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Bang JB, Oh CK, Kim YS, Kim SH, Yu HC, Kim CD, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Ahn HJ, Lee SH, Jeon JY. Changes in glucose metabolism among recipients with diabetes 1 year after kidney transplant: a multicenter 1-year prospective study. Front Endocrinol (Lausanne) 2023; 14:1197475. [PMID: 37424863 PMCID: PMC10325682 DOI: 10.3389/fendo.2023.1197475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Diabetes mellitus is a common and crucial metabolic complication in kidney transplantation. It is necessary to analyze the course of glucose metabolism in patients who already have diabetes after receiving a transplant. In this study, we investigated the changes in glucose metabolism after transplantation, and a detailed analysis was performed on some patients whose glycemic status improved. Methods The multicenter prospective cohort study was conducted between 1 April 2016 and 31 September 2018. Adult patients (aged 20 to 65 years) who received kidney allografts from living or deceased donors were included. Seventy-four subjects with pre-transplant diabetes were followed up for 1 year after kidney transplantation. Diabetes remission was defined as the results of the oral glucose tolerance test performed one year after transplantation and the presence or absence of diabetes medications. After 1-year post-transplant, 74 recipients were divided into the persistent diabetes group (n = 58) and the remission group (n = 16). Multivariable logistic regression was performed to identify clinical factors associated with diabetes remission. Results Of 74 recipients, 16 (21.6%) showed diabetes remission after 1-year post-transplant. The homeostatic model assessment for insulin resistance numerically increased in both groups throughout the first year after transplantation and significantly increased in the persistent diabetes group. The insulinogenic index (IGI30) value significantly increased only in the remission group, and the IGI30 value remained low in the persistent diabetes group. In univariate analysis, younger age, newly diagnosed diabetes before transplantation, low baseline hemoglobin A1c, and high baseline IGI30 were significantly associated with remission of diabetes. After multivariate analysis, only newly diagnosed diabetes before transplantation and IGI30 at baseline were associated with remission of diabetes (34.00 [1.192-969.84], P = 0.039, and 17.625 [1.412-220.001], P = 0.026, respectively). Conclusion In conclusion, some kidney recipients with pre-transplant diabetes have diabetes remission 1 year after transplantation. Our prospective study revealed that preserved insulin secretory function and newly diagnosed diabetes at the time of kidney transplantation were favorable factors for which glucose metabolism did not worsen or improve 1 year after kidney transplantation.
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Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery and Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University College of Medicine, Jeonju, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jun So
- Department of Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sang Ho Lee
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Republic of Korea
| | - Hyung Joon Ahn
- Department of Surgery, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
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Park K, Sonn SK, Seo S, Kim J, Hur KY, Oh GT, Lee MS. Impaired TFEB activation and mitophagy as a cause of PPP3/calcineurin inhibitor-induced pancreatic β-cell dysfunction. Autophagy 2023; 19:1444-1458. [PMID: 36217215 PMCID: PMC10240995 DOI: 10.1080/15548627.2022.2132686] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/02/2022] Open
Abstract
Macroautophagy/autophagy or mitophagy plays crucial roles in the maintenance of pancreatic β-cell function. PPP3/calcineurin can modulate the activity of TFEB, a master regulator of lysosomal biogenesis and autophagy gene expression, through dephosphorylation. We studied whether PPP3/calcineurin inhibitors can affect the mitophagy of pancreatic β-cells and pancreatic β-cell function employing FK506, an immunosuppressive drug against graft rejection. FK506 suppressed rotenone- or oligomycin+antimycin-A-induced mitophagy measured by Mito-Keima localization in acidic lysosomes or RFP-LC3 puncta colocalized with TOMM20 in INS-1 insulinoma cells. FK506 diminished nuclear translocation of TFEB after treatment with rotenone or oligomycin+antimycin A. Forced TFEB nuclear translocation by a constitutively active TFEB mutant transfection restored impaired mitophagy by FK506, suggesting the role of decreased TFEB nuclear translocation in FK506-mediated mitophagy impairment. Probably due to reduced mitophagy, recovery of mitochondrial potential or quenching of mitochondrial ROS after removal of rotenone or oligomycin+antimycin A was delayed by FK506. Mitochondrial oxygen consumption was reduced by FK506, indicating reduced mitochondrial function by FK506. Likely due to mitochondrial dysfunction, insulin release from INS-1 cells was reduced by FK506 in vitro. FK506 treatment also reduced insulin release and impaired glucose tolerance in vivo, which was associated with decreased mitophagy and mitochondrial COX activity in pancreatic islets. FK506-induced mitochondrial dysfunction and glucose intolerance were ameliorated by an autophagy enhancer activating TFEB. These results suggest that diminished mitophagy and consequent mitochondrial dysfunction of pancreatic β-cells contribute to FK506-induced β-cell dysfunction or glucose intolerance, and autophagy enhancement could be a therapeutic modality against post-transplantation diabetes mellitus caused by PPP3/calcineurin inhibitors.
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Affiliation(s)
- Kihyoun Park
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Keun Sonn
- Heart-Immune-Brain Network Research Center, Department of Life Science, Ewha Womans University, Seoul, Korea
| | - Seungwoon Seo
- Heart-Immune-Brain Network Research Center, Department of Life Science, Ewha Womans University, Seoul, Korea
| | - Jinyoung Kim
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Yeon Hur
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo Taeg Oh
- Heart-Immune-Brain Network Research Center, Department of Life Science, Ewha Womans University, Seoul, Korea
| | - Myung-Shik Lee
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
- Soonchunhyang Institute of Medi-bio Science and Division of Endocrinology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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3
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Sitagliptin Versus Placebo to Reduce the Incidence and Severity of Posttransplant Diabetes Mellitus After Kidney Transplantation-A Single-center, Randomized, Double-blind Controlled Trial. Transplantation 2022; 107:1180-1187. [PMID: 36279020 PMCID: PMC10125117 DOI: 10.1097/tp.0000000000004373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Postkidney transplant diabetes mellitus (PTDM) affects cardiovascular, allograft, and recipient health. We tested whether early intervention with sitagliptin for hyperglycemia (blood glucose >200 mg/dL) within the first week of transplant and discontinued at 3 mo could prevent development of PTDM in patients without preexisting diabetes. METHODS The primary efficacy objective was to improve 2-h oral glucose tolerance test (OGTT) by > 20 mg/dL at 3 mo posttransplant. The secondary efficacy objective was to prevent new onset PTDM, defined as a normal OGTT at 3 mo. RESULTS Sixty-one patients consented, and 50 patients were analyzed. The 3-mo 2-h OGTT (end of treatment) was 141.00 ± 62.44 mg/dL in the sitagliptin arm and 165.22 ± 72.03 mg/dL ( P = 0.218) in the placebo arm. The 6-mo 2-h OGTT (end of follow-up) was 174.38 ± 77.93 mg/dL in the sitagliptin arm and 171.86 ± 83.69 ng/dL ( P = 0.918) in the placebo arm. Mean intrapatient difference between 3- and 6-mo 2-h OGTT in the 3-mo period off study drug was 27.56 + 52.74 mg/dL in the sitagliptin arm and -0.14 + 45.80 mg/dL in the placebo arm ( P = 0.0692). At 3 mo, 61.54% of sitagliptin and 43.48% of placebo patients had a normal 2-h OGTT ( P = 0.2062), with the absolute risk reduction 18.06%. There were no differences in HbA1c at 3 or 6 mo between sitagliptin and placebo groups. Participants tolerated sitagliptin well. CONCLUSION Although this study did not show a significant difference between groups, it can inform future studies in the use of sitagliptin in the very early posttransplant period.
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Singer J, Aouad LJ, Wyburn K, Gracey DM, Ying T, Chadban SJ. The Utility of Pre- and Post-Transplant Oral Glucose Tolerance Tests: Identifying Kidney Transplant Recipients With or at Risk of New Onset Diabetes After Transplant. Transpl Int 2022; 35:10078. [PMID: 35368638 PMCID: PMC8967957 DOI: 10.3389/ti.2022.10078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/24/2022] [Indexed: 11/13/2022]
Abstract
Background: New onset diabetes after transplant (NODAT) is common in kidney transplant recipients (KTRs). Identifying patients at risk prior to transplant may enable strategies to mitigate NODAT, with a pre-transplant oral glucose tolerance test (OGTT) suggested by the KDIGO 2020 Guidelines for this purpose. Methods: We investigated the utility of pre- and post-transplant OGTTs to stratify risk and diagnose NODAT in a retrospective, single-centre cohort study of all non-diabetic KTRs transplanted between 2003 and 2018. Results: We identified 597 KTRs who performed a pre-transplant OGTT, of which 441 had their post-transplant glycaemic status determined by a clinical diagnosis of NODAT or OGTT. Pre-transplant dysglycaemia was identified in 28% of KTRs and was associated with increasing age (p < 0.001), BMI (p = 0.03), and peritoneal dialysis (p < 0.001). Post-transplant dysglycaemia was common with NODAT and impaired glucose tolerance (IGT) occurring in 143 (32%) and 121 (27%) patients, respectively. Pre-transplant IGT was strongly associated with NODAT development (OR 3.8, p < 0.001). Conclusion: A pre-transplant OGTT identified candidates at increased risk of post-transplant dysglycaemia and NODAT, as diagnosed by an OGTT. Robust prospective trials are needed to determine whether various interventions can reduce post-transplant risk for candidates with an abnormal pre-transplant OGTT.
