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Rodríguez-Rodríguez AE, Porrini E, Hornum M, Donate-Correa J, Morales-Febles R, Khemlani Ramchand S, Molina Lima MX, Torres A. Post-Transplant Diabetes Mellitus and Prediabetes in Renal Transplant Recipients: An Update. Nephron Clin Pract 2021; 145:317-329. [PMID: 33902027 DOI: 10.1159/000514288] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent and relevant complication after renal transplantation: it affects 20-30% of renal transplant recipients and increases the risk for cardiovascular and infectious events. Thus, understanding pathogenesis of PTDM would help limiting its consequences. In this review, we analyse novel aspects of PTDM, based on studies of the last decade, such as the clinical evolution of PTDM, early and late, the reversibility rate, diagnostic criteria, risk factors, including pre-transplant metabolic syndrome and insulin resistance (IR) and the interaction between these factors and immunosuppressive medications. Also, we discuss novel pathogenic factors, in particular the role of β-cell function in an environment of IR and common pathways between pre-existing cell damage and tacrolimus-induced toxicity. The relevant role of prediabetes in the pathogenesis of PTDM and cardiovascular disease is also addressed. Finally, current evidence on PTDM treatment is discussed.
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Affiliation(s)
| | - Esteban Porrini
- Research Unit, Hospital Universitario de Canarias, Universidad de la Laguna, Tenerife, Spain.,Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Javier Donate-Correa
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | | | | | | | - Armando Torres
- Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Instituto de Tecnologías Biomédicas (ITB), Faculty of Medicine, Universidad de la Laguna, Tenerife, Spain.,Servicio de Nefrología, Hospital Universitario de Canarias, Tenerife, Spain
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2
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Hecking M, Sharif A, Eller K, Jenssen T. Management of post-transplant diabetes: immunosuppression, early prevention, and novel antidiabetics. Transpl Int 2021; 34:27-48. [PMID: 33135259 PMCID: PMC7839745 DOI: 10.1111/tri.13783] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/20/2020] [Accepted: 10/29/2020] [Indexed: 12/12/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) shows a relationship with risk factors including obesity and tacrolimus-based immunosuppression, which decreases pancreatic insulin secretion. Several of the sodium-glucose-linked transporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP1-RAs) dramatically improve outcomes of individuals with type 2 diabetes with and without chronic kidney disease, which is, as heart failure and atherosclerotic cardiovascular disease, differentially affected by both drug classes (presumably). Here, we discuss SGLT2is and GLP1-RAs in context with other PTDM management strategies, including modification of immunosuppression, active lifestyle intervention, and early postoperative insulin administration. We also review recent studies with SGLT2is in PTDM, reporting their safety and antihyperglycemic efficacy, which is moderate to low, depending on kidney function. Finally, we reference retrospective case reports with GLP1-RAs that have not brought forth major concerns, likely indicating that GLP1-RAs are ideal for PTDM patients suffering from obesity. Although our article encompasses PTDM after solid organ transplantation in general, data from kidney transplant recipients constitute the largest proportion. The PTDM research community still requires data that treating and preventing PTDM will improve clinical conditions beyond hyperglycemia. We therefore suggest that it is time to collaborate, in testing novel antidiabetics among patients of all transplant disciplines.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine IIIClinical Division of Nephrology & DialysisMedical University of ViennaViennaAustria
| | - Adnan Sharif
- Department of Nephrology and TransplantationQueen Elizabeth HospitalBirminghamUK
| | - Kathrin Eller
- Clinical Division of NephrologyMedical University of GrazGrazAustria
| | - Trond Jenssen
- Department of Organ TransplantationOslo University HospitalRikshospitaletOsloNorway
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3
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Cohen E, Korah M, Callender G, Belfort de Aguiar R, Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol 2020; 15:732-742. [PMID: 32284323 PMCID: PMC7269213 DOI: 10.2215/cjn.09310819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Metabolic disorders are highly prevalent in kidney transplant candidates and recipients and can adversely affect post-transplant graft outcomes. Management of diabetes, hyperparathyroidism, and obesity presents distinct opportunities to optimize patients both before and after transplant as well as the ability to track objective data over time to assess a patient's ability to partner effectively with the health care team and adhere to complex treatment regimens. Optimization of these particular disorders can most dramatically decrease the risk of surgical and cardiovascular complications post-transplant. Approximately 60% of nondiabetic patients experience hyperglycemia in the immediate post-transplant phase. Multiple risk factors have been identified related to development of new onset diabetes after transplant, and it is estimated that upward of 7%-30% of patients will develop new onset diabetes within the first year post-transplant. There are a number of medications studied in the kidney transplant population for diabetes management, and recent data and the risks and benefits of each regimen should be optimized. Secondary hyperparathyroidism occurs in most patients with CKD and can persist after kidney transplant in up to 66% of patients, despite an initial decrease in parathyroid hormone levels. Parathyroidectomy and medical management are the options for treatment of secondary hyperparathyroidism, but there is no randomized, controlled trial providing clear recommendations for optimal management, and patient-specific factors should be considered. Obesity is the most common metabolic disorder affecting the transplant population in both the pre- and post-transplant phases of care. Not only does obesity have associations and interactions with comorbid illnesses, such as diabetes, dyslipidemia, and cardiovascular disease, all of which increase morbidity and mortality post-transplant, but it also is intimately inter-related with access to transplantation for patients with kidney failure. We review these metabolic disorders and their management, including data in patients with kidney transplants.
