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Dziedziejko V, Safranow K, Kijko-Nowak M, Malinowski D, Domanski L, Pawlik A. Leptin receptor gene polymorphisms in kidney transplant patients with post-transplant diabetes mellitus treated with tacrolimus. Int Immunopharmacol 2023; 124:110989. [PMID: 37776770 DOI: 10.1016/j.intimp.2023.110989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/17/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023]
Abstract
Post-transplant diabetes mellitus (PTDM) is a metabolic complication that often occurs after kidney transplantation. Factors that increase the risk of this complication are currently being researched, including polymorphisms in genes affecting carbohydrate-lipid metabolism. Leptin is a hormone that affects appetite and adipose tissue and plays an important role in regulating insulin secretion as well as glucose and lipid metabolism. The aim of this study was to examine the association between leptin receptor gene polymorphisms and the development of post-transplant diabetes mellitus in patients treated with tacrolimus. The study was carried out in a group of 201 patients who underwent kidney transplantation. The follow-up period was 12 months. PTDM was diagnosed in 35 patients. Analysing the LEPR gene rs1137101 polymorphism, we observed in patients with PTDM an increased frequency of GG genotype carriers (GG vs AA, OR 3.36; 95 % CI 0.99-11.46; p = 0.04). There were no statistically significant differences in the distribution of the LEPR rs1137100 and LEPR rs1805094 polymorphisms between patients with and without PTDM. Multivariate regression analysis confirmed that female sex, advanced age, increased BMI and a higher number of LEPR rs1137101 G alleles were independent risk factors for PTDM development. The risk of PTDM development was almost 3.5 times greater in LEPR rs1137101 G allele carriers than in AA homozygotes (GG + AG vs AA; OR 3.48; 95 %CI (1.09-11.18), p = 0.035). The results suggest that patients after kidney transplantation with the LEPR gene rs1137101 G allele may have an increased risk of post-transplant diabetes development.
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Affiliation(s)
- Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Mirosława Kijko-Nowak
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Damian Malinowski
- Department of Experimental and Clinical Pharmacology, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Leszek Domanski
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland.
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland.
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Brodosi L, Petta S, Petroni ML, Marchesini G, Morelli MC. Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients. Transplantation 2022; 106:462-478. [PMID: 34172646 PMCID: PMC9904447 DOI: 10.1097/tp.0000000000003867] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.
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Affiliation(s)
- Lucia Brodosi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Maria L. Petroni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Giulio Marchesini
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Maria C. Morelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Sokooti S, Klont F, Tye SC, Kremer D, Douwes RM, Hopfgartner G, Dullaart RPF, Heerspink HJL, Bakker SJL. Association of diuretic use with increased risk for long-term post-transplantation diabetes mellitus in kidney transplant recipients. Nephrol Dial Transplant 2022; 37:1375-1383. [PMID: 35092430 PMCID: PMC9217635 DOI: 10.1093/ndt/gfac012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background Post-transplantation diabetes mellitus (PTDM) is a major clinical problem in kidney transplant recipients (KTRs). Diuretic-induced hyperglycaemia and diabetes have been described in the general population. We aimed to investigate whether diuretics also increase PTDM risk in KTRs. Methods We included 486 stable outpatient KTRs (with a functioning graft ≥1 year) without diabetes from a prospective cohort study. Participants were classified as diuretic users and non-users based on their medication use verified by medical records. Results At the baseline study, 168 (35%) KTRs used a diuretic (thiazide, n = 74; loop diuretic, n = 76; others, n = 18) and 318 KTRs did not use a diuretic. After 5.2 years [interquartile range (IQR) 4.0‒5.9] of follow up, 54 (11%) KTRs developed PTDM. In Cox regression analyses, diuretic use was associated with incident PTDM, independent of age, sex, fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c) {hazard ratio [HR] 3.28 [95% confidence interval (CI) 1.84–5.83]; P <0.001}. Further adjustment for potential confounders, including lifestyle, family history of cardiovascular disease, use of other medication, kidney function, transplantation-specific parameters, BMI, lipids and blood pressure did not materially change the association. Moreover, in Cox regression analyses, both thiazide and loop diuretics associated with the development of PTDM, independent of age, sex, FPG and HbA1c [HR 2.70 (95% CI 1.24–5.29); P = 0.012 and HR 5.08 (95% CI 2.49–10.34); P <0.001), respectively]. Conclusions This study demonstrates that diuretics overall are associated with an increased risk of developing PTDM in KTRs, independent of established risk factors for PTDM development. The association was present for both thiazide and loop diuretics.
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Affiliation(s)
- Sara Sokooti
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Klont
- Life Sciences Mass Spectrometry, Department of Inorganic and Analytical Chemistry, University of Geneva, Geneva, Switzerland
| | - Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan Kremer
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rianne M Douwes
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gérard Hopfgartner
- Life Sciences Mass Spectrometry, Department of Inorganic and Analytical Chemistry, University of Geneva, Geneva, Switzerland
| | - Robin P F Dullaart
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Yousef B, Elzain A, Badi S, Elkheir H. Incidence of new-onset diabetes among sudanese renal transplant patients using different immunosuppressive regimens: A retrospective study. CHRISMED JOURNAL OF HEALTH AND RESEARCH 2021. [DOI: 10.4103/cjhr.cjhr_45_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Temporal Changes on the Risks and Complications of Posttransplantion Diabetes Mellitus Following Cardiac Transplantation. J Transplant 2018; 2018:9205083. [PMID: 30533218 PMCID: PMC6250037 DOI: 10.1155/2018/9205083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/27/2018] [Accepted: 10/21/2018] [Indexed: 01/14/2023] Open
Abstract
Background Recent changes in the demographic of cardiac donors and recipients have modulated the rate and risk, associated with posttransplant diabetes mellitus (PTDM). We investigated the secular trends of the risk of PTDM at 1 year and 3 years after transplantation over 30 years and explored its effect on major outcomes. Methods Three hundred and three nondiabetic patients were followed for a minimum of 36 months, after a first cardiac transplantation performed between 1983 and 2011. Based on the year of their transplantation, the patients were divided into 3 eras: (1983-1992 [era 1], 1993-2002 [era 2], and 2003-2011 [era 3]). Results In eras 1, 2, and 3, the proportions of patients with PTDM at 1 versus 3 years were 23% versus 39%, 21% versus 26%, and 33% versus 38%, respectively. Independent risk factors predicting PTDM at one year were recipient's age, duration of cold ischemic time, treatment with furosemide, and tacrolimus. There was a trend for overall survival being worse for patients with PTDM in comparison to patients without PTDM (p = 0.08). Patients with PTDM exhibited a significantly higher rate of renal failure over a median follow-up of 10 years (p = 0.03). Conclusion The development of PTDM following cardiac transplantation approaches 40% at 3 years and has not significantly changed over thirty years. The presence of PTDM is weakly associated with an increased mortality and is significantly associated with a worsening in renal function long-term following cardiac transplantation.
