Pretransplant fasting glucose predicts new-onset diabetes after liver transplantation. J Transplant. 2012;2012:614781. [PMID: 22461975 PMCID: PMC3306927 DOI: 10.1155/2012/614781]

Posttransplantation diabetes mellitus after liver transplant and the impact of family history of diabetes in a Mexican cohort

INTRODUCTION AND AIMS

Posttransplantation diabetes mellitus (PTDM) is a serious long-term complication that has a negative impact on graft and patient survival. The purpose of the present study was to describe the incidence of PTDM in a Mexican cohort and evaluate its association with a previous family history of diabetes (FHD).

METHODS

A retrospective single-center cohort study was conducted on patients undergoing liver transplantation (LT). The primary outcome was time from LT to PTDM. The diagnosis of PTDM was established using the ADA criteria. A mediation analysis that used adjusted Cox regression models and considered pretransplant prediabetes a mediator was performed, to determine the total effect and direct effect of FHD on PTDM.

RESULTS

A total of 152 patients were included, with a median follow-up time of 41 months; 19.2% (n = 29) had pretransplant diabetes. During the follow-up time, 15% of patients developed PTDM (n = 23), with an incidence rate of 4.71 cases/100 person-years. PTDM was significantly higher in patients with FHD, compared with those with no FHD (8.72 cases/100 person-years vs 2.04 cases/100 person-years, respectively; p = 0.001). The adjusted hazard ratio of PTDM for FHD was 4.14 (95% CI 1.60-10.7), p = 0.005) and 3.48 (95% CI 1.35-9.01, p = 0.010), when further controlled for pretransplant prediabetes.

CONCLUSION

The occurrence of PTDM was similar to that reported in most international studies. As with type 2 diabetes, family history plays an important role in the development of PTDM, even after accounting for pretransplant prediabetes. Patients with FHD should undergo a stricter metabolic program.

Newly developed sarcopenia after liver transplantation, determined by a fully automated 3D muscle volume estimation on abdominal CT, can predict post-transplant diabetes mellitus and poor survival outcomes

BACKGROUND

Loss of muscle mass is the most common complication of end-stage liver disease and negatively affects outcomes for liver transplantation (LT) recipients. We aimed to determine the prognostic value of a fully automated three-dimensional (3D) muscle volume estimation using deep learning algorithms on abdominal CT in patients who underwent liver transplantation (LT).

METHODS

This retrospective study included 107 patients who underwent LT from 2014 to 2015. Serial CT scans, including pre-LT and 1- and 2-year follow-ups were performed. From the CT scans, deep learning-based automated body composition segmentation software was used to calculate muscle volumes in 3D. Sarcopenia was calculated by dividing average skeletal muscle area by height squared. Newly developed-(ND) sarcopenia was defined as the onset of sarcopenia 1 or 2 years after LT in patients without a history of sarcopenia before LT. Patients' clinical characteristics, including post-transplant diabetes mellitus (PTDM) and Model for end-stage liver disease score, were compared according to the presence or absence of sarcopenia after LT. A subgroup analysis was performed in the post-LT sarcopenic group. The Kaplan-Meier method was used for overall survival (OS).

RESULTS

Patients with ND-sarcopenia had poorer OS than those who did not (P = 0.04, hazard ratio [HR], 3.34; 95% confidence interval [CI] 1.05 - 10.7). In the subgroup analysis for post-LT sarcopenia (n = 94), 34 patients (36.2%) had ND-sarcopenia. Patients with ND-sarcopenia had significantly worse OS (P = 0.002, HR 7.12; 95% CI 2.00 - 25.32) and higher PTDM occurrence rates (P = 0.02, HR 4.93; 95% CI 1.18 - 20.54) than those with sarcopenia prior to LT.

CONCLUSION

ND-sarcopenia determined by muscle volume on abdominal CT can predict poor survival outcomes and the occurrence of PTDM for LT recipients.

