Obesity, adiponectin and inflammation as predictors of new-onset diabetes mellitus after kidney transplantation

Regular Physical Activity in the Prevention of Post-Transplant Diabetes Mellitus in Patients after Kidney Transplantation

Background and Objectives: Post-transplant diabetes mellitus (PTDM) is a significant risk factor for the survival of graft recipients and occurs in 10-30% of patients after kidney transplant (KT). PTDM is associated with premature cardiovascular morbidity and mortality. Weight gain, obesity, and dyslipidemia are strong predictors of PTDM, and by modifying them with an active lifestyle it is possible to reduce the incidence of PTDM and affect the long-term survival of patients and grafts. The aim of our study was to determine the effect of regular physical activity on the development of PTDM and its risk factors in patients after KT. Materials and Methods: Participants in the study had to achieve at least 150 min of moderate-intensity physical exertion per week. The study group (n = 22) performed aerobic or combined (aerobic + strength) types of sports activities. Monitoring was provided by the sports tracker (Xiaomi Mi Band 4 compatible with the Mi Fit mobile application). The control group consisted of 22 stable patients after KT. Each patient underwent an oral glucose tolerance test (oGTT) at the end of the follow-up. The patients in both groups have the same immunosuppressive protocol. The total duration of the study was 6 months. Results: The patients in the study group had significantly more normal oGTT results at 6 months compared to the control group (p < 0.0001). In the control group, there were significantly more patients diagnosed with PTDM (p = 0.0212) and with pre-diabetic conditions (impaired plasma glucose and impaired glucose tolerance) at 6 months (p = 0.0078). Conclusions: Regular physical activity after KT provides significant prevention against the development of pre-diabetic conditions and PTDM.

An update review of post-transplant diabetes mellitus: Concept, risk factors, clinical implications and management

OBJECTIVE

Kidney transplantation is the gold standard therapeutic alternative for patients with end-stage renal disease; nevertheless, it is not without potential complications leading to considerable morbidity and mortality such as post-transplant diabetes mellitus (PTDM). This narrative review aims to comprehensively evaluate PTDM in terms of its diagnostic approach, underlying pathophysiological pathways, epidemiological data, and management strategies.

METHODS

Articles were retrieved from electronic databases using predefined search terms. Inclusion criteria encompassed studies investigating PTDM diagnosis, pathophysiology, epidemiology, and management strategies.

RESULTS

PTDM emerges as a significant complication following kidney transplantation, influenced by various pathophysiological factors including peripheral insulin resistance, immunosuppressive medications, infections, and proinflammatory pathways. Despite discrepancies in prevalence estimates, PTDM poses substantial challenges to transplant. Diagnostic approaches, including traditional criteria such as fasting plasma glucose (FPG) and HbA1c, are limited in their ability to capture early PTDM manifestations. Oral glucose tolerance test (OGTT) emerges as a valuable tool, particularly in the early post-transplant period. Management strategies for PTDM remain unclear, within sufficient evidence from large-scale randomized clinical trials to guide optimal interventions. Nevertheless, glucose-lowering agents and life style modifications constitute primary modalities for managing hyperglycemia in transplant recipients.

DISCUSSION

The complex interplay between PTDM and the transplant process necessitates individualized diagnostic and management approaches. While early recognition and intervention are paramount, modifications to maintenance immunosuppressive regimens based solely on PTDM risk are not warranted, given the potential adverse consequences such as increased rejection risk. Further research is essential to refine management strategies and enhance outcomes for transplant recipients.

Neutrophil: Lymphocyte and Platelet: Lymphocyte ratios measured before transplantation and their correlation with new-onset diabetes post-transplantation in renal transplant recipients

PURPOSE

Our goal was to evaluate the neutrophil:lymphocyte (NLR) and platelet:lymphocyte (PLR) ratios measured before transplantation and their correlation with new-onset diabetes after transplantation (NODAT) in renal transplant recipients.

PATIENTS AND METHODS

We conducted our study in 324 adult patients consecutively admitted to Military Hospital 103, Ha Noi, Viet Nam, who received kidney allografts from living donors. These patients were followed-up during the first 2 years post-transplantation for NODAT. We examined the association between NLR and PLR measured prior to transplantation in patients with NODAT: NLR and PLR were calculated based on the results of the complete blood count. The criteria for diagnosis of a fully symptomatic NODAT case were based on the guidelines established by the American Diabetes Association and included fasting venous blood glucose and glycosylated hemoglobin A1c (HbA1c) levels, with or without an oral glucose tolerance test.

RESULTS

The overall rate of NODAT during the two years after kidney transplantation was 13.6%. We found mean values of age and body mass index (BMI), and median values of NLR, PLR, high sensitivity C-reactive protein (hs-CRP) levels, and the arteriosclerosis ratio in the NODAT group to be significantly higher than those of the non-NODAT group (all p < 0.05). Furthermore, an adjusted multivariate regression analysis showed that age (area under the curve [AUC] = 0.727, p < 0.001), BMI (AUC = 0.846, p < 0.001), serum hs-CRP levels (AUC = 0.884, p < 0.001), NLR (AUC = 0.888; p < 0.001), and PLR (AUC = 0.818; p < 0.001) had predictive value for NODAT.

CONCLUSION

NLR and PLR measured before transplantation were good predictors for NODAT in the first 2 years post-renal transplantation.

Bariatric Surgery Outcomes in Patients with Kidney Transplantation

Obesity and kidney transplantation (KTx) are closely related. Obesity increases the risk of chronic kidney disease and can be a relative contraindication for KTx. Besides, KTx recipients are predisposed to obesity and its comorbidities. Consequently, bariatric surgery (BS) emerges as a powerful therapeutic tool either before or after KTx. Since evidence regarding the best approach is still scarce, we aimed to describe renal and metabolic outcomes in a single centre with more than 15-year experience in both surgeries. Methods: A retrospective study including patients who had received a KTx either before or after BS. Usual metabolic and renal outcomes, but also new variables (as renal graft dysfunction) were collected for a minimum follow-up of 1-year post-BS. Results: A total of 11 patients were included: n = 6 (BS-post-KTx) and n = 5 (BS-pre-KTx). One patient was assessed in both groups. No differences in the main outcomes were identified, but BS-post-KTx group tended to gain more weight during the follow-up. The incidence of renal graft dysfunction was comparable (4/6 for BS-post-KTx, 3/5 for BS-pre-KTx) between groups. Conclusions: BS in patients with KTx appears to be safe and effective attending to metabolic and renal outcomes. These results seem irrespective of the time course, except for weight regain, which appears to be a common pattern in the BS-post-KTx group.

Association of serum adiponectin and leptin levels with renal function in kidney transplant recipients with or without new-onset diabetes after transplantation

PURPOSE

To evaluate serum adiponectin and leptin concentration in new-onset diabetes after transplantation (NODAT) and non-NODAT patients and association with renal function in kidney transplant recipients (KTRs).

PATIENTS AND METHODS

A study of 314 consecutive adults KTRs divided into four groups: 236 individuals without NODAT who had renal insufficiency (RI; n = 56) or normal renal function (n = 180) and 78 patients with NODAT who had RI (n = 17) or normal renal function (n = 61). NODAT was diagnosed based on venous fasting blood glucose or HbA1c with the criteria of the American Diabetes Association. Renal insufficiency was defined according to KDOQI 2002 guidelines.

