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Nodular glomerulosclerosis in a kidney transplant recipient with impaired glucose tolerance: diabetic or idiopathic? A case report and literature review. CEN Case Rep 2021; 10:273-280. [PMID: 33393072 DOI: 10.1007/s13730-020-00546-x] [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: 07/01/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022] Open
Abstract
Nodular glomerulosclerosis, typically diagnosed in patients with diabetes mellitus, has been reported in native kidneys of pre-diabetic patients but similar cases in kidney transplant recipients are lacking. We describe a case of nodular glomerulosclerosis in a kidney transplant recipient who had not been found to be diabetic despite regular screening and discuss the implications for the pathogenesis and diagnosis of nodular glomerulosclerosis and screening of post-transplant diabetes mellitus.
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Comparing Glycaemic Benefits of Active Versus Passive Lifestyle Intervention in Kidney Allograft Recipients: A Randomized Controlled Trial. Transplantation 2020; 104:1491-1499. [PMID: 31568390 DOI: 10.1097/tp.0000000000002969] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND New-onset diabetes is common after kidney transplantation, but the benefit of lifestyle intervention to improve glucose metabolism posttransplantation is unproven. METHODS We conducted a single-center, randomized controlled trial involving 130 nondiabetic kidney transplant recipients with stable function between 3 and 24 months post-transplantation. Participants were randomly assigned in a 1:1 ratio to receive active intervention (lifestyle advice delivered by renal dietitians using behavior change techniques) versus passive intervention (leaflet advice alone). Primary outcome was 6-month change in insulin secretion, insulin sensitivity, and disposition index. Secondary outcomes included patient-reported outcomes, cardiometabolic parameters, clinical outcomes, and safety endpoints. RESULTS Between August 17, 2015 and December 18, 2017, 130 individuals were recruited, of whom 103 completed the study (drop-out rate 20.8%). Active versus passive intervention was not associated with any change in glucose metabolism: insulin secretion (mean difference, -446; 95% confidence interval [CI], -3184 to 2292; P = 0.748), insulin sensitivity (mean difference, -0.45; 95% CI, -1.34 to 0.44; P = 0.319), or disposition index (mean difference, -940; 95% CI, -5655 to 3775; P = 0.693). Clinically, active versus passive lifestyle intervention resulted in reduced incidence of posttransplantation diabetes (7.6% versus 15.6%, respectively, P = 0.123), reduction in fat mass (mean difference, -1.537 kg; 95% CI, -2.947 to -0.127; P = 0.033), and improvement in weight (mean difference, -2.47 kg; 95% CI, -4.01 to -0.92; P = 0.002). No serious adverse events were noted. CONCLUSIONS Active lifestyle intervention led by renal dietitians did not improve surrogate markers of glucose metabolism. Further investigation is warranted to determine if clinical outcomes can be improved using this methodology.
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Wang HH, Lin KJ, Liu KL, Huang CW, Lin CT, Chu SH, Chiang YJ. Homeostatic Model Assessment in Kidney Transplantation. Transplant Proc 2019; 51:1357-1361. [PMID: 31076145 DOI: 10.1016/j.transproceed.2019.01.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/28/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Long-term kidney transplantation survival has been limited to cardiovascular-disease-associated death, which may be related to insulin resistance. The aim of this study is to evaluate the association between homeostatic model assessment (HOMA) and renal graft function. MATERIALS AND METHODS From January 2013 to March 2015, 55 nondiabetic kidney recipients were reviewed retrospectively with their baseline fasting serum insulin and glucose levels as the basis the following indexes: 1. HOMA insulin resistance (HOMA-IR), 2. HOMA-β, and 3. insulin-glucose ratio (IGR). These patients were divided into 2 groups according to their HOMA indexes, and the serum creatinine (Cr) and estimated glomerular filtration rate (eGFR) were analyzed on the basis of every 6 months up to 3 years after kidney transplantation. Finally, we evaluate whether these HOMA indexes are a determinant factor of eGFR at post-transplant 1 year, 2 year, and 3 year. RESULTS There was no persisting difference in Cr and eGFR between high- and low-HOMA indexes except that the Cr and eGFR difference by HOMA-β stratification increased with time and became nearly significant at 3 years after transplantation. Further univariate and multivariate linear regression models showed no factor affected the 1-year eGFR independently, while weight affected the 2-year eGFR and only HOMA-β affected the 3-year eGFR independently. CONCLUSION In non-diabetic kidney recipients, the eGFR difference between high- and low-HOMA-β patients increases over time. In multivariate linear regression, HOMA-β, but not HOMA-IR nor IGR, has independent significant association with eGFR at 3 years after transplantation.