Short-term multifactorial intervention (STEMI): An approach using structured blood glucose monitoring (BGM) and conventional therapies in persons with diabetes

Background

Achieving glucose and glycosylated hemoglobin (HbA1c) targets have been shown to reduce long-term microvascular complications of diabetes; however, suboptimal glucose control is common. We tested whether glucose control could be improved within 8 weeks by employing structured blood glucose monitoring (BGM) qid in addition to seven times per day prior to visits for diabetes education and medication management that occurred every 2-4 weeks.

Methods

This single-center, prospective study was conducted on 78 adults with either type 1 diabetes (T1D) or type 2 diabetes (T2D), HbA1c >8%, and serum creatinine (sCr) <2.0 mg/dl. HbA1c was checked at baseline, Week 2, Week 4, and at Week 8. Patients were evaluated by a physician and a certified diabetes educator (CDE) at baseline, Week 2, and Week 4 for treatment adjustments and lifestyle advice based on a review of BGM done qid plus 7-point profiles conducted before Weeks 2, 4, and 8. Study outcomes were change in HbA1c from baseline to Week 8 and change in mean glucose on the 7-point profile from Week 2 to Week 8. These were compared using one-way repeated measures ANOVA.

Results

Of the 78 patients, 64.1% had T2D, 50% were women, and 72% were Caucasian. Mean age (±SD) was 51.3.5 ± 11.1 years, and median diabetes duration was 9 (5-17) years. The percentage of patients using insulin increased from 58.9% at baseline to 67.9% at Week 8. The mean (±SD) HbA1c was 9.53% (±1.71) at baseline, declined -1.38% from baseline to week 8 (CI -1.62 to -0.14, P < 0.001). The mean (±SD) glucose on the 7-point profile was 187 (±52) mg/dl at Week 2, and 157 (±5) mg/dl at Week 8. (P < 0.01).

Conclusions

An intensive glucose optimization program using structured BGM qid plus 7-point profiles, diabetes education, and conventional anti-diabetic therapies was successful in reducing HbA1c by 1.38% over 8 weeks in patients with poor glucose control.

Clinical implications of diabetes in chronic liver disease: Diagnosis, outcomes and management, current and future perspectives

Diabetes mellitus (DM) is common in liver cirrhosis (LC). The pathophysiological association is bidirectional. DM is a risk factor of LC and LC is a diabetogenic condition. In the recent years, research on different aspects of the association DM and LC has been intensified. Nevertheless, it has been insufficient and still exist many gaps. The aims of this review are: (1) To discuss the latest understandings of the association of DM and LC in order to identify the strategies of early diagnosis; (2) To evaluate the impact of DM on outcomes of LC patients; and (3) To select the most adequate management benefiting the two conditions. Literature searches were conducted using PubMed, Ovid and Scopus engines for DM and LC, diagnosis, outcomes and management. The authors also provided insight from their own published experience. Based on the published studies, two types of DM associated with LC have emerged: Type 2 DM (T2DM) and hepatogenous diabetes (HD). High-quality evidences have determined that T2DM or HD significantly increase complications and death pre and post-liver transplantation. HD has been poorly studied and has not been recognized as a complication of LC. The management of DM in LC patients continues to be difficult and should be based on drug pharmacokinetics and the degree of liver failure. In conclusion, the clinical impact of DM in outcomes of LC patients has been the most studied item recently. Nevertheless many gaps still exist particularly in the management. These most important gaps were highlighted in order to propose future lines for research.

A Time-Based Meta-Analysis on the Incidence of New Onset Diabetes after Liver Transplantation

NODAT (new-onset diabetes after transplantation) is an important complication after liver transplant, however, there is variation in the reported incidence of NODAT. Therefore, a meta-analysis was performed to estimate the incidence of NODAT in liver transplant. Electronic databases were searched for articles regarding NODAT incidence after liver transplantation. Incidence of NODAT were analyzed at six different timepoints. Summary statistics were calculated using a generalized linear mixed model in random effects. 28 articles were included and out of a pooled population of 71,257 patients, overall incidence of NODAT was found to be 15.51%, 16.09%, 18.30%, 20.86%, 18.08%, 25.05% for three-months, six-months, one-year, three-year, five-year, and ten-year timepoints respectively. After a sensitivity analysis which only included articles with clear definitions of NODAT, the incidence of NODAT was found to be higher at three-year (21.79%), five-year (25.82%), and ten-year (44.95%) timepoints. Subgroup analysis according to ethnicity found no significant differences for all timepoints. However, studies with predominantly Asian participants generally had a higher incidence of NODAT. In conclusion, this meta-analysis provides a pooled estimate of the incidence of NODAT following liver transplantation. Further studies are required to provide a more comprehensive understanding on how ethnicity can affect the incidence of NODAT.