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Affiliation(s)
- Julian Singer
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Leyla J Aouad
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Kate Wyburn
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - David M Gracey
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Tracey Ying
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Kidney Centre, Level 2 Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.,Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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5
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Ben-David E, Hull R, Banerjee D. Diabetes mellitus in dialysis and renal transplantation. Ther Adv Endocrinol Metab 2021; 12:20420188211048663. [PMID: 34631007 PMCID: PMC8495524 DOI: 10.1177/20420188211048663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/29/2021] [Indexed: 12/31/2022] Open
Abstract
Diabetes mellitus is the commonest cause of end-stage kidney failure worldwide and is a proven and significant risk factor for the development of cardiovascular disease. Renal impairment has a significant impact on the physiology of glucose homeostasis as it reduces tissue sensitivity to insulin and reduces insulin clearance. Renal replacement therapy itself affects glucose control: peritoneal dialysis may induce hyperglycaemia due to glucose-rich dialysate and haemodialysis often causes hypoglycaemia due to the relatively low concentration of glucose in the dialysate. Autonomic neuropathy which is common in chronic kidney disease (CKD) and diabetes increases the risk for asymptomatic hypoglycaemia. Pharmacological options for improving glycaemic control are limited due to alterations to drug metabolism. Impaired glucose tolerance and diabetes are also common in the post-kidney-transplant setting and increase the risk of graft failure and mortality. This review seeks to summarise the literature and tackle the intricacies of glycaemic management in patients with CKD who are either on maintenance haemodialysis or have received a kidney transplant. It outlines changes to glycaemic targets, monitoring of glycaemic control, the use of oral hypoglycaemic agents, the management of severe hyperglycaemia in dialysis and kidney transplantation patients.
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Affiliation(s)
- Eyal Ben-David
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Richard Hull
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Room G2.113, Second Floor, Grosvenor Wing, Blackshaw Road, Tooting, London SW17 0QT, UK
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6
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Kim JE, Park SJ, Kim YC, Min SI, Ha J, Kim YS, Yoon SH, Han SS. Deep Learning-Based Quantification of Visceral Fat Volumes Predicts Posttransplant Diabetes Mellitus in Kidney Transplant Recipients. Front Med (Lausanne) 2021; 8:632097. [PMID: 34113628 PMCID: PMC8185023 DOI: 10.3389/fmed.2021.632097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/30/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Because obesity is associated with the risk of posttransplant diabetes mellitus (PTDM), the precise estimation of visceral fat mass before transplantation may be helpful. Herein, we addressed whether a deep-learning based volumetric fat quantification on pretransplant computed tomographic images predicted the risk of PTDM more precisely than body mass index (BMI). Methods: We retrospectively included a total of 718 nondiabetic kidney recipients who underwent pretransplant abdominal computed tomography. The 2D (waist) and 3D (waist or abdominal) volumes of visceral, subcutaneous, and total fat masses were automatically quantified using the deep neural network. The predictability of the PTDM risk was estimated using a multivariate Cox model and compared among the fat parameters using the areas under the receiver operating characteristic curves (AUROCs). Results: PTDM occurred in 179 patients (24.9%) during the median follow-up period of 5 years (interquartile range, 2.5–8.6 years). All the fat parameters predicted the risk of PTDM, but the visceral and total fat volumes from 2D and 3D evaluations had higher AUROC values than BMI did, and the best predictor of PTDM was the 3D abdominal visceral fat volumes [AUROC, 0.688 (0.636–0.741)]. The addition of the 3D abdominal VF volume to the model with clinical risk factors increased the predictability of PTDM, but BMI did not. Conclusions: A deep-learning based quantification of visceral fat volumes on computed tomographic images better predicts the risk of PTDM after kidney transplantation than BMI.
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Affiliation(s)
- Ji Eun Kim
- Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sang Joon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea.,Department of Radiology, UMass Memorial Medical Center, Worcester, MA, United States
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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7
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Montada-Atin T, Prasad GVR. Recent advances in new-onset diabetes mellitus after kidney transplantation. World J Diabetes 2021; 12:541-555. [PMID: 33995843 PMCID: PMC8107982 DOI: 10.4239/wjd.v12.i5.541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/05/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
A common challenge in managing kidney transplant recipients (KTR) is post-transplant diabetes mellitus (PTDM) or diabetes mellitus (DM) newly diagnosed after transplantation, in addition to known pre-existing DM. PTDM is an important risk factor for post-transplant cardiovascular (CV) disease, which adversely affects patient survival and quality of life. CV disease in KTR may manifest as ischemic heart disease, heart failure, and/or left ventricular hypertrophy. Available therapies for PTDM include most agents currently used to treat type 2 diabetes. More recently, the use of sodium glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and dipeptidyl peptidase 4 inhibitors (DPP4i) has cautiously extended to KTR with PTDM, even though KTR are typically excluded from large general population clinical trials. Initial evidence from observational studies seems to indicate that SGLT2i, GLP-1 RA, and DPP4i may be safe and effective for glycemic control in KTR, but their benefit in reducing CV events in this otherwise high-risk population remains unproven. These newer drugs must still be used with care due to the increased propensity of KTR for intravascular volume depletion and acute kidney injury due to diarrhea and their single-kidney status, pre-existing burden of peripheral vascular disease, urinary tract infections due to immunosuppression and a surgically altered urinary tract, erythrocytosis from calcineurin inhibitors, and reduced kidney function from acute or chronic rejection.
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Affiliation(s)
- Tess Montada-Atin
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, Ontario, Canada
| | - G V Ramesh Prasad
- Kidney Transplant Program, St. Michael's Hospital, Toronto M5C 2T2, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto M5C 2T2, Canada
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8
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Bang JB, Oh CK, Kim YS, Kim SH, Yu HC, Kim CD, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Lee SH, Jeon JY. Insulin Secretion and Insulin Resistance Trajectories over 1 Year after Kidney Transplantation: A Multicenter Prospective Cohort Study. Endocrinol Metab (Seoul) 2020; 35:820-829. [PMID: 33202516 PMCID: PMC7803593 DOI: 10.3803/enm.2020.743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/22/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND We investigated the changing patterns of insulin secretion and resistance and risk factors contributing to the development of post-transplant diabetes mellitus (PTDM) in kidney recipients under tacrolimus-based immunosuppression regimen during 1 year after transplantation. METHODS This was a multicenter prospective cohort study. Of the 168 subjects enrolled in this study, we analyzed a total 87 kidney transplant recipients without diabetes which was assessed by oral glucose tolerance test before transplantation. We evaluated the incidence of PTDM and followed up the index of insulin secretion (insulinogenic index [IGI]) and resistance (homeostatic model assessment for insulin resistance [HOMA-IR]) at 3, 6, 9 months, and 1 year after transplantation by oral glucose tolerance test and diabetes treatment. We also assessed the risk factors for incident PTDM. RESULTS PTDM developed in 23 of 87 subjects (26.4%) during 1 year after transplantation. More than half of total PTDM (56.5%) occurred in the first 3 months after transplantation. During 1 year after transplantation, insulin resistance (HOMA-IR) was increased in both PTDM and no PTDM group. In no PTDM group, the increase in insulin secretory function to overcome insulin resistance was also observed. However, PTDM group showed no increase in insulin secretion function (IGI). Old age, status of prediabetes and episode of acute rejection were significantly associated with the development of PTDM. CONCLUSION In tacrolimus-based immunosuppressive drugs regimen, impaired insulin secretory function for reduced insulin sensitivity contributed to the development of PTDM than insulin resistance during 1 year after transplantation.