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Affiliation(s)
- Hsu-Han Wang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuo-Jen Lin
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuan-Lin Liu
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Wei Huang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Te Lin
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Sheng-Hsien Chu
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yang-Jen Chiang
- Department of Urology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Impaired mitochondrial calcium uptake caused by tacrolimus underlies beta-cell failure. Cell Commun Signal 2017; 15:47. [PMID: 29132395 PMCID: PMC5684747 DOI: 10.1186/s12964-017-0203-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/02/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND One of the most common side effects of the immunosuppressive drug tacrolimus (FK506) is the increased risk of new-onset diabetes mellitus. However, the molecular mechanisms underlying this association have not been fully clarified. METHODS We studied the effects of the therapeutic dose of tacrolimus on mitochondrial fitness in beta-cells. RESULTS We demonstrate that tacrolimus impairs glucose-stimulated insulin secretion (GSIS) in beta-cells through a previously unidentified mechanism. Indeed, tacrolimus causes a decrease in mitochondrial Ca2+ uptake, accompanied by altered mitochondrial respiration and reduced ATP production, eventually leading to impaired GSIS. CONCLUSION Our observations individuate a new fundamental mechanism responsible for the augmented incidence of diabetes following tacrolimus treatment. Indeed, this drug alters Ca2+ fluxes in mitochondria, thereby compromising metabolism-secretion coupling in beta-cells.
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Liver Enzymes and the Development of Posttransplantation Diabetes Mellitus in Renal Transplant Recipients. Transplant Direct 2017; 3:e208. [PMID: 28894795 PMCID: PMC5585424 DOI: 10.1097/txd.0000000000000717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/15/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Posttransplantation diabetes mellitus (PTDM) is common in renal transplant recipients (RTR), increasing the risk of graft failure, cardiovascular disease, and mortality. Early detection of a high risk for PTDM is warranted. Because liver function and liver fat are involved, we investigated whether serum liver markers are associated with future PTDM in RTR. METHODS Between 2001 and 2003, 606 RTR with a functioning allograft beyond the first year after transplantation were included of which 500 participants (56% men; age, 50 ± 12 years) were free of diabetes at baseline and had liver enzyme values (1 missing) available. Serum concentrations of alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase were measured at baseline at 6.0 (6.2-11.5) years posttransplantation. PTDM cases were recorded until April 2012. RESULTS During median follow-up for 9.6 years (interquartile range [IQR], 6.2-10.2) beyond baseline, 76 (15.2%) patients developed PTDM. Comparing the highest to the lower tertiles, higher liver enzyme activities were significantly related to incident PTDM for ALT (hazard ratio [HR], 2.22; IQR, 1.42-3.48), for GGT (HR, 2.93; IQR, 1.87-4.61), and for alkaline phosphatase (HR, 1.78; IQR, 1.13-2.80). The associations of ALT and GGT with development of PTDM were independent of potential confounders and risk factors, including age, sex, renal function, medication use, lifestyle factors, adiposity, presence of the metabolic syndrome, fasting glucose, HbA1c, proinsulin, and cytomegalovirus status. CONCLUSIONS Markers for liver function and liver fat in the subclinical range are potential markers for future PTDM, independent of other known risk factors. This may allow for early detection and management of PTDM development.
