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Chaitou AR, Valmiki S, Valmiki M, Zahid M, Aid MA, Fawzy P, Khan S. New-Onset Diabetes Mellitus (NODM) After Liver Transplantation (LT): The Ultimate Non-diabetogenic Immunosuppressive Therapy. Cureus 2022; 14:e23635. [PMID: 35510006 PMCID: PMC9057316 DOI: 10.7759/cureus.23635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 03/29/2022] [Indexed: 11/05/2022] Open
Abstract
New-onset diabetes mellitus (NODM) is a common long-term complication after liver transplantation (LT). It is thought to be drug-induced in most cases, no matter the underlying disease that cause liver failure and indicated transplantation. Standard post-transplantation (PT) immunosuppressive regimens include prolonged use of calcineurin inhibitors (CNIs), namely tacrolimus (TAC), alongside corticosteroids to avoid acute and chronic graft rejection. This combination is well known for its diabetogenicity. Significant differences between the applied regimens stand out concerning the duration and dosages to prevent the metabolic side effects of these drugs in the long run without compromising the graft's survival. Studies were collected after an extensive research of PubMed database for this very specific topic using the following MeSH keywords in multiple combinations: "Liver Transplantation," "Diabetes Mellitus," "NODM," "Tacrolimus," "Cyclosporine A," and "Steroids." In addition, we used the same keywords for regular searches in Google Scholar. Only the relevant English human studies between 2010 and 2020 were collected except for review articles. Duplicates were eliminated using Mendeley software. Twelve relevant studies directly related to the targeted topic were collected and discussed, including five retrospective cohorts, four prospective cohorts, one clinical trial, one prospective pilot, and one case report. Their topics included primarily the factors increasing the risk of new-onset diabetes mellitus after liver transplantation (NODALT), TAC-based immunosuppression and its relative blood levels affecting the possible development of NODALT, the role of cyclosporine in substituting TAC regimen, and the effect of different steroids-avoiding protocols on the prevention of NODALT. The reviewed studies suggested that lowering the serum concentration of tacrolimus (cTAC) throughout the PT period and eliminating the corticosteroids regimen as early as possible, among other measures, can significantly impact the rate of emergence of NODM. This traditional review tackles the most recent studies about NODALT to establish a comprehensive view on this issue and guide clinicians and researchers for the safest immunosuppressive regimen to date, while maintaining a balanced metabolic profile.
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Shen T, Zhuang L, Sun XD, Qi XS, Wang ZH, Li RD, Chang WX, Yang JY, Yang Y, Zheng SS, Xu X. Expert consensus on management of metabolic disease in Chinese liver transplant recipients. World J Gastroenterol 2020; 26:3851-3864. [PMID: 32774062 PMCID: PMC7385566 DOI: 10.3748/wjg.v26.i27.3851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/28/2020] [Accepted: 07/04/2020] [Indexed: 02/06/2023] Open
Abstract
Metabolic disease, including diabetes mellitus, hypertension, dyslipidemia, obesity, and hyperuricemia, is a common complication after liver transplantation and a risk factor for cardiovascular disease and death. The development of metabolic disease is closely related to the side effects of immunosuppressants. Therefore, optimization of the immunosuppressive regimen is very important for the prevention and treatment of metabolic disease. The Chinese Society of Organ Transplantation has developed an expert consensus on the management of metabolic diseases in Chinese liver transplant recipients based on recent studies. Emphasis is placed on the risk factors of metabolic diseases, the effect of immunosuppressants on metabolic disease, and the prevention and treatment of metabolic diseases.