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Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery and Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, Seoul, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Seoul, Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Jun So
- Department of Surgery, Wonkwang University Hospital, Iksan, Seoul, Korea
| | - Sang Ho Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Seoul, Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
- Su Hyung Lee, Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea, Tel: +82-31-219-5760, Fax: +82-31-219-4438, E-mail:
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Korea
- Corresponding authors: Ja Young Jeon, Department of Endocrinology and Metabolism, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea, Tel: +82-31-219-7459, Fax: +82-31-219-4497, E-mail:
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9
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Evaluation of Tacrolimus Trough Level in Patients Who Developed Post-transplant Diabetes Mellitus After Kidney Transplantation: A Retrospective Single-Center Study in Saudi Arabia. Transplant Proc 2020; 52:3160-3167. [PMID: 32636070 DOI: 10.1016/j.transproceed.2020.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is a complication after kidney transplantation. Studies showed an association between high trough levels of tacrolimus FK506 and PTDM. This study aims to investigate the association between FK506 trough levels during the first year after kidney transplant and the incidence of PTDM. METHODS This retrospective study included adult kidney transplant patients who were not diabetic before transplantation from 2011 to 2014. The analysis evaluated FK506 trough levels at different time points post-transplant, as well as other variables to determine whether they were associated with PTDM. RESULTS The cumulative incidence of PTDM was 22.5% with a median time to PTDM diagnosis of 10 months. PTDM patients had higher first FK506 (ng/mL) levels (P = .001), and more patients in the PTDM group had FK506 level >10 ng/mL during the first 3 months (P = .004). After 12 months of transplant, PTDM patients had higher body mass index (BMI) 28.3 ± 6.9 kg/m2 compared to non-PTDM patients 26.4 ± 6.7 kg/m2 (P = .015). Binary logistic regression analysis showed that age ≥40 years (odds ratio [OR] = 2.75, P = .004), BMI ≥25 kg/m2 (OR = 2.04, P = .040), and FK506 level ≥10 ng/mL during the first 3 months (OR = 2.65, P = .009) were significantly related to PTDM development. CONCLUSION Patients with FK506 trough level >10 ng/mL during the first 3 months after transplantation are at higher risk of PTDM, especially in patients >40 years of age and/or who are overweight. These results may strengthen the notion that there is a connection between high FK506 trough levels and PTDM development.
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Gulsoy Kirnap N, Bozkus Y, Haberal M. Analysis of Risk Factors for Posttransplant Diabetes Mellitus After Kidney Transplantation: Single-Center Experience. EXP CLIN TRANSPLANT 2020; 18:36-40. [PMID: 32008491 DOI: 10.6002/ect.tond-tdtd2019.o8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Posttransplant diabetes mellitus may severely affect the short-term and long-term outcomes of grafts and patient survival in kidney transplant recipients. The annual incidence rate of posttransplant diabetes mellitus ranges from 4% to 25%. In this study, our aim was to determine the possible risk factors in patients diagnosed with this disease. MATERIALS AND METHODS From November 1975 to May 2019, our transplant team performed 3012 kidney transplant procedures at different units within Baskent University Transplantation Centers. We retrospectively analyzed data of patients who were diagnosed with posttransplant diabetes mellitus between 2010 and 2019. The diagnosis was made according to the 2001 American Diabetes Association criteria (fasting plasma glucose level ≥ 126 mg/dL [7 mmol/L] in 2 measurements or random blood glucose level ≥ 200 mg/dL [11.1 mmol/L] within 12 months posttransplant). RESULTS For this study, 400 patients (292 male, 108 female) with end-stage renal disease and without diabetes met the initial inclusion criteria; 270 received hemodialysis, 26 received peritoneal dialysis, and 104 underwent preemptive kidney transplant. In this patient group, 62 patients (15.5%) developed post-transplant diabetes mellitus. When we compared patients who developed and did not develop posttransplant diabetes mellitus, cause of end-stage renal disease, dialysis type and duration, type of donor (living or deceased), and graft survival posttransplant were similar between groups. Baseline fasting plasma glucose level was significantly higher in patients who developed posttransplant diabetes mellitus (90 vs 85 mg/dL; P = .034). Patients who developed the disease were significantly older. CONCLUSIONS In our study, recipient age was the only risk factor for posttransplant diabetes mellitus. Older recipients should be examined more carefully for posttransplant diabetes mellitus, and less diabetogenic immunosuppressive drugs may be preferred.
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Soypacaci Z, Akgun AO, Sengul S, Keven K. Insulin Resistance in Nonobese Renal Allograft Recipients on Maintenance Doses of Cyclosporine or Tacrolimus. Transplant Proc 2019; 51:2339-2342. [PMID: 31402251 DOI: 10.1016/j.transproceed.2019.01.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE In comparison to cyclosporine (CsA), tacrolimus (Tac) seems to be more diabetogenic in renal transplant recipients, and post-transplant diabetes mellitus is more common in patients using Tac, especially during the first year after transplantation. However, at maintenance doses, there are no comparative data of insulin resistance (IR) in patients using Tac or CsA. The purpose of this study was to investigate the IR indexes in patients on maintenance doses of CsA or Tac. METHODS Forty-five nondiabetic and nonobese renal transplant recipients participated in the study (M:F, 30:15; age, 36 ± 9 years); 27 patients were on CsA, and 18 were on Tac. All had stable graft function, were transplanted at least 6 months previously, and were receiving maintenance doses of steroids (5.0 mg/d), azathioprine or mycophenolate mofetil, and calcineurin inhibitors (CsA [2.14 ± 0.46 mg/kg/d] or Tac [0.06 ± 0.03 mg/kg/d]). IR was evaluated by the homeostasis model assessment (HOMA) index and composite body insulin sensitivity index. RESULTS We did not determine any significant difference in the HOMA and composite body insulin sensitivity index levels among patients using CsA or Tac (1.5 ± 1.3 vs 1.5 ± 1.1, P > .05, and 9.9 ± 5.8 vs 14.6 ± 11.7, P > .05, respectively). There was a significant correlation between creatinine and HOMA values. CONCLUSION There was no difference in IR indexes in renal transplant recipients receiving maintenance doses of either CsA or Tac.
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Affiliation(s)
- Zeki Soypacaci
- Department of Nephrology, School of Medicine, Izmir Katip Celebi University, Izmir, Turkey.
| | - A Oguz Akgun
- Department of Nephrology, School of Medicine, Ankara University, Ankara, Turkey
| | - Sule Sengul
- Department of Nephrology, School of Medicine, Ankara University, Ankara, Turkey
| | - Kenan Keven
- Department of Nephrology, School of Medicine, Ankara University, Ankara, Turkey
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12
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13
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Conte C, Secchi A. Post-transplantation diabetes in kidney transplant recipients: an update on management and prevention. Acta Diabetol 2018; 55:763-779. [PMID: 29619563 DOI: 10.1007/s00592-018-1137-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022]
Abstract
Post-transplantation diabetes mellitus (PTDM) may severely impact both short- and long-term outcomes of kidney transplant recipients in terms of graft and patient survival. However, PTDM often goes undiagnosed is underestimated or poorly managed. A diagnosis of PTDM should be delayed until the patient is on stable maintenance doses of immunosuppressive drugs, with stable kidney graft function and in the absence of acute infections. Risk factors for PTDM should be assessed during the pre-transplant evaluation period, in order to reduce the likelihood of developing diabetes. The oral glucose tolerance test is considered as the gold standard for diagnosing PTDM, whereas HbA1c is not reliable during the first months after transplantation. Glycaemic targets should be individualised, and comorbidities such as dyslipidaemia and hypertension should be treated with drugs that have the least possible impact on glucose metabolism, at doses that do not interact with immunosuppressants. While insulin is the preferred agent for treating inpatient hyperglycaemia in the immediate post-transplantation period, little evidence is available to guide therapeutic choices in the management of PTDM. Metformin and incretins may offer some advantage over other glucose-lowering agents, particularly with respect to risk of hypoglycaemia and weight gain. Tailoring immunosuppressive regimens may be of help, although maintenance of good kidney function should be prioritised over prevention/treatment of PTDM. The aim of this narrative review is to provide an overview of the available evidence on management and prevention of PTDM, with a focus on the available therapeutic options.
