Strategies for risk reduction and management of posttransplant diabetes mellitus

New-onset diabetes after liver transplantation: from pathogenesis to management

New-onset diabetes mellitus (NODM) develops in approximately 15% of liver transplant recipients, and a similar proportion of patients have diabetes prior to transplantation. Preexisting diabetes and probably NODM are associated with increased mortality and risk of infection. NODM occurs more frequently among patients with hepatitis C infection; additional risk factors include family history, male gender, increasing weight, and alcoholic cirrhosis. Corticosteroid therapy, particularly bolus injections, increases likelihood of NODM, and randomized clinical trials and retrospective studies have shown NODM to occur more frequently with tacrolimus compared with cyclosporine. Patients undergoing liver transplantation should be screened for diabetes risk factors, and fasting plasma glucose should be monitored regularly in all transplant recipients. Management of NODM is essentially similar to that of diabetes in the nontransplant population, and includes dietary and lifestyle modifications. In choosing oral agents and/or insulin, the individual medical profile of the patient must be considered carefully. Corticosteroid exposure should be limited as much as possible, and reduction of calcineurin inhibitor dose is prudent. Switching from tacrolimus to cyclosporine may be required in some cases to achieve improvement or resolution. In conclusion, prospective trials are necessary to properly define antidiabetic therapy and immunosuppressive strategies in this population.

New-onset diabetes after transplantation

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

Impact of kidney transplantation on the progression of cardiovascular disease

Kidney transplantation, of all the treatment modalities for end-stage renal disease, affords the greatest potential for prolonged survival and improved quality of life. Great strides in immunosuppressant therapy have improved graft survival and forced clinicians to consider other health-care needs of kidney transplant recipients. Chief among these needs is the prevention and treatment of cardiovascular disease. Cardiovascular disease is the most common cause of death among patients with a working renal allograft. Because therapies for primary and secondary prevention are successful in the general population, transplant clinicians are increasingly focused on preventing or limiting the progression of cardiovascular disease. Initiation of aggressive management of conventional atherosclerotic risk factors and uremia-related risk factors, ideally during the early stages of chronic kidney disease (CKD) or after kidney transplantation, and efforts to delay the progression of kidney disease will hopefully reduce the cardiovascular burden in transplant recipients.

Diabetes mellitus in transplantation: 2002 consensus guidelines

Diabetes mellitus is a serious complication following organ transplantation that is underdiagnosed, possibly due to the inadequate definitions used in published literature and the lack of standardized screening. Diabetes in transplantation amplifies the already increased risk of cardiovascular disease among transplant patients, and increases the risk of graft loss and death. Patients at risk of developing diabetes in transplantation should therefore be prospectively identified and given individualized immunosuppressive therapy to minimize the risk of developing this disease. These guidelines are intended to: (1) help identify patients at risk for diabetes after transplantation; (2) set down a standard definition of posttransplant diabetes mellitus (PTDM); (3) create a standard monitoring protocol for the diagnosis of PTDM; and (4) optimize the management of patients at risk of developing or who develop diabetes after transplantation. With improved diagnosis, individualization of therapy, and proper early management, the incidence of diabetes in transplantation, and the accompanying additional burden of illness the disease carries, may be diminished. In turn, this will help achieve the therapeutic goals of reducing the risk of graft complications, improving quality of life, and reducing postoperative morbidity and mortality in transplant patients.