading indication for transplantation in this group (54.8%), and cytomegalovirus infection during the first year after transplantation. Other clinical and demographic variables, such as gender, age, ethnicity, rejection episodes, body mass index, and immunosuppression, were not identified as risk factors for posttransplant diabetes mellitus in liver transplant recipients.

The impact of diabetes mellitus on fibrosis progression in patients transplanted for hepatitis C

Despite the recognition of numerous factors for aggressive hepatitis C virus (HCV) recurrence after liver transplantation (LT) our understanding of this phenomenon is incomplete. We tested the hypothesis that diabetes mellitus (DM) was implicated. One hundred sixty-three patients undergoing primary LT for HCV from 1990 to 2004 were evaluated and biopsies were scored according to the modified Ishak score. Severe recurrence of HCV was defined as a fibrosis score > or = 4 within 6 years of LT. Risk factors assessed included recipient, donor and transplant variables. Fifty-four patients (33.1%) had a fibrosis score > or = 4 at the end of the study period. Factors associated with progression to severe fibrosis was donor age (p = 0.008) especially donor age >55 (p = 0.038, HR 2.43), pre-LT DM (p = 0.039, HR 2.68) and DM post-LT (p = 0.004, HR 3.28). The combination of receiving a liver from a donor older than 55 years and having DM post-LT was associated with an 8.38-fold risk of progression to severe fibrosis (p = 0.000124) when compared to patients not diabetic post-LT who received livers from donors aged <55 years. These data indicate that diabetic status is one of the more important variables determining the severity of HCV recurrence and is synergistic with donor age. This observation may provide an additional management opportunity to modify the impact of HCV recurrence.