RESULTS

In the NODAT group, the median level of serum adiponectin was lower than that of non-NODAT one (30 µg/ml vs 37.15 µg/ml, p < 0.001); in contrast, the median leptin concentration was higher (4.27 ng/ml vs 4.05 ng/ml, p = 0.024). In the RI group, both median serum adiponectin and leptin levels were higher than those of non-RI one (Adiponectin: 40.01 µg/ml vs 33.7 µg/ml; Leptin: 4.51 ng/ml vs 3.91 ng/ml, p < 0.001 both). We found that BMI was related to both adiponectin and leptin levels in both NODAT, non-NODAT, and all subject groups, based on univariate and multivariate linear regression analysis.

CONCLUSION

New-onset diabetes after transplantation, BMI, and renal insufficiency were affected to the serum level of adiponectin and leptin in KTRs.

Global Epidemiology, Health Outcomes, and Treatment Options for Patients With Type 2 Diabetes and Kidney Failure

The burden of type 2 diabetes and related complications has steadily increased over the last few decades and is one of the foremost global public health threats in the 21st century. Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is an important contributor to the cardiovascular morbidity and mortality in this population. In addition, up to one in three patients who have received kidney transplants develop post-transplant diabetes, but the management of this common complication continues to pose a significant challenge for clinicians. In this review, we will describe the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. We will examine the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or have received kidney transplants. With the increased availability of novel hypoglycemic agents, we will address the potential impacts of these novel agents in patients with diabetes and kidney failure and in those who have developed post-transplant diabetes.

Serum hs-CRP measured prior transplantation predicts of new-onset diabetes after transplantation in renal transplant recipients

BACKGROUND

To assess the incidence of new-onset diabetes after transplantation (NODAT) for the first year post-transplantation and the predictive value of high-sensitivity C-reactive Protein (hs-CRP) before transplantation for NODAT prediction in kidney transplantation patients.

MATERIAL AND METHODS

A study of 251 consecutive adult end-stage kidney disease patients transplanted kidneys from living donors, follow-up during the first year to find NODAT. We diagnosed NODAT based on blood glucose or HbA1c following to the criteria of the American Diabetes Association.

RESULTS

The ratio of NODAT was 12.4%. The mean age, mean BMI, the proportion of arteriosclerosis, and the median hs-CRP level in NODAT group were significantly higher than those of non-NODAT group with p < 0.05. Age, BMI and serum hs-CRP had a predictive value for NODAT (Age: AUC = 0.62, p < 0.05, BMI: AUC = 0.626, hs-CRP: AUC = 0.748, p < 0.001).

CONCLUSION

Serum hs-CRP level measured prior transplantation is a good predictor for NODAT in renal transplant recipients.

Diabetes and Cardiovascular Risk in Renal Transplant Patients

End-stage kidney disease (ESKD) is a main public health problem, the prevalence of which is continuously increasing worldwide. Due to adverse effects of renal replacement therapies, kidney transplantation seems to be the optimal form of therapy with significantly improved survival, quality of life and diminished overall costs compared with dialysis. However, post-transplant patients frequently suffer from post-transplant diabetes mellitus (PTDM) which an important risk factor for cardiovascular and cardiovascular-related deaths after transplantation. The management of post-transplant diabetes resembles that of diabetes in the general population as it is based on strict glycemic control as well as screening and treatment of common complications. Lifestyle interventions accompanied by the tailoring of immunosuppressive regimen may be of key importance to mitigate PTDM-associated complications in kidney transplant patients. More transplant-specific approach can include the exchange of tacrolimus with an alternative immunosuppressant (cyclosporine or mammalian target of rapamycin (mTOR) inhibitor), the decrease or cessation of corticosteroid therapy and caution in the prescribing of diuretics since they are independently connected with post-transplant diabetes. Early identification of high-risk patients for cardiovascular diseases enables timely introduction of appropriate therapeutic strategy and results in higher survival rates for patients with a transplanted kidney.

Management of metabolic alterations in adult kidney transplant recipients: A joint position statement of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID)

Chronic metabolic alterations such as post-transplant diabetes mellitus (PTDM), dyslipidaemias and overweight/obesity significantly impact on kidney transplant (KT) outcomes. This joint position statement is based on the evidence on the management of metabolic alterations in KT recipients (KTRs) published after the release of the 2009 KDIGO clinical practice guideline for the care of KTRs. Members of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID) selected to represent professionals involved in the management of KTRs undertook a systematic review of the published evidence for the management of PTDM, dyslipidaemias and obesity in this setting. The aim of this work is to provide an updated review of the evidence on the prevention, diagnosis and treatment of metabolic alterations in KTRs, in order to support physicians, patients and the Healthcare System in the decision-making process when choosing among the various available options.

Pregnancy-associated plasma protein A as a predictor of all-cause mortality and cardiovascular events in patients with chronic kidney disease: a meta-analysis of prospective studies

INTRODUCTION

The aim of the study was to assess the association of elevated serum pregnancy associated plasma protein A (PAPP-A) and the risk of all-cause mortality, cardiovascular events and mortality due to infection in patients with chronic kidney disease (CKD).

MATERIAL AND METHODS

We systematically searched the Medline database up to March 2017. A random effects model was used to pool the relative risks (RRs) and their 95% confidence intervals (CIs). Sensitivity analysis and subgroup analysis were performed to explore the potential sources of heterogeneity.

RESULTS

Six studies involving 2034 subjects were included. The pooled RRs for the risk of all-cause mortality and cardiovascular events were 1.50 (95% CI: 1.17-1.92), 1.26 (95% CI: 0.95-1.69), respectively. Sensitivity analysis by excluding each individual study showed no influence on the main results. Subgroup analysis showed that age, male proportion, follow-up term, and assay methods were not modifiable factors.

CONCLUSIONS

Our study suggests that elevated serum PAPP-A is associated with the risk of all-cause mortality in patients with CKD.

Body Fat Area as a Predictive Marker of New-Onset Diabetes Mellitus After Kidney Transplantation

BACKGROUND

New-onset diabetes after kidney transplantation (NODAT) adversely affects patient survival. Excessive fat accumulation is generally considered a risk factor of NODAT. Body mass index (BMI) and abdominal circumference (AC) are frequently used to assess fat accumulation but cannot directly measure it. This study measured body fat area (BFA) via computed tomography and aimed to clarify whether preoperative BFA can predict the development of NODAT more accurately than BMI and AC.

METHODS

This retrospective study included 62 patients without diabetes mellitus who received living-donor kidney transplantation at our institute between July 2005 and April 2016. We investigated the association between preoperative BMI, AC, and BFA and the development of NODAT.

RESULTS

Eight patients (12.9%) developed NODAT during a mean follow-up period of 78.1 months. The preoperative BMI, AC, and BFA were markedly higher in NODAT patients than in patients without NODAT (P = .05, P = .02, P < .01, respectively). Correlation analyses revealed that BFA had a strong relationship with BMI (r = 0.68, P < .01) and AC (r = 0.77, P < .01). Receiver operating characteristic curve analyses demonstrated that BFA, compared to BMI and AC, had considerable predictive accuracy for the development of NODAT, with an area under the curve of 0.803 (sensitivity 75%, specificity 87%).