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Prediabetes in Pediatric Recipients of Liver Transplant: Mechanism and Risk Factors. J Pediatr 2017; 182:223-231.e3. [PMID: 28041666 PMCID: PMC5328850 DOI: 10.1016/j.jpeds.2016.11.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate the role of calcineurin inhibitor exposure and states of insulin resistance-obesity and adolescence-in prediabetes after pediatric liver transplant via oral glucose tolerance testing, which previously has not been done systematically in these at-risk youths. STUDY DESIGN This was a cross-sectional study of 81 pediatric recipients of liver transplant. Prediabetes was defined as impaired glucose tolerance (IGT; glucose ≥140 mg/dL at 2 hours) or impaired fasting glucose (IFG, ≥100 mg/dL). Corrected insulin response (CIR) was calculated as measure of insulin secretion, corrected for glucose (CIR30, CIR60, CIR120). RESULTS Subjects were aged 8.1-30.0 years and 1.1-24.7 years post-transplant; 44% had prediabetes-27% IGT, 14% IFG, and 3% both. IGT was characterized by insulin hyposecretion, with lower CIR60 and CIR120 in IGT than subjects with normal glucose tolerance. Subjects with tacrolimus trough >6 µg/mL at study visit had lower CIR120 than those with trough ≤6 µg/mL and those off calcineurin-inhibitors. Mean of tacrolimus troughs preceding the study visit, years since transplant, and rejection episodes were not associated significantly with lower CIR. CIR suppression by tacrolimus was most pronounced >6 years from transplant. Overweight/obese subjects and adolescents who retained normal glucose tolerance had greater CIR than those who were IGT. CONCLUSION IGT after pediatric liver transplant is driven by inadequate insulin secretion. It is quite common but not detectable with fasting laboratory values-the screening recommended by current guidelines. Calcineurin inhibitors suppress insulin secretion in these patients in a dose-dependent manner. Given the recent focus on long-term outcomes and immunosuppression withdrawal in these children, longitudinal studies are warranted to investigate whether IGT is reversible with calcineurin inhibitor minimization.
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Comparing glycaemic benefits of Active Versus passive lifestyle Intervention in kidney Allograft Recipients (CAVIAR): study protocol for a randomised controlled trial. Trials 2016; 17:417. [PMID: 27550305 PMCID: PMC4994298 DOI: 10.1186/s13063-016-1543-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 08/05/2016] [Indexed: 12/14/2022] Open
Abstract
Background Lifestyle modification is widely recommended to kidney allograft recipients post transplantation due to the cardiometabolic risks associated with immunosuppression including new-onset diabetes, weight gain and cardiovascular events. However, we have no actual evidence that undertaking lifestyle modification protects from any adverse outcomes post transplantation. The aim of this study is to compare whether a more proactive versus passive interventional approach to modify lifestyle is associated with superior outcomes post kidney transplantation. Methods/design We designed this prospective, single-centre, open-label, randomised controlled study to compare the efficacy of active versus passive lifestyle intervention for kidney allograft recipients early post transplantation. A total of 130 eligible patients, who are stable, nondiabetic and between 3 and 24 months post kidney transplantation, will be recruited. Randomisation is being undertaken by random block permutations into passive (n = 65, leaflet guidance only) versus active lifestyle modification (n = 65, supervised intervention) over a 6-month period. Supervised intervention is being facilitated by two dietitians during the 6-month intervention period to provide continuous lifestyle intervention guidance, support and encouragement. Both dietitians are accredited with behavioural intervention skills and will utilise motivational aids to support study recruits randomised to active intervention. The primary outcome is change in abnormal glucose metabolism parameters after 6 months of comparing active versus passive lifestyle intervention. Secondary outcomes include changes in a wide array of cardiometabolic parameters, kidney allograft function and patient-reported outcome measures. Long-term tracking of patients via data linkage to electronic patient records and national registries will facilitate long-term comparison of outcomes after active versus passive lifestyle intervention beyond the 6-month intervention period. Discussion This is the first randomised controlled study to investigate the benefits of active versus passive lifestyle intervention in kidney allograft recipients for the prevention of abnormal cardiometabolic outcomes. In addition, this is the first example of utilising behaviour therapy intervention post kidney transplantation to achieve clinically beneficial outcomes, which has potential implications on many spheres of post-transplant care. Trial registration This study was registered with the Clinical Trials Registry on 27 August 2014 (ClinicalTrials.org Identifier: NCT02233491).