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Affiliation(s)
- Tian Shen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310003, Zhejiang Province, China
| | - Xiao-Dong Sun
- Department of Hepatobiliary and Pancreas Surgery, The First Hospital, Jilin University, Changchun 130021, Jilin Province, China
| | - Xiao-Sheng Qi
- Department of General Surgery, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Zhi-Hui Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Rui-Dong Li
- Department of General Surgery and Liver Transplant Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Wen-Xiu Chang
- Department of Nephrology, Tianjin First Center Hospital, Tianjin 300384, China
| | - Jia-Yin Yang
- Department of Liver Surgery and Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yang Yang
- Department of Hepatic Surgery and Liver Transplantation Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310003, Zhejiang Province, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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De Marchi U, Fernandez-Martinez S, de la Fuente S, Wiederkehr A, Santo-Domingo J. Mitochondrial ion channels in pancreatic β-cells: Novel pharmacological targets for the treatment of Type 2 diabetes. Br J Pharmacol 2020; 178:2077-2095. [PMID: 32056196 PMCID: PMC8246559 DOI: 10.1111/bph.15018] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/29/2020] [Accepted: 01/31/2020] [Indexed: 12/18/2022] Open
Abstract
Pancreatic beta‐cells are central regulators of glucose homeostasis. By tightly coupling nutrient sensing and granule exocytosis, beta‐cells adjust the secretion of insulin to the circulating blood glucose levels. Failure of beta‐cells to augment insulin secretion in insulin‐resistant individuals leads progressively to impaired glucose tolerance, Type 2 diabetes, and diabetes‐related diseases. Mitochondria play a crucial role in β‐cells during nutrient stimulation, linking the metabolism of glucose and other secretagogues to the generation of signals that promote insulin secretion. Mitochondria are double‐membrane organelles containing numerous channels allowing the transport of ions across both membranes. These channels regulate mitochondrial energy production, signalling, and cell death. The mitochondria of β‐cells express ion channels whose physio/pathological role is underappreciated. Here, we describe the mitochondrial ion channels identified in pancreatic β‐cells, we further discuss the possibility of targeting specific β‐cell mitochondrial channels for the treatment of Type 2 diabetes, and we finally highlight the evidence from clinical studies. LINKED ARTICLES This article is part of a themed issue on Cellular metabolism and diseases. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.10/issuetoc
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Affiliation(s)
| | - Silvia Fernandez-Martinez
- Division of Clinical Pharmacology and Toxicology, Centre de Recherche Clinique, HUG, Genève, Switzerland
| | - Sergio de la Fuente
- Center for Translational Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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Shao L, Jin J, Ye B, Xu B, Li Y, Gong J, Zhang J, Chen M, He Q. New-Onset Diabetes Mellitus in Patients with Idiopathic Membranous Nephropathy Undergoing Tacrolimus and Low-Dose Corticosteroid Therapy. Kidney Blood Press Res 2019; 44:1352-1362. [PMID: 31645044 DOI: 10.1159/000502693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 08/12/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is the most common cause of nephrotic syndrome in adults. Although various studies have demonstrated the efficacy of tacrolimus combined with corticosteroids for treating IMN, both tacrolimus and corticosteroids have been shown to be diabetogenic, particularly following organ transplantation. Furthermore, the frequency and risk factors for new-onset diabetes mellitus (NODM) in IMN patients treated with tacrolimus plus low-dose corticosteroids remain unclear. OBJECTIVES To evaluate the incidence of NODM in IMN patients undergoing tacrolimus plus low-dose corticosteroid therapy and to confirm the risk factors for NODM development. METHODS This retrospective study recruited 72 eligible patients with biopsy-proven IMN from our center, between September 2013 and June 2018. All subjects were treated with tacrolimus plus low-dose corticosteroids for a minimum of 3 months. The primary outcome was NODM development during the follow-up period. The secondary outcome was complete or partial remission. Patients were divided into 2 groups: patients with NODM (NODM group) and those without NODM (No-NODM group). Demographic and clinical data at baseline and follow-up were assessed. RESULTS During follow-up, 31 of the 72 patients developed NODM (43.0%). The median time to occurrence was 3 months after treatment initiation. NODM patients were significantly older (median age 59 vs. 40 years) than No-NODM patients. Baseline fasting blood glucose levels were slightly higher in the NODM group; however, the difference was not significant (p = 0.07). Older age was an independent risk factor for NODM (OR 1.73 and 95% CI 1.20-2.47, p = 0.003). Overall kidney remission rates were 80.6%. There was no significant difference in remission rate between groups. There was a significant difference in development of pulmonary infection, which occurred in 7 NODM patients and only in 1 No-NODM patient (p = 0.018). IMN reoccurred in 5 NODM patients but only 1 No-NODM patient. CONCLUSIONS Tacrolimus plus low-dose corticosteroid therapy was an efficient treatment for IMN; however, it was accompanied by increased NODM morbidity, which should be considered serious, due to the increased risk of life-threatening complications. Increasing age was a major risk factor for NODM in IMN patients treated with tacrolimus plus low-dose corticosteroid therapy.