CONCLUSIONS

Preoperative BFA could be a predictive marker of NODAT in renal graft recipients. Our findings underline the importance of routine preoperative BFA measurements in clinical practice.

Pretransplant Homeostasis Model Assessment of Insulin Resistance and Fasting Plasma Glucose Predict New-Onset Diabetes After Renal Transplant in Chinese Patients

BACKGROUND AND AIM

The present study aims to determine if homeostasis model assessment of insulin resistance (HOMA-IR) index, fasting plasma glucose (FPG), and plasma insulin (Ins) are able to predict development of new onset diabetes after transplant (NODAT) for kidney recipients.

METHODS

We performed a single-center retrospective study of 123 nondiabetic patients receiving a first renal transplant. The NODAT was diagnosed between 1 month and 1 year post transplant. Both univariate and multivariable analyses, including logistic regression analysis and Cox proportional hazards model, were applied to dissect potential pretransplant risk factors of NODAT.

RESULTS

A total of 26.8% (33/123) of recipients developed NODAT in the first year post transplant. The NODAT patients showed higher HOMA-IR index and increased levels of FPG and Ins than non-NODAT. Interestingly, we consistently revealed that both FPG (logistic: odds ratio [OR], 3.17 [1.41-6.45]; P = .01; Cox: OR, 2.75 [1.26-4.56]; P = .02) and HOMA-IR index (logistic: OR, 1.73 [1.21-2.87]; P = .02; Cox: OR, 1.72 [1.21-2.46]; P = .002) robustly predicted the development of NODAT. However, these analyses showed that neither plasma Ins nor hemoglobin A_1c was associated with NODAT.

CONCLUSION

Our findings suggest that pretransplant HOMA-IR and FPG are independent predictors for the development of NODAT in Chinese nondiabetic patients receiving a first renal transplant.

Pretransplant metabolic syndrome and its components predict post-transplantation diabetes mellitus in Chinese patients receiving a first renal transplant

Background

Post-transplantation diabetes mellitus (PTDM) remains a major clinical challenge following renal transplant. Identification of pretransplant modifiable risk factors may allow timely interventions to prevent PTDM. This study aims to determine whether pretransplant metabolic syndrome and its components are able to predict PTDM in Chinese patients receiving their first renal transplant.

Patients and methods

We conducted a single-center retrospective study of 633 non-diabetic patients receiving a first kidney transplant. PTDM was diagnosed between 1 month and 1 year post-transplant. Multivariable logistic regression and Cox proportional hazards model were applied to detect potential pretransplant risk factors for PTDM.

Results

One year post-transplant, 26.2% of recipients had developed PTDM. PTDM patients had significantly higher fasting plasma glucose (FPG) (P=0.026) and body mass index (BMI) (P=0.006) than non-PRDM patients, and lower levels of high-density lipoprotein cholesterol (P=0.015). The presence of metabolic syndrome was an independent risk factor for PTDM, as assessed by multivariable logistic regression analysis (OR 1.28, 95% CI 1.04–1.51, P=0.038) and Cox proportional hazards model (OR 2.75, 95% CI 1.45–6.05, P=0.021). Moreover, both FPG >5.6 mmol/L and BMI >28 kg/m² (obesity) were able to predict PTDM.

Conclusion

Our results suggest that the presence of metabolic syndrome and its components, impaired fasting glycemia and obesity, are independent risk factors for PTDM in Chinese non-diabetic patients receiving a first renal transplant. Interventions aimed at improving pretransplant metabolic syndrome may reduce the incidence of PTDM.

Genetic immune and inflammatory markers associated with diabetes in solid organ transplant recipients

New-onset diabetes mellitus after transplantation (NODAT) is a complication following solid organ transplantation (SOT) and may be related to immune or inflammatory responses. We investigated whether single nucleotide polymorphisms (SNPs) within 158 immune- or inflammation-related genes contribute to NODAT in SOT recipients. The association between 263 SNPs and NODAT was investigated in a discovery sample of SOT recipients from the Swiss Transplant Cohort Study (STCS, n₁  = 696). Positive results were tested in a first STCS replication sample (n₂  = 489) and SNPs remaining significant after multiple test corrections were tested in a second SOT replication sample (n₃  = 156). Associations with diabetic traits were further tested in several large general population-based samples (n > 480 000). Only SP110 rs2114592C>T remained associated with NODAT in the STCS replication sample. Carriers of rs2114592-TT had 9.9 times (95% confidence interval [CI]: 3.22-30.5, P = .00006) higher risk for NODAT in the combined STCS samples (n = 1184). rs2114592C>T was further associated with NODAT in the second SOT sample (odds ratio: 4.8, 95% CI: 1.55-14.6, P = .006). On the other hand, SP110 rs2114592C>T was not associated with diabetic traits in population-based samples, suggesting a specific gene-environment interaction, possibly due to the use of specific medications (ie, immunosuppressants) in transplant patients and/or to the illness that may unmask the gene effect.

Leptin - A new marker for development of post-transplant diabetes mellitus?

INTRODUCTION

Obese patients have increased leptin production and selective resistance to its central anti-adipogenic effects, yet its pro-inflammatory immunostimulating effects persist.

MATERIAL AND METHODS

In a group of 70 patients who underwent primary kidney transplantation (KT) we examined adiponectin and leptin levels at the time of KT and 6 months post-transplantation. Patients with diabetes mellitus type 1 or type 2 at the time of KT were excluded from the study.

RESULTS

We found that leptin levels significantly increased during the post-transplant period (P = 0.0065). Overall, leptin levels were positively correlated with the level of triacylglycerols, post-transplant diabetes mellitus (PTDM) development and acute rejection (AR). We discovered that, in particular, high leptin levels were associated with AR [OR 2.1273; 95% CI 1.0130-4.4671 (P = 0.0461)] and PTDM development [OR 7.200; 95% CI 1.0310-50.2836 (P = 0.0465)], whereas, low adiponectin levels represent a risk factor for the development of insulin resistance [HR 38.6135; 95% CI 13.3844-67.7699 (P < 0.0001)] and obesity [HR 3.0821; 95% CI 0.8700-10.9192 (P = 0.0053)].

CONCLUSION

We found that a high serum concentration of leptin before KT is associated with both PTDM development and AR and merits further investigation in relation to KT.

Association between anemia at three different time points and new-onset diabetes after kidney transplantation--a retrospective cohort study

PURPOSE

Anemia has been reported to be associated with diabetes, but the association between new-onset diabetes after transplantation (NODAT) and anemia has not been reported.

METHODS

Patients who underwent kidney transplantation and did not have diabetes prior to transplantation were included in this study. Hemoglobin levels and the prevalence of anemia (hemoglobin <12 g/dL in females and <13 g/dL in males) were evaluated at three time points (prior to transplantation, 6 months following transplantation or 1 month before the development of NODAT, 2 years following transplantation, or following the development of NODAT) and were compared between those who developed NODAT and those who did not. Variables associated with the development of anemia were compared between the two groups.