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Boloori A, Saghafian S, Chakkera HA, Cook CB. Characterization of Remitting and Relapsing Hyperglycemia in Post-Renal-Transplant Recipients. PLoS One 2015; 10:e0142363. [PMID: 26551468 PMCID: PMC4638338 DOI: 10.1371/journal.pone.0142363] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/21/2015] [Indexed: 01/08/2023] Open
Abstract
Background Hyperglycemia following solid organ transplant is common among patients without pre-existing diabetes mellitus (DM). Post-transplant hyperglycemia can occur once or multiple times, which if continued, causes new-onset diabetes after transplantation (NODAT). Objective To study if the first and recurrent incidence of hyperglycemia are affected differently by immunosuppressive regimens, demographic and medical-related risk factors, and inpatient hyperglycemic conditions (i.e., an emphasis on the time course of post-transplant complications). Methods We conducted a retrospective analysis of 407 patients who underwent kidney transplantation at Mayo Clinic Arizona. Among these, there were 292 patients with no signs of DM prior to transplant. For this category of patients, we evaluated the impact of (1) immunosuppressive drugs (e.g., tacrolimus, sirolimus, and steroid), (2) demographic and medical-related risk factors, and (3) inpatient hyperglycemic conditions on the first and recurrent incidence of hyperglycemia in one year post-transplant. We employed two versions of Cox regression analyses: (1) a time-dependent model to analyze the recurrent cases of hyperglycemia and (2) a time-independent model to analyze the first incidence of hyperglycemia. Results Age (P = 0.018), HDL cholesterol (P = 0.010), and the average trough level of tacrolimus (P<0.0001) are significant risk factors associated with the first incidence of hyperglycemia, while age (P<0.0001), non-White race (P = 0.002), BMI (P = 0.002), HDL cholesterol (P = 0.003), uric acid (P = 0.012), and using steroid (P = 0.007) are the significant risk factors for the recurrent cases of hyperglycemia. Discussion This study draws attention to the importance of analyzing the risk factors associated with a disease (specially a chronic one) with respect to both its first and recurrent incidence, as well as carefully differentiating these two perspectives: a fact that is currently overlooked in the literature.
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Affiliation(s)
- Alireza Boloori
- Department of Industrial Engineering, School of Computing, Informatics and Decision Systems Engineering, Arizona State University, Tempe, Arizona, United States of America
| | - Soroush Saghafian
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts, United States of America
- * E-mail:
| | - Harini A. Chakkera
- Division of Nephrology and Transplantation, Mayo Clinic School of Medicine, Scottsdale, Arizona, United States of America
| | - Curtiss B. Cook
- Division of Endocrinology, Mayo Clinic School of Medicine, Scottsdale, Arizona, United States of America
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Soliman AR, Fathy A, Khashab S, Shaheen N, Soliman MA. Sitagliptin might be a favorable antiobesity drug for new onset diabetes after a renal transplant. EXP CLIN TRANSPLANT 2014; 11:494-8. [PMID: 24344941 DOI: 10.6002/ect.2013.0018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effectiveness of sitagliptin, alone or in combination with metformin, in kidney transplant patients with newly diagnosed new-onset diabetes mellitus after transplant who had inadequate glycemic control, compared with a group of patients receiving insulin glargine with special emphasis on weight gain. MATERIALS AND METHODS Newly diagnosed renal transplant patients with new-onset