1
|
Heurtebize MA, Faillie JL. Drug-induced hyperglycemia and diabetes. Therapie 2024; 79:221-238. [PMID: 37985310 DOI: 10.1016/j.therap.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/14/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Drug-induced hyperglycemia and diabetes have negative and potentially serious health consequences but can often be unnoticed. METHODS We reviewed the literature searching Medline database for articles addressing drug-induced hyperglycemia and diabetes up to January 31, 2023. We also selected drugs that could induce hyperglycemia or diabetes according official data from drug information databases Thériaque and Micromedex. For each selected drug or pharmacotherapeutic class, the mechanisms of action potentially involved were investigated. For drugs considered to be at risk of hyperglycemia or diabetes, disproportionality analyses were performed using data from the international pharmacovigilance database VigiBase. In order to detect new pharmacovigilance signals, additional disproportionality analyses were carried out for drug classes with more than 100 cases reported in VigiBase, but not found in the literature or official documents. RESULTS The main drug classes found to cause hyperglycemia are glucocorticoids, HMG-coA reductase inhibitors, thiazide diuretics, beta-blockers, antipsychotics, fluoroquinolones, antiretrovirals, antineoplastic agents and immunosuppressants. The main mechanisms involved are alterations in insulin secretion and sensitivity, direct cytotoxic effects on pancreatic cells and increases in glucose production. Pharmacovigilance signal were found for a majority of drugs or pharmacological classes identified as being at risk of diabetes or hyperglycemia. We identified new pharmacovigilance signals with drugs not known to be at risk according to the literature or official data: phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, sodium oxybate, biphosphonates including alendronic acid, digoxin, sartans, linosipril, diltiazem, verapamil, and darbepoetin alpha. Further studies will be needed to confirm these signals. CONCLUSIONS The risks of induced hyperglycemia vary from one drug to another, and the underlying mechanisms are multiple and potentially complex. Clinicians need to be vigilant when using at-risk drugs in order to detect and manage these adverse drug reactions. However, it is to emphasize that the benefits of appropriately prescribed treatments most often outweigh their metabolic risks.
Collapse
Affiliation(s)
- Marie-Anne Heurtebize
- CHU de Montpellier, Medical Pharmacology and Toxicology Department, 34000 Montpellier, France
| | - Jean-Luc Faillie
- CHU de Montpellier, Medical Pharmacology and Toxicology Department, 34000 Montpellier, France; IDESP, Université de Montpellier, Inserm, 34295 Montpellier, France.
| |
Collapse
|
2
|
Gupta SK, Mostofsky E, Motiwala SR, Hage A, Mittleman MA. Induction immunosuppression and post-transplant diabetes mellitus: a propensity-matched cohort study. Front Endocrinol (Lausanne) 2023; 14:1248940. [PMID: 37929038 PMCID: PMC10623448 DOI: 10.3389/fendo.2023.1248940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Post-transplant diabetes mellitus (PTDM) is a common complication among cardiac transplant recipients, causing diabetes-related complications and death. While certain maintenance immunosuppressive drugs increase PTDM risk, it is unclear whether induction immunosuppression can do the same. Therefore, we evaluated whether induction immunosuppression with IL-2 receptor antagonists, polyclonal anti-lymphocyte antibodies, or Alemtuzumab given in the peri-transplant period is associated with PTDM. Methods We used the Scientific Registry of Transplant Recipients database to conduct a cohort study of US adults who received cardiac transplants between January 2008-December 2018. We excluded patients with prior or multiple organ transplants and those with a history of diabetes, resulting in 17,142 recipients. We created propensity-matched cohorts (n=7,412) using predictors of induction immunosuppression and examined the association between post-transplant diabetes and induction immunosuppression by estimating hazard ratios using Cox proportional-hazards models. Results In the propensity-matched cohort, the average age was 52.5 (SD=13.2) years, 28.7% were female and 3,706 received induction immunosuppression. There were 867 incident cases of PTDM during 26,710 person-years of follow-up (32.5 cases/1,000 person-years). There was no association between induction immunosuppression and post-transplant diabetes (Hazard Ratio= 1.04, 95% confidence interval 0.91 - 1.19). Similarly, no associations were observed for each class of induction immunosuppression agents and post-transplant diabetes. Conclusion The use of contemporary induction immunosuppression in cardiac transplant patients was not associated with post-transplant diabetes.
Collapse
Affiliation(s)
- Suruchi K. Gupta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Shweta R. Motiwala
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Ali Hage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| |
Collapse
|
3
|
Bang JB, Oh CK, Kim YS, Kim SH, Yu HC, Kim CD, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Ahn HJ, Lee SH, Jeon JY. Changes in glucose metabolism among recipients with diabetes 1 year after kidney transplant: a multicenter 1-year prospective study. Front Endocrinol (Lausanne) 2023; 14:1197475. [PMID: 37424863 PMCID: PMC10325682 DOI: 10.3389/fendo.2023.1197475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background Diabetes mellitus is a common and crucial metabolic complication in kidney transplantation. It is necessary to analyze the course of glucose metabolism in patients who already have diabetes after receiving a transplant. In this study, we investigated the changes in glucose metabolism after transplantation, and a detailed analysis was performed on some patients whose glycemic status improved. Methods The multicenter prospective cohort study was conducted between 1 April 2016 and 31 September 2018. Adult patients (aged 20 to 65 years) who received kidney allografts from living or deceased donors were included. Seventy-four subjects with pre-transplant diabetes were followed up for 1 year after kidney transplantation. Diabetes remission was defined as the results of the oral glucose tolerance test performed one year after transplantation and the presence or absence of diabetes medications. After 1-year post-transplant, 74 recipients were divided into the persistent diabetes group (n = 58) and the remission group (n = 16). Multivariable logistic regression was performed to identify clinical factors associated with diabetes remission. Results Of 74 recipients, 16 (21.6%) showed diabetes remission after 1-year post-transplant. The homeostatic model assessment for insulin resistance numerically increased in both groups throughout the first year after transplantation and significantly increased in the persistent diabetes group. The insulinogenic index (IGI30) value significantly increased only in the remission group, and the IGI30 value remained low in the persistent diabetes group. In univariate analysis, younger age, newly diagnosed diabetes before transplantation, low baseline hemoglobin A1c, and high baseline IGI30 were significantly associated with remission of diabetes. After multivariate analysis, only newly diagnosed diabetes before transplantation and IGI30 at baseline were associated with remission of diabetes (34.00 [1.192-969.84], P = 0.039, and 17.625 [1.412-220.001], P = 0.026, respectively). Conclusion In conclusion, some kidney recipients with pre-transplant diabetes have diabetes remission 1 year after transplantation. Our prospective study revealed that preserved insulin secretory function and newly diagnosed diabetes at the time of kidney transplantation were favorable factors for which glucose metabolism did not worsen or improve 1 year after kidney transplantation.