Body Weight Parameters are Related to Morbidity and Mortality After Liver Transplantation: A Systematic Review and Meta-analysis

BACKGROUND

Weight gain and obesity are well-known clinical issues in liver transplantation (LTx). However, their impacts on patient outcomes remain unclear, as only the impact of pre-LTx body mass index (BMI) on survival has been meta-analyzed. We summarized and synthesized the evidence on pre- and post-LTx body weight parameters' relations with post-LTx outcomes such as survival, metabolic and cardiovascular comorbidities, and healthcare utilization.

METHODS

We followed the Cochrane Handbook for Systematic Reviews of Interventions' recommendations. Quality was assessed via a 19-item instrument. Odds ratios and 95% confidence intervals were calculated for outcomes investigated in ≥5 studies.

RESULTS

Our meta-analysis included 37 studies. Patients with pre-LTx BMI ≥ 30 kg/m and BMI ≥ 35 kg/m had lower overall survival rates than those with pre-LTx normal weight (72.6% and 69.8% versus 84.2%; P = 0.02 and P = 0.03, respectively). Those with pre-LTx BMI ≥ 30 kg/m had worse overall graft survival than normal weight patients (75.8% and 85.4%; P = 0.003). Pre-LTx BMI and pre-LTx overweight were associated with new-onset diabetes (P < 0.001 and P = 0.015, respectively), but post-LTx BMI showed no relationship. No associations were evident with healthcare utilization.

CONCLUSIONS

Patients with BMI values ≥30 kg/m had worse patient and graft survival than those with normal weight. Few of the reviewed studies examined post-LTx body weight parameters or other relevant outcomes such as cardiovascular comorbidities. High heterogeneity as well as diverse definitions and operationalizations of measurement and outcomes severely impeded comparability.

Post-Liver Transplantation Diabetes Mellitus: A Review of Relevance and Approach to Treatment

Post-liver transplantation diabetes mellitus (PLTDM) develops in up to 30% of liver transplant recipients and is associated with increased risk of mortality and multiple morbid outcomes. PLTDM is a multicausal disorder, but the main risk factor is the use of immunosuppressive agents of the calcineurin inhibitor (CNI) family (tacrolimus and cyclosporine). Additional factors, such as pre-transplant overweight, nonalcoholic steatohepatitis and hepatitis C virus infection, may further increase risk of developing PLTDM. A diagnosis of PLTDM should be established only after doses of CNI and steroids are stable and the post-operative stress has been overcome. The predominant defect induced by CNI is insulin secretory dysfunction. Plasma glucose control must start immediately after the transplant procedure in order to improve long-term results for both patient and transplant. Among the better known antidiabetics, metformin and DPP-4 inhibitors have a particularly benign profile in the PLTDM context and are the preferred oral agents for long-term management. Insulin therapy is also an effective approach that addresses the prevailing pathophysiological defect of the disorder. There is still insufficient evidence about the impact of newer families of antidiabetics (GLP-1 agonists, SGLT-2 inhibitors) on PLTDM. In this review, we summarize current knowledge on the epidemiology, pathogenesis, course of disease and medical management of PLTDM.

New Onset Diabetes and Non-Alcoholic Fatty Liver Disease after Liver Transplantation

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is an emerging cause of graft dysfunction after liver transplantation (LT) frequently related to the development of new onset diabetes after LT (NODAT). This study was undertaken to evaluate the frequencies of NODAT and NAFLD after LT, to investigate their major risk factors and the impact of de novo or recurrent NAFLD in graft function.

MATERIAL AND METHODS

119 patients submitted to LT were prospectively evaluated.