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Affiliation(s)
- Lina Shao
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Juan Jin
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Binxian Ye
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Baihui Xu
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Yiwen Li
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Jianguang Gong
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Jiong Zhang
- Nephrology National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Maosheng Chen
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China.,People's Hospital of Hangzhou Medical College, Hangzhou, China.,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China, .,People's Hospital of Hangzhou Medical College, Hangzhou, China, .,Chinese Medical Nephrology Key Laboratory of Zhejiang Province, Hangzhou, China,
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Lancia P, Aurich B, Ha P, Maisin A, Baudouin V, Jacqz-Aigrain E. Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children. Clin Drug Investig 2018; 38:157-171. [PMID: 29236209 DOI: 10.1007/s40261-017-0594-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics. METHODS This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4. RESULTS One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics. CONCLUSIONS The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.
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Affiliation(s)
- Pauline Lancia
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Beate Aurich
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Phuong Ha
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Paris, France. .,Paris Diderot University, Sorbonne Paris Cité, Paris, France.
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Wissing KM, Abramowicz D, Weekers L, Budde K, Rath T, Witzke O, Broeders N, Kianda M, Kuypers DRJ. Prospective randomized study of conversion from tacrolimus to cyclosporine A to improve glucose metabolism in patients with posttransplant diabetes mellitus after renal transplantation. Am J Transplant 2018; 18:1726-1734. [PMID: 29337426 DOI: 10.1111/ajt.14665] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/22/2017] [Accepted: 01/07/2018] [Indexed: 02/06/2023]
Abstract
Tacrolimus (TAC) increases the risk of posttransplant diabetes (PTDM) compared with cyclosporine A (CYC). The present 12-month, multicenter, investigator-driven, prospective, randomized study was designed to assess whether conversion from tacrolimus to CYC can reverse PTDM after renal transplantation. Predominantly white patients with PTDM according to the 2005 American Diabetes Association criteria were randomized to either replacement of TAC with CYC or continuation of their TAC-based regimen after stratification for type of glucose-lowering therapy, steroid therapy, and hepatitis C status. At 12 months, 14 of 41 patients with complete data in the CYC arm (34%; 95%CI 19%-49%) were free of diabetes, whereas this was the case in only 4 of 39 patients (10%; 95%CI 3%-20%) in the TAC arm (P = .01). At 12 months, 39% of patients in the CYC arm were off glucose-lowering medication vs 13% of patients in the TAC arm (P = .01). The CYC group decreased glycated hemoglobin level during the 12-month follow-up, resulting in significantly lower levels compared with the TAC group (6.0 ± 0.9% vs 7.1 ± 1.7% at 12 months; P = .002). In conclusion, replacement of TAC with CYC significantly improves glucose metabolism and has the potential to reverse diabetes during the first year after conversion. (EU Clinical Trials Register No. 2006-001765-42).