RESULTS

A total of 266 kidney transplant recipients were included, of which 71 (27%) developed NODAT during the time of the follow-up. Hemoglobin and hematocrit levels and the prevalence of anemia were similar in those with and without NODAT at all three time points evaluated. Ferritin levels, prior to transplantation and mean corpuscular volume (MCV) posttransplantation post-NODAT development, were slightly but significantly lower in those with NODAT, although both were within the normal range.

CONCLUSIONS

Pretransplantation ferritin levels and posttransplantation post-NODAT development MCV are inversely associated with the development of NODAT in kidney transplants.

Association of Body Mass Index and the Risk of New-Onset Diabetes After Kidney Transplantation: A Meta-analysis

OBJECTIVE

To comprehensively examine the correlation between body mass index (BMI) and the risk of new-onset diabetes after kidney transplantation (NODAT).

METHODS

The electronic databases Pubmed, Embase, and Cochrane Library, updated in December 2016, were searched, and a literature review was conducted as well to identify relevant research studies. With the use of R 3.12 software, the association between BMI and NODAT risk was analyzed by means of a meta-analysis, with the mean differences (MDs) and their 95% confidence intervals (CIs) as effect indexes. Publication bias was assessed with the use of the Egger test. A sensitivity analysis was performed by excluding 1 study at a time. And the overall morbidity of NODAT was calculated.

RESULTS

In the meta-analysis, 55 eligible studies involving 15,458 kidney transplantation cases were included. After the heterogeneity test, the random-effects model was used to calculate the pooled results of the effect indexes. The results of the meta-analysis showed that BMI was an independent risk factor of NODAT (MD, 1.88; 95% CI, 1.48-2.27). No publication bias was found among the included studies (t = 0.3417; P = 0.7339). The sensitivity analysis revealed that the pooled MD did not reverse after ignoring 1 study at a time. In addition, the overall morbidity of NODAT was 21% (95% CI, 21%-23%).

CONCLUSIONS

Our results suggest that BMI is an independent risk factor for NODAT.

Association between ADIPOQ gene polymorphisms and the risk of new-onset diabetes mellitus after liver transplantation

BACKGROUND

New-onset diabetes after transplantation (NODAT) has become one of the major factors that affect the overall survival and long-term life quality in liver transplantation (LT) recipients. Previous studies found that the serum adiponectin concentration of diabetic patients is significantly lower than that of healthy subjects. Adiponectin regulates the blood glucose level by increasing body sensitivity to insulin through various mechanisms. In this study, we aimed to investigate the impact of diabetes related gene polymorphisms on the development of NODAT in liver recipients.

METHODS

A total of 256 LT patients in a single-center were selected retrospectively for the study. Genomic DNA was extracted from explanted liver tissues, and tested for twelve diabetes mellitus associated single nucleotide polymorphisms by Sequenom MassARRAY. Modified clinical models in predicting NODAT were established and evaluated.

RESULTS

The GG genotype of ADIPOQ rs1501299 gene polymorphism was significantly more frequent in NODAT than non-NODAT LT patients (56% vs 39%, P=0.014). Dominant model (GG vs GT+TT, P=0.030) and recessive model (GT+GG vs TT, P=0.005) also confirmed the genotype distribution difference between NODAT and non-NODAT groups. Age (OR=1.048, P=0.004), BMI (OR=1.107, P=0.041), and blood tacrolimus level at 1-month LT (OR=1.170, P=0.003) were clinical independent risk factors of NODAT. Furthermore, rs1501299 could improve the ability of clinical model in predicting NODAT (AUROC=0.743, P<0.001).

CONCLUSION

ADIPOQ rs1501299 gene polymorphism is associated with an increased risk of NODAT, which should be added to the clinical models in predicting the occurrence of NODAT in LT recipients.

Adiponectin and Its Receptors in Diabetic Kidney Disease: Molecular Mechanisms and Clinical Potential

Diabetic kidney disease (DKD) is a major complication for diabetic patients. Adiponectin is an insulin sensitizer and anti-inflammatory adipokine and is mainly secreted by adipocytes. Two types of adiponectin receptors, AdipoR1 and AdipoR2, have been identified. In both type 1 and type 2 diabetes (T2D) patients with DKD, elevated adiponectin serum levels have been observed, and adiponectin serum level is a prognostic factor of end-stage renal disease. Renal insufficiency and tubular injury possibly play a contributory role in increases in serum and urinary adiponectin levels in diabetic nephropathy by either increasing biodegradation or elimination of adiponectin in the kidneys, or enhancing production of adiponectin in adipose tissue. Increases in adiponectin levels resulted in amelioration of albuminuria, glomerular hypertrophy, and reduction of inflammatory response in kidney tissue. The renoprotection of adiponectin is associated with improvement of the endothelial dysfunction, reduction of oxidative stress, and upregulation of endothelial nitric oxide synthase expression through activation of adenosine 5'-monophosphate-activated protein kinase by AdipoR1 and activation of peroxisome proliferator-activated receptor (PPAR)-α signaling pathway by AdipoR2. Several single nucleotide polymorphisms in the AdipoQ gene, including the promoter, are associated with increased risk of the development of T2D and DKD. Renin-angiotensin-aldosterone system blockers, adiponectin receptor agonists, and PPAR agonists (e.g., tesaglitazar, thiazolidinediones, fenofibrate), which increase plasma adiponectin levels and adiponectin receptors expression, may be potential therapeutic drugs for the treatment of DKD.

[Post-transplantation diabetes mellitus in kidney recipients]

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.

Pretransplantation Risk Factors Associated With New-onset Diabetes After Living-donor Kidney Transplantation

Mid-term date of kidney recipients with new-onset diabetes mellitus after transplantation (NODAT) was poor. We made a retrospective study of 397 patients who had living-donor kidney transplantation between January 2007 and May 2010 in our center. Pretransplantation risk factors for NODAT were identified by univariate and multivariate analyses. The mean follow-up was 53.5 ± 10.4 months. The prevalence of NODAT was 9.3%. Univariate analyses found the mean recipient age ≥40 years, body mass index (BMI) ≥24 kg/m², family history of diabetes, fasting blood glucose (FBG) ≥5.6 mmol/L, 2-hour plasma glucose ≥7.8 mmol/L, and tacrolimus were risk factors for NODAT. In logistic regression, BMI ≥24 kg/m² (odds ratio [OR]: 4.14, confidence interval [CI]: 2.02 ∼ 8.49, P < .001), family history of diabetes (OR: 2.62, CI: 1.09 ∼ 6.34, P = .032), and FBG ≥5.6 mmol/L (OR: 3.21, CI: 1.52 ∼ 6.79, P = .002) were independent risk factors. In conclusion, the mid-term prevalence of NODAT in Chinese renal recipients was low (9.3%). Pretransplantation independent risk factors were BMI ≥24 kg/m², family history of diabetes, and FBG ≥5.6 mmol/L; thus identifying which factors might help to prevent NODAT.

Risk Factors Associated With Mammalian Target of Rapamycin Inhibitor Withdrawal in Kidney Transplant Recipients

BACKGROUND

Mammalian target of rapamycin inhibitors (mTORi) play an essential role as novel immunosuppressive agents in kidney transplantation (KT). Treatment cessation usually occurs after adverse effects occur. We investigated the risk factors associated with withdrawal of mTORi in KT recipients and evaluated the outcomes related to the withdrawal.