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Affiliation(s)
- Caterina Conte
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Antonio Secchi
- I.R.C.C.S. Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
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14
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Hap K, Madziarska K, Zmonarski S, Kamińska D, Magott-Procelewska M, Banasik M, Jędrzejak K, Madziarski M, Hap W, Klinger M, Mazanowska O. Pretransplantation Oral Glucose Tolerance Test Can Prevent Posttransplant Diabetes Mellitus After Renal Transplantation: Preliminary Study. Transplant Proc 2018; 50:1776-1780. [PMID: 30056899 DOI: 10.1016/j.transproceed.2018.03.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/08/2018] [Accepted: 03/23/2018] [Indexed: 12/13/2022]
Abstract
Posttransplant diabetes mellitus (PTDM) adversely affects renal graft and patient survival. Fasting plasma glucose (FPG) alone underestimates diagnosis of glucose metabolism disorders (GMD) detected using the oral glucose tolerance test (OGTT-75). Prediabetes including impaired fasting glucose (IFG): 100 to 125 mg/dL (5.6-6.9 mmol/L) and impaired glucose tolerance (IGT): 140 to 199 mg/dL (7.8-11 mmol/L) 2 hours post 75-g OGTT in the pretransplant period can have a connection with the occurrence of PTDM after renal transplantation (RTx). The aim of our study was to assess the benefit of performing OGTT-75 in dialyzed chronic kidney disease (stage 5) patients on the waiting list for kidney transplantation as a useful tool to prevent PTDM. MATERIALS AND METHODS Pretransplant glucose testing using OGTT-75 was performed in nondiabetic dialyzed chronic kidney disease patients on the waiting list for renal transplantation in the southwest region of Poland. GMD were diagnosed according to current criteria. Patients with recognized prediabetic stage were recommended a low carbohydrate diet, lifestyle modification, and increased physical activity. In the 12-month posttransplant period we estimated the prevalence of PTDM in the study group based on FPG >126 mg/dL (7 mmol/L) in 2 measurements or random blood glucose >200 mg/dL (11.1 mmol/L). RESULTS A total of 80 nondiabetic dialysis patients (65 hemodialysis/15 peritoneal dialysis; 47 male/33 female) met initial entry criteria. In pretransplant glucose testing prediabetes was found in 31 out of 80 patients (39%). Among them, 5 patients (6.25%) had combined IGT/IFG, 18 patients (22.5%) had IGT, and 8 patients (10%) had IFG. One year after RTx we recognized PTDM in 14% of all analyzed patients (11/80) and noticed a significant frequency of glucose disorders status change after RTx (P = .002). CONCLUSION Our findings suggest early detection of prediabetes using the OGTT-75 test in nondiabetic dialysis patients waiting for RTx to prevent occurrence of PTDM.
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Affiliation(s)
- K Hap
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - K Madziarska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
| | - S Zmonarski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - D Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - M Magott-Procelewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - M Banasik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - K Jędrzejak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - W Hap
- Department of General and Oncological Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - M Klinger
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - O Mazanowska
- Faculty of Medicine and Dentistry, Wroclaw Medical University, Wroclaw, Poland
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Longitudinal Pharmacokinetics of Tacrolimus in Elderly Compared With Younger Recipients in the First 6 Months After Renal Transplantation. Transplantation 2017; 101:1365-1372. [PMID: 27482958 DOI: 10.1097/tp.0000000000001369] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Elderly (Eld) (≥60 years) recipients are receiving renal transplants more frequently. The pharmacokinetics (PK) studies of immunosuppressive drugs in healthy volunteers, rarely, include old patients. METHODS We studied 208 12-hour tacrolimus (TAC) PK (0, 20, 40, 60, 90, 120, 180, 240, 360, 480, 600, 720 min) in 44 Eld (65 ± 3 years) and compared the results with 31 younger controls (Ctrl) (35 ± 6 years) recipients, taking oral TAC/mycophenolate sodium (MPS)/prednisone, at 4 different timepoints: PK1 (8 ± 2 days; n = 72), PK2 (31 ± 4 days; n = 61), PK3 (63 ± 6 days; n = 44), and PK4 (185 ± 10 days; n = 31). Tacrolimus PK was measured by ultraperformance liquid chromatography coupled to a mass spectrometer repetition and noncompartmental PKs were analyzed using Phoenix WinNonlin. RESULTS Mean TAC dose was lower in the Eld group than in Ctrl ones throughout timepoints either by total daily dose or adjusted (Adj) per body weight. Mean TAC trough level (Cmin), used to adjust daily dose, was not different between the 2 groups in all timepoints. AdjCmax and AdjTAC-area under the curve at dosing interval were both higher in the Eld compared to the Ctrl group in PKs1, 3, and 4. Estimated total body clearance normalized by dose and weight was lower in the Eld group compared with the Ctrl in all PKs and statistically lower at PKs 1 and 3. Similar to younger recipients TAC trough level has also a high correlation (R = 0.76) with area under the curve at dosing interval. CONCLUSIONS These data indicate that Eld recipients have a lower TAC clearance and therefore need a lower TAC dose than younger recipients.
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Dubois-Laforgue D. [Post-transplantation diabetes mellitus in kidney recipients]. Nephrol Ther 2017; 13 Suppl 1:S137-S146. [PMID: 28577736 DOI: 10.1016/j.nephro.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 10/19/2022]
Abstract
Post-transplantation diabetes mellitus is defined as diabetes that is diagnosed in grafted patients. It affects 20 to 30 % of kidney transplant recipients, with a high incidence in the first year. The increasing age at transplantation and the rising incidence of obesity may increase its prevalence in the next years. Post-transplantation diabetes mellitus is associated with poor outcomes, such as mortality, cardiovascular events or graft dysfunction. Its occurrence is mainly related to immunosuppressive agents, affecting both insulin secretion and sensibility. Immunosuppressants may be iatrogenic, and as such, induce an early and transient diabetes. They may also precociously determine a permanent diabetes, acting here as a promoting factor in patients proned to the development of type 2 diabetes. Lastly, they may behave, far from transplantation, as an additional risk factor for type 2 diabetes. The screening, management and prognosis of these different subtypes of post-transplantation diabetes mellitus will be different.
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Affiliation(s)
- Danièle Dubois-Laforgue
- Service de diabétologie, hôpital Cochin-Port Royal, 123, boulevard Port-Royal, 75014 Paris, France; Inserm U1016, institut Cochin, 22, rue Méchain, 75014 Paris, France.
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17
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Schachtner T, Stein M, Reinke P. Diabetic kidney transplant recipients: Impaired infection control and increased alloreactivity. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care; Campus Virchow Clinic; Charité University Medicine Berlin; Berlin Germany
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT); Berlin Germany
- Berlin Institute of Health (BIH) - Charité and Max-Delbrück Center; Berlin Germany
| | - Maik Stein
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT); Berlin Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care; Campus Virchow Clinic; Charité University Medicine Berlin; Berlin Germany
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT); Berlin Germany
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18
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The incidence of new onset diabetes after transplantation and related factors: Single center experience. Nefrologia 2017; 37:181-188. [PMID: 28262264 DOI: 10.1016/j.nefro.2016.11.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/27/2016] [Accepted: 11/17/2016] [Indexed: 12/17/2022] Open
Abstract
AIM New-onset diabetes after transplantation (NODAT) is a frequent metabolic complication and is considered a risk factor for patients undergoing renal transplant. The aim of this study was to evaluate the incidence and developing duration of new-onset diabetes after transplant (NODAT) and influencing factors. METHODS All patients' data was investigated retrospectively. Diabetics, follow-up period<6 months, age<18years were excluded. Demographic, clinical and laboratory data was recorded. Patients were divided into two groups: with/without NODAT. NODAT group was divided into four subgroups according to the time of developing NODAT, which were 0-3, 3-6, 6-12 and 12 months later. Two groups were compared, to investigate the incidence of NODAT and risk factors associated with the occurrence of NODAT. RESULTS We retrospectively analyzed the records of 570 patients, of which 420 patients were included. Seventy (16.6%) patients had NODAT (36 female, mean age 51.7±8.2 years, mean follow-up 41.6±21.5 months), 52.8% of patients developed NODAT within the first three months of being diagnosed. 350 patients (116 female, mean age 43.2±12.5 years, mean follow-up 41.6±21.5 months) were without NODAT. The incidence of impaired fasting glucose (IFG) during the first week after transplant was found to be higher in the patients with NODAT (p<0.001). There was positive correlation between NODAT and older age, obesity, family history of diabetes, presence of IFG, fasting plasma glucose, total and LDL-cholesterol, triglycerides, parathormone. Old age, obesity, presence of IFG, pretransplant hypertriglyceridemia and hyperparathyroidism were predictors of development of NODAT. CONCLUSION Incidence of NODAT, especially the first six months, was high. All patients should be screened for IFG within the first week. Patients with dyslipidemia, elderly and obese patients should be closely monitored for the risk of development of NODAT.