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Affiliation(s)
- Elizabeth Cohen
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - Maria Korah
- Yale University School of Medicine, New Haven, Connecticut
| | - Glenda Callender
- Department of Surgery, Section of Endocrine Surgery, Yale University, New Haven, Connecticut
| | | | - Danielle Haakinson
- Department of Surgery, Section of Transplant, Yale University, New Haven, Connecticut
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4
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Jahromi M, Al-Otaibi T, Othman N, Gheith O, Mahmoud T, Nair P, Halim MA, Nampoory N. Immunogenetics of new onset diabetes after transplantation in Kuwait. Diabetes Metab Syndr Obes 2019; 12:731-742. [PMID: 31190933 PMCID: PMC6535099 DOI: 10.2147/dmso.s195859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 03/07/2019] [Indexed: 01/14/2023] Open
Abstract
Introduction and aim: New onset diabetes after transplantation (NODAT) is a serious metabolic complication following kidney transplantation. Although beta-cell dysfunction is considered the main contributing factor in the development of this complication, its exact etiology is yet to be identified. We aimed to investigate NODAT among kidney transplant cohort in Kuwait with special stress on correlation between its risk factors and interferon gamma genotyping. Materials and methods: We surveyed 309 kidney transplant recipients from Hamed Al Essa Transplantation Centre, Kuwait. The participants were categorized into cohorts according to the development of NODAT diagnosed based on the American Diabetes Association guidelines. Statistical analyses were performed using SPSS software. We genotyped interferon gamma as the leading immunosignature for T lymphocyte. Results: No relationship between ethnicity and the development of NODAT was identified. However, there was a significant difference in age between cohorts. Younger patients demonstrated a lower rate of NODAT while, NODAT reached its maximum in 40-60-year age group. IFNG TT genotype was significantly associated with NODAT (p=0.005), while IFNG AA was considerably higher in the non-NODAT group. Conclusion: Beside the conventional contributing factors of NODAT, our results might represent a suitable platform for a larger cytokine and chemokine spectrum genotyping.