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Tanaka K, Sakai K, Kushiyama A, Hara S, Hattori M, Ohashi Y, Muramatsu M, Kawamura T, Shishido S, Aikawa A. Serum uric acid is an independent predictor of new-onset diabetes after living-donor kidney transplantation. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0169-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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D'Elia JA, Segal AR, Bayliss GP, Weinrauch LA. Sodium-glucose cotransporter-2 inhibition and acidosis in patients with type 2 diabetes: a review of US FDA data and possible conclusions. Int J Nephrol Renovasc Dis 2017; 10:153-158. [PMID: 28670136 PMCID: PMC5479258 DOI: 10.2147/ijnrd.s135899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective To evaluate whether adverse event reports to the US Food and Drug Administration on incidents of ketoacidosis from use of sodium glucose cotransport inhibitors (SGLT2 inhibitors) provide insight into ways this new class of drugs is being prescribed with other antihyperglycemic agents; to examine possible mechanisms to explain ketoacidosis. Design and methods Reports of adverse events concerned to SGLT2 inhibitors, namely, empagliflozin, dapagliflozin, and canagliflozin were obtained under the Freedom of Information Act for 5 years ending in August 31, 2015. The data were evaluated for incidents of ketoacidosis by looking for keywords such as diabetic ketoacidosis, ketoacidosis, lactic acidosis, acidosis, and metabolic acidosis. Results were tabulated individually for empagliflozin (n=260 adverse event reports), dapagliflozin (n=520), and canagliflozin (n=2159). Adverse events were categorized according to age, gender, and insulin use. Results There were 46, 144, and 450 reports of ketoacidosis concerned with the use of empagliflozin, dapagliflozin, and canagliflozin, respectively. The use of SGLT2 inhibitors was not strictly limited to patients with type 2 diabetes but was cut across categories of insulin use, including a total of 172 cases of SGLT2-related ketoacidosis in individuals above the age of 40 who were not on insulin. Conclusion Further studies should focus to detect pleiotropic effects of SGLT2 inhibitors, particularly with other oral antihyperglycemic drugs or insulin. A review of the literature suggests that patients with type 2 diabetes with low C-peptide level may be at increased risk of ketoacidosis, particularly if they are on statins and diuretics due to hypokalemia and impaired release of insulin. More studies are warranted to further clarify these mechanisms.
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Affiliation(s)
- John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center, Harvard Medical School
| | - Alissa R Segal
- Kidney and Hypertension Section, Joslin Diabetes Center, Harvard Medical School.,Department of Pharmacy Practice, MCPHS University, Boston, MA
| | - George P Bayliss
- Division of Kidney Diseases and Hypertension, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI, USA
| | - Larry A Weinrauch
- Kidney and Hypertension Section, Joslin Diabetes Center, Harvard Medical School
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Seroprevalence of human cytomegalovirus antibodies among children with type I diabetes mellitus in the Aseer Region, Southwest KSA. J Taibah Univ Med Sci 2016. [DOI: 10.1016/j.jtumed.2016.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Shivaswamy V, Boerner B, Larsen J. Post-Transplant Diabetes Mellitus: Causes, Treatment, and Impact on Outcomes. Endocr Rev 2016; 37:37-61. [PMID: 26650437 PMCID: PMC4740345 DOI: 10.1210/er.2015-1084] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent consequence of solid organ transplantation. PTDM has been associated with greater mortality and increased infections in different transplant groups using different diagnostic criteria. An international consensus panel recommended a consistent set of guidelines in 2003 based on American Diabetes Association glucose criteria but did not exclude the immediate post-transplant hospitalization when many patients receive large doses of corticosteroids. Greater glucose monitoring during all hospitalizations has revealed significant glucose intolerance in the majority of recipients immediately after transplant. As a result, the international consensus panel reviewed its earlier guidelines and recommended delaying screening and diagnosis of PTDM until the recipient is on stable doses of immunosuppression after discharge from initial transplant hospitalization. The group cautioned that whereas hemoglobin A1C has been adopted as a diagnostic criterion by many, it is not reliable as the sole diabetes screening method during the first year after transplant. Risk factors for PTDM include many of the immunosuppressant medications themselves as well as those for type 2 diabetes. The provider managing diabetes and associated dyslipidemia and hypertension after transplant must be careful of the greater risk for drug-drug interactions and infections with immunosuppressant medications. Treatment goals and therapies must consider the greater risk for fluctuating and reduced kidney function, which can cause hypoglycemia. Research is actively focused on strategies to prevent PTDM, but until strategies are found, it is imperative that immunosuppression regimens are chosen based on their evidence to prolong graft survival, not to avoid PTDM.
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Affiliation(s)
- Vijay Shivaswamy
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Brian Boerner
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Jennifer Larsen
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
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Dabrowska-Zamojcin E, Romanowski M, Dziedziejko V, Maciejewska-Karlowska A, Sawczuk M, Safranow K, Domanski L, Pawlik A. CCL2 gene polymorphism is associated with post-transplant diabetes mellitus. Int Immunopharmacol 2016; 32:62-65. [PMID: 26802601 DOI: 10.1016/j.intimp.2016.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/01/2016] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) is a common complication after solid organ transplantation, especially in recipients treated with calcineurin inhibitors. Previous studies suggest that chronic inflammation and chemokines play an important role in the pathogenesis of diabetes. Single-nucleotide polymorphisms (SNPs) can increase or decrease transcriptional activity and can change the production of chemokines. The aim of this study was to examine the association between CCL2 and CCL5 gene polymorphisms and the development of post-transplant diabetes mellitus. The study included 315 patients who received kidney transplants and were treated with calcineurin inhibitors. Patients were divided into two subgroups: with PTDM (n=43) and without PTDM (n=272). An additive model of univariate Cox regression analysis showed that the hazard of PTDM development was significantly positively associated with the number of CCL2 rs1024611 G alleles (HR 1.65; 95%CI 1.08-2.53; p=0.021). Multivariate Cox regression analysis, taking into the account the recipient's sex, age and BMI, as well as the number of G alleles of the CCL2 rs1024611 polymorphism, revealed that this polymorphism is an independent risk factor for post-transplant diabetes. The results of our study suggest an association between the CCL2 gene rs1024611 G allele and PTDM in patients treated with tacrolimus or cyclosporine.
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Affiliation(s)
| | - Maciej Romanowski
- Department of General and Transplantation Surgery, Pomeranian Medical University in Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | | | - Marek Sawczuk
- Faculty of Physical Education and Health Promotion, University of Szczecin, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Leszek Domanski
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, Szczecin, Poland.