RESULTS

After 4 ± 1 years, NODAT, recurrent and de novo NAFLD were observed in 31%, 56% and 43% of the subjects, respectively. Only 3 patients had non-alcoholic steatohepatitis (NASH) without fibrosis. Other risk factors for NAFLD such as arterial hypertension (AHT), metabolic syndrome (MS), hypertriglyceridemia and obesity were seen in 51%, 50%, 35% and 24% of the subjects, respectively. In addition, insulin resistance (IR), assessed by HOMA-IR and β-cell dysfunction, determined by HOMA-β, were observed in 16% and 94% of the patients, respectively. Occurrence of NODAT was associated with male gender, higher waist circumference, higher HOMA-IR and lower HOMA-β values. No correlation was found between NAFLD and NODAT, MS, hypertriglyceridemia, obesity and HOMAIR and HOMA-β levels.

CONCLUSIONS

NODAT, recurrent and de novo NAFLD are common after LT but are not associated with signs of graft dysfunction, possibly due to the low frequency of IR and NASH. No correlation is observed between NAFLD and NODAT, MS, hypertriglyceridemia, obesity and IR. β-cell dysfunction and diabetes, however, are seen in most of the patients, possibly due to calcineurin inhibitor toxicity.

Induction of IAPP amyloid deposition and associated diabetic abnormalities by a prion-like mechanism

In this article, Mukherjee et al. show that the pathologic and clinical alterations of type 2 diabetes can be induced in vitro and in vivo by prion-like transmission of IAPP misfolded aggregates, supporting an important role for IAPP aggregation in the disease.

Although a large proportion of patients with type 2 diabetes (T2D) accumulate misfolded aggregates composed of the islet amyloid polypeptide (IAPP), its role in the disease is unknown. Here, we show that pancreatic IAPP aggregates can promote the misfolding and aggregation of endogenous IAPP in islet cultures obtained from transgenic mouse or healthy human pancreas. Islet homogenates immunodepleted with anti-IAPP–specific antibodies were not able to induce IAPP aggregation. Importantly, intraperitoneal inoculation of pancreatic homogenates containing IAPP aggregates into transgenic mice expressing human IAPP dramatically accelerates IAPP amyloid deposition, which was accompanied by clinical abnormalities typical of T2D, including hyperglycemia, impaired glucose tolerance, and a substantial reduction on β cell number and mass. Finally, induction of IAPP deposition and diabetic abnormalities were also induced in vivo by administration of IAPP aggregates prepared in vitro using pure, synthetic IAPP. Our findings suggest that some of the pathologic and clinical alterations of T2D might be transmissible through a similar mechanism by which prions propagate in prion diseases.

Prion-Like Protein Aggregates and Type 2 Diabetes

Type 2 diabetes (T2D) is a highly prevalent metabolic disease characterized by chronic insulin resistance and β-cell dysfunction and loss, leading to impaired insulin release and hyperglycemia. Although the mechanism responsible for β-cell dysfunction and death is not completely understood, recent findings suggest that the accumulation of misfolded aggregates of the islet amyloid polypeptide (IAPP) in the islets of Langerhans may play an important role in pancreatic damage. Misfolding and aggregation of diverse proteins and their accumulation as amyloid in different organs is the hallmark feature in a group of chronic, degenerative diseases termed protein misfolding disorders (PMDs). PMDs include highly prevalent human illnesses such as Alzheimer's and Parkinson's disease, as well as more than 25 rarer disorders. Among them, prion diseases are unique because the pathology can be transmitted by a proteinaceous infectious agent, termed a prion, which induces disease by propagating protein misfolding and aggregation. This phenomenon has a striking resemblance to the process of protein misfolding and aggregation in all of the PMDs, suggesting that misfolded aggregates have an intrinsic potential to be transmissible. Indeed, recent studies have shown that the pathological hallmarks of various PMDs can be induced in vivo under experimental conditions by inoculating tissue extracts containing protein aggregates into animal models. In this review, we describe our current understanding of the molecular mechanism underlying the prion-like transmission of protein aggregates and its possible role in T2D.

