Kidney Transplantation in Type 2 Diabetic Patients: A Matched Survival Analysis

Influence of diabetes and other risk factors on in-hospital mortality following kidney transplantation: an analysis of the Spanish National Hospital Discharge Database from 2016 to 2020

INTRODUCTION

To assess time trends in incidence, clinical characteristics, complications, and hospital outcomes among patients with type 1 diabetes (T1D), with type 2 diabetes (T2D), and patients without diabetes who underwent kidney transplant (KT); to identify variables associated with in-hospital mortality (IHM); and to determine the impact of the COVID-19 pandemic.

RESEARCH DESIGN AND METHODS

We used a nationwide discharge database to select KT recipients admitted to Spanish hospitals from 2016 to 2020. We stratified patients according to diabetes status. We used multivariable logistic regression to identify the variables associated with IHM.

RESULTS

A total of 14 594 KTs were performed in Spain (T2D, 22.28%; T1D, 3.72%). The number of KTs rose between 2016 and 2019 and and decreased from 2019 to 2020 in all groups. In patients with T2D, the frequency of KT complications increased from 21.08% in 2016 to 34.17% in 2020 (p<0.001). Patients with T2D had significantly more comorbidity than patients with T1D and patients without diabetes (p<0.001). Patients with T1D experienced KT rejection significantly more frequently (8.09%) than patients with T2D (5.57%).COVID-19 was recorded in 26 out of the 2444 KTs performed in 2020, being found in 6 of the 39 patients deceased that year (15.38%) and in 0.83% of the survivors.The variables associated with IHM were comorbidity and complications of KT. The presence of T1D was associated with IHM (OR 2.6; 95% CI 1.36 to 5.16) when patients without diabetes were the reference category. However, T2D was not associated with a higher IHM (OR 0.86; 95% CI 0.61 to 1.2).

CONCLUSIONS

The COVID-19 pandemic led to a decrease in the number of transplants. Patients with T1D have more rejection of the transplanted organ than patients with T2D. Fewer women with T2D undergo KT. The presence of T1D is a risk factor for IHM.

A Comparative Study on Graft and Overall Survival Rates Between Diabetic and Nondiabetic Kidney Transplant Patients Through Survival Analysis

Background

Patients with diabetes mellitus (DM) have worse graft and overall survival, but recent evidence suggests that the difference is no longer significant.

Objective

To compare the outcomes between patients with end-stage kidney disease due to DM (ESKD-DM) and ESKD due to nondiabetic etiology (ESKD-non-DM) who underwent kidney transplantation (KT) up to 10 years of follow-up.

Design

Survival analysis of a retrospective cohort.

Setting and Patients

All patients who underwent KT at the Hospital Universitario San Ignacio, Colombia, between 2004 and 2022.

Measurements

Overall and graft survival in ESKD-DM and ESKD-non-DM who received KT. Patients who died with functional graft were censored for the calculation of kidney graft survival.

Methods

Log-rank test, Cox proportional hazards model, and competing risk analysis were used to compare overall and graft survival in patients with ESKD-DM and ESKD-non-DM who underwent KT.

Results

A total of 375 patients were included: 60 (16%) with ESKD-DM and 315 (84%) with ESKD-non-DM. Median follow-up was 83.3 months. Overall survival was lower in patients with ESKD-DM at 5 (75.0% vs 90.8%, P < .001) and 10 years (55.0% vs 86.7%, P < .001). Cardiovascular death was higher in patients with diabetes (27.3% vs 8.2%, P = .021). Death-censored graft survival was similar in both groups (96.7% vs 93.3% at 5 years, P = .324). On multivariate analysis, the factors associated with global survival were DM (hazard ratio [HR] = 2.11, 95% confidence interval [CI] = 1.23-3.60, P = .006), recipient age (HR = 1.05, 95% CI = 1.02-1.08, P < .001), delayed graft function (HR = 2.07, 95% CI = 1.24-3.46, P = .005), and donor age (HR = 1.03, 95% CI = 1.01-1.05, P = .002). In the competing risk analysis, DM was associated with mortality only in the cardiovascular death group (sub-hazard ratio [SHR] = 6.06, 95% CI = 1.01-36.4, P = .049).