Collapse
Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery and Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University College of Medicine, Jeonju, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jun So
- Department of Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sang Ho Lee
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Republic of Korea
| | - Hyung Joon Ahn
- Department of Surgery, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Republic of Korea
| |
Collapse
|
4
|
Jehn U, Wiedmer N, Boeckel GR, Pavenstädt H, Thölking G, Reuter S. Fast Tacrolimus Metabolism Does Not Promote Post-Transplant Diabetes Mellitus after Kidney Transplantation. Int J Mol Sci 2022; 23:ijms23169131. [PMID: 36012395 PMCID: PMC9408810 DOI: 10.3390/ijms23169131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Post-transplant diabetes mellitus (PTDM) after kidney transplantation induced by tacrolimus is an important issue. Fast tacrolimus metabolism, which can be estimated by concentration-to-dose (C/D) ratio, is associated with increased nephrotoxicity and unfavorable outcomes after kidney transplantation. Herein, we elucidate whether fast tacrolimus metabolism also increases the risk for PTDM. Data from 596 non-diabetic patients treated with tacrolimus-based immunosuppression at the time of kidney transplantation between 2007 and 2015 were retrospectively analyzed. The median follow-up time after kidney transplantation was 4.7 years (IQR 4.2 years). Our analysis was complemented by experimental modeling of fast and slow tacrolimus metabolism kinetics in cultured insulin-producing pancreatic cells (INS-1 cells). During the follow-up period, 117 (19.6%) patients developed PTDM. Of all patients, 210 (35.2%) were classified as fast metabolizers (C/D ratio < 1.05 ng/mL × 1/mg). Fast tacrolimus metabolizers did not have a higher incidence of PTDM than slow tacrolimus metabolizers (p = 0.496). Consistent with this, insulin secretion and the viability of tacrolimus-treated INS-1 cells exposed to 12 h of tacrolimus concentrations analogous to the serum profiles of fast or slow tacrolimus metabolizers or to continuous exposure did not differ (p = 0.286). In conclusion, fast tacrolimus metabolism is not associated with increased incidence of PTDM after kidney transplantation, either in vitro or in vivo. A short period of incubation of INS-1 cells with tacrolimus using different concentration profiles led to comparable effects on cell viability and insulin secretion in vitro. Consistent with this, in our patient, collective fast Tac metabolizers did not show a higher PTDM incidence compared to slow metabolizers.
Collapse
Affiliation(s)
- Ulrich Jehn
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
- Correspondence: ; Tel.: +49-251-83-47540; Fax: +49-251-83-56973
| | - Nathalie Wiedmer
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
| | - Göran Ramin Boeckel
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
| | - Gerold Thölking
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565 Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany
| |
Collapse
|
5
|
Al-Imam A, Abdulrahman Al-Tabbakh A. Predictors of New-onset Diabetes After Kidney Transplantation During 2019-nCoV Pandemic: A Unison of Frequentist Inference and Narrow AI. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: New-onset diabetes after kidney transplant (NODAT) is a severe metabolic complication that frequently occurs in recipients following transplantation.
AIM: The study aims to verify NODAT, compare cases and non-cases of this entity, and explore potential predictors in recipients within 1 year following kidney transplantation.
METHODS: The research is a retrospective study of 90 renal transplant recipients (n = 90). Demographic factors and clinical aspects were analyzed using non-Bayesian statistics and machine learning (ML). The clinical aspects included the glycated hemoglobin (HbA1c) level, associated viral infections (hepatitis B virus [HBV], hepatitis C virus [HCV], and cytomegalovirus [CMV]), prior kidney transplant, hemodialysis status, body mass index (BMI) at transplant time, and 3 months later, primary causes of renal failure, and post-transplant therapeutics. All individuals were on cyclosporine and prednisolone treatment.
RESULTS: The mean age was 39 (±1.5) years; recipients included 27 females (30%) and 63 males (70%). Donor type was live related (16, 17.8%) or live unrelated (74, 82.2%); 27 recipients (30%) had O+ blood group, while 70% belonged to other groups. Thirteen recipients (14.4%) were not on dialysis. Only 32 individuals (35.6%) developed NODAT. Concerning virology, confirmed by real-time polymerase chain reaction before transplantation, 19 recipients (21.1%) were CMV positive, 9 (10%) were HCV positive, and 2 (2.2%) had HBV.
CONCLUSIONS: In reconciliation with frequentist statistics, the dual ML model validated several predictors that either negatively (protective) or positively (harmful) influenced HbA1c level, the majority of which were significant at 95% confidence interval. Individuals who are HCV and CMV positive are predicted to develop NODAT. Further, older individuals, with blood group O+ve, prior history of hemodialysis, a relatively high BMI before the transplant, and receiving higher doses of prednisolone following the transplant are more likely to develop NODAT. The current study represents the first research from Iraq to explore NODAT predictors among kidney transplant recipients using frequentist statistics and artificial intelligence models.