diabetes mellitus after a transplant was defined by a blood glucose ≥ 11.1 mmol/L after an oral glucose tolerance test were examined. They were treated with standard immunosuppression composed of triple therapy with tacrolimus or cyclosporine, mycophenolate mofetil or azathioprine, and prednisone. They had stable graft function for more than 6 months after the transplant. RESULTS Patients with new-onset diabetes mellitus after transplant (n=28) whose glycemia was not controlled adequately with oral hypoglycemic agents (either alone or in combination) received oral sitagliptin 100 mg once daily in addition to existing therapy for 12 weeks. Patients who received insulin glargine as add-on therapy (n=17) served as the control group. Data analyses included glycated hemoglobin, fasting plasma glucose, lipid profile, body weight, and the occurrence of hypoglycemia. We found significant reductions in glycated hemoglobin and fasting plasma glucose values after 12 weeks of additional sitagliptin therapy that were comparable to those with insulin glargine. While the addition of stagliptin resulted in a small weight loss (0.4 kg), the addition of insulin glargine resulted in a weight gain (0.8 kg). The overall incidence of adverse experiences was low and generally mild in both groups. CONCLUSIONS In a group of renal transplant recipients with new-onset diabetes mellitus after a transplant in whom glycemia was not controlled adequately by oral hypoglycemic agents, the addition of sitagliptin helped to achieve glycemic control similar to insulin glargine but with a marginal weight advantage.
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Affiliation(s)
- Amin R Soliman
- Department of Nephrology, Cairo University, Cairo, Egypt
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Long-term progression of abnormal glucose tolerance and its relationship with the metabolic syndrome after kidney transplantation. Transplantation 2014; 97:576-81. [PMID: 24398851 DOI: 10.1097/01.tp.0000438202.11971.2e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Metabolic syndrome (MS) diagnosed early after kidney transplantation is a risk factor for developing new-onset diabetes. The aim of this study was to examine whether glucose intolerance and MS identified late after transplantation influence the progression of glycemic abnormalities in kidney transplant recipients. METHODS This is a retrospective study in which 76 non-diabetic renal transplant recipients underwent oral glucose tolerance tests (OGTT) in 2005 to 2006 (baseline) and then in 2011 to 2012 (follow-up). MS was identified using the International Diabetes Federation criteria and OGTT was interpreted according to the WHO classification. RESULTS At follow-up, median time from transplantation was 11.1 years (range 6.2-23.8). Mean 0-hour and 2-hour plasma glucose levels were significantly higher at follow-up compared to baseline (5.7 ± 0.7 vs. 5.9 ± 0.9 mmol/L, P=0.03 and 6.7 ± 1.9 vs. 7.5 ± 2.8 mmol/L, P=0.03, respectively). The proportion of patients with an abnormal OGTT increased from 42% at baseline to 61% at follow-up (P=0.007). Patients with MS were more likely to progress to a higher degree of glucose intolerance compared to those without MS (58% vs. 27%, P=0.01). On multivariable logistic regression adjusted for age and gender, MS was significantly associated with the progression of glucose intolerance (OR 3.5, CI 1.2-9.9, P=0.01), as was a fasting glucose greater than 5.6 mmol/L (OR 4.8, CI 1.6-14.8, P=0.006). CONCLUSION MS is a risk factor for the progression of glucose intolerance in renal transplant recipients in the late posttransplant period. Therefore, MS has to be considered in tandem with OGTT results to assess cardiovascular risk.