Limitations

Change in diabetes treatment received over time and adherence to glycemic targets were not considered. The sample size is relatively small, which limits the precision of our estimates. The Kidney Donor Profile Index and the occurrence of treated acute rejection were not included in the regression models.

Conclusion

Overall survival is lower in patients with diabetes, possibly due to older age and cardiovascular comorbidities. Therefore, patients with diabetes should be followed more closely to control cardiovascular risk factors. However, there is no difference in graft survival.

Cardiovascular Outcomes in De Novo Kidney Transplant Recipients Receiving Everolimus and Reduced Calcineurin Inhibitor or Standard Triple Therapy: 24-month Post Hoc Analysis From TRANSFORM Study

BACKGROUND

The comparative impact of everolimus (EVR)-based regimens versus standard of care (mycophenolic acid+standard calcineurin inhibitor [MPA+sCNI]) on cardiovascular outcomes in de novo kidney transplant recipients (KTRs) is poorly understood. The incidence of major adverse cardiac events (MACEs) in KTRs receiving EVR+reduced CNI (rCNI) or MPA+sCNI from the TRANSplant eFficacy and safety Outcomes with an eveRolimus-based regiMen study was evaluated.

METHODS

The incidence of MACE was determined for all randomized patients receiving at least 1 dose of the study drug. Factors associated with MACEs were determined by logistic regression. Risk of MACE out to 3 y post-study was calculated using the Patient Outcome in Renal Transplantation equation.

RESULTS

MACE occurred in 81 of 1014 (8.0%; EVR+rCNI) versus 89 of 1012 (8.8%; MPA+sCNI) KTRs (risk ratio, 0.91 [95% confidence interval [CI], 0.68-1.21]). The incidence of circulatory death, myocardial infarction, revascularization, or angina was similar between the arms. Incidence of MACE was similar between EVR+rCNI and MPA+sCNI arms with a higher incidence in prespecified risk groups: older age, pretransplant diabetes (15.1% versus 15.9%), statin use (8.5% versus 10.8%), and low estimated glomerular filtration rate (Month 2 estimated glomerular filtration rate <30 versus >60 mL/min/1.73 m 2 ; odds ratio, 2.23 [95% CI, 1.02-4.86]; P = 0.044), respectively. Predicted risk of MACE within 3 y of follow-up did not differ between the treatment arms.

CONCLUSIONS

Cardiovascular morbidity and mortality were similar between de novo KTRs receiving EVR+rCNI and MPA+sCNI. EVR+rCNI is a viable alternative to the current standard of care in KTRs.

Outcome of Renal Transplantation in Patients With Diabetes Mellitus: A Single-Center Experience

BACKGROUND

An increasing proportion of kidney recipients have diabetes mellitus (DM). Some concerns have been raised about the kidney transplantation results in diabetic patients. Therefore, we assessed the effect of DM on morbidity and mortality of diabetic patients with renal transplantation.

METHODS

We retrospectively studied adult patients with and without DM who underwent living donor transplantation between 2007 and 2016. Information concerning demographic and clinical data were retrospectively analyzed by reviewing the patient files.

RESULTS

Of the 1536 transplant recipients, 126 (8%) had diabetes mellitus (mean age 49.4 ± 11.8) and 525 patients were evaluated in the non-diabetic control group (mean age 36.2 ± 15.9). The diabetic and non-diabetic patient groups had a mean follow-up after kidney transplantation 42.5 months (0.27-101.7 months) and 58.8 ± 10.6 months, respectively. In the diabetic patient group, only 3 patients had lost graft and 13 patients were exitus. Three patients had lost graft and 5 patients were exitus in non-diabetic patient group. Cardiac death (54.5%) was the most common cause of mortality in diabetic group. The 6-year patient and graft survival rates are 84.9% and 95.3%; 97.5% and 97.2% in the diabetic and non-diabetic patient groups, respectively.