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Affiliation(s)
- Karl M Wissing
- Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Universitair Ziekenhuis Antwerpen, Antwerpen, Belgium
| | - Laurent Weekers
- Department of Nephrology, Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Rath
- Department of Nephrology, Westpfalz Klinikum Kaiserslautern, Kaiserslautern, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nilufer Broeders
- Department of Nephrology, Centre Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Mireille Kianda
- Department of Nephrology, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Lancia P, Adam de Beaumais T, Elie V, Garaix F, Fila M, Nobili F, Ranchin B, Testevuide P, Ulinski T, Zhao W, Deschênes G, Jacqz-Aigrain E. Pharmacogenetics of post-transplant diabetes mellitus in children with renal transplantation treated with tacrolimus. Pediatr Nephrol 2018; 33:1045-1055. [PMID: 29399716 DOI: 10.1007/s00467-017-3881-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is a major complication of immunosuppressive therapy, with many risk factors reported in adults with renal transplantation. The objective of this study was to investigate potential non-genetic and genetic risk factors of PTDM in children with renal transplantation treated with tacrolimus. METHODS A national database was screened for patients developing PTDM within 4 years following tacrolimus introduction. PTDM was defined as glucose disorder requiring anti-diabetic treatment. PTDM patients were matched to "non-PTDM" control transplanted children according to age, gender, and duration of post-transplant follow-up. Patients were genotyped for six selected genetic variants in POR*28 (rs1057868), PPARa (rs4253728), CYP3A5 (rs776746), VDR (rs2228570 and rs731236), and ABCB1 (rs1045642) genes, implicated in glucose homeostasis and tacrolimus disposition. RESULTS Among the 98 children with renal transplantation enrolled in this multicentre study, 18 developed PTDM. None of the clinical and biological parameters was significant between PTDM and control patients. Homozygous carriers of POR*28 or wild-type ABCB1 (rs1045642) gene variants were more frequent in PTDM than in control patients with differences close to significance (p = 0.114 and p = 0.066 respectively). A genetic score based on these variants demonstrated that POR*28/*28 and ABCB1 CC or CT genotype carriers were at a significantly higher risk of developing PTDM after renal transplantation. CONCLUSION Identification of PTDM risk factors should allow clinicians to allocate the best immunosuppressant for each patient with renal transplantation, and improve care for patients who are at a higher risk.
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Affiliation(s)
- Pauline Lancia
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Tiphaine Adam de Beaumais
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Valéry Elie
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Florentine Garaix
- Department of Pediatric Nephrology, CHU La Timone, APHM, 264 rue Saint Pierre, 13005, Marseille, France
| | - Marc Fila
- Department of Pediatric Nephrology, Arnaud de Villeneuve Hospital, 371 avenue du Doyen Gaston Giraud, 34090, Montpellier, France
| | - François Nobili
- Department of Pediatric Nephrology, Saint Jacques Hospital, 2 Place Saint Jacques, 25000, Besançon, France
| | - Bruno Ranchin
- Department of Pediatric Nephrology, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron, France
| | - Pascale Testevuide
- Department of Pediatric Nephrology, Territorial Hospital Center, Papeete, Polynésie Française, France
| | - Tim Ulinski
- Department of Pediatric Nephrology, Armand Trousseau Hospital, APHP, 26 rue du Dr Arnold Netter, 75012, Paris, France
| | - Wei Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France.,Clinical Investigation Center CIC1426, INSERM, Robert Debré Hospital, 48 boulevard Serurier, 75019, Paris, France.,Paris Diderot University Sorbonne Paris Cité, Paris, France
| | - Georges Deschênes
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, 48 boulevard Serurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Robert Debré Hospital, 48 boulevard Serurier, 75019, Paris, France. .,Paris Diderot University Sorbonne Paris Cité, Paris, France.
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Liu FC, Lin HT, Lin JR, Yu HP. Impact of immunosuppressant therapy on new-onset diabetes in liver transplant recipients. Ther Clin Risk Manag 2017; 13:1043-1051. [PMID: 28860788 PMCID: PMC5571855 DOI: 10.2147/tcrm.s142348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This nationwide, population-based study aimed to clarify the effects of immunosuppressive regimens on new-onset diabetes after liver transplantation (NODALT). The National Health Insurance database of Taiwan was explored for patients who received liver transplantation without pre-transplant diabetes from 1998 to 2012. Information regarding clinical conditions and immunosuppressant utilization among these patients was analyzed statistically. Of the 2,140 patients included in our study, 189 (8.8%) developed NODALT. The pre-transplant risk factors for NODALT were identified as old age, male sex, hepatitis C, alcoholic hepatitis, and immunosuppressant use of tacrolimus (TAC). All patients used corticosteroids as a baseline immunosuppressant. The immunosuppressant regimen of cyclosporine (CsA)+TAC+mycophenolate mofetil (MMF) contributed most to NODALT (adjusted hazard ratio 7.596) in comparison with the regimens of TAC+MMF and CsA+MMF; this regimen also contributed significantly to higher post-transplant bacteremia, urinary tract infection, pneumonia, renal failure, and mortality rate. In conclusion, our analysis confirmed TAC-based immunosuppression contributes to higher NODALT incidence than CsA-based regimen, and TAC-CsA conversion due to any causes might lead to worse clinical outcomes. Clinicians should make better risk stratifications before prescribing immunosuppressants for liver transplant recipients.