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Montada-Atin T, Choi D, Woo M, Retnakaran R, Huang M, Prasad GVR, Zaltzman JS. Reduction in new-onset diabetes mellitus after renal transplant with erythropoietin-stimulating agents: a retrospective cohort study. Can J Kidney Health Dis 2016; 3:23. [PMID: 27119016 PMCID: PMC4845385 DOI: 10.1186/s40697-016-0114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 04/05/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have shown that erythropoietin-stimulating agents (ESAs) protect mice against the development of diabetes through direct effects on pancreatic ß cells. However, the effect of ESAs on the incidence of diabetes in humans has not been well studied. It is unknown whether exposure to ESAs is associated with a reduced incidence of new-onset diabetes after transplant (NODAT). OBJECTIVE The objective of this study is to examine the relationship between ESA exposure post-renal transplant and the development of NODAT. DESIGN We performed a single center, retrospective cohort analysis. PATIENTS We compared patients who received a first live or deceased donor renal allograft, with any exposure to an ESA vs. those without such exposure and who developed NODAT and who did not. Patients with a prior history of diabetes mellitus or multi-organ transplant, including a second renal transplant were excluded. MEASUREMENTS AND METHODS NODAT was defined based on the 2008 Canadian Diabetes Association criteria. Multivariate logistic regression analysis was performed to determine factors independently associated with NODAT. RESULTS One hundred thirty-two (29 %) patients were exposed to an ESA, four of which developed NODAT compared to 128 who did not develop NODAT (p < 0.0001). Of those not exposed to an ESA, 15 % (48/319) developed NODAT. By Fisher's exact test, exposure to an ESA at any time post-transplant reduced the risk of developing NODAT; odds ratio (OR) = 0.08, 95 % confidence interval (CI) (0.018-0.352), p = 0.0008. Older age; OR = 1.41, 95 % CI (1.036-1.933), p < 0.02, higher random blood sugar at discharge; OR = 1.30, 95 % CI (1.077-1.57), p < 0.006 and deceased donor; OR 2.18 CI (1.009-4.729), p = 0.04 were associated with an increased risk of NODAT. LIMITATIONS The limitations of this study include its retrospective nature, single center, and homogenous population; thus, generalizability of the results must be approached with caution. CONCLUSION ESA exposure may be associated with a reduced incidence of NODAT in the post-renal transplant population. The role of ESA in preventing NODAT requires further investigation.
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Affiliation(s)
- Tess Montada-Atin
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Diana Choi
- />Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Minna Woo
- />Endocrinology and Metabolism, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON Canada M5G 2C4
- />Division of Endocrinology, University of Toronto, Toronto, Canada
- />Department of Medicine and Biophysics, University of Toronto, Toronto, Canada
| | - Ravi Retnakaran
- />Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, 60 Murray Street, Toronto, ON Canada M5T 3L9
- />Department of Medicine, University of Toronto, Toronto, Canada
- />Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Michael Huang
- />Renal Transplant Research, St. Michael’s Hospital, 30 Bond Street, Toronto, ON Canada M5B 1W8
| | - G. V. Ramesh Prasad
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Division of Nephrology, University of Toronto, Toronto, Canada
| | - Jeffrey S. Zaltzman
- />Renal Transplant Program, St. Michael’s Hospital, 61 Queen Street East, 9th Floor, Toronto, ON Canada M5C 2T2
- />Department of Medicine, University of Toronto, Toronto, Canada
- />Division of Nephrology, University of Toronto, Toronto, Canada
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20
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Karelis AD, Hébert MJ, Rabasa-Lhoret R, Räkel A. Impact of Resistance Training on Factors Involved in the Development of New-Onset Diabetes After Transplantation in Renal Transplant Recipients: An Open Randomized Pilot Study. Can J Diabetes 2015; 40:382-388. [PMID: 26656280 DOI: 10.1016/j.jcjd.2015.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/31/2015] [Accepted: 08/22/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVES New-onsetdiabetes after transplant (NODAT) is a major contributor to cardiovascular disease after transplantation. Kidney transplantation (KT) recipients have low levels of exercise capacity. Resistance training (RT) might be of special benefit in this population because underlying disease and immunosuppressive drugs favour muscle loss and insulin resistance. The aim of this study was to assess the feasibility of implementing an RT program within a population of KT recipients and its impact on the incidence of NODAT and cardiometabolic risk factors. METHODS This pilot study was an open-randomized study. We randomized 24 patients with a 1:1 allocation to 2 parallel groups, the exercise group (E) or the control group (C). The E group was submitted to RT 3 times a week for 16 weeks. Anthropometric, body composition, cardiometabolic risk factors, muscle strength, cardiorespiratory fitness and well-being were measured before and after 16 weeks. RESULTS Of the 24 recruited participants, 20 completed the study (10 in the E group and 10 in the C group). No injuries were reported. The intervention was associated with a significant increase in muscle strength (p=0.003). A significant group effect, in favour of the E group, was detected for the well-being score (p=0.03). However, no changes in body composition, cardiometabolic risk factors or cardiorespiratory fitness were noted for either group after the intervention. CONCLUSIONS This pilot study suggests that RT appears to be secure and feasible and improves strength and well-being in patients after KT. However, it does not improve cardiometabolic risk factors.
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Affiliation(s)
- Antony D Karelis
- Department of Exercise Science, Université du Québec à Montréal, Montreal, Quebec, Canada; Institut de Recherches Cliniques de Montréal (IRCM), Montreal, Quebec, Canada
| | - Marie-Josée Hébert
- University of Montreal Hospital Research Centre (CRCHUM), Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- University of Montreal Hospital Research Centre (CRCHUM), Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada; Institut de Recherches Cliniques de Montréal (IRCM), Montreal, Quebec, Canada
| | - Agnès Räkel
- University of Montreal Hospital Research Centre (CRCHUM), Montreal, Quebec, Canada.
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21
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Porrini EL, Díaz JM, Moreso F, Delgado Mallén PI, Silva Torres I, Ibernon M, Bayés-Genís B, Benitez-Ruiz R, Lampreabe I, Lauzurrica R, Osorio JM, Osuna A, Domínguez-Rollán R, Ruiz JC, Jiménez-Sosa A, González-Rinne A, Marrero-Miranda D, Macía M, García J, Torres A. Clinical evolution of post-transplant diabetes mellitus. Nephrol Dial Transplant 2015; 31:495-505. [DOI: 10.1093/ndt/gfv368] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/22/2015] [Indexed: 12/11/2022] Open
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22
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Weng LC, Chiang YJ, Lin MH, Hsieh CY, Lin SC, Wei TY, Chou HF. Association between use of FK506 and prevalence of post-transplantation diabetes mellitus in kidney transplant patients. Transplant Proc 2014; 46:529-31. [PMID: 24656004 DOI: 10.1016/j.transproceed.2013.11.141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tacrolimus (FK506) use has been suggested as a risk factor for post-transplantation diabetes mellitus (PTDM) because it can impair insulin secretion. This association warrants further investigation. This study aimed to examine the prevalence of PTDM and its association with FK506 use in kidney transplant recipients. The study also aimed to examine the relationship of FK506 use and diabetes-related biologic markers. METHODS A retrospective chart review was used to collect data at a medical center in northern Taiwan from September 2003 to February 2012. PTDM was defined with the use of the criteria of the American Diabetes Association. RESULTS Among 166 patients included in the analysis, PTDM was reported in 49 patients (29.5%). A total of 93 patients used the FK506 regimen, of whom 34 (36.6%) were PTDM cases. Logistic regression showed that FK506 use (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.20-6.11; P = .016) and older age (OR,1.08; 95% CI, 1.03-1.13; P = .001) were significant risk factors for PTDM. In addition, FK506 use in PTDM cases was associated with a significantly higher hemoglobin A1c level (7.55 vs 5.81; P = .01) and a borderline significantly higher insulin resistance index (3.24 vs 1.92; P = .053) than was FK506 use without the presence of PTDM. CONCLUSIONS Older age and an FK506 regimen were important predictors of the prevalence of PTDM. Greater early detection and prevention efforts for PTDM are needed for older transplant recipients. PTDM patients with an FK506 regimen had higher hemoglobin A1c levels and insulin resistance index than did patients who did not use FK506. The association of serum indicators with FK506 use in the prevalence of PTDM warrants further investigation.