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Le Fur A, Fournier MC, Gillaizeau F, Masson D, Giral M, Cariou B, Cantarovich D, Dantal J. Vitamin D deficiency is an independent risk factor for PTDM after kidney transplantation. Transpl Int 2015; 29:207-15. [DOI: 10.1111/tri.12697] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 09/25/2015] [Indexed: 01/05/2023]
Affiliation(s)
- Awena Le Fur
- Institute of Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- INSERM UMR 1064; Nantes University Hospital; Nantes France
| | - Marie-Cécile Fournier
- INSERM UMR 1064; Nantes University Hospital; Nantes France
- EA 4275 - SPHERE Biostatistics, Pharmacoepidemiology, and Human Sciences Research; Nantes University Hospital; Nantes France
| | - Florence Gillaizeau
- Institute of Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- INSERM UMR 1064; Nantes University Hospital; Nantes France
- EA 4275 - SPHERE Biostatistics, Pharmacoepidemiology, and Human Sciences Research; Nantes University Hospital; Nantes France
| | | | - Magali Giral
- Institute of Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- INSERM UMR 1064; Nantes University Hospital; Nantes France
- EA 4275 - SPHERE Biostatistics, Pharmacoepidemiology, and Human Sciences Research; Nantes University Hospital; Nantes France
| | - Bertrand Cariou
- Endocrinology Clinic; Nantes University Hospital; Nantes France
- INSERM UMR 1087; CNRS UMR 6291; Thorax Institute; Nantes University Hospital; Nantes France
| | - Diego Cantarovich
- Institute of Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- INSERM UMR 1064; Nantes University Hospital; Nantes France
| | - Jacques Dantal
- Institute of Transplantation, Urology and Nephrology (ITUN); Nantes University Hospital; Nantes France
- INSERM UMR 1064; Nantes University Hospital; Nantes France
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Huang JW, Famure O, Li Y, Kim SJ. Hypomagnesemia and the Risk of New-Onset Diabetes Mellitus after Kidney Transplantation. J Am Soc Nephrol 2015; 27:1793-800. [PMID: 26449610 DOI: 10.1681/asn.2015040391] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 08/13/2015] [Indexed: 12/13/2022] Open
Abstract
Several studies suggest a link between post-transplant hypomagnesemia and new-onset diabetes after transplantation (NODAT), but this relationship remains controversial. We conducted a retrospective cohort study of 948 nondiabetic kidney transplant recipients from January 1, 2000, to December 31, 2011, to examine the association between serum magnesium level and NODAT. Multivariable Cox proportional hazards models were fitted to evaluate the risk of NODAT as a function of baseline (at 1 month), time-varying (every 3 months), and rolling-average (i.e., mean for 3 months moving at 3-month intervals) serum magnesium levels while adjusting for potential confounders. A total of 182 NODAT events were observed over 2951.2 person-years of follow-up. Multivariable models showed an inverse relationship between baseline serum magnesium level and NODAT (hazard ratio [HR], 1.24 per 0.1 mmol/L decrease; 95% confidence interval [95% CI], 1.05 to 1.46; P=0.01). The association with the risk of NODAT persisted in conventional time-varying (HR, 1.32; 95% CI, 1.14 to 1.52; P<0.001) and rolling-average models (HR, 1.34; 95% CI, 1.13 to 1.57; P=0.001). Hypomagnesemia (serum magnesium <0.74 mmol/L) also significantly associated with increased risk of NODAT in baseline (HR, 1.58; 95% CI, 1.07 to 2.34; P=0.02), time-varying (HR, 1.78; 95% CI, 1.29 to 2.45; P<0.001), and rolling-average models (HR, 1.83; 95% CI, 1.30 to 2.57; P=0.001). Our results suggest that lower post-transplant serum magnesium level is an independent risk factor for NODAT in kidney transplant recipients. Interventions targeting serum magnesium to reduce the risk of NODAT should be evaluated.
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Affiliation(s)
- Johnny W Huang
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Olusegun Famure
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yanhong Li
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology and the Renal Transplant Program, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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14
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Romanowski M, Dziedziejko V, Maciejewska-Karlowska A, Sawczuk M, Safranow K, Domanski L, Pawlik A. Adiponectin and leptin gene polymorphisms in patients with post-transplant diabetes mellitus. Pharmacogenomics 2015; 16:1243-51. [DOI: 10.2217/pgs.15.71] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Post-transplant diabetes mellitus (PTDM) is a common metabolic complication after organ transplantation and may be associated with the use of calcineurin inhibitors (tacrolimus and cyclosporine). Leptin and adiponectin are adipokines and play an important role in the regulation of insulin secretion as well as glucose and lipid metabolism. Aim: The aim of this study was to examine the association between adiponectin and leptin gene polymorphisms and development of PTDM. Materials & methods: The study included 323 patients who received kidney transplants and were treated with calcineurin inhibitors (tacrolimus or cyclosporine). Results: The association between adiponectin and leptin gene polymorphisms and PTDM was studied in three models of Cox regression analysis – additive, dominant and recessive. In these three models, the LEP rs2167270 gene polymorphism was statistically significantly associated with increased risk of PTDM. The association between the LEP rs2167270 polymorphism and PTDM was confirmed by multivariate regression analysis. Conclusion: The results of our study suggest an association between the leptin rs2167270 gene A allele and PTDM. Original submitted 27 February 2015; Revision submitted 22 May 2015
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Affiliation(s)
- Maciej Romanowski
- Department of General & Transplantation Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry & Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | | | - Marek Sawczuk
- Faculty of Physical Education & Health Promotion, University of Szczecin, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry & Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
| | - Leszek Domanski
- Clinical Department of Nephrology, Transplantology & Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, Powstancow Wlkp. 72, 70–111 Szczecin, Poland
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Sezer S, Erkmen Uyar M, Tutal E, Bal Z, Guliyev O, Colak T, Hasdemir E, Haberal M. New-onset diabetes and glucose regulation are significant determinants of left ventricular hypertrophy in renal transplant recipients. J Diabetes Res 2015; 2015:293896. [PMID: 25945353 PMCID: PMC4405014 DOI: 10.1155/2015/293896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/17/2015] [Accepted: 02/24/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is associated with decreased graft survival and an increased risk for cardiovascular disease. The objective of this study was to evaluate the risk factors for development of NODAT and its' relationship with arterial stiffness and left ventricular mass index (LVMI) in kidney transplant recipients. METHODS 159 kidney transplant recipients were selected from our transplantation center who underwent renal transplantation between years 2007 and 2010. RESULTS Among 159 patients, 57 (32.2%) patients were with NODAT who were significantly older than patients without diabetes (P: 0.0001). Patients with NODAT had significantly higher pulse wave velocity (PWv) (P: 0.033) and left ventricular mass index LVMI (P: 0.001) compared to patients without NODAT. Further analysis was done according to LVMI as follows: LVMI > 130 g/m(2) (n: 57) and LVMI ≤ 130 g/m(2) (n: 102). We observed higher office systolic and diastolic BP, serum trygliceride, glucose, creatinine, age, and HbA1c (P: 0.0001) levels in patients with LVMI > 130 g/m(2). Linear regression analysis revealed that HbA1c was the major determinant of LVMI (P: 0.026, β: 0.361). CONCLUSIONS HbA1c is the major determinant of LVMI, so strict control of serum glucose levels is essential for preventing cardiovascular disease in patients with NODAT.