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Zelle DM, Corpeleijn E, Deinum J, Stolk RP, Gans ROB, Navis G, Bakker SJL. Pancreatic β-cell dysfunction and risk of new-onset diabetes after kidney transplantation. Diabetes Care 2013; 36:1926-32. [PMID: 23378624 PMCID: PMC3687295 DOI: 10.2337/dc12-1894] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic exposure to calcineurin inhibitors and corticosteroids poses renal transplant recipients (RTR) at high risk for development of new-onset diabetes after transplantation (NODAT). Pancreatic β-cell dysfunction may be crucial to the pathophysiology of NODAT and specific markers for β-cell dysfunction may have additive value for predicting NODAT in this population. Therefore, we prospectively investigated whether proinsulin, as a marker of pancreatic β-cell dysfunction, is associated with future development of NODAT and improves prediction of it. RESEARCH DESIGN AND METHODS All RTR between 2001 and 2003 with a functioning graft for ≥1 year were considered eligible for inclusion, except for subjects with diabetes at baseline who were excluded. We recorded incidence of NODAT until April 2012. RESULTS A total of 487 RTR (age 50 ± 12 years, 55% men) participated at a median time of 6.0 (interquartile range [IQR], 2.6-11.5) years after transplantation. Median fasting proinsulin levels were 16.6 (IQR, 11.0-24.2) pmol/L. During median follow-up for 10.1 (IQR, 9.1-10.4) years, 42 (35%) RTR had development of NODAT in the highest quartile of the distribution of proinsulin versus 34 (9%) in the lowest three quartiles (P < 0.001). In Cox regression analyses, proinsulin (hazard ratio, 2.29; 95% CI, 1.85-2.83; P < 0.001) was strongly associated with NODAT development. This was independent of age, sex, calcineurine inhibitors, prednisolone use, components of the metabolic syndrome, or homeostasis model assessment. CONCLUSIONS In conclusion, fasting proinsulin is strongly associated with NODAT development in RTR. Our results highlight the role of β-cell dysfunction in the pathophysiology of NODAT and indicate the potential value of proinsulin for identification of RTR at increased risk for NODAT.
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Affiliation(s)
- Dorien M Zelle
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands.
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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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Hecking M, Haidinger M, Döller D, Werzowa J, Tura A, Zhang J, Tekoglu H, Pleiner J, Wrba T, Rasoul-Rockenschaub S, Mühlbacher F, Schmaldienst S, Druml W, Hörl WH, Krebs M, Wolzt M, Pacini G, Port FK, Säemann MD. Early basal insulin therapy decreases new-onset diabetes after renal transplantation. J Am Soc Nephrol 2012; 23:739-49. [PMID: 22343119 DOI: 10.1681/asn.2011080835] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
No effective interventions to reduce risk for new-onset diabetes after transplantation (NODAT), a condition associated with postoperative hyperglycemia and reduced patient and graft survival, have been established. In this 1-year, proof-of-concept clinical trial, we randomly assigned 50 renal transplant recipients to immediate-postoperative isophane insulin for evening blood glucose ≥140 mg/dl (treatment group) or short-acting insulin and/or oral antidiabetic agents for blood glucose ≥180-250 mg/dl (standard-of-care control group). We included only patients without a history of diabetes who received tacrolimus. By the third postoperative evening, all patients in the treatment group had blood glucose ≥140 mg/dl and were subsequently treated with basal insulin; during the first 3 weeks after transplantation, the mean ± SD daily insulin dosage was 17±11 IU/d. Among controls, 23 (92%) of 25 had blood glucose ≥200 mg/dl and 18 (72%) of 25 received standard-of-care antihyperglycemic treatment. Asymptomatic hypoglycemia occurred five times in the treatment group and once in the control group. Throughout follow-up, the treatment group had 73% lower odds of NODAT (odds ratio, 0.27) than the control group, and hemoglobin A1c was on average 0.38% lower in the treatment group than the control group. Twelve months after transplantation, all patients in the treatment group were insulin-independent, whereas 7 (28%) of 25 controls required antidiabetic agents. The groups did not differ for insulin sensitivity, but the treatment group showed better β-cell function throughout the 1-year follow-up. In conclusion, this study suggests regimens that include basal insulin significantly reduce the odds for NODAT after renal transplantation, presumably via insulin-mediated protection of β cells.