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Affiliation(s)
- Mohamed Jahromi
- Clinical Research, Medical Division, Dasman Diabetes Institute, Kuwait City, Kuwait
- Correspondence: Mohamed JahromiClinical Research, Medical Division, Dasman Diabetes Institute, Jasmin Mohamas Al Bahar Street, PO Box 118015462Kuwait City, KuwaitTel +9 652 224 2999Fax +9 652 249 2408 Email
| | - Torki Al-Otaibi
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
| | - Nashwa Othman
- Education, Clinical Services Division, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Osama Gheith
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
| | - Tarek Mahmoud
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
| | - Prasad Nair
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
| | - Medhat A Halim
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
| | - Narayanam Nampoory
- Clinical Research, Medical Division, Dasman Diabetes Institute, Kuwait City, Kuwait
- Nephrology Department, Hamid Al-Essa Organ Transplant Center, Kuwait City, Kuwait
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5
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Torres A, Hernández D, Moreso F, Serón D, Burgos MD, Pallardó LM, Kanter J, Díaz Corte C, Rodríguez M, Diaz JM, Silva I, Valdes F, Fernández-Rivera C, Osuna A, Gracia Guindo MC, Gómez Alamillo C, Ruiz JC, Marrero Miranda D, Pérez-Tamajón L, Rodríguez A, González-Rinne A, Alvarez A, Perez-Carreño E, de la Vega Prieto MJ, Henriquez F, Gallego R, Salido E, Porrini E. Randomized Controlled Trial Assessing the Impact of Tacrolimus Versus Cyclosporine on the Incidence of Posttransplant Diabetes Mellitus. Kidney Int Rep 2018; 3:1304-1315. [PMID: 30450457 PMCID: PMC6224662 DOI: 10.1016/j.ekir.2018.07.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Despite the high incidence of posttransplant diabetes mellitus (PTDM) among high-risk recipients, no studies have investigated its prevention by immunosuppression optimization. METHODS We conducted an open-label, multicenter, randomized trial testing whether a tacrolimus-based immunosuppression and rapid steroid withdrawal (SW) within 1 week (Tac-SW) or cyclosporine A (CsA) with steroid minimization (SM) (CsA-SM), decreased the incidence of PTDM compared with tacrolimus with SM (Tac-SM). All arms received basiliximab and mycophenolate mofetil. High risk was defined by age >60 or >45 years plus metabolic criteria based on body mass index, triglycerides, and high-density lipoprotein-cholesterol levels. The primary endpoint was the incidence of PTDM after 12 months. RESULTS The study comprised 128 de novo renal transplant recipients without pretransplant diabetes (Tac-SW: 44, Tac-SM: 42, CsA-SM: 42). The 1-year incidence of PTDM in each arm was 37.8% for Tac-SW, 25.7% for Tac-SM, and 9.7% for CsA-SM (relative risk [RR] Tac-SW vs. CsA-SM 3.9 [1.2-12.4; P = 0.01]; RR Tac-SM vs. CsA-SM 2.7 [0.8-8.9; P = 0.1]). Antidiabetic therapy was required less commonly in the CsA-SM arm (P = 0.06); however, acute rejection rate was higher in CsA-SM arm (Tac-SW 11.4%, Tac-SM 4.8%, and CsA-SM 21.4% of patients; cumulative incidence P = 0.04). Graft and patient survival, and graft function were similar among arms. CONCLUSION In high-risk patients, tacrolimus-based immunosuppression with SM provides the best balance between PTDM and acute rejection incidence.
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Affiliation(s)
- Armando Torres
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Domingo Hernández
- Hospital Regional Universitario de Málaga, Universidad de Málaga, IBIMA, Málaga, Spain
| | - Francesc Moreso
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Serón
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - María Dolores Burgos
- Hospital Regional Universitario de Málaga, Universidad de Málaga, IBIMA, Málaga, Spain
| | | | - Julia Kanter
- Hospital Universitario Dr Peset, Valencia, Spain
| | | | | | | | | | - Francisco Valdes
- Complexo Hospitalario Universitario Juan Canalejo, A Coruña, Spain
| | | | - Antonio Osuna
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | - Juan C. Ruiz
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Domingo Marrero Miranda
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Lourdes Pérez-Tamajón
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Aurelio Rodríguez
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Ana González-Rinne
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Alejandra Alvarez
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Estefanía Perez-Carreño
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - María José de la Vega Prieto
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Fernando Henriquez
- Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de GC, Spain
| | - Roberto Gallego
- Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de GC, Spain
| | - Eduardo Salido
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Esteban Porrini
- Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
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6
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Wissing KM, De Meyer V, Pipeleers L. Balancing Immunosuppressive Efficacy and Prevention of Posttransplant Diabetes-A Question of Timing and Patient Selection. Kidney Int Rep 2018; 3:1249-1252. [PMID: 30450448 PMCID: PMC6224669 DOI: 10.1016/j.ekir.2018.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Karl Martin Wissing
- Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vicky De Meyer
- Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lissa Pipeleers
- Department of Nephrology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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7
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Pakkir Maideen NM, Manavalan G, Balasubramanian K. Drug interactions of meglitinide antidiabetics involving CYP enzymes and OATP1B1 transporter. Ther Adv Endocrinol Metab 2018; 9:259-268. [PMID: 30181852 PMCID: PMC6116761 DOI: 10.1177/2042018818767220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Meglitinides such as repaglinide and nateglinide are useful to treat type 2 diabetes patients who follow a flexible lifestyle. They are short-acting insulin secretagogues and are associated with less risk of hypoglycemia, weight gain and chronic hyperinsulinemia compared with sulfonylureas. Meglitinides are the substrates of cytochrome P450 (CYP) enzymes and organic anion transporting polypeptide 1B1 (OATP1B1 transporter) and the coadministration of the drugs affecting them will result in pharmacokinetic drug interactions. This article focuses on the drug interactions of meglitinides involving CYP enzymes and OATP1B1 transporter. To prevent the risk of hypoglycemic episodes, prescribers and pharmacists must be aware of the adverse drug interactions of meglitinides.