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Affiliation(s)
- Siren Sezer
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
| | - Mehtap Erkmen Uyar
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
- *Mehtap Erkmen Uyar:
| | - Emre Tutal
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
| | - Zeynep Bal
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
| | - Orhan Guliyev
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
| | - Turan Colak
- Department of Nephrology, Baskent University Medical School, 06490 Ankara, Turkey
| | - Efe Hasdemir
- Department of Internal Medicine, Baskent University Medical School, 06490 Ankara, Turkey
| | - Mehmet Haberal
- Department of Transplantation Surgery, Baskent University Medical School, 06490 Ankara, Turkey
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16
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Roman A, Manito N, Campistol JM, Cuervas-Mons V, Almenar L, Arias M, Casafont F, del Castillo D, Crespo-Leiro MG, Delgado JF, Herrero JI, Jara P, Morales JM, Navarro M, Oppenheimer F, Prieto M, Pulpón LA, Rimola A, Serón D, Ussetti P. The impact of the prevention strategies on the indirect effects of CMV infection in solid organ transplant recipients. Transplant Rev (Orlando) 2014; 28:84-91. [DOI: 10.1016/j.trre.2014.01.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/19/2014] [Indexed: 01/10/2023]
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Abstract
Obesity confers increased risk for graft loss and death among renal transplant recipients. However the relationship of changes in body weight and composition to outcome on the transplant waitlist and post-transplantation is not straightforward. Strategies to manage weight in the waitlisted patient and after kidney transplantation must be performed in the context of a multidisciplinary approach and individualized based on risk factors in particular patients. Although retrospective studies offer considerable insights into the relationship between obesity and kidney transplant outcome, causal inferences must be made with great caution.
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Affiliation(s)
- Titte R Srinivas
- Division of Nephrology, Medical University of South Carolina, Charleston, SC 29425, USA.
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18
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Santos L, Rodrigo E, Piñera C, Quintella E, Ruiz JC, Fernández-Fresnedo G, Palomar R, Gómez-Alamillo C, de Francisco A, Arias M. New-onset diabetes after transplantation: drug-related risk factors. Transplant Proc 2013; 44:2585-7. [PMID: 23146462 DOI: 10.1016/j.transproceed.2012.09.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION New-onset diabetes after transplantation (NODAT), an important complication of renal transplantation leads to reduced graft function and increased patient morbidity and mortality. Because of its high incidence and immense impact on clinical outcomes, prevention of NODAT is highly desirable. Several modifiable and nonmodifiable risk factors for NODAT have been described. The aim of this study was to analyze the influence of various drugs on the development of NODAT during the first year. METHODS A retrospective analysis was performed on 303 adult kidney transplant recipients free of previously known diabetes. NODAT was defined as a fasting plasma glucose level ≥ 126 mg/dL confirmed by repeat testing on a different day. We excluded patients with transiently elevated fasting plasma glucose during the first 3 months. RESULTS NODAT was diagnosed in 37 recipients (12.2%). Univariate analysis identified several variables related to NODAT: recipient age (P < .001), body mass index (P < .001), donor age (P = .005), family history of diabetes (P < .001), statin use (P = .005), diuretic use (P = .040) and tacrolimus therapy (P = .029). After multivariate analysis, recipient age (relative risk [RR] = 1.060, 95% confidence interval [CI] 1.019- 1.102, P = .004), family history of diabetes (RR = 3.562, 95% CI 1.574-8.058, P = .002), smoking habit (RR 2.514, 95% CI 1.118-5.655, P = .026) and diuretic use (RR = 2.496, 95% CI 1.087-5.733, P = .031) were independently associated with NODAT development. CONCLUSIONS In our population of kidney transplant recipients, the main nonmodifiable risk factors for NODAT were recipient age and a family history of diabetes. Diuretic use was a modifiable risk factor associated with the development of NODAT. To reduce NODAT incidence, it is necessary to consider not only immunosuppressive therapy, but also concomitant drugs such as diuretics.
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Affiliation(s)
- L Santos
- Nephrology Service, Hospital Marqués de Valdecilla, University of Cantabria, Santander, Cantabria, Spain.
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19
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Metformin improves immunosuppressant induced hyperglycemia and exocrine apoptosis in rats. Transplantation 2013; 95:280-4. [PMID: 23250335 DOI: 10.1097/tp.0b013e318275a322] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Immunosuppressants are an important cause of posttransplantation diabetes mellitus. We have shown that tacrolimus and sirolimus induce hyperglycemia and hyperinsulinemia in normal rats. We hypothesized that metformin, given concurrently with tacrolimus and/or sirolimus, prevents disturbances in glucose and insulin metabolism. METHODS Eight groups (n=6) of normal Sprague-Dawley rats were studied: four groups received tacrolimus, sirolimus, tacrolimus/sirolimus, or control for 14 days, and four more groups received similar treatments along with metformin. Daily glucoses were measured. All rats were administered an oral glucose challenge before sacrifice. Pancreata were analyzed by terminal deoxynucleotide tranferase-mediated dUTP nick-end labeling staining and immunohistochemistry. RESULTS Tacrolimus, sirolimus, and tacrolimus/sirolimus impaired glucose tolerance compared to control. Sirolimus and tacrolimus/sirolimus also increased random blood glucose levels. Sirolimus alone resulted in hyperinsulinemia after oral glucose challenge compared to control. In the sirolimus/metformin and tacrolimus/sirolimus/metformin groups, mean daily random glucose was no longer increased, although the response to glucose challenge was still impaired. Metformin decreased pancreatic exocrine and trended to decrease endocrine apoptosis in tacrolimus/sirolimus group and reduced islet insulin content in sirolimus group. CONCLUSIONS This is the first study to show that metformin can improve immunosuppressant-induced hyperglycemia, when administered concurrently, and reduces exocrine apoptosis (reducing the impact on potential islet progenitor cells).