CONCLUSIONS

Both infection and cardiovascular diseases increase morbidity and mortality in renal transplant patients with diabetes mellitus. The mortality risk of diabetic patients after renal transplantation is higher than the non-diabetic kidney recipients. Therefore, diabetic patients need meticulous cardiac evaluation before renal transplantation and a close follow-up, in terms of infection, after transplantation.

Survival Rate of Renal Transplant and Factors Affecting Renal Transplant Failure

OBJECTIVES

The most important complication in kidney transplant is acute/chronic rejection. In this study, we investigated the factors affecting kidney rejection and transplant survival.

MATERIALS AND METHODS

In this survival analysis study, 352 patients (mean follow-up of 12.9 ± 4.4 years) who underwent renal biopsy due to increased creatinine level from 2012 to 2016 were identified by glomerular filtration rate level and rejection. Probable factors affecting renal function and survival rate after transplant rejection were assessed. P < .05 was considered as significant.

RESULTS

Among our study patients, 40.9% developed early and 59.1% developed late acute kidney injury. Graft survival rates at 1 and 5 years were 98.9% and 68.5%, respectively, which was significant when rejection type was considered (P = .002). In addition, patient survival rates at 1 and 5 years were 99.7% and 98.6%, respectively. Graft survival at 5 years was significantly lower among older subjects, those with diabetes, those who received deceased donor organs, and those with late acute kidney injury (P < .002). Patient survival was significantly higher among young patients, those with systemic lupus erythematosus, those who received living donor organs, and those without cytomegalovirus infection (P < .003).

CONCLUSIONS

We observed that recipient age, type of donor, underlying disease, infection, and late acute kidney injury had great negative impacts on renal dysfunction and survival. In our center, because of the large number of kidney transplants from deceased donors, the necessity of antithymocyte globulin induction therapy was considered, since this study showed that patients who received rabbit antithymocyte globulin induction had better outcomes.

Transplant Prognosis in Kidney Transplant Recipients with Diabetes under Mycophenolic Acid-Focused Therapeutic Drug Monitoring

Mycophenolate mofetil is a key immunosuppressant that is metabolized into mycophenolic acid (MPA). The prognostic impact of MPA-focused therapeutic drug monitoring on allograft prognosis has not been determined in kidney transplant recipients with diabetes. In this study, we assessed the pharmacokinetics of MPA and allograft prognosis in recipients with diabetes. This study retrospectively analyzed 64 adult kidney transplant recipients. MPA blood concentration data (e.g., the time to the maximum concentration (Tmax), and the area under the concentration–time curve from 0 to 12 h (AUC_0–12)) were collected at 3 weeks and 3 months after kidney transplantation. Of the 64 recipients, 15 had pre-existing diabetes. At 3 months after kidney transplantation, the Tmax of MPA was significantly longer in recipients with diabetes (mean (standard deviation): 2.8 (2.1) h) than in recipients without diabetes (1.9 (1.1) h, p = 0.02). However, the allograft estimated glomerular filtration rate and acute rejection rate, including borderline change, did not differ according to the diabetes status in patients with adjusted AUC_0–12 of MPA within the target range. In conclusion, a longer Tmax of MPA was observed in recipients with diabetes; however, acceptable allograft prognosis was observed in kidney transplant recipients with diabetes and a sufficient AUC_0–12 of MPA.

Trends in the effects of pre-transplant diabetes on mortality and cardiovascular events after kidney transplantation

AIMS/INTRODUCTION

It is not clear whether survival in kidney transplant recipients with pre-transplant diabetes has improved over the past decades. We compared the rates of mortality and major adverse cardiovascular events (MACE) after renal transplantation in patients with and without pre-transplant diabetes. Furthermore, we investigated whether transplant era and recipient age affected the association between diabetes status and adverse events.

MATERIALS AND METHODS

This retrospective cohort study included 691 patients who underwent renal transplantation between 1994 and 2016 at a single tertiary center. We compared the incidences of post-transplant mortality and four-point MACE in patients with and without pre-transplant diabetes using Kaplan-Meier analysis and the Cox proportional hazard model, and assessed the interactions between diabetes status and transplant era and recipient age.