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8
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Guthoff M, Wagner R, Weichbrodt K, Nadalin S, Königsrainer A, Häring HU, Fritsche A, Heyne N. Dynamics of Glucose Metabolism After Kidney Transplantation. Kidney Blood Press Res 2017; 42:598-607. [PMID: 28930756 DOI: 10.1159/000481375] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/12/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Posttransplantation diabetes mellitus (PTDM) impacts patient and allograft survival after kidney transplantation. Prediabetes, which is an independent risk factor for PTDM, is modifiable also in a post-transplant setting. Understanding the risks and dynamics of impaired glucose metabolism after transplantation is a key component for targeted intervention. METHODS A retrospective chart analysis of all adult non-diabetic renal allograft recipients (n=251, 2007-2014) was performed. Longitudinal follow-up included fasting plasma glucose and HbA1c, as well as data on allograft function and immunosuppression at consecutive time points (months 3-6 to >5 years post transplantation). RESULTS Throughout follow-up, median prevalence of prediabetes and PTDM was 53.3 [52.4-55.7]% and 15.4 [15.0-16.5]%, respectively. Continuously high fluxes between states of glucose metabolism, with individual patients' state deteriorating or improving over time, resulted in a high number of incident patients even long after transplantation. The greatest number of patients shifted between normal glucose tolerance and prediabetes, followed by those between prediabetes and PTDM. CONCLUSION Prediabetes and PTDM are highly prevalent after kidney transplantation and incidences remain relevant throughout follow-up. Patient fluxes into and out of the prediabetic state show that glucose metabolism is highly dynamic after transplantation. This provides a continuous opportunity for intervention in an aim to reduce diabetes-associated complications.
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Affiliation(s)
- Martina Guthoff
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Robert Wagner
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Karoline Weichbrodt
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Dept. of General-, Visceral- and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Alfred Königsrainer
- Dept. of General-, Visceral- and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Hans-Ulrich Häring
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Andreas Fritsche
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Nils Heyne
- Dept. of Endocrinology and Diabetology, Angiology, Nephrology and Clinical Chemistry, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
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9
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Tran MH, Foster CE, Kalantar-Zadeh K, Ichii H. Kidney transplantation in obese patients. World J Transplant 2016; 6:135-143. [PMID: 27011911 PMCID: PMC4801789 DOI: 10.5500/wjt.v6.i1.135] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/25/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
The World Health Organization estimated that in 2014, over 600 million people met criteria for obesity. In 2011, over 30% of individuals undergoing kidney transplant had a body mass index (BMI) 35 kg/m2 or greater. A number of recent studies have confirmed the relationship between overweight/obesity and important comorbidities in kidney transplant patients. As with non-transplant surgeries, the rate of wound and soft tissue complications are increased following transplant as is the incidence of delayed graft function. These two issues appear to contribute to longer length of stay compared to normal BMI. New onset diabetes after transplant and cardiac outcomes also appear to be increased in the obese population. The impact of obesity on patient survival after kidney transplantation remains controversial, but appears to mirror the impact of extremes of BMI in non-transplant populations. Early experience with (open and laparoscopic) Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy support excellent weight loss (in the range of 50%-60% excess weight lost at 1 year), but experts have recommended the need for further studies. Long term nutrient deficiencies remain a concern but in general, these procedures do not appear to adversely impact absorption of immunosuppressive medications. In this study, we review the literature to arrive at a better understanding of the risks related to renal transplantation among individuals with obesity.