Collapse
|
6
|
Axelrod DA, Cheungpasitporn W, Bunnapradist S, Schnitzler MA, Xiao H, McAdams-DeMarco M, Caliskan Y, Bae S, Ahn JB, Segev DL, Lam NN, Hess GP, Lentine KL. Posttransplant Diabetes Mellitus and Immunosuppression Selection in Older and Obese Kidney Recipients. Kidney Med 2022; 4:100377. [PMID: 35072042 PMCID: PMC8767140 DOI: 10.1016/j.xkme.2021.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Rationale & Objective Posttransplant diabetes mellitus (DM) after kidney transplantation increases morbidity and mortality, particularly in older and obese recipients. We aimed to examine the impact of immunosuppression selection on the risk of posttransplant DM among both older and obese kidney transplant recipients. Study Design Retrospective database study. Setting & Participants Kidney-only transplant recipients aged ≥18 years from 2005 to 2016 in the United States from US Renal Data System records, which integrate Organ Procurement and Transplantation Network/United Network for Organ Sharing records with Medicare billing claims. Exposures Various immunosuppression regimens in the first 3 months after transplant. Outcomes Development of DM >3 months-to-1 year posttransplant. Analytical Approach We used multivariable Cox regression to compare the incidence of posttransplant DM by immunosuppression regimen with the reference regimen of thymoglobulin (TMG) or alemtuzumab (ALEM) with tacrolimus + mycophenolic acid + prednisone using inverse propensity weighting. Results 12.7% of kidney transplant recipients developed posttransplant DM with higher incidences in older (≥55 years vs <55 years: 16.7% vs 10.1%) and obese (body mass index [BMI] ≥ 30 kg/m2 vs BMI < 30 kg/m2: 17.1% vs 10.9%) patients. The incidence of posttransplant DM was lower with steroid avoidance [TMG/ALEM + no prednisone (8.4%) and IL2rAb + no prednisone (9.7%)] than TMG/ALEM with triple therapy (13.1%). After adjustment for donor and recipient characteristics, TMG/ALEM with steroid avoidance was beneficial for all groups [age < 55 years: adjusted HR (aHR), 0.63 (95% confidence interval [CI], 0.54-0.72); age ≥ 55 years: aHR, 0.69 (95% CI, 0.60-0.79); BMI < 30 kg/m2: aHR, 0.69 (95% CI, 0.60-0.78); BMI ≥ 30 kg/m2: aHR, 0.67 (95% CI, 0.57-0.79)]. However, IL2rAb with steroid avoidance was beneficial only for older patients (aHR, 0.76; 95% CI, 0.58-0.99) and for those with BMI < 30 kg/m2 (aHR, 0.63; 95% CI, 0.46-0.87). Limitations Retrospective study and lacked data on immunosuppression levels. Conclusions The beneficial impact of steroid avoidance using tacrolimus on posttransplant DM appears to differ by patient age and induction regimen.
Collapse
Affiliation(s)
| | | | | | - Mark A. Schnitzler
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Huiling Xiao
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, Saint Louis, Missouri
| | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | - Krista L. Lentine
- University of Iowa, Iowa City, Iowa
- Address for Correspondence: Krista L. Lentine, MD, PhD, Saint Louis University Center for Abdominal Transplantation, 1402 S. Grand Blvd., St. Louis, MO, 63104.
| |
Collapse
|
7
|
Martinez Cantarin MP. Diabetes in Kidney Transplantation. Adv Chronic Kidney Dis 2021; 28:596-605. [PMID: 35367028 DOI: 10.1053/j.ackd.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
Diabetes mellitus (DM) is one of the most common complications after kidney transplantation and is associated with unfavorable outcomes including death. DM can be present before transplant but post-transplant DM (PTDM) refers to diabetes that is diagnosed after solid organ transplantation. Despite its high prevalence, optimal treatment to prevent complications of PTDM is unknown. Medical therapy of pre-existent DM or PTDM after transplant is challenging because of frequent interactions between antidiabetic and immunosuppressive agents. There is also frequent need for medication dose adjustments due to residual kidney disease and a higher risk of medication side effects in patients treated with immunosuppressive agents. Sodium-glucose cotransporter 2 inhibitors have demonstrated a favorable cardio-renal profile in patients with DM without a transplant and hence hold great promise in this patient population although there is concern about the higher risk of urinary tract infections. The significant gaps in our understanding of the pathophysiology, diagnosis, and management of DM after kidney transplantation need to be urgently addressed.
Collapse
|
8
|
Thölking G, Schulte C, Jehn U, Schütte-Nütgen K, Pavenstädt H, Suwelack B, Reuter S. The Tacrolimus Metabolism Rate and Dyslipidemia after Kidney Transplantation. J Clin Med 2021; 10:jcm10143066. [PMID: 34300232 PMCID: PMC8306747 DOI: 10.3390/jcm10143066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 12/27/2022] Open
Abstract
Fast tacrolimus (Tac) metabolism is associated with reduced survival rates after renal transplantation (RTx), mainly due to cardiovascular events. Because dyslipidemia is a leading cause of cardiovascular death, we hypothesized that most RTx patients do not achieve recommended target low-density lipoprotein cholesterol (LDL-C) levels (European cardiology society guidelines) and that fast Tac metabolizers have higher dyslipidemia rates. This study included RTx recipients who received initial immunosuppression with immediate-release tacrolimus (IR-Tac), mycophenolate, and prednisolone. Patients were grouped according to their Tac concentration-to-dose ratio (C/D ratio) 3 months after RTx. Dyslipidemia parameters were analyzed at RTx, 3 months, and 12 months after RTx. Statin use and renal function were documented in a 12-month follow-up, and death was documented in a 60-month follow-up. Ninety-six RTx recipients were divided into two groups: 31 fast Tac metabolizers (C/D ratio < 1.05 ng/mL·1/mg) and 65 slow metabolizers (C/D ratio ≥ 1.05 ng/mL·1/mg). There were no differences in triglyceride or cholesterol levels between groups at RTx, 3, and 12 months after RTx. A total of 93.5% of fast and 95.4% of slow metabolizers did not achieve target LDL-C levels (p = 0.657). Fast metabolizers developed lower renal function compared to slow metabolizers 12 months after RTx (p = 0.009). Fast metabolizers showed a 60 month survival rate of 96.8% compared to 94.7% in the slow metabolizer group (p = 0.811). As most RTx recipients do not reach recommended target LDL-C levels, individualized nutritional counseling and lipid-lowering therapy must be intensified. Fast Tac metabolism is associated with lower renal function after RTx, but does not play a significant role in dyslipidemia.