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20
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Castón Osorio JJ, Zurbano Goñi F. [Indirect effects of cytomegalovirus infection]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:6-10. [PMID: 22541915 DOI: 10.1016/s0213-005x(11)70050-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite improvements in prevention strategies, cytomegalovirus (CMV) continues to be the main cause of infection in solid organ transplant recipients. In these patients, in addition to direct effects, such as viral syndrome or invasive organ disease, CMV can cause indirect effects resulting from the interaction of the virus with the host's immune system. This interaction may increase immunosuppression, with a consequent rise in opportunistic infections and the risk of malignancies (Epstein-Barr virus-associated posttransplantation lymphoproliferative disease) and graft dysfunction. Currently, a direct causal relation between CMV and most of the indirect effects described cannot be established. However, numerous experimental and clinical studies have found an association between the development of these effects and CMV. Moreover, some of these effects, such as the development of opportunistic infections, have been reduced by CMV prophylaxis.
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Affiliation(s)
- Juan José Castón Osorio
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Ciudad Real, Ciudad Real, España.
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21
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Torre-Cisneros J, Fariñas MC, Castón JJ, Aguado JM, Cantisán S, Carratalá J, Cervera C, Cisneros JM, Cordero E, Crespo-Leiro MG, Fortún J, Frauca E, Gavaldá J, Gil-Vernet S, Gurguí M, Len O, Lumbreras C, Marcos MÁ, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pahissa A, Pérez JL, Rodriguez-Bernot A, Rumbao J, San Juan R, Santos F, Varo E, Zurbano F. GESITRA-SEIMC/REIPI recommendations for the management of cytomegalovirus infection in solid-organ transplant patients. Enferm Infecc Microbiol Clin 2011; 29:735-58. [DOI: 10.1016/j.eimc.2011.05.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 05/30/2011] [Indexed: 12/31/2022]
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22
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Bee YM, Tan HC, Tay TL, Kee TYS, Goh SY, Kek PC. Incidence and Risk Factors for Development of New-onset Diabetes after Kidney Transplantation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2011. [DOI: 10.47102/annals-acadmedsg.v40n4p160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: New-onset diabetes after transplantation (NODAT) is an increasingly recognised metabolic complication of kidney transplantation that is associated with increased morbidity and mortality. This study aimed to determine the incidence of NODAT and identify risk factors for development of NODAT among kidney allograft recipients in a single centre. Materials and Methods: We retrospectively reviewed all kidney allograft recipients in our centre between 1998 and 2007. NODAT were determined using criteria as per American Diabetes Association guidelines. Logistic regression analyses were performed to identify predictors of NODAT. Results: Among 388 patients included in the analysis, NODAT was reported in 94 patients (24.2%) after a median follow-up time of 52.1 months. The cumulative incidence of NODAT was 15.8%, 22.8% and 24.5% at 1, 3, and 5 years following transplantation. Seven clinical factors were independent predictors of NODAT: older age, HLA B13 and B15 phenotypes, use of sirolimus, acute rejections, higher pre-transplant and post-transplant (day 1) plasma glucose levels. Patients with NODAT had poorer outcomes in both graft and patient survival. Conclusion: Our study demonstrates a significant risk and burden of NODAT in an Asian transplant population. Risk stratification and aggressive monitoring of blood glucose early post-transplantation is necessary to identify high-risk patients so that appropriate tailoring of immunosuppression and early institution of lifestyle modifications can be implemented.
Key words: Diabetes mellitus, Immunosuppression, Kidney transplantation, Metabolic complication, Sirolimus
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23
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Impending hyperglycemia in normoglycemic renal transplant recipients--an experimental predictive surrogate. Transplantation 2010; 89:1341-6. [PMID: 20354482 DOI: 10.1097/tp.0b013e3181d9e1d8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND beta-Cell dysfunction and insulin resistance combine to cause new-onset diabetes after transplantation. The product of these two parameters, quantitatively measured as disposition index (DI), is a mathematical constant in normoglycemia and declines in advance of impending hyperglycemia. The aim of this study was to derive a simple surrogate for the DI to expose predysglycemic abnormalities posttransplantation. METHODS First-phase insulin secretion and sensitivity were determined by mathematical minimal model analysis of 58 frequently sampled, intravenous glucose tolerance tests in 58 non-diabetic renal transplant recipients and correlated against surrogate indexes based on fasting blood samples. Products of insulin secretion/resistance indexes were correlated against calculated DI, regression analysis performed for hyperbolic compatibility, autocorrelation studies conducted, and surrogates tested in various subgroups of renal transplant recipients to ensure robustness in a heterogeneous group. RESULTS The best correlation was achieved with "HOMA(sec) (first-phase insulin secretion)xMcAuley's index (insulin resistance)" (r=0.594, P<0.001). Regression analysis was consistent with a mathematical hyperbola (ln HOMA(sec) vs. ln McAuley's index, r=-0.639 [95% confidence interval, -1.772 to -0.950]), statistical autocorrelation was excluded (in a subset of 20 patients with repeat metabolic investigations), and the surrogate remained valid in different subgroups of transplant recipients. CONCLUSIONS Our surrogate "HOMA(sec)xMcAuley's index," requiring only fasting glucose, insulin, and triglycerides, is a simple and noninvasive surrogate for the DI. Its predictive utility for identifying impending hyperglycemia posttransplantation should be investigated further to ascertain whether its experimental nature can translate to clinical validity.
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24
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Hornum M, Jørgensen KA, Hansen JM, Nielsen FT, Christensen KB, Mathiesen ER, Feldt-Rasmussen B. New-onset diabetes mellitus after kidney transplantation in Denmark. Clin J Am Soc Nephrol 2010; 5:709-16. [PMID: 20167685 PMCID: PMC2849691 DOI: 10.2215/cjn.05360709] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 12/30/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES This study aimed to investigate the development of new-onset diabetes mellitus (NODM) in a prospective study of 97 nondiabetic uremic patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Included were 57 kidney recipients (Tx group, age 39 +/- 13 years) and 40 uremic patients remaining on the waiting list for kidney transplantation (uremic controls, age 47 +/- 11 years). All were examined at baseline before possible transplantation and after 12 months. The prevalence of diabetes, prediabetes, insulin sensitivity index (ISI), and insulin secretion index (Isecr) were estimated using an oral glucose tolerance test with measurements of plasma glucose and plasma insulin. RESULTS One year after transplantation NODM was present in 14% (8 of 57) compared with 5% (2 of 40) in the uremic control group (P = 0.01). ISI in the Tx group deteriorated from 6.8 +/- 3.9 before transplantation to 4.9 +/- 2.8 at 12 months after transplantation (P = 0.005), and a slight increase in Isecr from 37 +/- 19 to 46 +/- 22 (P = 0.02) was seen. No significant changes occurred in the uremic controls (ISI was 7.9 +/- 5 and 8.5 +/- 5, and Isecr was 31 +/- 17 and 28 +/- 15). Using multivariate ordinal logistic regression, pre-Tx ISI and age predicted NODM (odds ratios: 0.82, P = 0.01 and 1.06, P = 0.02, respectively). CONCLUSIONS One year after kidney transplantation, NODM was present in 14% of patients. This was mainly caused by an increase in insulin resistance and was observed despite improvement in insulin secretion.