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Affiliation(s)
- L C Weng
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y J Chiang
- Transplantation Center and Urology Surgery, Chang Gung Medical Foundation-Linkuo Medical Center, Taoyuan, Taiwan.
| | - M H Lin
- Department of Nursing, Chang Gung Medical Foundation-Linkuo Medical Center, Taoyuan, Taiwan
| | - C Y Hsieh
- Department of Nursing, Chang Gung Medical Foundation-Linkuo Medical Center, Taoyuan, Taiwan
| | - S C Lin
- Department of Nursing, Chang Gung Medical Foundation-Linkuo Medical Center, Taoyuan, Taiwan
| | - T Y Wei
- Department of Nursing, Chang Gung Medical Foundation-Linkuo Medical Center, Taoyuan, Taiwan
| | - H F Chou
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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23
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Prenner G, Wasler A, Fahrleinter-Pammer A, Werkgartner G, Mischinger HJ, Koter S, Roller R, Wagner D. The role of serum albumin in the prediction of malnutrition in patients at least five yr after heart transplantation. Clin Transplant 2014; 28:737-42. [DOI: 10.1111/ctr.12370] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Günther Prenner
- Division for Transplantation; Department of Surgery; Medical University of Graz; Graz Austria
| | - Andrä Wasler
- Division for Transplantation; Department of Surgery; Medical University of Graz; Graz Austria
| | - Astrid Fahrleinter-Pammer
- Division for Endocrinology and Nuclear Medicine; Department of Internal Medicine; Medical University of Graz; Graz Austria
| | - Georg Werkgartner
- Division for General Surgery; Department of Surgery; Medical University of Graz; Graz Austria
| | - Hans Jörg Mischinger
- Division for General Surgery; Department of Surgery; Medical University of Graz; Graz Austria
| | - Stephan Koter
- Division for Vascular Surgery; Department of Sugery; Medical University of Graz; Graz Austria
| | - Regina Roller
- Division for Geriatrics; Department of Internal Medicine; Medical University of Graz; Graz Austria
| | - Doris Wagner
- Division for General Surgery; Department of Surgery; Medical University of Graz; Graz Austria
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24
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Hornum M, Lindahl JP, von Zur-Mühlen B, Jenssen T, Feldt-Rasmussen B. Diagnosis, management and treatment of glucometabolic disorders emerging after kidney transplantation: a position statement from the Nordic Transplantation Societies. Transpl Int 2013; 26:1049-60. [PMID: 23634804 DOI: 10.1111/tri.12112] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 02/11/2013] [Accepted: 04/06/2013] [Indexed: 12/16/2022]
Abstract
After successful solid organ transplantation, new-onset diabetes (NODAT) is reported to develop in about 15-40% of the patients. The variation in incidence may partly depend on differences in the populations that have been studied and partly depend on the different definitions of NODAT that have been used. The diagnosis was often based on 'the use of insulin postoperatively', 'oral agents used', random glucose monitoring and a fasting glucose value between 7 and 13 mmol/l (126-234 mg/dl). Only few have used a 2-h glucose tolerance test performed before transplantation. There is a huge variation in the literature regarding risk factors for developing NODAT. They can be divided into factors related to glucose metabolism or to patient demographics and the latter into modifiable and nonmodifiable. Screening for risk factors should start early and be re-evaluated while being on the waitlist. Patients on the waiting list for renal transplantation and transplanted patients share many characteristics in having hyperglycaemia, disturbed insulin secretion and increased insulin resistance. We present guidelines for early risk factor assessment and a screening/treatment strategy for disturbed glucose metabolism, both before and after transplantation. The aim was to avoid the increased cardiovascular disease and mortality rates associated with NODAT.
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Affiliation(s)
- Mads Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Nagaraja P, Ravindran V, Morris-Stiff G, Baboolal K. Role of insulin resistance indices in predicting new-onset diabetes after kidney transplantation. Transpl Int 2012; 26:273-80. [PMID: 23230898 DOI: 10.1111/tri.12026] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 08/08/2012] [Accepted: 11/01/2012] [Indexed: 01/28/2023]
Abstract
New-onset diabetes mellitus (NODAT) is a serious complication following renal transplantation. In this cohort study, we studied 118 nondiabetic renal transplant recipients to examine whether indices of insulin resistance and secretion calculated before transplantation and at 3 months post-transplantation are associated with the development of NODAT within 1 year. We also analysed the long-term impact of early diagnosed NODAT. Insulin indices were calculated using homeostasis model assessment (HOMA) and McAuley's Index. NODAT was diagnosed using fasting plasma glucose. Median follow-up was 11 years. The cumulative incidence of NODAT at 1 year was 37%. By logistic regression, recipient age (per year) was the only significant pretransplant predictor of NODAT (OR 1.04, CI 1.009-1.072), while age (OR 1.04, CI 1.005-1.084) and impaired fasting glucose (OR 2.97, CI 1.009-8.733) were significant predictors at 3 months. Pretransplant and 3-month insulin resistance and secretion indices did not predict NODAT. All-cause mortality was significantly higher in recipients developing NODAT within 1 year compared with those remaining nondiabetic (44% vs. 22%, log-rank P = 0.008). By Cox's regression analysis, age (HR 1.075, CI 1.042-1.110), 1-year creatinine (HR 1.007, CI 1.004-1.010) and NODAT within 3 months (HR 2.4, CI 1.2-4.9) were independent predictors of death. In conclusion, NODAT developing early after renal transplantation was associated with poor long-term patient survival. Insulin indices calculated pretransplantation using HOMA and McAuley's Index did not predict NODAT.
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Affiliation(s)
- Pramod Nagaraja
- Nephrology and Transplantation Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK.
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Ozbay LA, Møller N, Juhl C, Bjerre M, Carstens J, Rungby J, Jørgensen KA. The impact of calcineurin inhibitors on insulin sensitivity and insulin secretion: a randomized crossover trial in uraemic patients. Diabet Med 2012; 29:e440-4. [PMID: 23003106 DOI: 10.1111/dme.12028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS The calcineurin inhibitors cyclosporine and tacrolimus are implicated in post-transplant complications such as new-onset diabetes after transplantation. The relative contribution of each calcineurin inhibitor to new-onset diabetes after transplantation remains unclear. We sought to compare the impact of cyclosporine and tacrolimus on glucose metabolism in humans. METHODS Eight haemodialysis patients received 8-10 days of oral treatment followed by 5-h infusions with cyclosporine, tacrolimus and saline in a randomized, investigator-blind, crossover study. Glucose metabolism and β-cell function was investigated through: a hyperinsulinaemic-euglycaemic clamp, an intravenous glucose tolerance test and insulin concentration time series. RESULTS Cyclosporine and tacrolimus decreased insulin sensitivity by 22% (P = 0.02) and 13% (P = 0.048), respectively. The acute insulin response and pulsatile insulin secretion were not significantly affected by the drugs. CONCLUSION In conclusion, 8-10 days of treatment with cyclosporine and tacrolimus impairs insulin sensitivity to a similar degree in haemodialysis patients, while acute insulin responses and pulsatile insulin secretion remain unaffected.
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Affiliation(s)
- L A Ozbay
- Department of Nephrology, Aarhus University Hospital, Skejby, Denmark.
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012; 2012:941640. [PMID: 23227307 PMCID: PMC3512323 DOI: 10.1155/2012/941640] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/21/2012] [Indexed: 11/17/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Renal Function and NODM in De Novo Renal Transplant Recipients Treated with Standard and Reduced Levels of Tacrolimus in Combination with EC-MPS. J Transplant 2012. [PMID: 23227307 DOI: 10.1155/2012/94164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Information is lacking concerning concomitant administration of enteric-coated mycophenolate sodium with tacrolimus (EC-MPS+Tac) in renal transplant recipients (RTxR). In this 6-month, prospective, open-label, multicenter study, de novo RTxR were randomized (1 : 1) to low-dose (LD) or standard-dose (SD) Tac with basiliximab, EC-MPS 720 mg bid, and steroids. Primary objective was to compare renal function at 6-month posttransplantation. Secondary objectives were to compare the incidences of biopsy-proven acute rejection (BPAR), graft loss and death, and new-onset diabetes mellitus (NODM). 292 patients (LD n = 151, SD n = 141) were included. Mean Tac levels were at the low end of the target range in standard-exposure patients (SD, n = 141) and exceeded target range in low-exposure patients (LD = 151) throughout the study. There was no significant difference in mean glomerular filtration rate (GFR) between treatments (ITT-population: 63.6 versus 61.0 mL/min). Incidence of BPAR was similar (10.6% versus 9.9%). NODM was significantly less frequent in LD Tac (17% versus 31%; P = 0.02); other adverse effects (AEs) were comparable. EC-MPS+Tac (LD/SD) was efficacious and well tolerated with well-preserved renal function. No renal function benefits were demonstrated, possibly related to poor adherence to reduced Tac exposure.