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10
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Handisurya A, Kerscher C, Tura A, Herkner H, Payer BA, Mandorfer M, Werzowa J, Winnicki W, Reiberger T, Kautzky-Willer A, Pacini G, Säemann M, Schmidt A. Conversion from Tacrolimus to Cyclosporine A Improves Glucose Tolerance in HCV-Positive Renal Transplant Recipients. PLoS One 2016; 11:e0145319. [PMID: 26735686 PMCID: PMC4703220 DOI: 10.1371/journal.pone.0145319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/25/2015] [Indexed: 01/04/2023] Open
Abstract
Background Calcineurin-inhibitors and hepatitis C virus (HCV) infection increase the risk of post-transplant diabetes mellitus. Chronic HCV infection promotes insulin resistance rather than beta-cell dysfunction. The objective was to elucidate whether a conversion from tacrolimus to cyclosporine A affects fasting and/or dynamic insulin sensitivity, insulin secretion or all in HCV-positive renal transplant recipients. Methods In this prospective, single-center study 10 HCV-positive renal transplant recipients underwent 2h-75g-oral glucose tolerance tests before and three months after the conversion of immunosuppression from tacrolimus to cyclosporine A. Established oral glucose tolerance test-based parameters of fasting and dynamic insulin sensitivity and insulin secretion were calculated. Data are expressed as median (IQR). Results After conversion, both fasting and challenged glucose levels decreased significantly. This was mainly attributable to a significant amelioration of post-prandial dynamic glucose sensitivity as measured by the oral glucose sensitivity-index OGIS [422.17 (370.82–441.92) vs. 468.80 (414.27–488.57) mL/min/m2, p = 0.005), which also resulted in significant improvements of the disposition index (p = 0.017) and adaptation index (p = 0.017) as markers of overall glucose tolerance and beta-cell function. Fasting insulin sensitivity (p = 0.721), insulinogenic index as marker of first-phase insulin secretion [0.064 (0.032–0.106) vs. 0.083 (0.054–0.144) nmol/mmol, p = 0.093) and hepatic insulin extraction (p = 0.646) remained unaltered. No changes of plasma HCV-RNA levels (p = 0.285) or liver stiffness (hepatic fibrosis and necroinflammation, p = 0.463) were observed after the conversion of immunosuppression. Conclusions HCV-positive renal transplant recipients show significantly improved glucose-stimulated insulin sensitivity and overall glucose tolerance after conversion from tacrolimus to cyclosporine A. Considering the HCV-induced insulin resistance, HCV-positive renal transplant recipients may benefit from a cyclosporine A-based immunosuppressive regimen. Trial Registration ClinicalTrials.gov NCT02108301
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Affiliation(s)
- Ammon Handisurya
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Corinna Kerscher
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- Institute of Neurosciences, CNR, Padova, Italy
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Berit Anna Payer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Winnicki
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | | | - Marcus Säemann
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- * E-mail:
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11
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Multicenter analytical evaluation of the automated electrochemiluminescence immunoassay for cyclosporine. Ther Drug Monit 2015; 36:640-50. [PMID: 24646730 PMCID: PMC4218761 DOI: 10.1097/ftd.0000000000000068] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Cyclosporine A (CsA) is used as a posttransplantation immunosuppressant drug, and careful monitoring of CsA concentration in whole blood is essential. A new automated electrochemiluminescence immunoassay (ECLIA) for CsA measurement has been assessed in a multicenter evaluation. Methods: Residual EDTA whole blood samples from patients undergoing CsA therapy after organ transplant were used in assay evaluation at 5 clinical laboratories in Europe. Experiments included imprecision according to CLSI EP5-A2 (within-run and intermediate), lower limit of quantification, linearity according to CLSI EP6-A, and recovery of commercial external quality control samples. In addition, comparisons to liquid chromatography-tandem mass spectrometry methods in routine use at each investigational site and to commercial chemiluminescent microparticle immunoassay and antibody-conjugated magnetic immunoassay methods were performed. Results: Imprecision testing gave coefficients of variation of less than 9% in the 30–2000 mcg/L range for both within-run and intermediate imprecision. Lower limit of quantification of 6.8 mcg/L at one investigational site and 1.8 mcg/L at a second site at 20% coefficient of variation were observed. Linearity was measured over the concentration range 0–2000 mcg/L, yielding a deviation of less than ±12%. External quality control sample recovery by ECLIA was 93%–114% of LC-MS/MS sample recovery. Deming regression analysis of ECLIA method comparison to combined LC-MS/MS results yielded a slope of 1.04 [95% confidence interval (CI), 1.03–1.06] and intercept of 2.8 mcg/L (95% CI, 1.5–4.1 mcg/L). Comparison to chemiluminescent microparticle immunoassay yielded a slope of 0.87 (95% CI, 0.85–0.89) and intercept of 1.4 mcg/L (95% CI, −0.89 to 3.7 mcg/L); comparison to antibody-conjugated magnetic immunoassay yielded a slope of 0.96 (95% CI, 0.93–0.98) and intercept of −4.2 mcg/L (95% CI, −7.1 to −1.2 mcg/L). Conclusions: The data from this multicenter evaluation indicate that the new ECLIA-based cyclosporine assay is fit for its purpose, the therapeutic monitoring of CsA.