RESULTS

Of 691 kidney recipients, 143 (20.7%) had pre-transplant diabetes. The mean follow-up duration was 94.5 months. Kaplan-Meier analysis showed that patients with pre-transplant diabetes had higher incidences of post-transplant mortality and four-point MACE compared with those without pre-transplant diabetes (log-rank test, P < 0.001 for both). After adjusting for potential confounding factors, pre-transplant diabetes was associated with an increased risk of post-transplant mortality and four-point MACE (hazard ratio 1.90, 95% confidence interval 1.05-3.44, P = 0.034; and hazard ratio 1.75; 95% confidence interval 1.02-3.00, P = 0.043, respectively). The associations between pre-transplant diabetes status and all-cause mortality and four-point MACE were not affected by transplant era or recipient age.

CONCLUSIONS

Pre-transplant diabetes remains a significant risk factor for mortality and four-point MACE in kidney transplant recipients.

Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation

Background

Type 2 diabetic (T2DM) patients on renal replacement therapy (RRT) seldom receive a kidney transplant, which is partly due to age and comorbidities. Adjusting for case mix, we investigated whether T2DM patients have equal opportunity for renal transplantation compared to other patients on dialysis, and whether survival after transplantation is comparable.

Methods

Patients who entered RRT in Finland in 2000–2010 (n = 5419) were identified from the Finnish Registry for Kidney Diseases and followed until the end of 2012. Of these, 20% had T2DM, 14% type 1 diabetes (T1DM) and 66% other than diabetes as the cause of ESRD. Uni-/multivariate survival analysis techniques were employed to assess the probability of kidney transplantation after the start of dialysis and survival after transplantation.

Results

T2DM patients had a relative probability of renal transplantation of 0.18 (95% CI 0.15–0.22, P<0.001) compared to T1DM patients: this increased to 0.51 (95% CI 0.36–0.72, P<0.001) after adjustment for case mix (age, gender, laboratory values and comorbidities). When T2DM patients were compared to non-diabetic patients, the corresponding relative probabilities were 0.25 (95% CI 0.20–0.30, P<0.001) and 0.59 (95% CI 0.43–0.83, P = 0.002). After renal transplantation when adjusted for age and gender, relative risk of death was 1.25 (95% CI 0.64–2.44, P = 0.518) for T1DM patients and 0.72 (0.43–1.22, P = 0.227) for other patients compared to T2DM patients.

Conclusions

T2DM patients had a considerably lower probability of receiving a kidney transplant, which could not be fully explained by differences in the patient characteristics. Survival within 5 years after transplantation is comparably good in T2DM patients.

Outcomes in patients with diabetes 10 years after liver transplantation

BACKGROUND

There are discrepancies between studies regarding the effect of diabetes mellitus on morbidity and mortality in patients undergoing liver transplantation. The aim of the present study was to compare mortality, risk of liver graft rejection, and cardiovascular events in patients with and without diabetes undergoing liver transplantation over a 10-year follow-up period.

METHODS

A retrospective study was performed on 183 patients who underwent liver transplantation in 2005 and 2006. Mortality and morbidity data were collected until 2016, including information on mortality and survival time, graft rejection and graft survival time, coronary heart disease, stroke, and peripheral arterial ischemia.

RESULTS

During the follow-up, 41.3% and 27.8% of patients in the groups with and without diabetes, respectively, died. A trend for lower survival time was observed in patients with diabetes, although this effect was not confirmed by the Cox regression model. There was an increased risk of graft rejection in the group with diabetes compared with the group without diabetes ( P  < 0.001). In the survival analysis, diabetes was associated with reduced graft survival time ( P  = 0.001). Cardiovascular events were also more likely in the group with diabetes ( P  = 0.005).

CONCLUSIONS

In the present study diabetes was associated with a higher risk of liver graft rejection and cardiovascular events. There was also a trend for higher mortality, although the effect was not statistically significant. These findings suggest that patients with diabetes require a more rigorous pretransplant evaluation and closer monitoring after transplantation in order to try to reduce associated complications.

Prolonged Delayed Graft Function Due to an Extensive Renal Graft Subcapsular Hematoma: Is Conservative Management Justified?