β-cell function prior to liver transplantation contributes to post-operative diabetes

Liver cirrhosis and diabetes mellitus (DM) are closely associated. The present study aimed to determine whether liver transplantation (LT) may prevent/cure DM in patients with cirrhosis and whether the degree of glucose tolerance prior to transplantation is associated with the onset of DM after transplantation. Seventy-three patients who received a living donor LT at Nagasaki University Hospital (Nagasaki, Japan) between November 2005 and December 2012 were recruited. Among them, patients were considered diabetic if they had been prescribed diabetes medications or had impaired glucose tolerance, as evidenced by an oral glucose tolerance test (OGTT). Patients were followed up until December 31, 2013 to evaluate glucose tolerance. Patients who had developed DM 2 years after transplantation were found to be older and the incidence of diabetes prior to transplantation (n=73) was higher than in those who did not. Multivariate analysis revealed that DM requiring treatment prior to transplantation was the only independent factor for DM developed at 2 years after transplantation. OGTT results showed that in patients with poor insulin sensitivity indices prior to transplantation (n=45), improvements were seen at 2 years after transplantation, while β-cell function and insulinogenic index had decreased, which may have been the cause of DM after transplantation. In conclusion, the pre-operative β-cell function determined by an OGTT may be a useful predictive tool for the recurrence of DM after LT.

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.

Nonalcoholic Fatty Liver Disease: Key Considerations Before and After Liver Transplantation

Nonalcoholic fatty liver disease (NAFLD) is the most common etiology of chronic liver disease in developed countries and is on trajectory to become the leading indication for liver transplantation in the USA and much of the world. Patients with NAFLD cirrhosis awaiting liver transplant face unique challenges and increased risk for waiting list stagnation and dropout due to burdensome comorbidities including obesity, diabetes, cardiovascular disease, and kidney disease. Thus far, patients transplanted for NAFLD cirrhosis have excellent mid- and long-term patient and graft survival, but concerns regarding short-term morbidity and mortality continue to exist. Post-liver transplantation, NAFLD occurs as both a recurrent and de novo manifestation, each with unique outcomes. NAFLD in the donor population is of concern given the growing demand for liver transplantation and mounting pressure to expand the donor pool. This review addresses key issues surrounding NAFLD as an indication for transplantation, including its increasing prevalence, unique patient demographics, outcomes related to liver transplantation, development of post-liver transplantation NAFLD, and NAFLD in the liver donor population. It also highlights exciting areas where further research is needed, such as the role of bariatric surgery and preconditioning of marginal donor grafts.

Hyperglycemia during the immediate period following liver transplantation

Aim:

High blood glucose levels in the hospital are common among transplant recipients.

Methods:

Retrospective analysis, stratified by diagnosis of pretransplant diabetes mellitus (DM).

Results:

Of 346 patients, 96 had pretransplant DM (insulin, n = 60; no insulin, n = 36) and 250 did not. Patients with pretransplant DM had higher inpatient mean glucose levels and more hyperglycemia and hypoglycemia (all p < 0.01). For patients without pretransplant DM, the need for insulin at discharge increased 23% for every 5-year age increase (odds ratio: 1.23; 95% CI: 1.06–1.44; p = 0.007) and 51% for every five units of glucose measurements >180 mg/dl (OR: 1.51; 95% CI: 1.23–1.95; p < 0.01).

Conclusion:

Inpatient hyperglycemia was common in liver transplant recipients. Hospital practitioners must anticipate the need to teach self-management skills to liver transplant recipients.

Lay abstract: High blood glucose levels (also known as hyperglycemia) in the hospital are common among patients who have received a transplant. The authors conducted a study to determine how often high blood glucose values occurred in patients who received a liver transplant and found that values were highest in people who had diabetes before the transplant. However, even patients who did not have a history of diabetes had hyperglycemia and needed insulin treatment. Providers caring for these patients in the hospital must be prepared to provide education in diabetes self-management skills to virtually all patients undergoing a liver transplant.

New-onset diabetes after liver transplantation and its impact on complications and patient survival

BACKGROUND

The aim of the present study was to investigate the incidence and risk factors of new-onset diabetes after transplantation (NODAT) in liver transplant recipients and the influence of NODAT on complications and long-term patient survival.