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Sharif A, Hecking M, de Vries APJ, Porrini E, Hornum M, Rasoul-Rockenschaub S, Krebs G, Berlakovich M, Kautzky-Willer A, Schernthaner G, Marchetti P, Pacini G, Ojo A, Takahara S, Larsen JL, Budde K, Eller K, Pascual J, Jardine A, Bakker SJL, Valderhaug TG, Jenssen TG, Cohney S, Säemann MD. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014; 14:1992-2000. [PMID: 25307034 PMCID: PMC4374739 DOI: 10.1111/ajt.12850] [Citation(s) in RCA: 360] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/21/2014] [Accepted: 05/26/2014] [Indexed: 01/25/2023]
Abstract
A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.
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Affiliation(s)
- A. Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK,Corresponding author: Adnan Sharif,
| | - M. Hecking
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - A. P. J. de Vries
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - E. Porrini
- Center for Biomedical Research of the Canary Islands, CIBICAN, University of La Laguna, Tenerife, Spain
| | - M. Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - G Krebs
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - M. Berlakovich
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - A. Kautzky-Willer
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - G. Schernthaner
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - P. Marchetti
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy
| | - G. Pacini
- Metabolic Unit, Institute of Biomedical Engineering, National Research Council, Padova, Italy
| | - A. Ojo
- Division of Nephrology, University of Michigan Health System, Ann Arbor, MI
| | - S. Takahara
- Department of Advanced Technology for Transplantation, Osaka University Graduate School of Medicine, Osaka, Japan
| | - J. L. Larsen
- Department of Internal Medicine, Nebraska Medical Center, Omaha, NE
| | - K. Budde
- Department of Nephrology, Charité University, Berlin, Germany
| | - K. Eller
- Clinical Division of Nephrology, Medical University of Graz, Graz, Austria
| | - J. Pascual
- Servicio de Nefrología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - A. Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - S. J. L. Bakker
- Department of Internal Medicine, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - T. G. Valderhaug
- Department of Endocrinology, Akershus University Hospital, Lorenskog, Norway
| | - T. G. Jenssen
- Department of Organ Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - S. Cohney
- Department of Nephrology, Royal Melbourne and Western Hospitals, Melbourne, Australia
| | - M. D. Säemann
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
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Conversion to sirolimus therapy in kidney transplant recipients with new onset diabetes mellitus after transplantation. Clin Dev Immunol 2013; 2013:496974. [PMID: 23762090 PMCID: PMC3671526 DOI: 10.1155/2013/496974] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/22/2013] [Accepted: 04/23/2013] [Indexed: 12/19/2022]
Abstract
New-onset diabetes mellitus after transplantation (NODAT) may complicate 2–50% of kidney transplantation, and it is associated with reduced graft and patient survivals. In this retrospective study, we applied a conversion protocol to sirolimus in a cohort of kidney transplant recipients with NODAT. Among 344 kidney transplant recipients, 29 patients developed a NODAT (6.6%) and continued with a reduced dose of calcineurin inhibitors (CNI) (8 patients, Group A) or were converted to sirolimus (SIR) (21 patients, Group B). NODAT resolved in 37.5% and in 80% patients in Group A and Group B, respectively. In Group A, patient and graft survivals were 100% and 75%, respectively, not significantly different from Group B (83.4% and 68%, resp., P = 0.847). Graft function improved after conversion to sirolimus therapy: serum creatinine was 1.8 ± 0.7 mg/dL at the time of conversion and 1.6 ± 0.4 mg/dL five years after conversion to sirolimus therapy (P < 0.05), while in the group of patients remaining with a reduced dose of CNI, serum creatinine was 1.7 ± 0.6 mg/dL at the time of conversion and 1.65 ± 0.6 mg/dL at five-year followup (P = 0.732). This study demonstrated that the conversion from CNI to SIR in patients could improve significantly the metabolic parameters of patients with NODAT, without increasing the risk of acute graft rejection.