METHODS

The study enrolled KT recipients being followed up in a medical center in southern Taiwan from January 1999 through December 2014.

RESULTS

Risk factors associated with mTORi withdrawal were initial proteinuria level, higher initial serum creatinine level posttransplantation, and history of glomerulonephritis as the primary etiology of renal failure. mTORi withdrawal was associated with increased risk of graft failure (hazard ratio [HR], 9.97 [95% confidence interval (CI), 1.03-96.8]; P = .047). Higher body mass index (HR, 11.2 [95% CI, 1.63-76.6]; P = .01) and tacrolimus usage (HR, 8.30 [95% CI, 1.14-60.7]; P = .037) were associated with increased risk of new-onset diabetes after transplantation in mTORi withdrawal groups.

CONCLUSIONS

Proteinuria, poor graft function, and primary glomerulonephritis were associated with cessation of mTORi treatment. Earlier identification of these risk factors may prevent further adverse events and optimize transplantation outcomes after mTORi conversion.

Association of Inflammation prior to Kidney Transplantation with Post-Transplant Diabetes Mellitus

BACKGROUND/OBJECTIVE

Post-transplant diabetes mellitus (PTDM) is both common and associated with poor outcomes after kidney transplantation. Our objective was to examine relationships of uremia-associated inflammation and adiponectin with PTDM.

METHODS

Nondiabetic kidney transplant patients were enrolled with donor controls. Inflammatory cytokines and adiponectin were measured before and after transplantation. Adipose tissue was obtained for gene expression analysis. Glucose transport was quantified in vitro in C2C12 cells following cytokine exposure. The patients were monitored up to 12 months for PTDM.

RESULTS

We studied 36 controls and 32 transplant patients, of whom 11 (35%) developed PTDM. Compared to controls, plasma TNFα, IL-6, MCP-1, and CRP levels were higher in transplant patients (p < 0.01). In multivariable analysis, TNFα plasma levels before transplantation were associated with development of PTDM (OR = 2.03, p = 0.04). Visceral adipose tissue TNFα mRNA expression was higher in transplant patients than controls (fold change 1.33; p < 0.05). TNFα mRNA expression was also higher in patients who developed PTDM than in those who did not (fold change 1.42; p = 0.05), and adiponectin mRNA expression was lower (fold change 0.48; p < 0.05). The studies on the C2C12 cells demonstrated an increase in glucose uptake following exposure to adiponectin and no significant change after exposure to TNFα alone. Concomitant TNFα and adiponectin exposure blunted adiponectin-induced glucose uptake (11% reduction; p < 0.001).

CONCLUSION

Our in vitro and clinical observations suggest that TNFα could contribute to PTDM through an effect on adiponectin. Our study proposes that inflammation is involved in glucose regulation after kidney transplantation.

Prospective Analysis of Metabolic Parameters in the Detection of Diabetes and Metabolic Syndrome in Liver Transplant Recipients

BACKGROUND

Liver transplant recipients are at increased risk of metabolic complications, including new-onset diabetes mellitus after transplantation (NODAT) and post-transplant metabolic syndrome (PTMS), both of which are associated with decreased patient survival. We prospectively monitored traditional and novel metabolic parameters in nondiabetic liver transplantation (LT) candidates to determine their role in detecting these conditions.

METHODS

Nondiabetic adults undergoing initial LT were prospectively identified. NODAT and PTMS were defined according to WHO and ATP III criteria. Metabolic measures were collected at pre-LT, 4, and 12 months post-LT.

RESULTS

Of 49 subjects enrolled, 24.5% were found to be diabetic pre-LT by 2-hr oral glucose tolerance test (OGTT) despite fasting glucose below the diabetic range. Two patients developed NODAT post-LT. A single patient was found to have MS at baseline, while PTMS developed in 26% and 31.3% of patients at 4 and 12 months. Novel metabolic markers did not detect these conditions.

CONCLUSIONS

Screening OGTT detected pre-LT diabetes in patients with normal fasting glucose. Serial measurement of metabolic parameters allowed earlier detection of PTMS. Novel metabolic parameters did not correspond to post-LT outcomes, but provided a baseline for future study. More frequent and intensive metabolic monitoring appears reasonable, but larger studies are needed to clarify its efficacy.

Adipocytokines in renal transplant recipients

In the last two decades, perceptions about the role of body fat have changed. Adipocytes modulate endocrine and immune homeostasis by synthesizing hundreds of hormones, known as adipocytokines. Many studies have been investigating the influences and effects of these adipocytokines and suggest that they are modulated by the nutritional and immunologic milieu. Kidney transplant recipients (KTRs) are a unique and relevant population in which the function of adipocytokines can be examined, given their altered nutritional and immune status and subsequent dysregulation of adipocytokine metabolism. In this review, we summarize the recent findings about four specific adipocytokines and their respective roles in KTRs. We decided to evaluate the most widely described adipocytokines, including leptin, adiponectin, visfatin and resistin. Increasing evidence suggests that these adipocytokines may lead to cardiovascular events and metabolic changes in the general population and may also increase mortality and graft loss rate in KTRs. In addition, we present findings on the interrelationship between serum adipocytokine levels and nutritional and immunologic status, and mechanisms by which adipocytokines modulate morbidity and outcomes in KTRs.

Hyperglycemia and Diabetes Mellitus Following Organ Transplantation

Hyperglycemia is common following organ transplantation, regardless of the pre-transplant diabetes status. Transient post-transplant hyperglycemia and/or new-onset diabetes after transplantation (NODAT) are common and are associated with increased morbidity and mortality. NODAT and type 2 diabetes share similar characteristics, but the pathophysiology may differ. Immunosuppressive agents and steroids play a key role in the development of NODAT. Glycemic control is challenging in this population due to fluctuating renal/end-organ function, immunosuppressive dosing, nutritional status, and drug-drug interactions. A proactive and multidisciplinary approach is essential, along with flexible protocols to adjust to patient status, type of organ transplanted, and corticosteroid regimens. Insulin is the preferred agent for hospitalized patients and during the early post-transplant period; optimal glycemic control (BG < 180 mg/dl with minimal hypoglycemia [<70 mg/dl]) is desired.

Visceral fat is better related to impaired glucose metabolism than body mass index after kidney transplantation

The role of visceral adipose tissue (VAT) in post-transplant hyperglycaemia is not known. We evaluated 167 patients without diabetes 8-10 weeks after kidney transplantation, performing oral glucose tolerance tests and measuring VAT content from dual-energy X-ray absorptiometry scans. Median VAT weight in normal glucose tolerance patients was 0.9 kg, impaired fasting glucose patients 1.0 kg, impaired glucose tolerance patients 1.3 kg and patients with post-transplant diabetes (PTDM) 2.1 kg (P = 0.004, indicating a difference between groups). Percentage VAT of total body fat was associated with fasting (R(2) = 0.094, P < 0.001) and 2-h glucose concentration (R(2) = 0.062, P = 0.001), while BMI was only associated with 2-h glucose concentration (R(2) = 0.029, P = 0.028). An association between BMI and 2-h glucose concentration was lost in adjusted models, as opposed to the associations between VAT as percentage of total body fat and glucose concentrations (R(2) = 0.132, P < 0.001 and R(2) = 0.097, P = 0.001, respectively for fasting and 2-h glucose concentration). In conclusion, VAT is more closely related to impaired glucose metabolism than BMI after kidney transplantation. The association with central obesity should encourage additional studies on lifestyle interventions to prevent PTDM.