Collapse
Affiliation(s)
- Gerold Thölking
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565 Steinfurt, Germany;
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
- Correspondence: ; Tel.: +49-2552-791226; Fax: +49-2552-791181
| | - Christian Schulte
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, 48565 Steinfurt, Germany;
| | - Ulrich Jehn
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
| | - Katharina Schütte-Nütgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, 48149 Münster, Germany; (U.J.); (K.S.-N.); (H.P.); (B.S.); (S.R.)
| |
Collapse
|
9
|
Rysz J, Franczyk B, Radek M, Ciałkowska-Rysz A, Gluba-Brzózka A. Diabetes and Cardiovascular Risk in Renal Transplant Patients. Int J Mol Sci 2021; 22:3422. [PMID: 33810367 PMCID: PMC8036743 DOI: 10.3390/ijms22073422] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Maciej Radek
- Department of Neurosurgery, Surgery of Spine and Peripheral Nerves, Medical University of Lodz, 90-549 Lodz, Poland;
| | | | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| |
Collapse
|
10
|
Arafa N, Bazaraa HM, Sharaf ElDin H, Hussein M, Salah DM. Glucose tolerance in a cohort of Egyptian children after kidney transplantation. Diabetes Res Clin Pract 2021; 172:108605. [PMID: 33333203 DOI: 10.1016/j.diabres.2020.108605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/13/2020] [Accepted: 12/01/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Post- transplantation diabetes mellitus (PTDM) in children is a serious metabolic complication that can endanger both graft and patient survival. These complications can be partially reduced by early diagnosis & prompt treatment of impaired glucose tolerance. The aim of this study was to assess glucose tolerance & insulin resistance among a cohort of kidney transplanted children. METHODS Thirty consecutive pediatric kidney transplant recipients were subjected to basal evaluation of plasma glucose and insulin then underwent oral glucose tolerance test (OGTT). RESULTS Abnormal glucose metabolism was detected in 7 (23.3%) patients; 3 (10%) patients with PTDM; 3 (10%) patients with impaired fasting glucose (IFG) and 1 (3.3%) patient with IFG and impaired glucose tolerance (IGT). Four (13.3%) patients had high Homeostatic model assessment of insulin resistance (HOMA-IR). Patients with abnormal glucose metabolism had significantly higher tacrolimus trough levels and higher maintainence steroid doses (p values = 0.003,0.026). Significant positive correlation existed between pre-transplantation glucose level and post-transplantation fasting glucose (p = 0.001, r = 0.69), glucose at 120 min (p = 0.018, r = 0.429) and HOMA-IR (p = 0.008, r = 0.47). CONCLUSION Abnormalities in glucose metabolism (IFG, IGT &PTDM) are frequent in Egyptian pediatric kidney transplant recipients. OGTT is the gold standard for assessment of abnormalities in glucose metabolism.
Collapse
Affiliation(s)
- Noha Arafa
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Hafez M Bazaraa
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Heba Sharaf ElDin
- Department of Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | - Doaa M Salah
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
| |
Collapse
|
11
|
Bang JB, Oh CK, Kim YS, Kim SH, Yu HC, Kim CD, Ju MK, So BJ, Lee SH, Han SY, Jung CW, Kim JK, Lee SH, Jeon JY. Insulin Secretion and Insulin Resistance Trajectories over 1 Year after Kidney Transplantation: A Multicenter Prospective Cohort Study. Endocrinol Metab (Seoul) 2020; 35:820-829. [PMID: 33202516 PMCID: PMC7803593 DOI: 10.3803/enm.2020.743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/22/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND We investigated the changing patterns of insulin secretion and resistance and risk factors contributing to the development of post-transplant diabetes mellitus (PTDM) in kidney recipients under tacrolimus-based immunosuppression regimen during 1 year after transplantation. METHODS This was a multicenter prospective cohort study. Of the 168 subjects enrolled in this study, we analyzed a total 87 kidney transplant recipients without diabetes which was assessed by oral glucose tolerance test before transplantation. We evaluated the incidence of PTDM and followed up the index of insulin secretion (insulinogenic index [IGI]) and resistance (homeostatic model assessment for insulin resistance [HOMA-IR]) at 3, 6, 9 months, and 1 year after transplantation by oral glucose tolerance test and diabetes treatment. We also assessed the risk factors for incident PTDM. RESULTS PTDM developed in 23 of 87 subjects (26.4%) during 1 year after transplantation. More than half of total PTDM (56.5%) occurred in the first 3 months after transplantation. During 1 year after transplantation, insulin resistance (HOMA-IR) was increased in both PTDM and no PTDM group. In no PTDM group, the increase in insulin secretory function to overcome insulin resistance was also observed. However, PTDM group showed no increase in insulin secretion function (IGI). Old age, status of prediabetes and episode of acute rejection were significantly associated with the development of PTDM. CONCLUSION In tacrolimus-based immunosuppressive drugs regimen, impaired insulin secretory function for reduced insulin sensitivity contributed to the development of PTDM than insulin resistance during 1 year after transplantation.
Collapse
Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery and Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, Seoul, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Seoul, Korea
| | - Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Jun So
- Department of Surgery, Wonkwang University Hospital, Iksan, Seoul, Korea
| | - Sang Ho Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Seoul, Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Joong Kyung Kim
- Department of Internal Medicine, Bong Seng Memorial Hospital, Busan, Korea
| | - Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Seoul, Korea
- Su Hyung Lee, Department of Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea, Tel: +82-31-219-5760, Fax: +82-31-219-4438, E-mail:
| | - Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, Korea
- Corresponding authors: Ja Young Jeon, Department of Endocrinology and Metabolism, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea, Tel: +82-31-219-7459, Fax: +82-31-219-4497, E-mail:
| |
Collapse
|
12
|
Cohen E, Korah M, Callender G, Belfort de Aguiar R, Haakinson D. Metabolic Disorders with Kidney Transplant. Clin J Am Soc Nephrol 2020; 15:732-742. [PMID: 32284323 PMCID: PMC7269213 DOI: 10.2215/cjn.09310819] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Metabolic disorders are highly prevalent in kidney transplant candidates and recipients and can adversely affect post-transplant graft outcomes. Management of diabetes, hyperparathyroidism, and obesity presents distinct opportunities to optimize patients both before and after transplant as well as the ability to track objective data over time to assess a patient's ability to partner effectively with the health care team and adhere to complex treatment regimens. Optimization of these particular disorders can most dramatically decrease the risk of surgical and cardiovascular complications post-transplant. Approximately 60% of nondiabetic patients experience hyperglycemia in the immediate post-transplant phase. Multiple risk factors have been identified related to development of new onset diabetes after transplant, and it is estimated that upward of 7%-30% of patients will develop new onset diabetes within the first year post-transplant. There are a number of medications studied in the kidney transplant population for diabetes management, and recent data and the risks and benefits of each regimen should be optimized. Secondary hyperparathyroidism occurs in most patients with CKD and can persist after kidney transplant in up to 66% of patients, despite an initial decrease in parathyroid hormone levels. Parathyroidectomy and medical management are the options for treatment of secondary hyperparathyroidism, but there is no randomized, controlled trial providing clear recommendations for optimal management, and patient-specific factors should be considered. Obesity is the most common metabolic disorder affecting the transplant population in both the pre- and post-transplant phases of care. Not only does obesity have associations and interactions with comorbid illnesses, such as diabetes, dyslipidemia, and cardiovascular disease, all of which increase morbidity and mortality post-transplant, but it also is intimately inter-related with access to transplantation for patients with kidney failure. We review these metabolic disorders and their management, including data in patients with kidney transplants.
