Post-transplant diabetes mellitus

Post-transplant diabetes mellitus: risk factors and outcomes in a 5-year follow-up

Introduction

Kidney transplantation is associated with an increased risk of posttransplant diabetes mellitus (PTDM), impacting recipient and graft survivals. The incidence of PTDM ranges from 15% to 30%, with most cases occurring in the first year post-transplant. Some clinical and laboratory characteristics pre- and post-transplant may be associated with a higher PTDM incidence in a more extended follow-up period. This study aimed to analyze the prevalence of PTDM among renal transplant recipients without previous DM diagnosis during a five-year post-transplant follow-up, as well as clinical and laboratory characteristics associated with a higher incidence of PTDM during this period.

Material and methods

Single-center retrospective cohort including kidney transplant recipients older than 18 years with a functioning graft over six months of follow-up between January and December 2018. Exclusion criteria were recipients younger than 18 years at kidney transplantation, previous diabetes mellitus diagnosis, and death with a functioning graft or graft failure within six months post-transplant.

Results

From 117 kidney transplants performed during the period, 71 (60.7%) fulfilled the inclusion criteria, 18 (25.3%) had PTDM diagnosis, and most (n=16, 88.9%) during the 1st year post-transplant. The need for insulin therapy during the hospital stay was significantly higher in the PTDM group (n=11, 61.1% vs. n=14, 26.4%, PTDM vs. non-PTDM). Other PTDM risk factors, such as older age, high body mass index, HLA mismatches, and cytomegalovirus or hepatitis C virus infections, were not associated with PTDM occurrence in this series. During 5-year post-transplant follow-up, the graft function remained stable in both groups.

Conclusion

The accumulated incidence of PTDM in this series was similar to the reported in other studies. The perioperative hyperglycemia with the need for treatment with insulin before hospital discharge was associated with PTDM.

Treatment of insulin-dependent diabetes by hematopoietic stem cell transplantation

Type 1 diabetes (T1D) is an autoimmune disease resulting from the demolition of β-cells that are responsible for producing insulin in the pancreas. Treatment with insulin (lifelong applying) and islet transplantation (in rare cases and severe diseases), are standards of care for T1D. Pancreas or islet transplantation have some limitations, such as lack of sufficient donors and longtime immune suppression for preventing allograft rejection. Recent studies demonstrate that autologous hematopoietic stem cells (HSC) can regenerate immune tolerance against auto-antigens. Taking advantage of this feature, autologous HSC transplantation (auto-HSCT) is likely the only treatment for T1D that is associated with lasting and complete remission. None of the other evaluated immunotherapies worldwide had the clinical efficacy of auto-HSCT. Therapy with auto-HSCT is insulin-independent rather than reducing insulin needs or delaying loss of insulin production. This review provided the latest findings in auto-HSCT for treatment of T1D.

Tacrolimus inhibits insulin release and promotes apoptosis of Min6 cells through the inhibition of the PI3K/Akt/mTOR pathway