New-onset diabetes after renal transplantation

Renal transplantation has important benefits in people with end-stage renal disease, with improvements in mortality, morbidity and quality of life. Whilst significant advances in transplantation techniques and immunosuppressive regimens have led to improvements in short-term outcomes, longer-term outcomes have not improved dramatically. New-onset diabetes after transplantation appears to be a major factor in morbidity and cardiovascular mortality in renal transplant recipients. The diagnosis of new-onset diabetes after renal transplantation has been hampered by a lack of clarity over diagnostic tests in early studies, although the use of the WHO criteria is now generally accepted. HbA1c may be useful diagnostically, but should probably be avoided in the first 3 months after transplantation. The pathogenesis of new-onset diabetes after renal transplantation is likely to be related to standard pathogenic factors in Type 2 diabetes (e.g. insulin resistance, β-cell failure, inflammation and genetic factors) as well as other factors, such as hepatitis C infection, and could be exacerbated by the use of immunosuppression (glucocorticoids and calcineurin inhibitors). Pre-transplant risk scores may help identify those people at risk of new-onset diabetes after renal transplantation. There are no randomized trials of treatment of new-onset diabetes after renal transplantation to determine whether intensive glucose control has an impact on cardiovascular or renal morbidity, therefore, treatment is guided by guidelines used in non-transplant diabetes. Many areas of uncertainty in the pathogenesis, diagnosis and management of new-onset diabetes after renal transplantation require further research.

Association between 276G/T adiponectin gene polymorphism and new-onset diabetes after kidney transplantation

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a well-recognized complication of kidney transplantation and is associated with poor outcomes. Both adiponectin and chemokine ligand 5 (CCL5) proteins are related to glucose metabolism and genetic variations in their genes can lead to development of NODAT. The aim of this study was to investigate the association of adiponectin and CCL5 genes polymorphisms with NODAT in a population of Caucasian kidney transplant recipients.

METHODS

Two hundred seventy Caucasian kidney transplant recipients (83 with NODAT and 187 without NODAT) were included in a nested case-control study. Patients with pretransplantation diabetes mellitus and multiorgan transplantation were excluded. NODAT diagnosis was determined by American Diabetes Association criteria. Subjects were genotyped for 276G/T adiponectin gene polymorphism (rs1501299) and rs2280789 and rs3817655 CCL5 gene polymorphisms by real-time polymerase chain reaction.

RESULTS

The TT genotype of 276G/T adiponectin gene polymorphism was significantly more frequent in NODAT than non-NODAT patients compared with GG/GT genotypes (recessive model; P=0.031). TT genotype was identified as an independent risk factor for NODAT in Caucasian kidney transplant recipients after adjusting for age at transplantation, pretransplantation body mass index, and use of tacrolimus (TT vs. GG/GT, hazard ratio=1.88, 95% confidence interval=1.03-3.45, P=0.041). There were no differences in genotype distribution and allele frequency of rs2280789 and rs3817655 CCL5 gene polymorphisms between NODAT and non-NODAT groups.

CONCLUSIONS

The 276G/T adiponectin gene polymorphism is associated with NODAT in Caucasian kidney transplant recipients.

Comparing risk of new onset diabetes mellitus in chronic kidney disease patients receiving peritoneal dialysis and hemodialysis using propensity score matching

Chronic kidney disease (CKD) patients are at risk for developing new-onset diabetes mellitus (NODM) even after hemodialysis (HD) and peritoneal dialysis (PD) treatment. It is not clear if the incidence for NODM is different in CKD patients receiving HD and PD. This study compared the risk of NODM in PD patients and HD patients.

Methods

All HD and PD patients in Taiwan Renal Registry Database from 1997 to 2005 were included and all patients were followed to December 31, 2008. The risk of NODM was analyzed in PD patients and propensity score matched HD patients using logistic regression for early type NODM (< = 6 months after dialysis) and Cox regression for late type NODM (>6 months after dialysis).

Results

A total of 2548 PD patients and 10192 HD patients who had no diabetes on the initiation of dialysis were analyzed. The incidence for NODM was 3.7 per 100 patient/year for HD and 2.4 for PD patients. HD patients are more at risk for developing early type NODM (p<0.001) with an adjusted odds ratio of 1.41 [95% confidence interval (CI) 1.12–1.78)]. HD patients are more at risk for late type NODM (p<0.001) with an adjusted hazard ratio of 2.01 (95% CI: 1.77–2.29). Patient’s age was negatively associated with risk of early type of NODM (p<0.001) but positively associated with risk of late type NODM (p<0.001).

Conclusions

Chronic kidney disease patients receiving hemodialysis are more at risk for developing new-onset diabetes mellitus compared to those receiving peritoneal dialysis.

Diabetes mellitus in the transplanted kidney

Diabetes mellitus (DM) is the most common cause of chronic kidney disease and end stage renal disease. New onset diabetes mellitus after transplant (NODAT) has been described in approximately 30% of non-diabetic kidney-transplant recipients many years post transplantation. DM in patients with kidney transplantation constitutes a major comorbidity, and has significant impact on the patients and allografts' outcome. In addition to the major comorbidity and mortality that result from cardiovascular and other DM complications, long standing DM after kidney-transplant has significant pathological injury to the allograft, which results in lowering the allografts and the patients' survivals. In spite of the cumulative body of data on diabetic nephropathy (DN) in the native kidney, there has been very limited data on the DN in the transplanted kidney. In this review, we will shed the light on the risk factors that lead to the development of NODAT. We will also describe the impact of DM on the transplanted kidney, and the outcome of kidney-transplant recipients with NODAT. Additionally, we will present the most acceptable data on management of NODAT.

Validation of a pretransplant risk score for new-onset diabetes after kidney transplantation

OBJECTIVE

Identification of patients at high risk for new-onset diabetes after kidney transplantation (NODAT) will facilitate clinical trials for its prevention.

RESEARCH DESIGN AND METHODS

We previously described a pretransplant predictive risk model for NODAT using seven pretransplant variables (age, planned use of maintenance corticosteroids, prescription for gout medicine, BMI, fasting glucose, fasting triglycerides, and family history of diabetes). We have now applied the initial model to a cohort of 474 transplant recipients from another center for validation. We performed two analyses in the validation cohort. The first was a standard model with variables derived from the original study. The second was a summary score model, in which the sum of dichotomized variables (all the variables dichotomized at clinically relevant cut points) was used to categorize, individuals into low (0-1), intermediate (2, 3), or high (4-7) risk groups. We also conducted a combined database analyses, merging the initial and validation cohorts (n=792) to obtain better estimates for a prediction equation.

RESULTS

Although the frequency of several risk factors differed significantly between the two cohorts, the models performed similarly in each cohort. Using the summary score model, incidences of NODAT in low-risk, medium-risk, and high-risk groups in the initial cohort were 12, 29, and 56%, and in the validation cohort incidences were 11, 29, and 51%.

CONCLUSIONS

A pretransplant model for NODAT, including many type 2 diabetes risk factors, predicted NODAT in the validation cohort.