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Yates CJ, Fourlanos S, Hjelmesaeth J, Colman PG, Cohney SJ. New-onset diabetes after kidney transplantation-changes and challenges. Am J Transplant 2012; 12:820-8. [PMID: 22123607 DOI: 10.1111/j.1600-6143.2011.03855.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite substantial improvement in short-term results after kidney transplantation, increases in long-term graft survival have been modest. A significant impediment has been the morbidity and mortality attributable to cardiovascular disease (CVD). New-onset diabetes after transplantation (NODAT) is an independent predictor of cardiovascular events. This review examines recent literature surrounding diagnosis, outcomes and management of NODAT. Amongst otherwise heterogeneous studies, a common finding is the relative insensitivity of fasting blood glucose (FBG) as a screening test. Incorporating self-testing of afternoon capillary BG and glycohemoglobin (HbA(1c) ) detects many cases that would otherwise remain undetected without the oral glucose tolerance test (OGTT). Assessing the impact of NODAT on patient and graft survival is complicated by changes to diagnostic criteria, evolution of immunosuppressive regimens and increasing attention to cardiovascular risk management. Although recent studies reinforce a link between NODAT and death with a functioning graft (DWFG), there seems to be little effect on death-censored graft loss. The significance of glycemic control and diabetes resolution for patient outcomes remain notably absent from NODAT literature and treatment is also a neglected area. This review examines new and old therapeutic options, emphasizing the need to assess β-cell pathology in customizing therapy. Finally, areas warranting further research are considered.
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Affiliation(s)
- C J Yates
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, Melbourne, Australia
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Lorho R, Hardwigsen J, Dumortier J, Pageaux GP, Durand F, Bizollon T, Blanc AS, Di Giambattista F, Duvoux C. Regression of new-onset diabetes mellitus after conversion from tacrolimus to cyclosporine in liver transplant patients: results of a pilot study. Clin Res Hepatol Gastroenterol 2011; 35:482-8. [PMID: 21530445 DOI: 10.1016/j.clinre.2011.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/11/2011] [Accepted: 03/16/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION New-onset diabetes mellitus (NODM) has important implications for long-term outcome following liver transplantation. AIM To evaluate the impact of conversion from tacrolimus to cyclosporine in liver transplant patients presenting NODM. METHOD In a 12-month pilot study, 39 liver transplant patients with NODM were converted from tacrolimus to cyclosporine. Most patients (59%) were receiving antidiabetic therapy (18% insulin, 41% oral) and all patients had received dietary advice prior to the study. RESULTS At month 12, NODM had significantly resolved (FBG<7 mmol/L without treatment) in 36% of patients (95% CI 20.8-51.0%). In the 16 patients not receiving antidiabetic drugs at baseline, mean FBG decreased from 8.1 mmol/L to 6.6 mmol/L (P=0.008) and mean HbA(1c) decreased from 6.4 to 6.0% (P=0.05). Steroids were stopped rapidly in the nine patients receiving steroids at inclusion but NODM resolution was observed in only one of these nine patients. No significant factors were identified that could have affected NODM resolution. There were three episodes of biopsy-proven acute rejection (7.7%), no graft losses and one death. Overall, cyclosporine tolerance was good with no significant change in creatinine clearance at month 12. Total cholesterol increased from 4.6 mmol/L to 5.1 mmol/L (P<0.001). CONCLUSIONS These results suggest that liver transplant patients with NODM may benefit from conversion to cyclosporine from tacrolimus through improved glucose metabolism. Confirmation in a prospective, randomized comparative study is required.
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Affiliation(s)
- R Lorho
- Hepatology and Liver Transplant Unit, Pontchaillou Hospital, 35033 Rennes cedex 9, France
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Kahan B. Toxicity spectrum of inhibitors of mammalian target of rapamycin in organ transplantation: etiology, pathogenesis and treatment. Expert Opin Drug Saf 2011; 10:727-49. [DOI: 10.1517/14740338.2011.579898] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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32
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Zeier M, Van Der Giet M. Calcineurin inhibitor sparing regimens using m-target of rapamycin inhibitors: an opportunity to improve cardiovascular risk following kidney transplantation? Transpl Int 2010; 24:30-42. [DOI: 10.1111/j.1432-2277.2010.01140.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Bai JPF, Lesko LJ, Burckart GJ. Understanding the genetic basis for adverse drug effects: the calcineurin inhibitors. Pharmacotherapy 2010; 30:195-209. [PMID: 20099993 DOI: 10.1592/phco.30.2.195] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The calcineurin inhibitors-cyclosporine and tacrolimus-are the mainstay of immunosuppressive therapy in solid organ transplantation. These drugs produce severe adverse drug effects (ADEs) such as nephrotoxicity, posttransplantation diabetes mellitus, and hypertension. Accumulated evidence suggests that the development of type 2 diabetes, hypertension, and renal failure may be associated with specific DNA genotypes. In this review, the genes involved with the development of these disease processes are compared with those implicated in calcineurin inhibitor-induced ADEs. The renin-angiotensin system genes, cytokine-encoding genes, and plasminogen activator inhibitor type 1 genes have been implicated in calcineurin inhibitor-induced nephrotoxicity, as well as in development of renal failure. A number of genes are implicated in contributing to diabetes, and these include the vitamin D receptor gene, VDR; hepatocyte nuclear factor genes, HNF; transcription factor 7-like 2 gene, TCF7L2; angiotensin-converting enzyme gene, ACE; cytokines; peroxisome proliferator-activated receptor gamma gene, PPARG; and others. Studies have suggested that the VDR, PPARG, HNF1A, and adenosine 5'-triphosphate-binding cassette ABCC8 (which encodes the sulfonylurea receptor) genes are associated with calcineurin inhibitor-induced diabetes. The genes encoding for the angiotensin-converting enzyme, endothelial constitutive nitric oxide synthase, and cytochrome P450 3A isoenzyme have been involved in the development of hypertension and in calcineurin inhibitor-induced hypertension. The genetic study of disease states can be the stepping stones for thoroughly understanding the genetic basis of ADEs. Gene polymorphisms are implicated in the development of diseases and corresponding disease-like ADEs. The disease-associated genes provide candidate genes for exploring ADEs and may provide genomic biomarkers for assessing the risk for developing severe calcineurin inhibitor-related ADEs as well as for developing preventive strategies.
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Affiliation(s)
- Jane P F Bai
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
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Newsome PN. Recurrence of nonalcoholic fatty liver disease after liver transplantation: it is common, but does it affect outcome? Liver Transpl 2010; 16:420-2. [PMID: 20373452 DOI: 10.1002/lt.22038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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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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Abstract
In recent decades, Diabetes Mellitus has become a severe and growing global public healthcare problem due to the increase of its prevalence, morbidity and mortality. Post-transplant diabetes mellitus (PTDM) is a complication which takes place after a solid organ transplant, and its incidence is widely variable, ranging from 2 to 53%. Some factors increase the risk of PTDM, such as age, ethnicity, cadaver-donor kidney presence of the hepatitis C virus and cytomegalovirus, overweight and obesity and the Immunosuppression scheme established in the immediate post-transplant period. High doses of tacrolimus and corticosteroid represent the highest risk for developing PTDM.Considering that the development of PTDM is associated with a higher risk of complications, such as infections and cardiovascular disease - thus representing a higher life threatening risk and a higher cost for the Health System - the relevance of identifying the risk factors and of the early diagnosis combined with appropriate therapy will be high for the follow up, and eventually resulting in the success of the procedure as far as patient survival and transplantation durability.
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Affiliation(s)
- Marília B Gomes
- Diabetes and Metabology Unit from Pedro Ernesto University Hospital, Medical Science School, State University of Rio de Janeiro (UERJ
| | - Roberta A Cobas
- Program in Clinical and Experimental Pathophysiology (PGCLINEX) Diabetes and Metabology Unit, Pedro Ernesto University Hospital, State University of Rio de Janeiro (UERJ
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Insulin resistance and insulin secretion changes in kidney transplant recipients with normal graft function compared with those with delayed graft function early after transplantation. Transplant Proc 2009; 41:2817-9. [PMID: 19765444 DOI: 10.1016/j.transproceed.2009.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION We compared insulin resistance (IR) and insulin secretion (IS) among kidney transplant recipients with normal versus delayed graft function (DGF) early after transplantation. METHODS We selected 55 kidney transplant recipients without a history of clinical diabetes mellitus. The basal values of glucose (G) and insulin (I) were used to calculate indices of IR and IS before, on the third day, as well as at the end of the first, second, and third weeks after transplantation. RESULTS Before transplantation IR was more prevalent (62.5%) than impaired IS (20%; P = .012). Three weeks after engraftment, IR was significantly reduced (P < .001), whereas the reduction in the IS was not significant (P = .17). Splitting the results between normal and delayed functioning grafts showed a significant difference in both IR and IS between the 2 groups on the third day after transplantation (P = .018 and .024, respectively). Regression models showed that only cumulative administered cyclosporine dose and plasma creatinine were significantly (or near significantly) associated with IR (P = .04 and .07, respectively). CONCLUSION Among patients with DGF there was a significantly greater prevalence of IR and IS compared with successfully engrafted patients in the middle of the first week after transplantation. With resumption of normal kidney function among the DGF group, this difference disappeared at the end of the third week after transplantation.