METHODS

We examined 438 patients who underwent liver transplantation between April 2001 and December 2008 and were not diabetic before transplantation.

RESULTS

The mean (± SD) follow-up duration was 2.46 ± 1.62 years. The incidence of NODAT 3, 6, 9, 12, 36, and 60 months after transplantation was 44.24%, 25.59%, 23.08%, 25.17%, 17.86%, and 18.18%, respectively. Multifactor analysis indicated that preoperative fasting plasma glucose (FPG) levels and donor liver steatosis were independent risk factors for NODAT, whereas administration of an interleukin-2 receptor (IL-2R) antagonist reduced the risk of NODAT. Compared with the no NODAT group (N-NODAT), the NODAT group had a higher rate of sepsis and chronic renal insufficiency. Mean survival was significantly longer in the N-NODAT than NODAT group. Cox regression analysis showed that pre- and/or postoperative FPG levels, tumor recurrence or metastasis, and renal insufficiency after liver transplantation were independent risk factors of mortality. Pulmonary infection or multisystem failure were specific causes of death in the NODAT group, whereas patients in both groups died primarily from tumor relapse or metastasis.

CONCLUSIONS

Preoperative FPG levels and donor liver steatosis were independent risk factors for NODAT, whereas administration of an IL-2R antagonist reduced the risk of NODAT. Patients with NODAT had reduced survival and an increased incidence of sepsis and chronic renal insufficiency. Significant causes of death in the NODAT group were pulmonary infection and multisystem failure.

Risk factors of metabolic disorders after liver transplantation: an analysis of data from fasted patients

BACKGROUND

Metabolic disorders are common complications after orthotopic liver transplantation (OLT) and may lead to increased morbidity and mortality.

METHODS

Fasting glucose and lipid metabolism, and body weight of 81 patients undergoing primary OLT were prospectively analyzed. Patients were investigated preoperatively, on postoperative days 1, 3, 5, 10, 14, 28 as well as 6 months and 1 year after OLT. Data of nonfasted patients were excluded from the analysis. Standardized definitions and classifications for diabetes mellitus (DM), body mass index (BMI), and dyslipidemia were used.

RESULTS

Prevalence of new-onset diabetes after transplantation was 9.3%, and obesity was its only independent risk factor (odds ratio [OR], 16.5). Preoperative impaired glucose homeostasis (OR, 10.8) and initial poor graft function (OR, 6.89) were independent risk factors for postoperative DM. Maximum prevalence of hypertriglyceridemia and hypercholesterolemia was found on postoperative day 10 and 6 months post-OLT, respectively. Risk factors for hypercholesterolemia at 1 year were patient age (OR, 1.17) and postoperative renal dysfunction (OR, 16.33). Higher preoperative BMI was a risk factor for postoperative hypertriglyceridemia (OR, 1.17). Overall body weight and BMI significantly decreased over 1 year (P < 0.05). Prevalence of obesity was 22.2% before and 20.9% after OLT.

CONCLUSION

For the first time, initial poor graft function was identified as a risk factor for post-OLT DM. By ruling out any exogenous factors influencing metabolism, we believe we were able to show the true prevalence of metabolic disorders and therefore provided a valuable contribution to the identification of potential risk factors.

Early occurrence of new-onset diabetes after transplantation is related to type of liver graft and warm ischaemic injury

BACKGROUND & AIMS

We studied new-onset diabetes after transplantation (NODAT) in liver transplantation with grafts donated after brain death (DBD) or circulatory death (DCD), focusing on the early post-transplant period.

METHODS

A total of 430 non-diabetic primary liver transplant recipients [DCD, n = 90 (21%)] were followed up for 30 months (range 5-69). NODAT was defined as the composite endpoint of one of following: (i) Two non-fasting plasma glucose levels > 11.1 mmol/L ≥ 30 days apart, (ii) oral hypoglycaemic drugs ≥ 30 days consecutively (iii) insulin therapy ≥ 30 days and (iv) HbA1c ≥ 48 mmol/L. Resolution of NODAT was defined as cessation of treatment or hyperglycaemia.