As a calcineurin inhibitor, tacrolimus is commonly used as a first‑line immunosuppressant in organ transplant recipients. Post‑transplantation diabetes mellitus (PTDM) is a common complication following kidney transplantation and is associated with immunosuppressant drugs, such as tacrolimus. PTDM caused by tacrolimus may be related to its influence on insulin secretion and insulin resistance. However, the specific mechanism has not been fully elucidated. The aim of the present study was to investigate whether the PI3K/Akt/mTOR signaling pathway served an important role in the pathogenesis of PTDM induced by tacrolimus. In the present study, the Cell Counting Kit‑8 assay was used to measure the effect of tacrolimus on the viability of Min6 mouse insulinoma cells. The effects of tacrolimus on the insulin secretion and the activity of caspase‑3 of Min6 cells stimulated by glucose exposure were measured by ELISA. Superoxide dismutase (SOD) and malondialdehyde (MDA) levels were measured using WST‑8 and thiobarbituric acid assays, respectively. The effects of tacrolimus on the mRNA expression levels of PI3K, Akt and mTOR were detected by reverse transcription‑quantitative PCR (RT‑qPCR), whereas the protein expression levels of PI3K, Akt, mTOR, phosphorylated (p)‑AKT and p‑mTOR in Min6 cells were assessed using western blotting. The present data indicated that, compared with the control group, 5, 25 and 50 ng/ml tacrolimus treatment could inhibit the insulin secretion of Min6 cells stimulated by glucose solution, and 50 ng/ml tacrolimus could notably decrease the stimulation index (P<0.05). Moreover, 50 ng/ml tacrolimus markedly increased the activity of caspase‑3 by 175.1% (P<0.05), it also decreased the SOD activity (P<0.01) and increased MDA levels (P<0.05). The RT‑qPCR results demonstrated that the mRNA expression levels of PI3K, Akt and mTOR were downregulated by 25 and 50 ng/ml tacrolimus (P<0.01). Furthermore, the western blotting results suggested that tacrolimus had no significant effects on the expression levels of total PI3K, Akt and mTOR proteins (P>0.05), but 25 and 50 ng/ml tacrolimus could significantly inhibit the expression levels of p‑Akt and p‑mTOR (P<0.01). In conclusion, tacrolimus decreased the activity and insulin secretion of pancreatic β cells and induced the apoptosis of islet β cells by inhibiting the mRNA expression levels of PI3K, Akt and mTOR and reducing the phosphorylation of Akt and mTOR proteins in the PI3K/Akt/mTOR signaling pathway, which may ultimately lead to the occurrence of diabetes mellitus, and may be considered as one of the specific mechanisms of PTDM caused by tacrolimus.

Glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for diabetes after solid organ transplantation

Post-transplant diabetes mellitus (PTDM) is a common complication of solid organ transplantation and a major cause of increased morbidity and mortality. Additionally, solid organ transplant patients may have pre-existent type 2 diabetes mellitus (T2DM). While insulin is the treatment of choice for hyperglycemia in the first weeks after transplantation, there is no preferred first line agent for long-term management of PTDM or pre-existent T2DM. Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 (SGLT2) inhibitors improve glycemic control, lower body weight, and blood pressure, are recommended after lifestyle and metformin as initial therapy for diabetic patients with cardiovascular or kidney comorbidities regarding their cardiorenal benefits. Furthermore, the mechanisms of action of GLP-1RA may counteract some of the driving forces for PTDM, as calcineurin-induced β cell toxicity as per preclinical data, and improve obesity. However, their use in the treatment of PTDM is currently limited by a paucity of data. Retrospective observational and small exploratory studies suggest that GLP-1RA effectively improve glycemic control and induce weight loss in patients with PTDM without interacting with commonly used immunosuppressive agents, although randomized-controlled clinical trials are required to confirm their safety and efficacy. In this narrative review, we evaluate the risk factors and pathogenesis of PTDM and compare the potential roles of GLP-1RA and SGLT2 inhibitors in PTDM prevention and management as well as in pre-existent T2DM, and providing a roadmap for evidence generation on newer antidiabetic drugs for solid organ transplantation.

Analysis of Risk Factors for Posttransplant Diabetes Mellitus After Kidney Transplantation: Single-Center Experience

OBJECTIVES

Posttransplant diabetes mellitus may severely affect the short-term and long-term outcomes of grafts and patient survival in kidney transplant recipients. The annual incidence rate of posttransplant diabetes mellitus ranges from 4% to 25%. In this study, our aim was to determine the possible risk factors in patients diagnosed with this disease.

MATERIALS AND METHODS

From November 1975 to May 2019, our transplant team performed 3012 kidney transplant procedures at different units within Baskent University Transplantation Centers. We retrospectively analyzed data of patients who were diagnosed with posttransplant diabetes mellitus between 2010 and 2019. The diagnosis was made according to the 2001 American Diabetes Association criteria (fasting plasma glucose level ≥ 126 mg/dL [7 mmol/L] in 2 measurements or random blood glucose level ≥ 200 mg/dL [11.1 mmol/L] within 12 months posttransplant).