Adiposity and cardiovascular disease risk factors in renal transplant recipients: Are there differences between sexes?

OBJECTIVE

The aim of this study was to evaluate high body adiposity and cardiovascular disease (CVD) risk factors prevalence, in renal transplant recipients (RTR), comparing men with women.

METHODS

In this retrospective cross-sectional study, 102 patients (55 men) who were 49 ± 1.2 y and 114.3 ± 9 mo post-transplant (post-tx) were evaluated. Pretransplant (pre-tx) period data and weight gain during the first year post-tx were obtained from patient charts and post-tx data were collected during a routine visit at nephrology clinic. Body mass index (BMI) ≥ 25 kg/m(2) defined overweight and BMI ≥ 30 kg/m(2) defined obesity.

RESULTS

Pre-tx overweight prevalence was low and similar between men and women (26%), whereas only women showed obesity (11%). Post-tx body weight increased significantly in the entire group, leading to an increase in overweight (to 38% in men and 51% in women) and obesity (to 11% in men and 23% in women) prevalence. Post-tx comparisons between men and women showed that women had higher (women versus men; P < 0.05) BMI values (26.7 ± 0.8 versus 24.7 ± 0.5 kg/m(2)), weight gain during first year post-tx (9.2 ± 1.1 versus 5.5 ± 1 kg), abdominal obesity (57% versus 23%) and diabetes (34% versus 16%) prevalence. The associations between adiposity and CVD risk factors showed that pre-tx overweight increased the risk for diabetes in post-tx; pos-tx high BMI and abdominal obesity increased the risk for metabolic syndrome; abdominal obesity increased the risk for dyslipidemia in women.

CONCLUSIONS

High body adiposity prevalence was high after transplantation and increased the risk for metabolic syndrome, an important CVD risk factor. Women showed higher total body adiposity values, abdominal obesity, and diabetes prevalence than men. Abdominal obesity increased the risk for dyslipidemia in women.

Normal adiponectin levels in kidney transplant patients with hypertension

BACKGROUND

Kidney transplant patients are a unique population where despite correction of their kidney function they are still considered to be at high cardiovascular (CV) risk. Adiponectin, an adipokine secreted from adipocytes, has protective CV properties. Patients with essential hypertension (HTN) have low adiponectin levels that are associated with a high CV risk. The aim of this study was to assess adiponectin levels in hypertensive renal transplant recipients.

MATERIALS AND METHODS

Fasting blood adiponectin levels were measured in hypertensive kidney transplant patients (n = 18), patients with essential HTN (n = 17) and healthy subjects (n = 14). Patients with diabetes mellitus and renal failure were excluded from the study. Anthropomorphic and metabolic parameters were also measured.

RESULTS

Patients with essential HTN had lower adiponectin levels than healthy controls (6 ± 0.7 μg/mL vs. 11 ± 0.9 μg/mL, p < 0.001), whereas hypertensive kidney transplant patients had adiponectin levels that were similar to adiponectin levels found in normal controls (11 ± 1.1 μg/mL). Adiponectin levels in healthy subjects were inversely correlated with plasma triglycerides (r = -0.876, p < 0.001) and with body weight (r = -0.7, p < 0.001). There was no such a correlation in patients with HTN.

CONCLUSION

Adiponectin in hypertensive kidney transplant recipients is not an appropriate CV risk marker as it does not adequately distinguish these patients from normal controls.

Can new-onset diabetes after kidney transplant be prevented?

Because the negative consequences of new-onset diabetes mellitus after transplantation (NODAT) diminish the significant gains of kidney transplantation, it is imperative to develop clinical interventions to reduce the incidence of NODAT. In this review, we discuss whether intensive lifestyle interventions that delay or prevent type 2 diabetes mellitus may decrease the incidence of NODAT. We examine the literature pertaining to incidence and timing of onset of NODAT, as well as the risk factors and pathophysiology that NODAT shares with type 2 diabetes mellitus, namely pathways related to increased insulin resistance and decreased insulin secretion. Our central hypothesis is that NODAT results from the same metabolic risk factors that underlie type 2 diabetes mellitus. These risk factors are altered and enhanced by transplantation, "tipping" some transplant recipients with seemingly normal glucose homeostasis before transplant toward the development of NODAT. We describe the diabetogenic properties of transplant immunosuppressive drugs. We describe novel methods of prevention that are being explored, including resting the pancreatic β-cells by administration of basal insulin during the period immediately after transplant. On the basis of the current evidence, we propose that intensive lifestyle modification, adapted for individuals with chronic kidney disease or end-stage renal disease, as well as resting pancreatic β-cells during the immediate postoperative period, may lower the incidence of NODAT.

New-onset diabetes after kidney transplantation: prevalence, risk factors, and management

New-Onset Diabetes After Transplantation (NODAT) is an increasingly recognized severe metabolic complication of kidney transplantation causing lower graft function and survival and reduced long-term patient survival mainly due to cardiovascular events. The real incidence of NODAT after kidney transplantation is difficult to establish, because different classification systems and definitions have been employed over the years. Several risk factors, already present before or arising after transplantation, in particular the employed immunosuppressive regimens, have been related to the development of NODAT. However the responsible pathogenic mechanisms are still far to be perfectly known. Awareness of NODAT and of the NODAT-related factors is of paramount importance for the clinicians in order to individuate higher risk patients and arrange screening strategies. The risk of NODAT can be reduced by planning preventive measures and by tailoring immunosuppressive regimens according to the patient characteristics. Once NODAT has been diagnosed, the administration of specific anti-hyperglycemic therapy is mandatory to reach a tight glycemic control, which contributes to significantly reduce posttransplant mortality and morbidity.

Adipocytokine associations with insulin resistance in british South asians

Aims. Adipocytokines are implicated in the pathogenesis of type 2 diabetes and may represent identifiable precursors of metabolic disease within high-risk groups. We investigated adiponectin, leptin, and TNF- α and assessed the contribution of these molecules to insulin resistance in south Asians. Hypothesis. South Asians have adverse adipocytokine profiles which associate with an HOMA-derived insulin resistance phenotype. Methods. We measured adipocytokine concentrations in south Asians with newly diagnosed impaired glucose tolerance or Type 2 Diabetes Mellitus in a case-control study. 158 (48.5% males) volunteers aged 25-75 years with risk factors for diabetes but no known vascular or metabolic disease provided serum samples for ELISA and bioplex assays. Results. Total adiponectin concentration progressively decreased across the glucose spectrum in both sexes. A reciprocal trend in leptin concentration was observed only in south Asian men. Adiponectin but not leptin independently associated with HOMA-derived insulin resistance after logistic multivariate regression. Conclusion. Diasporic south Asian populations have an adverse adipocytokine profile which deteriorates further with glucose dysregulation. Insulin resistance is inversely associated with adiponectin independent of BMI and waist circumference in south Asians, implying that adipocytokine interplay contributes to the pathogenesis of metabolic disease in this group.

Metabolic syndrome in hemodialysis patients as a risk factor for new-onset diabetes mellitus after renal transplant: a prospective observational study

PURPOSE

Metabolic syndrome is a cluster of biochemical abnormalities including cardiovascular and diabetes risk factors. The development of diabetes mellitus after renal transplant represents a major posttransplant complication that may adversely affect graft/patient survival. The aim of this study was to assess the role of metabolic syndrome in patients on hemodialysis as a risk factor for the incidence of new-onset diabetes mellitus after renal transplant.