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Abstract
New onset diabetes mellitus after transplant (NODAT) refers to the development of diabetes post-transplant in previously non-diabetic patients and is associated with increased rates of acute transplant rejection, infection, late cardiovascular events, and decreased survival. NODAT is primarily due to the immunosuppressive drug regimen but the standard predisposing risk factors for diabetes also pertain. NODAT is diagnosed by the standard ADA criteria, once prednisone doses are less than 10 mg per day and in the absence of acute illness. Sulfonylureas, metformin, DPP-4 inhibitors, GLP-1 agonists, and insulin can be used in treatment, but when there is impaired kidney or hepatic function, special precautions are necessary. In addition, those drugs interacting with P450 enzymes require additional consideration because of possible interaction with immunosuppressive drug metabolism.
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Affiliation(s)
- Ashley Therasse
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611, USA
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Hecking M, Werzowa J, Haidinger M, Hörl WH, Pascual J, Budde K, Luan FL, Ojo A, de Vries APJ, Porrini E, Pacini G, Port FK, Sharif A, Säemann MD. Novel views on new-onset diabetes after transplantation: development, prevention and treatment. Nephrol Dial Transplant 2013; 28:550-66. [PMID: 23328712 DOI: 10.1093/ndt/gfs583] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
New-onset diabetes after transplantation (NODAT) is associated with increased risk of allograft failure, cardiovascular disease and mortality, and therefore, jeopardizes the success of renal transplantation. Increased awareness of NODAT and the prediabetic states (impaired fasting glucose and impaired glucose tolerance, IGT) has fostered previous and present recommendations, based on the management of type 2 diabetes mellitus (T2DM). Unfortunately, the idea that NODAT merely resembles T2DM is potentially misleading, because the opportunity to initiate adequate anti-hyperglycaemic treatment early after transplantation might be given away for 'tailored' immunosuppression in patients who have developed NODAT or carry personal risk factors. Risk factor-independent mechanisms, however, seem to render postoperative hyperglycaemia with subsequent development of overt or 'full-blown' NODAT, the unavoidable consequence of the transplant and immunosuppressive process itself, at least in many cases. A proof of the concept that timely preventive intervention with exogenous insulin against post-transplant hyperglycaemia may decrease NODAT was recently provided by a small clinical trial, which is awaiting confirmation from a multicentre study. However, because early insulin therapy aimed at beta-cell protection seems to contrast the currently recommended, stepwise approach of 'watchful waiting' prior to pancreatic decompensation, we here aim at reviewing recent concepts regarding the development, prevention and treatment of NODAT, some of which seem to challenge the traditional view on T2DM and NODAT. In summary, we suggest a novel, risk factor-independent management approach to NODAT, which includes glycaemic monitoring and anti-hyperglycaemic treatment in virtually everybody after transplantation. This approach has widespread implications for future research and is intended to tackle NODAT and also ultimately cardiovascular disease.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
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Ghisdal L, Van Laecke S, Abramowicz MJ, Vanholder R, Abramowicz D. New-onset diabetes after renal transplantation: risk assessment and management. Diabetes Care 2012; 35:181-8. [PMID: 22187441 PMCID: PMC3241330 DOI: 10.2337/dc11-1230] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Lidia Ghisdal
- Renal Transplantation Clinic, Erasme Hospital, University of Brussels (ULB), Brussels, Belgium.
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