RESULTS

For this study, 400 patients (292 male, 108 female) with end-stage renal disease and without diabetes met the initial inclusion criteria; 270 received hemodialysis, 26 received peritoneal dialysis, and 104 underwent preemptive kidney transplant. In this patient group, 62 patients (15.5%) developed post-transplant diabetes mellitus. When we compared patients who developed and did not develop posttransplant diabetes mellitus, cause of end-stage renal disease, dialysis type and duration, type of donor (living or deceased), and graft survival posttransplant were similar between groups. Baseline fasting plasma glucose level was significantly higher in patients who developed posttransplant diabetes mellitus (90 vs 85 mg/dL; P = .034). Patients who developed the disease were significantly older.

CONCLUSIONS

In our study, recipient age was the only risk factor for posttransplant diabetes mellitus. Older recipients should be examined more carefully for posttransplant diabetes mellitus, and less diabetogenic immunosuppressive drugs may be preferred.

Risk Factors Related to New-Onset Diabetes after Renal Transplantation in Patients of a High Complexity University Hospital in Colombia, 20 Years of Experience

INTRODUCTION

New-onset diabetes after transplantation (NODAT) is associated with immunosuppression. Its complications can negatively influence patients' quality of life, which is why it is important to study the associated risk factors and expand the possible therapies in this particular group of patients. Materials and methods. Case-control study nested in a retrospective cohort. It included patients who received kidney transplantation at the high complexity University Hospital Fundación Valle del Lili in Cali, Colombia, between 1995 and 2014. Two controls were assigned for each case, depending on the type of donor and the date of the surgery. Information was collected from clinical records and the institutional TRENAL registry. We carried out a descriptive analysis of the selected variables and identified the risk factors with conditional logistic regression.

RESULTS

122 cases were identified to which 224 controls were assigned. The median age was 44 years (IQR: 34-55), and 54% were men. Having >50 years of age at the time of transplantation (OR: 3.18, 95% CI: 1.6-6.3, p = 0.001), body mass index >30 kg/m² (OR: 3.6, 95% CI: 1.3-9.7, p = 0.010) and being afro-descendant (OR: 2.74, 95% CI: 1.1-6.5, p = 0.023) were identified as risk factors for the development of NODAT. Pretransplant fasting plasma glucose >100 mg/dl (OR: 2.9, 95% CI: 1.4-6.4, p = 0.005) and serum triglycerides >200 mg/dl (OR: 2.5, 95% CI: 1.4-4.4, p = 0.002) were also reported as independent risk factors.

CONCLUSION

We ratify some risk factors for the development of this important disease, which include certain modifiable characteristics. Interventions aimed at changes in lifestyle could be established in a timely manner before transplant surgery.

Impact of Cytomegalovirus Disease on New-Onset Type 2 Diabetes Mellitus: Population-Based Matched Case-Control Cohort Study

BACKGROUND

A latent cytomegalovirus (CMV) cause chronic inflammation through undesirable inflation of cell-mediated immune response. CMV immunoglobulin G has been associated with cardiovascular disease and type 1 diabetes mellitus. We evaluated impact of CMV diseases on new-onset type 2 diabetes mellitus (T2DM).

METHODS

From the Korean Health Insurance Review and Assessment Service claim database of entire population with 50 million, we retrieved 576 adult case group with CMV diseases diagnosed with International Statistical Classification of Diseases and Related-Health Problems 10th Revision (ICD-10) B25 code between 2010 and 2014 after exclusion of patients with T2DM to 2006. The 2,880 control patients without T2DM from 2006 to cohort entry point were selected between 2010 and 2014 by age, sex matching with case group. The subjects without new-onset T2DM were followed until 2015. T2DM, hypertension (HTN), dyslipidemia (DYS), and end-stage renal disease (ESRD) were coded as ICD-10.

RESULTS

The frequency of new-onset T2DM in case group was significantly higher than that in control (5.6% vs. 2.2%, P<0.001). The group with T2DM (n=95) had higher incidence of CMV diseases than the group without T2DM (n=3,361) (33.7% vs. 16.2%, P<0.001). In multivariate regression model adjusted by age, sex, lower income, HTN, and DYS, the incidence rate (IR) of T2DM in case group was significantly higher than that in the control group (IR per 1,000, 19.0 vs. 7.3; odds ratio, 2.1; 95% confidence interval, 1.3 to 3.2). The co-existence of HTN, DYS, and ESRD with CMV diseases did not influence the IR of T2DM.

CONCLUSION

CMV diseases increase the patients' risk of developing T2DM.