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Affiliation(s)
- Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine
| | - Huan-Tang Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine
| | - Jr-Rung Lin
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine.,Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine
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9
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Modification of immunosuppressive therapy as risk factor for complications after liver transplantation. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624108 DOI: 10.1016/j.bpg.2017.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Management of complications post-liver transplantation (LT) includes immunosuppressive manipulations with the aim to reduce the overall burden of immunologic suppression and compensate for renal, cardiovascular, metabolic toxicities, and for the increased oncologic risk. Two approaches can be implemented to reduce immunosuppression-related adverse events: upfront schedules tailored to the pretransplant individual patient's risk profile versus downstream modifications in the event of immunosuppression-related complications. Upfront strategies are supported by evidence originating from prospective randomized trials and consist of triple/quadruple schedules whereby calcineurin inhibitors (CNI)-exposure is reduced with combination of anti-CD25 monoclonal antibodies, antimetabolites and corticosteroids. Quadruple regimens allow for staggering of CNI introduction and higher renal function in the early term, but their superiority in the long term has not yet been established. A more recent upfront schedule contemplates early (4 weeks) introduction of mammalian target of rapamycin inhibitor (mTORi) everolimus and allows for reduction of CNI up to 4 years posttransplantation. Incorporation of mTORi has the potential to prolong time to recurrence for patients with hepatocellular carcinoma. However, as suggested by the available evidence, downstream immunosuppressive manipulations are more frequently adopted in clinical practice. These encompass CNI replacement and immunosuppression withdrawal. Switching CNI to mTORi monotherapy is the option most commonly adopted to relieve renal function and compensate for posttransplant malignancies. Its impact is dependent on interval from transplantation and underlying severity of renal impairment. Introduction of mTORi is associated with longer overall survival for patients with extrahepatic posttransplant malignancies, but results are awaited for recurrences of hepatocellular carcinoma. Immunosuppression withdrawal seems feasible (70%) in very long term survivors (>10 years), but is not associated with reversal of immunosuppression-related complications. Awaiting novel immunosuppressive drug categories, integration of upfront strategies with the aim to reduce CNI-exposure and a low threshold for adjustment in the posttransplant course are both advisable to improve long-term outcomes of LT.
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10
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Herzer K, Strassburg CP, Braun F, Engelmann C, Guba M, Lehner F, Nadalin S, Pascher A, Scherer MN, Schnitzbauer AA, Zimmermann T, Nashan B, Sterneck M. Selection and use of immunosuppressive therapies after liver transplantation: current German practice. Clin Transplant 2016; 30:487-501. [PMID: 26855333 DOI: 10.1111/ctr.12708] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/01/2023]
Abstract
In recent years, immunosuppression (IS) after liver transplantation (LT) has become increasingly diversified as the choice of agents has expanded and clinicians seek to optimize the balance of immunosuppressive potency with the risk of adverse events in individual patients. Calcineurin inhibitors (CNIs) are the primary agents used for patients undergoing liver transplantation. Other therapeutic agents like interleukin-2 receptor antagonists are not universally administered, but can be considered for the delay or reduction in CNI exposure. An early addition of mycophenolate mofetil (MMF) or the mTOR inhibitor everolimus also allows for the reduction in the CNI dose. To reduce the risk of malignancy, in particular of skin tumors, as well as to prevent the deterioration of renal function, everolimus-based therapy may be advantageous. Apart from patients with autoimmune hepatitis, steroids are withdrawn within 3-6 months after transplantation. Overall, immunosuppression can only be standardized in a limited proportion of patients due to specific clinical requirements and risk factors. Future studies should attempt to refine accurate individualization of the immunosuppressive regimen in specific difficult-to-treat patient subpopulations.