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Affiliation(s)
- Manfred Hecking
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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Pérez-Flores I, Sánchez-Fructuoso A, Calvo N, Valga EF, Barrientos A. Incidence and risk factors for the metabolic syndrome and posttransplant diabetes in renal transplant recipients taking tacrolimus. Transplant Proc 2011; 42:2902-4. [PMID: 20970565 DOI: 10.1016/j.transproceed.2010.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We investigated the incidence and risk factors for the metabolic syndrome (MS) and posttransplant diabetes mellitus (PTDM) among renal transplant recipients on tacrolimus-based immunosuppressive regimens during the first year posttransplant. In addition, we studied the relationship between MS and PTDM with transplant renal function at 1 year. METHODS We included the 100 patients who received a renal transplant in our unit between January 2007 and June 2008, collecting demographic, clinical and biochemical characteristics at 1, 6, and 12 months posttransplantation. We excluded 15% of patients with pretransplantation diabetes. MS was defined according to the National Cholesterol Education Program criteria and PTDM according to World Health Organization criteria. Insulin resistance at one year posttransplant was measured using the homeostasis model assessment (HOMA) index. RESULTS Insulin therapy was required in 46% of patients during the first hospitalization and hyperglycemia was present in 65% of the cases. The incidence of PTDM decreased throughout the first year posttransplant, namely, 44%, 24%, and 13% at 1, 6, and 12 months, respectively. The incidence of MS increased to 33%, 48% and 50% at 1, 6, and 12 months, respectively. Age, body mass index, plasma fasting glucose levels at 1 month posttransplant, and pretransplant fasting triglyceridemia predicted PTDM. Rejection and in-patient hyperglycemia predicted MS. PTDM and MS were closely correlated (P=.004). The HOMA index was higher among patients with MS than other subjects at 1 year posttransplant: 3.2 (1.2) versus 2.3 (0.9; P=.035). Neither PTDM nor MS was associated with impaired plasma creatinine levels at 1 year after kidney transplantation. CONCLUSION There was an high incidence of PTDM and MS among kidney transplant recipients treated with tacrolimus as the main immunosuppressive agent. The HOMA index was a good test of insulin resistance in this population. Screening and treatment of risk factors may avoid the development of these entities, which are related to poor cardiovascular outcomes.
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Affiliation(s)
- I Pérez-Flores
- Nephrology Department, Hospital Clínico San Carlos, Madrid, Spain.
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Impending hyperglycemia in normoglycemic renal transplant recipients--an experimental predictive surrogate. Transplantation 2010; 89:1341-6. [PMID: 20354482 DOI: 10.1097/tp.0b013e3181d9e1d8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND beta-Cell dysfunction and insulin resistance combine to cause new-onset diabetes after transplantation. The product of these two parameters, quantitatively measured as disposition index (DI), is a mathematical constant in normoglycemia and declines in advance of impending hyperglycemia. The aim of this study was to derive a simple surrogate for the DI to expose predysglycemic abnormalities posttransplantation. METHODS First-phase insulin secretion and sensitivity were determined by mathematical minimal model analysis of 58 frequently sampled, intravenous glucose tolerance tests in 58 non-diabetic renal transplant recipients and correlated against surrogate indexes based on fasting blood samples. Products of insulin secretion/resistance indexes were correlated against calculated DI, regression analysis performed for hyperbolic compatibility, autocorrelation studies conducted, and surrogates tested in various subgroups of renal transplant recipients to ensure robustness in a heterogeneous group. RESULTS The best correlation was achieved with "HOMA(sec) (first-phase insulin secretion)xMcAuley's index (insulin resistance)" (r=0.594, P<0.001). Regression analysis was consistent with a mathematical hyperbola (ln HOMA(sec) vs. ln McAuley's index, r=-0.639 [95% confidence interval, -1.772 to -0.950]), statistical autocorrelation was excluded (in a subset of 20 patients with repeat metabolic investigations), and the surrogate remained valid in different subgroups of transplant recipients. CONCLUSIONS Our surrogate "HOMA(sec)xMcAuley's index," requiring only fasting glucose, insulin, and triglycerides, is a simple and noninvasive surrogate for the DI. Its predictive utility for identifying impending hyperglycemia posttransplantation should be investigated further to ascertain whether its experimental nature can translate to clinical validity.
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