Evaluation of Angiotensinogen M235T and T174M Polymorphisms, Demographic and Clinical Factors in New-Onset Diabetes after Liver Transplantation in Iranian Patients

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a serious complication which runs the risk of infections, morbidity and mortality.

OBJECTIVE

To evaluate M235T and T174M polymorphisms of angiotensinogen gene along with some demographic and clinical factors including age; sex; body mass index (BMI); model for end-stage liver disease (MELD) score; prednisolone, mycophenolate mofetil and tacrolimus dose; and serum level in NODAT among liver recipients.

METHODS

In this study 115 patients (53 with and 62 without NODAT) who had no history of diabetes before the transplantation were investigated. Furthermore, 80 randomly selected apparently healthy people (no transplantation) were used as the control group. Two angiotensinogen polymorphisms (M235T and T174M) were studied using polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Patients included 68 (59.1%) females and 47 (40.9%) males; they had a mean±SD age of 37.4±16.9 years. The M allele frequency was 55.7% (n=128) in M235T and 20.0% (n=46) in T174M polymorphisms. Binary logistic regression analysis confirmed that age (p=0.005), prednisolone dose (p<0.001) and mutated M235T polymorphism (p=0.003) were independent risk factors.

CONCLUSION

Presence of M235T T allele may significantly (p<0.001) increase the NODAT risk, and increase the likelihood of developing end-stage liver disease (p=0.003). T174M T allele had a significantly (p=0.007) higher frequency in NODAT group.

Genetic and clinic predictors of new onset diabetes mellitus after transplantation

New Onset Diabetes after Transplantation (NODAT) is a frequent complication after solid organ transplantation, with higher incidence during the first year. Several clinical and genetic factors have been described as risk factors of Type 2 Diabetes (T2DM). Additionally, T2DM shares some genetic factors with NODAT. We investigated if three genetic risk scores (w-GRS) and clinical factors were associated with NODAT and how they predicted NODAT development 1 year after transplantation. In both main (n = 725) and replication (n = 156) samples the clinical risk score was significantly associated with NODAT (OR_main: 1.60 [1.36-1.90], p = 3.72*10^-8 and OR_replication: 2.14 [1.39-3.41], p = 0.0008, respectively). Two w-GRS were significantly associated with NODAT in the main sample (OR_{w-GRS 2}:1.09 [1.04-1.15], p = 0.001 and OR_{w-GRS 3}:1.14 [1.01-1.29], p = 0.03) and a similar OR_{w-GRS 2} was found in the replication sample, although it did not reach significance probably due to a power issue. Despite the low OR of w-GRS on NODAT compared to clinical covariates, when integrating w-GRS 2 and w-GRS 3 in the clinical model, the Area under the Receiver Operating Characteristics curve (AUROC), specificity, sensitivity and accuracy were 0.69, 0.71, 0.58 and 0.68, respectively, with significant Likelihood Ratio test discrimination index (p-value 0.0004), performing better in NODAT discrimination than the clinical model alone. Twenty-five patients needed to be genotyped in order to detect one misclassified case that would have developed NODAT 1 year after transplantation if using only clinical covariates. To our knowledge, this is the first study extensively examining genetic risk scores contributing to NODAT development.

Correlation between KCNQ1 and KCNJ11 gene polymorphisms and type 2 and post-transplant diabetes mellitus in the Asian Indian population

Type 2 diabetes mellitus (T2DM) and post-transplant diabetes mellitus (PTDM) share a common pathophysiology. However, diabetes mellitus is a complex disease, and T2DM and PTDM have different etiologies. T2DM is a metabolic disorder, characterized by persistent hyperglycemia, whereas PTDM is a condition of abnormal glucose tolerance, with variable onset after organ transplant. The KCNQ1 and KCNJ11 gene encode potassium channels, which mediate insulin secretion from pancreatic β-cells, and KCN gene mutations are correlated with the development of diabetes. However, no studies have been carried out to establish an association between KCNQ1 and KCNJ11 gene polymorphisms and T2DM and PTDM. Therefore, our study was aimed at the identification of the role of KCNQ1 and KCNJ11 gene polymorphisms associated with T2DM and the risk of developing PTDM in the Asian Indian population. We have carried out a case-control study including 250 patients with T2DM, 250 control subjects, 42 patients with PTDM and 98 subjects with non-PTDM. PCR-RFLP analysis was carried out following the isolation of genomic DNA from EDTA-blood samples. The results of the present study reveal that two single nucleotide polymorphisms (rs2283228 and rs5210, of the KCNQ1 and KCNJ11 genes, respectively) are associated with both T2DM and PTDM. The results of our study suggest a role of KCNQ1 and KCNJ11 gene variants in the increased risk of T2DM and PTDM in the Asian Indian population.