A 62-year-old male patient with diabetes underwent deceased-donor kidney transplant at our transplant unit. At reperfusion, a small and clinically not significant subcapsular hematoma was noted. The patient's postoperative course was characterized by delayed graft function since the beginning but was further complicated on postoperative day 6 by evidence (shown at daily Doppler ultrasonography) of a wide increase of the hematoma. The hematoma, which was just visible before, was now leading to graft compression because it covered up to two-thirds of the cortical surface. The patient showed no hemo-dynamic instability and showed no significant drop in hemoglobin values. Capsulotomy was not performed because it was deemed too risky. The patient was given strict follow-up with Doppler ultrasonography and high-resolution imaging techniques (magnetic resonance imaging and computed tomography scan). In the following days, spontaneous resolution of the hematoma and progressive improvement of Doppler findings were observed, which preceded full recovery of graft function. Conservative management, in hemodynamically stable patients, seems to be a valid approach of this condition. By avoiding surgery or other interventional procedures, a conservative approach allows reduced risk of further complications. Strict monitoring with Doppler ultrasonography is a valid tool for follow-up, along with high-resolution imaging techniques such as magnetic resonance imaging and computed tomography to confirm diagnosis.

Role of glycemic control on hospital-related outcomes in patients with diabetes mellitus undergoing renal transplantation

OBJECTIVE

To compare length of stay (LOS) and incidence of hypoglycemic events and infections in hospitalized patients with diabetes mellitus (DM) undergoing renal transplantation, among groups of patients defined by admission glucose and mean inpatient daily glucose.

METHODS

A retrospective analysis of 190 charts of patients with DM who underwent renal transplantation over a 2-year period was conducted. Patients were grouped according to admission glucose and mean inpatient daily glucose (≤140 mg/dL, 141-180 mg/dL, and >180 mg/dL).

RESULTS

Admission glucose was not associated with LOS. A mean inpatient daily glucose of ≤140 mg/dL was associated with a longer LOS compared to a mean inpatient daily glucose of >180 mg/dL (p=0.03). Patients with an admission glucose of ≤140 mg/dL had approximately half the rate of hypoglycemic events compared to those with admission glucose of 141-180 mg/dL (odds ratio [OR]=2.1; p=0.02) or >180 mg/dL (OR=1.9; p=0.04). However, patients whose mean daily glucose was ≤140 mg/dL had approximately twice the rate of hypoglycemic events than those whose mean daily glucose was 141-180 mg/dL (OR=0.4; p=0.01) or >180 mg/dL (OR=0.4; p=0.004). The incidence of infections was low and was not associated with admission or mean daily glucose levels.

CONCLUSION

Lower mean daily inpatient glucose levels (≤140 mg/dL) are associated with longer LOS and greater incidence of hypoglycemic episodes in diabetes patients undergoing renal transplantation. Our findings suggest that target blood glucose levels of 140-180 mg/dL may be appropriate in this specific population. Additional prospective research is needed to confirm these findings.

Traumatic breast transposal to the abdominal wall: A case report

Although abdominal wall masses are commonly observed in clinical practice, traumatic breast transposal appearing as an abdominal wall mass is a rare event. The unique phenomenon of a post-traumatic breast growing healthily in the abdominal wall has never previously been reported. The current study presents the case of a 40-year-old female who developed an unusually transposed, but healthy mammary gland in the right upper abdominal wall following a severe pedestrian traffic accident. In that accident, the powerful impact of the car caused multiple right-sided rib fractures, lung injuries and a protruding mass on the right abdominal wall. This sudden onset protruding mass was indicated to be breast tissue by computed tomography imaging and ultrasound scanning. The transposed mammary gland was resected and a pathological examination confirmed that it consisted of normal breast tissue. In this case, the force of the car caused no significant damage or necrosis to the right breast, but instead was sufficient to shift the mammary gland to the abdomen, where it grew healthily 6 months in its new location. This case highlights the capability of the mammary gland to withstand a powerful impact and survive. Moreover, it advances our knowledge of how mammary tissues respond to severe blunt-force impacts.