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Affiliation(s)
- Mads Hornum
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, P 2131, DK-2100 Copenhagen, Denmark.
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25
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Abstract
Cytomegalovirus (CMV) remains the most important infection in the immunocompromized host even in the era of effective therapy. CMV is usually acquired early in life and can be transmitted by contact with infected body fluids. In the immunocompetent population, primary infection is almost always of little clinical consequence. However, CMV infection in immunocompromized patients, especially those naive to CMV exposure, can cause tissue invasive disease, severe symptoms and/or death. However, beyond these direct effects, increasing in vitro evidence is accumulating that suggests CMV has many other effects on the host's immune response which may explain some of the detrimental consequences for the immunosuppressed patient, and may also be partially responsible for a variety of conditions in immunocompetent individuals. In its latent state, CMV employs several mechanisms to evade detection by the host's immune system. The virus also employs other methods to take advantage of activation of the immune system and replicate in sites of inflammation. This review focuses on the immunosuppressive and inflammatory mechanisms that have been attributed to CMV and will relate them to some of the clinical sequellae that have been associated with the indirect effects of CMV infection.
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Affiliation(s)
- R B Freeman
- Division of Transplantation, Tufts Medical Center, Boston, MA, USA.
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26
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Reduced incidence of new-onset posttransplantation diabetes mellitus during the last decade. Transplantation 2008; 84:1125-30. [PMID: 17998867 DOI: 10.1097/01.tp.0000287191.45032.38] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND A previous study (1995-1996) of 173 nondiabetic renal transplant recipients (historical cohort; HC) revealed a 20% incidence of new-onset posttransplantation diabetes mellitus (PTDM) and 32% with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). We examined whether glucose tolerance has improved after recent changes in our immunosuppressive protocol and a switch from deferred to preemptive cytomegalovirus (CMV) therapy. METHODS A total of 321 consecutive, nondiabetic patients (new cohort; NC) were examined 10 weeks after kidney transplantation with an oral glucose tolerance test (n=301) between January 2004 and December 2005. RESULTS Although recipients in the NC were on average 3 years older [mean (SD): 50.3 (14.6) vs. 47.4 (16.0), P=0.038] and had a higher mean body mass index [24.5 (3.6) vs. 23.5 (3.8) kg/m(2), P=0.003], a significantly lower incidence of both PTDM (13%) and IGT/IFG (18%) was observed in the NC (P<0.001) as compared to the HC. The patients in the NC received a significantly lower mean daily oral prednisolone dose [13.2 (4.7) vs. 15.3 (6.6) mg/day, P<0.001], and had lower frequencies of rejections (36% vs. 57%, P<0.001) and CMV infection (54% vs. 63%, P=0.071). Patients in the NC had significantly lower odds of developing PTDM, even after adjustment for age, prednisolone dose, HLA-B27 status and CMV infection (odds ratio: 0.42, 95% CI: 0.23-0.77, P=0.005). CONCLUSIONS The odds of developing PTDM are more than halved over the last decade. Possible explanations are changes in immunosuppressive therapy, fewer rejections, and lower doses of steroids.
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27
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Arthurs SK, Eid AJ, Pedersen RA, Dierkhising RA, Kremers WK, Patel R, Razonable RR. Delayed-onset primary cytomegalovirus disease after liver transplantation. Liver Transpl 2007; 13:1703-9. [PMID: 18044717 DOI: 10.1002/lt.21280] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Clinical practice guidelines recommend antiviral prophylaxis to cytomegalovirus (CMV) donor-positive/recipient-negative (D+/R-) liver transplant recipients. We assessed the outcome of this strategy by determining the incidence, clinical features, and risk factors of CMV disease among CMV D+/R- liver transplant recipients who received antiviral prophylaxis. Sixty-seven CMV D+/R- liver transplant recipients (mean age+/-standard deviation: 49.5+/-11.4 years; 75% male) received oral ganciclovir [n=9 (13%)] or valganciclovir [n=58 (87%)] prophylaxis for a median duration of 92 days (interquartile range: 91-100). No breakthrough CMV disease was observed during antiviral prophylaxis. However, primary CMV disease was observed in 2%, 25%, 27%, 27%, and 29% of patients at 1, 3, 6, 12, and 24 months, respectively, after antiviral prophylaxis was stopped. The incidence of delayed-onset primary CMV disease was similar between those who received oral ganciclovir and valganciclovir. Nine (47%) patients had CMV syndrome, 8 (42%) had gastrointestinal CMV disease, and 2 (11%) had CMV hepatitis. Female patients (P=0.01) and younger age at transplant (P=0.03) were associated with an increased risk, whereas diabetes mellitus (P<0.001) was significantly associated with a lower risk of delayed-onset primary CMV disease. Allograft loss or mortality occurred in 8 (12%) patients during the median follow-up period of 3.31 (range: 0.8-5.9) years. No significant association was observed between CMV disease and patient and allograft survival. In conclusion, CMV disease remains a common complication in CMV D+/R- liver transplant patients during the contemporary era of antiviral prophylaxis. Female patients and younger patients are at increased risk of delayed-onset primary CMV disease.
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Affiliation(s)
- Supha K Arthurs
- Division of Infectious Diseases, William J. von Liebig Transplant Center, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Leung Ki EL, Venetz JP, Meylan P, Lamoth F, Ruiz J, Pascual M. Cytomegalovirus infection and new-onset post-transplant diabetes mellitus. Clin Transplant 2007; 22:245-9. [DOI: 10.1111/j.1399-0012.2007.00758.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Hur KY, Kim MS, Kim YS, Kang ES, Nam JH, Kim SH, Nam CM, Ahn CW, Cha BS, Kim SI, Lee HC. Risk factors associated with the onset and progression of posttransplantation diabetes in renal allograft recipients. Diabetes Care 2007; 30:609-15. [PMID: 17327329 DOI: 10.2337/dc06-1277] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to assess the incidence of posttransplantation diabetes mellitus (PTDM) in renal allograft recipients and to investigate factors contributing to the onset and progression of PTDM and its underlying pathogenic mechanism(s). RESEARCH DESIGN AND METHODS A total of 77 patients with normal glucose tolerance (NGT) were enrolled in this study. An oral glucose tolerance test was performed 1 week before transplantation and repeated at 1 and 7 years after transplantation. RESULTS The overall incidence of PTDM was 39% at 1 year and 35.1% at 7 years posttransplantation. The incidence for each category of PTDM was as follows: persistent PTDM (P-PTDM) (patients who developed diabetes mellitus within 1 year of transplantation and remained diabetic during 7 years), 23.4%; transient PTDM (T-PTDM) (patients who developed diabetes mellitus during the 1st year after transplantation but eventually recovered to have NGT), 15.6%; late PTDM (L-PTDM) (patients who developed diabetes mellitus later than 1 year after transplantation), 11.7%; and non-PTDM during 7 years (N-PTDM7) (patients who did not develop diabetes mellitus during 7 years), 49.3%. Older age (> or = 40 years) at transplantation was a higher risk factor for P-PTDM, whereas a high BMI (> or = 25 kg/m2) and impaired fasting glucose (IFG) at 1 year posttransplantation were higher risk factors for L-PTDM. Impaired insulin secretion rather than insulin resistance was significantly associated with the development of P- and L-PTDM. CONCLUSIONS Impaired insulin secretion may be the main mechanism for the development of PTDM. Older age at transplantation seems to be associated with P-PTDM, whereas a high BMI and IFG at 1 year after transplantation were associated with L-PTDM.