Post renal transplant type 2 diabetes mellitus in a case of familial juvenile nephrophthisis

Familial juvenile nephronophtisis, an autosomal recessive tubulointerstitial chronic nephritis, is characterized by progressive renal disease and end stage renal failure, which require kidney transplantation. Post-transplant diabetes mellitus (PTDM) incidence after kidney transplantation varies from 4-25%. Obesity, positive oral glucose tolerance test, metabolic syndromes, and post-transplantation multi-drug, high dose, long-term immunosuppressive therapy are the risk factors incriminated.We present the case of a 15-year-old overweight boy who was diagnosed with familial juvenile nephronophtisis five years before, afterwards progressive renal disease and end stage renal failure. This young patient developed PTDM three years after renal transplantation. His underweight brother, with the same medical history, did not develop PTDM.Transplantation was mandatory for a child with familial juvenile nephronophtisis.The case illustrates the risk factors for PTDM.

Variants of the adiponectin and adiponectin receptor-1 genes and posttransplantation diabetes mellitus in renal allograft recipients

CONTEXT

Posttransplantation diabetes mellitus (PTDM) is a major metabolic complication in renal transplant recipients. Adiponectin (ADIPOQ) and adiponectin receptor-1 (ADIPOR1) gene polymorphisms have been associated with type 2 diabetes. However, it is unknown whether these polymorphisms are also risk factors for PTDM.

OBJECTIVE

We investigated the association between PTDM and single-nucleotide polymorphisms of ADIPOQ and ADIPOR1 in a cohort of renal allograft recipients.

DESIGN, SETTING, AND PARTICIPANTS

Five hundred seventy-five patients (367 men and 208 women) who received kidney transplants between 1989 and 2007, without a history of diabetes and with a pretransplant fasting glucose concentration less than 5.5 mmol/liter. Patients were followed up for a median 10 yr. Genotypes included single-nucleotide polymorphisms of the following: ADIPOQ rs266729, rs822395, rs822396, rs2241766, and rs1501299 and ADIPOR1 rs2232853, rs12733285, and rs1342387.

RESULTS

TT-homozygotes in ADIPOQ rs1501299 [hazard ratio (HR) = 1.70, P = 0.032] had greater risk of PTDM after adjusting for age, sex, amount of weight gain, and type of immunosuppressant. There was a significant interaction between sex and ADIPOQ rs1501299 genotype (P = 0.037). In men, but not in women, TT-homozygotes in ADIPOQ rs1501299 were more likely to develop PTDM than the wild GG-homozygotes (HR = 2.50, P = 0.002), whereas GT-heterozygotes had nonsignificantly elevated risk (HR = 1.41, P = 0.128).

CONCLUSION

Genetic variation in ADIPOQ rs1501299 is associated with PTDM in a sex-specific manner.

Solid-organ transplantation in childhood: transitioning to adult health care

Pediatric solid-organ transplantation is an increasingly successful treatment for solid-organ failure. With dramatic improvements in patient survival rates over the last several decades, there has been a corresponding emergence of complications attributable to pretransplant factors, transplantation itself, and the management of transplantation with effective immunosuppression. The predominant solid-organ transplantation sequelae are medical and psychosocial. These sequelae have a substantial effect on transition to adult care; as such, hurdles to successful transition of care arise from the patients, their families, and pediatric and adult health care providers. Crucial to successful transitioning is the ongoing development of a sense of autonomy and responsibility for one's own care. In this article we address the barriers to transitioning that occur with long-term survival in pediatric solid-organ transplantation. Although a particular transitioning model is not promoted, practical tools and strategies that contribute to successful transitioning of pediatric patients who have received a transplant are suggested.