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Affiliation(s)
- Kerstin Herzer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Felix Braun
- Department for Transplantation Surgery, University Hospital Kiel, Kiel, Germany
| | - Cornelius Engelmann
- Department for Gastroenterology and Rheumatology, Section Hepatology, University of Leipzig, Leipzig, Germany
| | - Markus Guba
- Department for Transplant Surgery, University Hospital Munich, Munich, Germany
| | - Frank Lehner
- Department for Transplant Surgery, University Hospital Hannover, Hannover, Germany
| | - Silvio Nadalin
- Department for General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Andreas Pascher
- Department of Visceral and Transplant Surgery, Charite-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus N Scherer
- Department for General-, Visceral- and Transplant Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, Frankfurt University Hospitals, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Tim Zimmermann
- Department for Gastroenterology and Hepatology, University Hospital Mainz, Mainz, Germany
| | - Björn Nashan
- Department for Hepatobiliary Surgery and Transplantation, University Hospital Hamburg, Hamburg, Germany
| | - Martina Sterneck
- University Transplant Center, University Hospital Hamburg, Hamburg, Germany
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11
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Loria P, Marchesini G, Nascimbeni F, Ballestri S, Maurantonio M, Carubbi F, Ratziu V, Lonardo A. Cardiovascular risk, lipidemic phenotype and steatosis. A comparative analysis of cirrhotic and non-cirrhotic liver disease due to varying etiology. Atherosclerosis 2014; 232:99-109. [PMID: 24401223 DOI: 10.1016/j.atherosclerosis.2013.10.030] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
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12
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Wissing KM, Pipeleers L. Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: prevention and treatment. Transplant Rev (Orlando) 2013; 28:37-46. [PMID: 24507957 DOI: 10.1016/j.trre.2013.12.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/18/2013] [Indexed: 02/06/2023]
Abstract
The prevalence of the metabolic syndrome in dialysis patients is high and further increases after transplantation due to weight gain and the detrimental metabolic effects of immunosuppressive drugs. Corticosteroids cause insulin resistance, hyperlipidemia, abnormal glucose metabolism and arterial hypertension. The calcineurin inhibitor tacrolimus is diabetogenic by inhibiting insulin secretion, whereas cyclosporine causes hypertension and increases cholesterol levels. Mtor antagonists are responsible for hyperlipidemia and abnormal glucose metabolism by mechanisms that also implicate insulin resistance. The metabolic syndrome in transplant recipients has numerous detrimental effects such as increasing the risk of new onset diabetes, cardiovascular disease events and patient death. In addition, it has also been linked with accelerated loss of graft function, proteinuria and ultimately graft loss. Prevention and management of the metabolic syndrome are based on increasing physical activity, promotion of weight loss and control of cardiovascular risk factors. Bariatric surgery before or after renal transplantation in patients with body mass index >35 kg/m(2) is an option but its long term effects on graft and patient survival have not been investigated. Steroid withdrawal and replacement of tacrolimus with cyclosporine facilitate control of diabetes, whereas replacement of cyclosporine and mtor antagonists can improve hyperlipidemia. The new costimulation inhibitor belatacept has potent immunosuppressive properties without metabolic adverse effects and will be an important component of immunosuppressive regimens with better metabolic risk profile. Medical treatment of cardiovascular risk factors has to take potential drug interactions with immunosuppressive medication and drug accumulation due to renal insufficiency into account.