Collapse
Affiliation(s)
- Elizabeth Cohen
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut
| | - Maria Korah
- Yale University School of Medicine, New Haven, Connecticut
| | - Glenda Callender
- Department of Surgery, Section of Endocrine Surgery, Yale University, New Haven, Connecticut
| | | | - Danielle Haakinson
- Department of Surgery, Section of Transplant, Yale University, New Haven, Connecticut
| |
Collapse
|
13
|
Takahashi T, Okamoto T, Sato Y, Hayashi A, Ueda Y, Ariga T. Glucose metabolism disorders in children with refractory nephrotic syndrome. Pediatr Nephrol 2020; 35:649-657. [PMID: 31950245 DOI: 10.1007/s00467-019-04360-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/13/2019] [Accepted: 09/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with refractory nephrotic syndrome (NS) are at high risk of medication-induced glucose metabolism disorders, because of their long-term use of diabetogenic medications, particularly glucocorticoids and calcineurin inhibitors (CNIs). However, there have been no comprehensive evaluations of glucose metabolism disorders in pediatric patients with refractory NS. Moreover, glucocorticoids and CNIs could not be discontinued in these patients until the effectiveness of rituximab on refractory NS was shown, and therefore, there has been limited opportunity to evaluate glucose metabolism disorders after discontinuation of these medications. METHODS Consecutive pediatric patients who started rituximab treatment for refractory NS were enrolled. Their glucose metabolism conditions were evaluated using the oral glucose tolerance tests (OGTT) and HbA1c levels at the initiation of rituximab treatment. Patients with glucose metabolism disorders at the first evaluation were reevaluated after approximately 2 years. RESULTS Overall, 57% (20/35) of study patients had glucose metabolism disorders, and 40% (8/20) of these patients were detected only by their 2-h OGTT blood glucose levels and not by their fasting blood glucose or HbA1c levels. Non-obese/non-overweight patients had significantly more glucose metabolism disorders than obese/overweight patients (p = 0.019). In addition, glucose metabolism disorders in 71% (10/14) of patients persisted after the discontinuation of glucocorticoids and CNIs. CONCLUSIONS Whether the patient is obese/overweight or not, patients with refractory NS are at high risk of developing glucose metabolism disorders, even in childhood. Non-obese/non-overweight patients who are at high risk of diabetes need extra vigilance.
Collapse
Affiliation(s)
- Toshiyuki Takahashi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takayuki Okamoto
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan. .,Department of Pediatrics, Hokkaido University Hospital, North 15, West 7, Sapporo, Japan.
| | - Yasuyuki Sato
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Asako Hayashi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yasuhiro Ueda
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tadashi Ariga
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
14
|
de Lucena DD, de Sá JR, Medina-Pestana JO, Rangel ÉB. Modifiable Variables Are Major Risk Factors for Posttransplant Diabetes Mellitus in a Time-Dependent Manner in Kidney Transplant: An Observational Cohort Study. J Diabetes Res 2020; 2020:1938703. [PMID: 32258163 PMCID: PMC7109550 DOI: 10.1155/2020/1938703] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/04/2020] [Indexed: 02/07/2023] Open
Abstract
Modifiable and nonmodifiable risk factors for developing posttransplant diabetes mellitus (PTDM) have already been established in kidney transplant setting and impact adversely both patient and allograft survival. We analysed 450 recipients of living and deceased donor kidney transplants using current immunosuppressive regimen in the modern era and verified PTDM prevalence and risk factors over three-year posttransplant. Tacrolimus (85%), prednisone (100%), and mycophenolate (53%) were the main immunosuppressive regimen. Sixty-one recipients (13.5%) developed PTDM and remained in this condition throughout the study, whereas 74 (16.5%) recipients developed altered fasting glucose over time. Univariate analyses demonstrated that recipient age (46.2 ± 1.3vs. 40.7 ± 0.6 years old, OR 1.04; P = 0.001) and pretransplant hyperglycaemia and BMI ≥ 25 kg/m2 (32.8% vs. 21.6%, OR 0.54; P = 0.032 and 57.4% vs. 27.7%, OR 3.5; P < 0.0001, respectively) were the pretransplant variables associated with PTDM. Posttransplant transient hyperglycaemia (86.8%. 18.5%, OR 0.03; P = 0.0001), acute rejection (P = 0.021), calcium channel blockers (P = 0.014), TG/HDL (triglyceride/high-density lipoprotein cholesterol) ratio ≥ 3.5 at 1 year (P = 0.01) and at 3 years (P = 0.0001), and tacrolimus trough levels at months 1, 3, and 6 were equally predictors of PTDM. In multivariate analyses, pretransplant hyperglycaemia (P = 0.035), pretransplant BMI ≥ 25 kg/m2 (P = 0.0001), posttransplant transient hyperglycaemia (P = 0.0001), and TG/HDL ratio ≥ 3.5 at 3-year posttransplant (P = 0.003) were associated with PTDM diagnosis and maintenance over time. Early identification of risk factors associated with increased insulin resistance and decreased insulin secretion, such as pretransplant hyperglycaemia and overweight, posttransplant transient hyperglycaemia, tacrolimus trough levels, and TG/HDL ratio may be useful for risk stratification of patients to determine appropriate strategies to reduce PTDM.
Collapse
Affiliation(s)
- Débora Dias de Lucena
- Nephrology Division, Universidade Federal de São Paulo/Hospital do Rim, São Paulo, SP, Brazil
| | - João Roberto de Sá
- Endocrinology Division, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - José O. Medina-Pestana
- Nephrology Division, Universidade Federal de São Paulo/Hospital do Rim, São Paulo, SP, Brazil
| | - Érika Bevilaqua Rangel
- Nephrology Division, Universidade Federal de São Paulo/Hospital do Rim, São Paulo, SP, Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| |
Collapse
|
15
|
Lecronier M, Tashk P, Tamzali Y, Tenaillon O, Denamur E, Barrou B, Aron-Wisnewsky J, Tourret J. Gut microbiota composition alterations are associated with the onset of diabetes in kidney transplant recipients. PLoS One 2020; 15:e0227373. [PMID: 31910227 PMCID: PMC6946168 DOI: 10.1371/journal.pone.0227373] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022] Open
Abstract
Background The gut dysbiosis associated with diabetes acquired before or after kidney transplantation (KT) has not been explored.