Outcomes in pediatric solid-organ transplantation

LaR Pediatric solid-organ transplantation is an increasingly successful treatment for organ failure. Five- and 10-yr patient survival rates have dramatically improved over the last couple of decades, and currently, over 80% of pediatric patients survive into adolescence and young adulthood. Waiting list mortality has been a concern for liver, heart, and intestinal transplantation, illustrating the importance of transplant as a life-saving therapy. Unfortunately, the success of pediatric transplantation comes at the cost of long-term or late complications that arise as a result of allograft rejection or injury, immunosuppression-related morbidity, or both. As transplant recipients enter adolescence treatment, non-adherence becomes a significant issue, and the medical and psychosocial impacts transition to adulthood not only with regard to healthcare but also in terms of functional outcomes, economic potential, and overall QoL. This review addresses the clinical and psychosocial challenges encountered by pediatric transplant recipients in the current era. A better understanding of pediatric transplant outcomes and adult morbidity and mortality requires further ongoing assessment.

Polymorphisms of superoxide dismutase, glutathione peroxidase and catalase genes in patients with post-transplant diabetes mellitus

BACKGROUND AND AIMS

Post-transplant diabetes mellitus (PTDM) is a metabolic disorder that develops in response to a relative insulin deficiency in patients after organ transplantation treated with immunosuppressive drugs. Several studies have suggested that oxidative stress may be associated with diabetes and its complications. The aim of this study was to examine the association of polymorphisms in superoxide dismutase, catalase and glutathione peroxidase genes with PTDM in patients after kidney transplantation.

METHODS

The study included 159 patients receiving kidney transplants. PTDM was diagnosed in 21 patients.

RESULTS

Analyzing the C599T (Pro200Leu) polymorphism in the GPX1 gene PTDM was diagnosed in 8.45% of patients with CC genotype, 13.43% with CT and in 28.57% with TT. Allele T was significantly more frequent among patients with PTDM compared to patients without PTDM (OR = 2.14, 95% CI = 1.11-4.12, p = 0.024). There were no associations between SOD1, SOD2 and CAT polymorphisms and PTDM.

CONCLUSIONS

The present results suggest that Pro200Leu polymorphism of the GPX1 gene may be associated with the risk of PTDM development in renal graft recipients.

Nonimmune complications after transplantation

As posttransplant longevity has increased, nonimmune complications related to the transplant and posttransplant course have emerged as important factors in defining long-term outcomes. The incidence of, and risk factors for these complications may vary by transplanted organ based on immunosuppressive protocols and preexisting risk factors. This article discusses the relevant nonimmune complications associated with posttransplant care, with a focus on risk factors and management strategies.

[Medical complications of lung transplantation]

In 2010, lung transplantation is a valuable therapeutic option for a number of patients suffering from of end-stage non-neoplastic pulmonary diseases. The patients frequently regain a very good quality of life, however, long-term survival is often hampered by the development of complications such as the bronchiolitis obliterans syndrome, metabolic and infectious complications. As the bronchiolitis obliterans syndrome is the first cause of death in the medium and long term, an intense immunosuppressive treatment is maintained for life in order to prevent or stabilize this complication. The immunosuppression on the other hand induces a number of potentially severe complications including metabolic complications, infections and malignancies. The most frequent metabolic complications are arterial hypertension, chronic renal insufficiency, diabetes, hyperlipidemia and osteoporosis. Bacterial, viral and fungal infections are the second cause of mortality. They are to be considered as medical emergencies and require urgent assessment and targeted therapy after microbiologic specimens have been obtained. They should not, under any circumstances, be treated empirically and it has also to be kept in mind that the lung transplant recipient may present several concomitant infections. The most frequent malignancies are skin cancers, the post-transplant lymphoproliferative disorders, Kaposi's sarcoma and some types of bronchogenic carcinomas, head/neck and digestive cancers. Lung transplantation is no longer an exceptional procedure; thus, the pulmonologist will be confronted with such patients and should be able to recognize the symptoms and signs of the principal non-surgical complications. The goal of this review is to give a general overview of the most frequently encountered complications. Their assessment and treatment, though, will most often require the input of other specialists and a multidisciplinary and transversal approach.