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Affiliation(s)
- Karl Martin Wissing
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Nephrology and Dialysis Clinic, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Lissa Pipeleers
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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13
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Lankarani KB, Eshraghian A, Nikeghbalian S, Janghorban P, Malek-Hosseini SA. New onset diabetes and impaired fasting glucose after liver transplant: risk analysis and the impact of tacrolimus dose. EXP CLIN TRANSPLANT 2013; 12:46-51. [PMID: 23902591 DOI: 10.6002/ect.2013.0047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES New onset diabetes mellitus after transplant is one of the major metabolic complications after liver transplant. Development of impaired fasting glucose after liver transplant is thought to be associated with increased risk of cardiovascular mortality and has not been well studied before. The aim of this study was to evaluate incidence and risk factors of new onset diabetes mellitus after transplant and impaired fasting glucose in liver transplant patients. MATERIALS AND METHODS In a cross-sectional study, all adult patients (aged≥18 years) who were transplanted because of chronic liver diseases from June 2002 to September 2010 at Shiraz Liver Transplant Center were evaluated for developing diabetes and impaired fasting glucose. RESULTS Totally, 86 patients (18.81%) were found to have diabetes after liver transplant. Forty patients (27 men and 13 women; 8.75%) developed new onset diabetes mellitus after transplant and 36 patients (7.87%) developed impaired fasting glucose after liver transplant. The mean age of patients with new onset diabetes mellitus after transplant was higher than that of nondiabetic patients (P = .001). Mean fasting plasma glucose before liver transplant was significantly higher in diabetic patients compared with nondiabetic patients (P = .002) (5.20±0.93 mmol/L vs 4.44±0.56 mmol/L) (93.86±16.80 mg/dL vs 80±10.14 mg/dL). Patients with new onset diabetes mellitus after transplant received higher doses of tacrolimus as immunosuppressive medication than nondiabetic patients (P = .001). CONCLUSIONS Fasting plasma glucose before transplant can predict development of new onset diabetes mellitus after transplant. Age and tacrolimus dosage are independent risk factors for new onset diabetes mellitus after transplant in our patients.
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Affiliation(s)
- Kamran Bagheri Lankarani
- Health Policy Research Center, Namazi Hospital, Shiraz University of Medical Science, Shiraz, Iran
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14
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Tian YF, Tsai CS, Lee PC, Chu SH, Chien YS, Loong CC, Chen CH, Wu MS, Chu SH, Lian JD. New-onset diabetes mellitus in cyclosporine-treated organ transplant patients in Taiwan: interim analysis (6 months) of postmarketing surveillance. Transplant Proc 2012; 44:661-6. [PMID: 22483463 DOI: 10.1016/j.transproceed.2012.01.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Posttransplant new-onset diabetes mellitus (NODM) is an important complication among patients receiving immunosuppressants. It has a considerable impact on chronic allograft dysfunction. Calcineurin inhibitors have been implicated in the development of posttransplant NODM. Since high-risk candidates also undergo transplantation, prevention and control of posttransplant NODM is important. A 3-year postmarketing surveillance study is currently underway in Taiwan to evaluate the incidence and risk factors leading to development of NODM among de novo and maintenance solid-organ transplant patients receiving cyclosporine (CsA)-based immunosuppressive therapy. Concomitant therapy consisted of basiliximab, mycophenolate mofetil or enteric-coated mycophenolate sodium, and corticosteroids. Diabetes was diagnosed according to the American Diabetes Association criteria. This 6-month protocol-defined interim analysis included 101 patients (84 de novo, 17 maintenance) who received renal (n = 77), liver (n = 13), or heart (n = 11) transplantation. At the end of 6 months, 8/101 (7.92%) patients experienced NODM. The mean time to NODM was 3.05 months. No significant difference was observed between NODM and non-NODM patients for risk factors: age, body mass index, blood pressure, gender, high-density lipoproteins/triglycerides hdl/tg, and anti-hepatitis C virus. The composite endpoint of biopsy-proven acute rejection, graft loss, or death was reached in four patients, with a mean time to event of 3.81 months. Infections were noted in 34 subjects but, no malignancies. Among 389 adverse events reported in 91 patients (90.1%), the majority were of mild to moderate severity. Two deaths were reported: heart transplant recipients with acute rejection and cytomegalovirus meningitis with respiratory failure. Long-term enrollment with follow-up evaluation of these NODM patients up to 3 years will help evaluate the NODM incidence rates and exact graft survival and overall survival rates of CsA-treated transplant patients in Taiwan.
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Affiliation(s)
- Y-F Tian
- Division of General Surgery, Chi Mei Medical Center, Chia Nan University of Pharmacy & Science, Tainan, Taiwan
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