RESULTS

Total of 81/430 (19%) patients developed NODAT. Incidence and resolution of NODAT over time showed significantly different patterns between DCD and DBD liver graft recipients; early occurrence, high peak incidence and early resolution were seen in DCD. In multivariate logistic regression including age, ethnicity, HCV, tacrolimus level and pulsed steroids, only DCD was independently associated with NODAT at day 15 post-transplant (OR 6.5, 95% CI 2.3-18.4, P < 0.001), whereas age and pulsed steroids were significant factors between 30-90 days. Combined in multivariate Cox regression model for NODAT-free survival, graft type, age and pulsed steroids were each independent predictor for decreased NODAT-free survival in the first 90-postoperative days.

CONCLUSION

Early peak of NODAT in DCD graft recipients is a novel finding, occurring independently from known risk factors. Donor warm ischaemia and impact on insulin sensitivity should be further studied and could perhaps be associated with graft function.

Risk factors for new onset diabetes mellitus after liver transplantation: A meta-analysis

AIM: To determine the risk factors for new-onset diabetes mellitus (NODM) after liver transplantation by conducting a systematic review and meta-analysis.

METHODS: We electronically searched the databases of MEDLINE, EMBASE and the Cochrane Library from January 1980 to December 2013 to identify relevant studies reporting risk factors for NODM after liver transplantation. Two authors independently assessed the trials for inclusion and extracted the data. Discrepancies were resolved in consultation with a third reviewer. All statistical analyses were performed with the RevMan5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated using either a fixed effects or a random effects model, based on the presence (I² < 50%) or absence (I² > 50%) of significant heterogeneity.

RESULTS: Twenty studies with 4580 patients were included in the meta-analysis, all of which were retrospective. The meta-analysis identified the following significant risk factors: hepatitis C virus (HCV) infection (OR = 2.68; 95%CI: 1.92-3.72); a family history of diabetes (OR = 1.69, 95%CI: 1.09-2.63, P < 0.00001); male gender (OR = 1.53; 95%CI: 1.24-1.90; P < 0.0001); impaired fasting glucose (IFG; OR = 3.27; 95%CI: 1.84-5.81; P < 0.0001); a family history of diabetes (OR = 1.69; 95%CI: 1.09-2.63; P = 0.02); use of tacrolimus (OR = 1.34; 95%CI: 1.03-1.76; P = 0.03) and body mass index (BMI)(WMD = 1.19, 95%CI: 0.69-1.68, P < 0.00001). Other factors, such as hepatitis B virus infection and alcoholism, were not found to be associated with the incidence of NODM.

CONCLUSION: The study showed that HCV infection, IFG, a family history of diabetes, male gender, tacrolimus and BMI are risk factors for NODM after liver transplantation.

New Onset Diabetes Mellitus in Living Donor versus Deceased Donor Liver Transplant Recipients: Analysis of the UNOS/OPTN Database

New onset diabetes after transplantation (NODAT) occurs less frequently in living donor liver transplant (LDLT) recipients than in deceased donor liver transplant (DDLT) recipients. The aim of this study was to compare the incidence and predictive factors for NODAT in LDLT versus DDLT recipients. The Organ Procurement and Transplant Network/United Network for Organ Sharing database was reviewed from 2004 to 2010, and 902 LDLT and 19,582 DDLT nondiabetic recipients were included. The overall incidence of NODAT was 12.2% at 1 year after liver transplantation. At 1, 3, and 5 years after transplant, the incidence of NODAT in LDLT recipients was 7.4, 2.1, and 2.6%, respectively, compared to 12.5, 3.4, and 1.9%, respectively, in DDLT recipients. LDLT recipients have a lower risk of NODAT compared to DDLT recipients (hazard ratio = 0.63 (0.52–0.75), P < 0.001). Predictors for NODAT in LDLT recipients were hepatitis C (HCV) and treated acute cellular rejection (ACR). Risk factors in DDLT recipients were recipient male gender, recipient age, body mass index, donor age, donor diabetes, HCV, and treated ACR. LDLT recipients have a lower incidence and fewer risk factors for NODAT compared to DDLT recipients. Early identification of risk factors will assist timely clinical interventions to prevent NODAT complications.