Collapse
Affiliation(s)
- Marie Lecronier
- INSERM, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Parvine Tashk
- INSERM, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Yanis Tamzali
- AP-HP, Département d’Urologie, Néphrologie et Transplantation, GH Pitié-Salpêtrière Charles Foix, Paris, France
| | - Olivier Tenaillon
- INSERM, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Erick Denamur
- INSERM, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- AP-HP, Laboratoire de Génétique Moléculaire, Hôpital Bichat, Paris, France
| | - Benoit Barrou
- AP-HP, Département d’Urologie, Néphrologie et Transplantation, GH Pitié-Salpêtrière Charles Foix, Paris, France
- Sorbonne Université, Paris, France
| | - Judith Aron-Wisnewsky
- Sorbonne Université, Paris, France
- AP-HP, Institute of Cardiometabolism and Nutrition, ICAN, Service de nutrition, GH Pitié-Salpêtrière Charles Foix, Paris, France
- INSERM, UMR_S U1166, équipe NutriOmics, Paris, France
| | - Jérôme Tourret
- INSERM, IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- AP-HP, Département d’Urologie, Néphrologie et Transplantation, GH Pitié-Salpêtrière Charles Foix, Paris, France
- Sorbonne Université, Paris, France
- * E-mail:
| |
Collapse
|
16
|
mTOR Inhibitor in Combination with Cyclosporine as Primary Maintenance Immunosuppression in Combined Kidney/Pancreas Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
17
|
Abstract
Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10-20% of patients with kidney transplants and in 20-40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.
Collapse
Affiliation(s)
- Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
18
|
Randomized, Open-Label, Phase IV, Korean Study of Kidney Transplant Patients Converting From Cyclosporine to Prolonged-Release Tacrolimus Plus Standard- or Reduced-Dose Corticosteroids. Transplant Proc 2019; 51:749-760. [PMID: 30979460 DOI: 10.1016/j.transproceed.2019.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND This 24-week, multicenter, randomized, exploratory, comparative, open-label, phase-IV study assessed the safety and efficacy of prolonged-release tacrolimus (PR-T) with reduced-dose versus standard-dose corticosteroids in stable kidney transplant recipients in Korea after converting from cyclosporine-based therapy. METHODS At baseline, patients were converted from cyclosporine-based to PR-T-based immunosuppression and randomized (1:1) to receive either corticosteroids maintained at prestudy dose (standard-dose group) or tapered from week 4 to 50% of the prestudy dose by week 12 (reduced-dose group). Patients were seen at baseline and weeks 1, 4, 12, and 24. The primary endpoint was change in estimated glomerular filtration rate (Modification-of-Diet-in-Renal-Disease-4) between baseline and week 24. Secondary endpoints included either acute rejection or patient-reported satisfaction with PR-T. Adverse events (AEs) were recorded. RESULTS Overall, 150 patients were randomized into a reduced-dose group (n = 73) and a standard-dose group (n = 77). At week 24, mean ± standard deviation for corticosteroid dose was 2.5 ± 0.9 mg and 5.0 ± 1.3 mg, respectively. Mean change in estimated glomerular filtration rate from baseline to week 24 was +1.5 ± 9.1 mL/min/1.73 m2 (P = .1567) and +3.4 ± 10.6 mL/min/1.73 m2 (P = .0065), respectively, and not significantly different between groups. There were no acute rejection episodes. Most respondents (>70%) considered PR-T more convenient than cyclosporine. AE incidence was similar between groups. The most common AEs experienced by ≥3% of patients in either treatment group were gastrointestinal events (20.8% and 28.6% of patients receiving reduced- and standard-dose corticosteroids, respectively). Most AEs in both treatment groups were mild or moderate in severity. CONCLUSION Renal function was maintained following conversion from cyclosporine to PR-T, irrespective of corticosteroid regimen; PR-T enables reduced corticosteroid dosage.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW The leading cause of death in both chronic kidney disease (CKD) and renal transplant patients is cardiovascular events. Post-transplant diabetes mellitus (PTx-DM), which is a major cardiovascular risk factor, is a metabolic disorder that affects 5.5-60.2% of renal allograft recipients by 1-year posttransplant (PTx). PTx-DM has been associated with a negative impact on patient and graft outcomes and survival. RECENT FINDINGS Individuals who develop PTx-DM are usually prone to this condition prior to and/or after developing CKD. Genetic factors, obesity, inflammation, medications and CKD all are risk factors for PTx-diabetes mellitus. The path to development of disease continues PTx frequently augmented by the use of diabetogenic maintenance immunosuppressive and some nonimmunosuppressive medications. These risk factors are usually associated with an increase in insulin resistance, a decrease in insulin gene expression and/or β-cell dysfunction and apoptosis. SUMMARY Some new anti-diabetes mellitus medications may help to improve the overall outcome; however, there is a real need for developing a preventive strategy. Identifying and targeting PTx-DM risk factors may help to guide the development of an effective programme. This could include the adoption of nondiabetogenic immunosuppressive protocols for high-risk patients.
Collapse
|
20
|
De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
21
|
Lancia P, Aurich B, Ha P, Maisin A, Baudouin V, Jacqz-Aigrain E. Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children. Clin Drug Investig 2018; 38:157-171. [PMID: 29236209 DOI: 10.1007/s40261-017-0594-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics. METHODS This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4. RESULTS One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics. CONCLUSIONS The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.