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Guida B, Perrino NR, Laccetti R, Trio R, Nastasi A, Pesola D, Maiello C, Marra C, De Santo LS, Cotrufo M. Role of dietary intervention and nutritional follow-up in heart transplant recipients. Clin Transplant 2009; 23:101-7. [DOI: 10.1111/j.1399-0012.2008.00915.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bianchi G, Marchesini G, Marzocchi R, Pinna AD, Zoli M. Metabolic syndrome in liver transplantation: relation to etiology and immunosuppression. Liver Transpl 2008; 14:1648-54. [PMID: 18975273 DOI: 10.1002/lt.21588] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Excessive weight gain, hypertension, hyperlipidemia, and diabetes are frequently observed in patients having undergone liver transplantation (LTx). These alterations are probably multifactorial in origin, and cluster to generate a metabolic syndrome (MS), increasing the risk of cardiovascular events. We assessed the prevalence of MS (National Cholesterol Education Program-Adult Treatment Panel III criteria) in 296 LTx patients in the course of regular follow-up, at least 6 months after transplantation (median, 38 months). Several pre-LTx and post-LTx data were collected to identify the factors associated with the presence of MS. In a subset of 99 patients, insulin resistance was measured by the homeostasis model assessment. High blood pressure was present in 53% of cases, hyperlipidemia in 51%, high glucose in 37%, and enlarged waist circumference in 32%. Overall, MS (defined as 3 or more of the above features) was present in 44.5% of cases. Insulin resistance (homeostasis model assessment > 2.7) was observed in 41% of cases. Hypertension and hyperlipidemia were more frequent in subjects on cyclosporine than in tacrolimus-treated cases, whereas the type of immunosuppressive drug had no effect on the prevalence of diabetes, enlarged waist, and MS. In a logistic regression analysis, only pre-LTx body mass index (odds ratio, 1.20), body mass index increase (odds ratio, 1.18), and pre-LTx diabetes (odds ratio, 2.36) predicted MS; age, gender, etiology of liver disease, time from LTx, type of immunosuppressive drug, and previous hepatocellular carcinoma were removed from the model. Disorders related to MS are frequent in LTx patients, and are related to both pre-LTx conditions and to weight gain. Weight control is mandatory in LTx patients to prevent risk factors of premature atherosclerosis.
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Affiliation(s)
- Giampaolo Bianchi
- Dipartimento di Medicina Interna and Centro Trapianti di Fegato e Multiorgano, Alma Mater Studiorum, Universitá di Bologna, Bologna, Italy.
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Chan HW, Cheung CY, Liu YL, Chan YH, Wong HS, Chak WL, Choi KS, Chau KF, Li CS. Prevalence of abnormal glucose metabolism in Chinese renal transplant recipients: a single centre study. Nephrol Dial Transplant 2008; 23:3337-42. [DOI: 10.1093/ndt/gfn246] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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41
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Prediabetes in Patients Receiving Tacrolimus in the First Year After Kidney Transplantation: A Prospective and Multicenter Study. Transplantation 2008; 85:1133-8. [DOI: 10.1097/tp.0b013e31816b16bd] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Delgado P, Diaz JM, Silva I, Osorio JM, Osuna A, Bayés B, Lauzurica R, Arellano E, Campistol JM, Dominguez R, Gómez-Alamillo C, Ibernon M, Moreso F, Benitez R, Lampreave I, Porrini E, Torres A. Unmasking glucose metabolism alterations in stable renal transplant recipients: a multicenter study. Clin J Am Soc Nephrol 2008. [PMID: 18322043 DOI: 10.2215/cjn.0492110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Emerging information indicates that glucose metabolism alterations are common after renal transplantation and are associated with carotid atheromatosis. The aims of this study were to investigate the prevalence of different glucose metabolism alterations in stable recipients as well as the factors related to the condition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A multicenter, cross-sectional study was conducted of 374 renal transplant recipients without pre- or posttransplantation diabetes. A standard 75-g oral glucose tolerance test was performed. RESULTS Glucose metabolism alterations were present in 119 (31.8%) recipients: 92 (24.6%) with an abnormal oral glucose tolerance test and 27 (7.2%) with isolated impaired fasting glucose. The most common disorder was impaired glucose tolerance (17.9%), and an abnormal oral glucose tolerance test was observed for 21.5% of recipients with a normal fasting glucose. By multivariate analysis, age, prednisone dosage, triglyceride/high-density lipoprotein cholesterol ratio, and beta blocker use were shown to be factors related to glucose metabolism alterations. Remarkably, triglyceride levels, triglyceride/high-density lipoprotein cholesterol ratio, and the proportion of recipients with impaired fasting glucose were already higher throughout the first posttransplantation year in recipients with a current glucose metabolism alteration as compared with those without the condition. CONCLUSIONS Glucose metabolism alterations are common in stable renal transplant recipients, and an oral glucose tolerance test is required for its detection. They are associated with a worse metabolic profile, which is already present during the first posttransplantation year. These findings may help planning strategies for early detection and intervention.
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Affiliation(s)
- Patricia Delgado
- Nephrology Section and Research Unit, Hospital Universitario de Canarias, University of La Laguna (Tenerife), Spain
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Delgado P, Diaz JM, Silva I, Osorio JM, Osuna A, Bayés B, Lauzurica R, Arellano E, Campistol JM, Dominguez R, Gómez-Alamillo C, Ibernon M, Moreso F, Benitez R, Lampreave I, Porrini E, Torres A. Unmasking glucose metabolism alterations in stable renal transplant recipients: a multicenter study. Clin J Am Soc Nephrol 2008; 3:808-13. [PMID: 18322043 DOI: 10.2215/cjn.04921107] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Emerging information indicates that glucose metabolism alterations are common after renal transplantation and are associated with carotid atheromatosis. The aims of this study were to investigate the prevalence of different glucose metabolism alterations in stable recipients as well as the factors related to the condition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A multicenter, cross-sectional study was conducted of 374 renal transplant recipients without pre- or posttransplantation diabetes. A standard 75-g oral glucose tolerance test was performed. RESULTS Glucose metabolism alterations were present in 119 (31.8%) recipients: 92 (24.6%) with an abnormal oral glucose tolerance test and 27 (7.2%) with isolated impaired fasting glucose. The most common disorder was impaired glucose tolerance (17.9%), and an abnormal oral glucose tolerance test was observed for 21.5% of recipients with a normal fasting glucose. By multivariate analysis, age, prednisone dosage, triglyceride/high-density lipoprotein cholesterol ratio, and beta blocker use were shown to be factors related to glucose metabolism alterations. Remarkably, triglyceride levels, triglyceride/high-density lipoprotein cholesterol ratio, and the proportion of recipients with impaired fasting glucose were already higher throughout the first posttransplantation year in recipients with a current glucose metabolism alteration as compared with those without the condition. CONCLUSIONS Glucose metabolism alterations are common in stable renal transplant recipients, and an oral glucose tolerance test is required for its detection. They are associated with a worse metabolic profile, which is already present during the first posttransplantation year. These findings may help planning strategies for early detection and intervention.
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Affiliation(s)
- Patricia Delgado
- Nephrology Section and Research Unit, Hospital Universitario de Canarias, University of La Laguna (Tenerife), Spain
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Pascher A, Kohler S, Neuhaus P, Pratschke J. Present status and future perspectives of intestinal transplantation. Transpl Int 2008; 21:401-14. [PMID: 18282247 DOI: 10.1111/j.1432-2277.2008.00637.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Intestinal transplantation (ITx) is the only definitive therapy for irreversible intestinal failure. Owing to the limited short- and long-term graft survival over the years, ITx has been a complementary treatment to home parenteral nutrition. However, the development of intestinal and multivisceral transplantation has been significant over the past 15-20 years owing to the progress in immunosuppressive therapy, refinement of surgical techniques, post-transplant care, intestinal immunology, and immunological as well as anti-infectious monitoring. The improvement of patient- and graft survival over the last few years together with data on the cost effectiveness of ITx, following 2 years after transplantation, may require a redefinition of the indication for ITx.
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Affiliation(s)
- Andreas Pascher
- Department of Visceral and Transplantation Surgery, Universitaetsmedizin Berlin - Charité, Berlin, Germany.
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