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Affiliation(s)
- Kyu Yeon Hur
- Department of Internal Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong Seodaemun-Gu, Seoul, 120-752, Korea
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Driscoll CJ, Cashion AK, Hathaway DK, Thompson C, Conley Y, Gaber O, Vera S, Shokouh-Amiri H. Posttransplant diabetes mellitus in liver transplant recipients. Prog Transplant 2006; 16:110-6. [PMID: 16789699 DOI: 10.1177/152692480601600204] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Driscoll C, Cashion A, Hathaway D, Thompson C, Conley Y, Gaber O, Vera S, Shokouh-Amiri H. Posttransplant diabetes mellitus in liver transplant recipients. Prog Transplant 2006. [DOI: 10.7182/prtr.16.2.h2621054365l113p] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Hjelmesaeth J, Flyvbjerg A, Jenssen T, Frystyk J, Ueland T, Hagen M, Hartmann A. Hypoadiponectinemia is associated with insulin resistance and glucose intolerance after renal transplantation: impact of immunosuppressive and antihypertensive drug therapy. Clin J Am Soc Nephrol 2006; 1:575-82. [PMID: 17699261 DOI: 10.2215/cjn.01471005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The objectives of this analysis were (1) to assess whether low serum adiponectin concentrations are associated with insulin resistance, metabolic syndrome, and new-onset posttransplantation diabetes mellitus (PTDM) and (2) to examine the possible effects of immunosuppressive and antihypertensive therapies on circulating adiponectin levels after renal transplantation. A total of 172 consecutive previously nondiabetic renal transplant recipients were examined 3 mo after transplantation, the majority (n = 167) with an oral glucose tolerance test. Serum adiponectin was measured by an in-house time-resolved immunofluorometric assay. Insulin secretion and insulin sensitivity were estimated by previously validated oral glucose tolerance test-derived indexes. One- and 6-yr follow-up data were available in subgroups of patients. Lower adiponectin levels were significantly associated with insulin resistance but not with insulinopenia. Patients with low adiponectin levels (first quartile) had significantly higher odds of PTDM (odds ratio [OR] 3.6; 95% confidence interval [CI] 1.1 to 12.7; P = 0.049) and metabolic syndrome (OR 3.9; 95% CI 1.6 to 9.5; P = 0.003) than patients in the upper (fourth) quartile. The increased risk for PTDM in patients with low adiponectin levels remained significant after adjustment for age, steroid dose, and family history of diabetes. Treatment with beta blockers was independently associated with lower serum adiponectin levels, and total steroid dose was associated with higher serum adiponectin levels. Low baseline adiponectin levels were also associated with significantly higher odds of PTDM at 6 yr (OR 6.9; 95% CI = 1.1 to 41.8; P = 0.037). Serum adiponectin levels correlate with posttransplantation insulin sensitivity and glucose tolerance. Glucocorticoids and beta blockers seem to have opposite effects on circulating adiponectin levels.
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Affiliation(s)
- Jøran Hjelmesaeth
- Department of Medicine, Rikshospitalet University Hospital, Oslo, Norway.
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Shah A, Kendall G, Demme RA, Taylor J, Bozorgzadeh A, Orloff M, Jain A, Abt P, Zand MS. Home glucometer monitoring markedly improves diagnosis of post renal transplant diabetes mellitus in renal transplant recipients. Transplantation 2005; 80:775-81. [PMID: 16210964 DOI: 10.1097/01.tp.0000173769.09518.f1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Definitions of de novo posttransplant diabetes mellitus (PTDM) have varied widely in the renal transplant literature, and most have not used the American Diabetes Association (ADA) definition of diabetes (fasting plasma glucose [FPG] > or = 126 mg/dl on two occasions, or a casual plasma glucose level >200 mg/dl). Most patients are monitored for PTDM by 12-hour FPG levels drawn for clinic visits. In contrast, we describe the diagnosis of PTDM by home glucometer monitoring METHODS We screened 89 consecutive nondiabetic renal transplant recipients for PTDM by ADA criteria and home glucometer monitoring during the first 3 months posttransplant RESULTS Of 23 patients with impaired fasting glucose levels of 111-126 mg/dl, 14 (61%) met ADA criteria for diabetes mellitus of based on home glucometer monitoring. The incidence of de novo PTDM was 31% during this period. Predictors of PTDM in a Cox proportional hazards model were race and acute rejection, with a trend towards BMI. Clinic visit FPG levels did not differ between PTDM and non-PTDM patients. All diagnoses were made based on prelunch or supper FPG >200 mg/dl. CONCLUSIONS Overnight FPG are inadequate for diagnosis of PTDM. All renal transplant recipients with impaired FPG should, at minimum, have home FPG testing.
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Affiliation(s)
- Amish Shah
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
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Teutonico A, Schena PF, Di Paolo S. Glucose metabolism in renal transplant recipients: effect of calcineurin inhibitor withdrawal and conversion to sirolimus. J Am Soc Nephrol 2005; 16:3128-35. [PMID: 16107580 DOI: 10.1681/asn.2005050487] [Citation(s) in RCA: 196] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cyclosporine A (CsA) and tacrolimus have been associated with an increased risk for diabetes after transplantation, whereas sirolimus is deemed to be devoid of any effect on glucose metabolism. This study was performed to investigate the effect of the withdrawal of calcineurin inhibitors and the switch to sirolimus on peripheral insulin resistance and pancreatic beta cell response. Twenty-six patients who received a kidney transplant and discontinued CsA and were converted to sirolimus and 15 recipients of suboptimal kidneys who were treated with tacrolimus plus sirolimus for the first 3 mo after grafting and thereafter with sirolimus alone were enrolled. All patients underwent an oral glucose tolerance test and intravenous insulin tolerance test before and 6 mo after the conversion to sirolimus-alone therapy. The withdrawal of CsA or tacrolimus was associated with a significant fall of insulin sensitivity (both P = 0.01) and with a defect in the compensatory beta cell response, as measured by the disposition index (P = 0.004 and P = 0.02, respectively). The increase of insulin resistance and the decrease of disposition index significantly correlated with the change of serum triglyceride concentration after the conversion to sirolimus-based therapy (R(2) = 0.30, P = 0.0002; and R(2) = 0.19, P = 0.004, respectively). Clinically, the switch to sirolimus was associated with a 30% increase of incidence of impaired glucose tolerance and with four patients' developing new-onset diabetes. In conclusion, the discontinuation of calcineurin inhibitors and their replacement by sirolimus fail to ameliorate the glycometabolic profile of kidney transplant recipients. Rather, it is associated with a worsening of insulin resistance and an inappropriately low insulin response.