Collapse
Affiliation(s)
- Pauline Lancia
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Beate Aurich
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Phuong Ha
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Paris, France. .,Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| |
Collapse
|
22
|
Lancia P, Adam de Beaumais T, Elie V, Garaix F, Fila M, Nobili F, Ranchin B, Testevuide P, Ulinski T, Zhao W, Deschênes G, Jacqz-Aigrain E. Pharmacogenetics of post-transplant diabetes mellitus in children with renal transplantation treated with tacrolimus. Pediatr Nephrol 2018; 33:1045-1055. [PMID: 29399716 DOI: 10.1007/s00467-017-3881-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is a major complication of immunosuppressive therapy, with many risk factors reported in adults with renal transplantation. The objective of this study was to investigate potential non-genetic and genetic risk factors of PTDM in children with renal transplantation treated with tacrolimus. METHODS A national database was screened for patients developing PTDM within 4 years following tacrolimus introduction. PTDM was defined as glucose disorder requiring anti-diabetic treatment. PTDM patients were matched to "non-PTDM" control transplanted children according to age, gender, and duration of post-transplant follow-up. Patients were genotyped for six selected genetic variants in POR*28 (rs1057868), PPARa (rs4253728), CYP3A5 (rs776746), VDR (rs2228570 and rs731236), and ABCB1 (rs1045642) genes, implicated in glucose homeostasis and tacrolimus disposition. RESULTS Among the 98 children with renal transplantation enrolled in this multicentre study, 18 developed PTDM. None of the clinical and biological parameters was significant between PTDM and control patients. Homozygous carriers of POR*28 or wild-type ABCB1 (rs1045642) gene variants were more frequent in PTDM than in control patients with differences close to significance (p = 0.114 and p = 0.066 respectively). A genetic score based on these variants demonstrated that POR*28/*28 and ABCB1 CC or CT genotype carriers were at a significantly higher risk of developing PTDM after renal transplantation. CONCLUSION Identification of PTDM risk factors should allow clinicians to allocate the best immunosuppressant for each patient with renal transplantation, and improve care for patients who are at a higher risk.
Collapse
Affiliation(s)
- Pauline Lancia
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Tiphaine Adam de Beaumais
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Valéry Elie
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France
| | - Florentine Garaix
- Department of Pediatric Nephrology, CHU La Timone, APHM, 264 rue Saint Pierre, 13005, Marseille, France
| | - Marc Fila
- Department of Pediatric Nephrology, Arnaud de Villeneuve Hospital, 371 avenue du Doyen Gaston Giraud, 34090, Montpellier, France
| | - François Nobili
- Department of Pediatric Nephrology, Saint Jacques Hospital, 2 Place Saint Jacques, 25000, Besançon, France
| | - Bruno Ranchin
- Department of Pediatric Nephrology, Femme-Mère-Enfant Hospital, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron, France
| | - Pascale Testevuide
- Department of Pediatric Nephrology, Territorial Hospital Center, Papeete, Polynésie Française, France
| | - Tim Ulinski
- Department of Pediatric Nephrology, Armand Trousseau Hospital, APHP, 26 rue du Dr Arnold Netter, 75012, Paris, France
| | - Wei Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France.,Clinical Investigation Center CIC1426, INSERM, Robert Debré Hospital, 48 boulevard Serurier, 75019, Paris, France.,Paris Diderot University Sorbonne Paris Cité, Paris, France
| | - Georges Deschênes
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, 48 boulevard Serurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Robert Debré Hospital, 48 boulevard Serurier, 75019, Paris, France. .,Paris Diderot University Sorbonne Paris Cité, Paris, France.
| |
Collapse
|
23
|
Castedal M, Skoglund C, Axelson C, Bennet W. Steroid-free immunosuppression with low-dose tacrolimus is safe and significantly reduces the incidence of new-onset diabetes mellitus following liver transplantation. Scand J Gastroenterol 2018; 53:741-747. [PMID: 29688072 DOI: 10.1080/00365521.2018.1463390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Corticosteroids (CS) are traditionally used as part of the basal immunosuppression (IS) following liver transplantation (LT) but are known to be associated with an increased risk of new-onset diabetes mellitus (NODM), cardiovascular morbidity and mortality. The aim of this study was to retrospectively compare the incidence of transient as well as persistent NODM, rejection rate and patient- and graft survival between patients receiving steroid-based and steroid-free maintenance IS. MATERIALS AND METHODS A total of 238 patients liver transplanted (2008-2011) with deceased donor livers were divided into two groups, one group that received steroid-based IS (tacrolimus (TAC), corticosteroids (CS), ± mycophenolate mofetil (MMF); n = 155) (2008-2011) and another group of non-autoimmune recipients that received steroid-free IS (TAC, MMF; n = 83) according to our new maintenance IS-protocol starting January 2010. The primary and secondary end-points were patient- and graft survival, rejection rates and the incidence of NODM. The median follow-up times were 1248 days and 681 days, respectively. RESULTS The one-year patient- and graft survival in the steroid-based and steroid-free group was 92.7% and 93.3% (ns) and 87.6% and 84.9% (ns), respectively. The incidence of biopsy proven acute rejection (BPAR) was 27.7% in both groups (ns) during follow-up. The overall incidence of persistent NODM in the two groups were 16.8% and 2.9%, respectively (p < .01). CONCLUSIONS The results show that steroid-free low-dose tacrolimus-based IS following LT is safe and decreases the incidence of NODM significantly.
Collapse
Affiliation(s)
- M Castedal
- a The Transplant Institute , Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - C Skoglund
- a The Transplant Institute , Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - C Axelson
- a The Transplant Institute , Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - W Bennet
- a The Transplant Institute , Sahlgrenska University Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| |
Collapse
|
24
|
Improved Glucose Tolerance in a Kidney Transplant Recipient With Type 2 Diabetes Mellitus After Switching From Tacrolimus To Belatacept: A Case Report and Review of Potential Mechanisms. Transplant Direct 2018; 4:e350. [PMID: 29707621 PMCID: PMC5912016 DOI: 10.1097/txd.0000000000000767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/31/2017] [Indexed: 12/15/2022] Open
Abstract
Supplemental digital content is available in the text. The introduction of immunosuppressant belatacept, an inhibitor of the CD28-80/86 pathway, has improved 1-year outcomes in kidney transplant recipients with preexistent diabetes mellitus and has also reduced the risk of posttransplant diabetes mellitus. So far, no studies have compared a tacrolimus-based with a belatacept-based immunosuppressive regimen with regard to improving glucose tolerance after kidney transplantation. Here, we present the case of a 54-year-old man with type 2 diabetes mellitus who was converted from belatacept to tacrolimus 1 year after a successful kidney transplantation. Thereafter, he quickly developed severe hyperglycemia, and administration of insulin was needed to improve metabolic control. Six months after this episode, he was converted back to belatacept because of nausea, diarrhea, and hyperglycemia. After switching back to belatacept and within 4 days after stopping tacrolimus glucose tolerance improved and insulin therapy could be discontinued. Although belatacept is considered less diabetogenic than tacrolimus, the rapid improvement of glucose tolerance after switching to belatacept is remarkable. In this article, the potential mechanisms of this observation are discussed.