PATIENTS AND METHODS

This was a prospective observational epidemiologic study carried out in adult nondiabetic patients undergoing chronic hemodialysis and on the renal transplant waiting list between November 2008 and April 2009. Patients were followed up from Visit 1 (baseline) to 6 months after the renal transplant. The analysis of the role of metabolic syndrome in hemodialysis patients as a risk factor for the incidence of new-onset diabetes mellitus after renal transplant included the estimation of relative risk and its 95% confidence interval (CI).

RESULTS

A total of 383 evaluable patients were entered into the study (mean age, 52.7 years; male, 57.7%; Caucasian, 90.1%). The prevalence of metabolic syndrome on hemodialysis was 30.4% (95% CI, 25.8%-35.4%). Hypertension was the most prevalent criterion for metabolic syndrome (65.0%), followed by low levels of high-density lipoprotein cholesterol (52.7%), abdominal obesity (36.2%), hypertriglyceridemia (32.4%), and impaired glucose (8.9%). After the renal transplant, the prevalence of metabolic syndrome was still 25.8%. During the posttransplant period, the incidence of new-onset diabetes mellitus reached 13.0% (95% CI, 7.8%-20.6%) and patients with pretransplant metabolic syndrome were 2.6 times (95% CI, 1.043-6.608) more likely to develop new-onset diabetes mellitus after the renal transplant than those without metabolic syndrome.

CONCLUSION

The presence of metabolic syndrome in patients undergoing hemodialysis represents an independent risk factor for the incidence of new-onset diabetes mellitus after renal transplant.

Serum adiponectin levels and mortality after kidney transplantation

BACKGROUND AND OBJECTIVES

Adiponectin (ADPN), an adipose tissue-derived hormone, has protective properties with respect to atherogenesis, inflammation, and energy homeostasis. Its beneficial role has not been consistent in patients with CKD or those undergoing dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study examined the association of plasma ADPN levels in 987 prevalent kidney transplant recipients (mean age ± SD, 51.0±12.8 years; estimated GFR, 52.8±21.9 ml/min per 1.73 m(2); median time since transplant, 78 months) on all-cause mortality and death-censored graft failure. Patients were enrolled between February and August 2007 and were followed for a median of 51 months (interquartile range, 49-53 months). Using Cox proportional hazard models, the association of log-transformed plasma adiponectin was studied, with and without adjustment for demographic variables, baseline GFR, markers of inflammation, and cardiovascular risk factors.

RESULTS

At baseline, patients in the lowest ADPN tertile were significantly more likely to be male; to be smokers; to have a higher baseline GFR, lower systolic BP, and lower HDL cholesterol level; and to have higher body mass index, abdominal circumference, C-reactive protein level, and total cholesterol level. The adjusted hazard ratio for death with elevated plasma ADPN (per natural log) was 1.44, and there was no significant interaction with any relevant cardiovascular risk subgroups (i.e., advanced age; diabetes; or elevated body mass index, waist circumference, C-reactive protein, or Framingham risk score). The hazard for death-censored graft failure was nonsignificant at 1.03.

CONCLUSION

Elevated ADPN levels are associated with higher risk for death but not allograft failure in prevalent kidney transplant recipients.

Adiponectin in renal disease--a review of the evidence as a risk factor for cardiovascular and all-cause mortality

Adiponectin, an adipokine, was discovered in 1995. The initial evidence led to the study of adiponectin as a determinant of insulin sensitivity and blood glucose levels. The literature then evolved to reports of the inverse association of adiponectin with incident Type 2 diabetes mellitus and coronary heart disease. Shortly thereafter, reports of a positive association with heart failure and mortality appeared and were replicated. We review here the basic science evidence and clinical studies of the role of renal function and kidney disease as a determinant of adiponectin.

Plasma adiponectin before and after kidney transplantation

The role of plasma adiponectin (ADPN) in patients with impaired kidney function and following kidney transplantation (Tx) is debated. We aimed to: (i) determine whether pretransplant ADPN level is an independent risk factor for deterioration of glucose tolerance including development of new-onset diabetes mellitus after Tx, (ii) describe which parameters that influence the ADPN concentration before and after Tx. Fifty-seven nondiabetic kidney allograft recipients and 40 nondiabetic uraemic patients were included. The Tx group was examined at baseline and 3 and 12 months after Tx. The uraemic control group was examined twice, separated by 12 months. ADPN levels declined significantly following Tx (P < 0.0001), while estimated glomerular filtration rate (eGFR) increased (P < 0.0005). eGFR, BMI and insulin sensitivity index were independently associated with ADPN in a multivariate regression analysis, whereas an ordinal logistic regression analysis revealed no predictive characteristic of ADPN for aggravation of the glucose tolerance after Tx. In conclusion, kidney transplantation is accompanied by a significant reduction in ADPN concentration. Several factors determine the ADPN concentration before and after Tx including kidney function, insulin resistance, use of immunosuppressive agents and BMI. Pretransplant ADPN level did not predict development of new-onset diabetes mellitus or even deterioration of the glucose tolerance following Tx.

Low pre-transplant adiponectin multimers are associated with adverse allograft outcomes in kidney transplant recipients a 3-year prospective study

BACKGROUND

In kidney transplant recipients endothelial dysfunction is almost a universal risk factor for allograft failure. Adiponectin, an adipocyte derived hormone, has endothelial-protective properties and the high-molecular weight (HMW) multimer is the major active form, exerting anti-inflammatory and anti-apoptotic effects on endothelial cells. This study evaluated, whether pre-transplant total and HMW multimer adiponectin levels are associated with markers of endothelial dysfunction and arteriosclerosis and predict long-term graft survival in patients after kidney transplantation.

METHODS

In 206 renal transplant recipients pre-transplant total and HMW adiponectin levels were measured in serum by ELISA and Western blot, respectively. During the 36 months active follow up (median [interquartile range] 1249 [1020; 1445] days) 13 patients died (94% patient survival) and renal allograft failure was reported in 18 patients (91% graft survival).

RESULTS

Pre-transplant total and HMW adiponectin levels were significantly associated with lipid and glucose parameters at baseline. After 3 years follow-up pre-transplant total and HMW adiponectin levels were significantly inversely associated with the incidence of allograft failure (adiponectin: r=-0.216; p=0.002: HMW: r=-0.218; p=0.002). In multivariable adjusted Cox proportional hazard regression models patients in the lowest total and HMW adiponectin quartile had a significantly increased risk for allograft failure within 3 years post-transplantation: odds ratio [95%CI]: total adiponectin: 4.25 [1.27-14.24; p=0.019], and HMW multimers: 3.35 [1.04-10.76; p=0.042], respectively.

CONCLUSION

Low pre-transplant levels of total and HMW adiponectin reflect a pro-atherogenic endothelial milieu and independently predict an increased risk of allograft failure in kidney-transplant recipients. Measurement of adiponectin levels may identify patients at risk for adverse allograft outcomes after kidney transplantation.

Diets and enteral supplements for improving outcomes in chronic kidney disease

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.