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Affiliation(s)
- Annalisa Teutonico
- Department of Emergency and Organ Transplants, Division of Nephrology, Dialysis and Transplantation, University of Bari, Policlinico-Piazza Giulio Cesare 11, Bari 70124, Italy
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Sagedal S, Hartmann A, Rollag H. The impact of early cytomegalovirus infection and disease in renal transplant recipients. Clin Microbiol Infect 2005; 11:518-30. [PMID: 15966969 DOI: 10.1111/j.1469-0691.2005.01190.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human cytomegalovirus (HCMV) infection is the single most frequent infectious complication in the early period after kidney transplantation. The HCMV load in blood, measured by HCMV PCR or the HCMV pp65 antigen test, is a predictor of HCMV disease in seropositive recipients. However, plasma virus load measurements are of only modest value in predicting the risk of HCMV disease in seronegative recipients of kidneys from seropositive donors. HCMV infection is an independent risk-factor for acute kidney graft rejection. There is also evidence that HCMV is associated with an increased long-term mortality and post-transplant diabetes mellitus. Whether pre-emptive or prophylactic therapy should be the preferred strategy is not yet decided. Some studies indicate that HCMV prophylaxis may reduce the risk of acute rejection, and thereby increase long-term graft survival in seronegative recipients of kidneys from seropositive donors.
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Affiliation(s)
- S Sagedal
- Department of Internal Medicine, Rikshospitalet University Hospital, Oslo, Norway.
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Hjelmesaeth J, Müller F, Jenssen T, Rollag H, Sagedal S, Hartmann A. Is there a link between cytomegalovirus infection and new-onset posttransplantation diabetes mellitus? Potential mechanisms of virus induced β-cell damage. Nephrol Dial Transplant 2005; 20:2311-5. [PMID: 16046502 DOI: 10.1093/ndt/gfi033] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Lo A. Immunosuppression and Metabolic Syndrome in Renal Transplant Recipients. Metab Syndr Relat Disord 2004; 2:263-73. [DOI: 10.1089/met.2004.2.263] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Agnes Lo
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
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Hjelmesaeth J, Sagedal S, Hartmann A, Rollag H, Egeland T, Hagen M, Nordal KP, Jenssen T. Asymptomatic cytomegalovirus infection is associated with increased risk of new-onset diabetes mellitus and impaired insulin release after renal transplantation. Diabetologia 2004; 47:1550-6. [PMID: 15338129 DOI: 10.1007/s00125-004-1499-z] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2003] [Accepted: 01/05/2004] [Indexed: 01/11/2023]
Abstract
AIMS/HYPOTHESIS The human cytomegalovirus (CMV) may increase the risk of diabetes mellitus, but the literature is scarce. The present study was designed to test the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset diabetes after renal transplantation, and to assess the impact of asymptomatic CMV infection on OGTT-derived estimates of insulin release and insulin action. METHODS A total of 160 consecutive non-diabetic renal transplant recipients on cyclosporine (Sandimmun Neoral)-based immunosuppression were closely monitored for CMV infection during the first 3 months after transplantation. All patients underwent a 75-g OGTT at 10 weeks. Excluded from the analyses were 36 patients with symptomatic CMV infection (disease). RESULTS The incidence of new-onset diabetes was 6% in a control group of recipients without CMV infection (4/63) and 26% in the group with asymptomatic CMV infection (16/61). Asymptomatic CMV infection was associated with a significantly increased risk of new-onset diabetes (adjusted odds ratio: 4.00; 95% CI: 1.19 to 13.43, p=0.025). The group of patients with CMV infection had a significantly lower median insulin release than controls. CONCLUSIONS/INTERPRETATION Our findings support the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset post-transplant diabetes mellitus, and suggest that impaired insulin release may involve one pathogenetic mechanism.
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Affiliation(s)
- J Hjelmesaeth
- Department of Medicine, Section of Nephrology, Rikshospitalet University Hospital, Oslo, Norway.
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Pfeffer F, Nauck MA, Drognitz O, Benz S, von Dobschuetz E, Hopt UT. Postoperative oral glucose tolerance and stimulated insulin secretion: a predictor of endocrine graft function more than 10 years after pancreas-kidney transplantation. Transplantation 2003; 76:1427-31. [PMID: 14657680 DOI: 10.1097/01.tp.0000098821.26466.de] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND After pancreas transplantation, endocrine function is determined by the insulin secretory capacity of the transplanted pancreas. The authors evaluated the predictive value of postoperative oral glucose tolerance test (OGTT) and stimulated insulin secretion on long-term endocrine function. METHODS Forty-one patients after pancreas-kidney transplantation with systemic venous drainage were studied. Patients were categorized to have normal glucose tolerance (NGT) or impaired glucose tolerance (IGT) (World Health Organization criteria: NGT, <7.8 mM; IGT, 7.8-11.1 mM 120 min after glucose intake) and high or low total insulin secretion. Mean follow-up of graft function and patient outcome was 10.2+/-0.5 years after OGTT. RESULTS Patients with IGT had grafts with a longer ischemia time and a significantly worse urine amylase excretion as compared with patients with NGT. Using Kaplan-Meier survival analysis, patients with NGT had better long-term pancreatic function as compared with IGT in the follow-up after performing the first OGTT (mean, 10.9+/-0.2 vs. 8.8+/-0.9 years of graft function; P=0.02), but there was no difference in patient survival and kidney graft function. Also, high insulin secretion predicted significantly longer pancreas graft function as compared with low insulin secretion (P=0.04). CONCLUSIONS Although IGT does not lead to poorer long-term patient survival and kidney graft function, it does predict compromised long-term endocrine function of the transplanted pancreas. Therefore, postoperative OGTT are useful tools for identification of patients at risk of long-term endocrine graft failure after pancreas transplantation.
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Affiliation(s)
- Frank Pfeffer
- Department of General Surgery, University of Freiburg, Freiburg, Germany.
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