Collapse
|
25
|
Gelens MACJ, van Hooff JP, Usvyat L, Christiaans MH. No evidence for progressive deterioration in stimulated insulin secretion in renal transplant recipients after 12years tacrolimus exposure. J Diabetes Complications 2017; 31:1384-1388. [PMID: 28720321 DOI: 10.1016/j.jdiacomp.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/29/2017] [Accepted: 07/03/2017] [Indexed: 11/21/2022]
Abstract
AIMS Tacrolimus (Tac) inhibits insulin secretion in a Tac-trough blood level dependent way early post-transplant in renal transplant recipients (Rtx). It is unknown whether long-term exposure results into a progressive beta cells dysfunction. METHODS Two independent cohorts of Tac-treated non-diabetic Rtx, previously participating in glucose metabolism studies using intravenous Glucose Tolerance Test (ivGTT) were included: Fifty-eight Rtx were tested by ivGTT cross-sectional between 0.25 and 12.6years post-transplant. Factors related to glucose metabolism parameters were explored by multilinear regression analysis. Eighteen non-diabetic Rtx tested by ivGTT 6months post-transplant were retested at 12years. The glucose metabolism outcome parameters were also adjusted according to the results of the cross-sectional study. RESULTS Multivariate analysis showed 'Age', 'BMI' and 'use of steroids' to be significantly related, in different combinations, to the glucose metabolism parameters 'insulin resistance', 'fasting insulin level' and 'stimulated insulin secretion'. However 'time on tacrolimus' wasn't related to any parameter. In the longitudinal study, none of the glucose metabolism parameters (either analyzed crude or adjusted) deteriorated clinically or statistically significant. Numerically, 'stimulated insulin secretion' even increased. CONCLUSIONS Chronic Tac exposure does NOT lead to a progressive decrease in 'stimulated insulin secretion' between 6months and 12years post renal transplant in our population of 18 patients.
Collapse
Affiliation(s)
- Mariëlle A C J Gelens
- Department of Internal Medicine, Maastricht University Medical Centre, PO-box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Johannes P van Hooff
- Department of Internal Medicine, Maastricht University Medical Centre, PO-box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Len Usvyat
- Renal Research Institute, 315E 62nd ST, New York, NY 10065, USA; Fresenius Medical Care North America, 950 Winter St, Waltham, MA 02451, USA.
| | - Maarten H Christiaans
- Department of Internal Medicine, Maastricht University Medical Centre, PO-box 5800, 6202 AZ Maastricht, The Netherlands.
| |
Collapse
|
26
|
Prediabetes in Pediatric Recipients of Liver Transplant: Mechanism and Risk Factors. J Pediatr 2017; 182:223-231.e3. [PMID: 28041666 PMCID: PMC5328850 DOI: 10.1016/j.jpeds.2016.11.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To investigate the role of calcineurin inhibitor exposure and states of insulin resistance-obesity and adolescence-in prediabetes after pediatric liver transplant via oral glucose tolerance testing, which previously has not been done systematically in these at-risk youths. STUDY DESIGN This was a cross-sectional study of 81 pediatric recipients of liver transplant. Prediabetes was defined as impaired glucose tolerance (IGT; glucose ≥140 mg/dL at 2 hours) or impaired fasting glucose (IFG, ≥100 mg/dL). Corrected insulin response (CIR) was calculated as measure of insulin secretion, corrected for glucose (CIR30, CIR60, CIR120). RESULTS Subjects were aged 8.1-30.0 years and 1.1-24.7 years post-transplant; 44% had prediabetes-27% IGT, 14% IFG, and 3% both. IGT was characterized by insulin hyposecretion, with lower CIR60 and CIR120 in IGT than subjects with normal glucose tolerance. Subjects with tacrolimus trough >6 µg/mL at study visit had lower CIR120 than those with trough ≤6 µg/mL and those off calcineurin-inhibitors. Mean of tacrolimus troughs preceding the study visit, years since transplant, and rejection episodes were not associated significantly with lower CIR. CIR suppression by tacrolimus was most pronounced >6 years from transplant. Overweight/obese subjects and adolescents who retained normal glucose tolerance had greater CIR than those who were IGT. CONCLUSION IGT after pediatric liver transplant is driven by inadequate insulin secretion. It is quite common but not detectable with fasting laboratory values-the screening recommended by current guidelines. Calcineurin inhibitors suppress insulin secretion in these patients in a dose-dependent manner. Given the recent focus on long-term outcomes and immunosuppression withdrawal in these children, longitudinal studies are warranted to investigate whether IGT is reversible with calcineurin inhibitor minimization.
Collapse
|
27
|
Jørgensen MB, Hornum M, van Hall G, Bistrup C, Hansen JM, Mathiesen ER, Feldt-Rasmussen B. The impact of kidney transplantation on insulin sensitivity. Transpl Int 2017; 30:295-304. [DOI: 10.1111/tri.12907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Morten B. Jørgensen
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Mads Hornum
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Gerrit van Hall
- Clinical Metabolomics Core Facility; Clinical Biochemistry, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Claus Bistrup
- Department of Nephrology; Odense University Hospital; Odense Denmark
| | - Jesper M. Hansen
- Department of Nephrology; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - Elisabeth R. Mathiesen
- Department of Endocrinology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| |
Collapse
|
28
|
Størset E, Åsberg A, Hartmann A, Reisaeter AV, Holdaas H, Skauby M, Bergan S, Midtvedt K. Low-target tacrolimus in de novo standard risk renal transplant recipients: A single-centre experience. Nephrology (Carlton) 2016; 21:821-7. [DOI: 10.1111/nep.12738] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/20/2016] [Accepted: 02/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Elisabet Størset
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Anders Åsberg
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
- School of Pharmacy; University of Oslo; Oslo Norway
| | - Anders Hartmann
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Anna V. Reisaeter
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Hallvard Holdaas
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Morten Skauby
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Stein Bergan
- School of Pharmacy; University of Oslo; Oslo Norway
- Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| |
Collapse
|
29
|
Abstract
Drug-induced hyperglycaemia and diabetes is a global issue. It may be a serious problem, as it increases the risk of microvascular and macrovascular complications, infections, metabolic coma and even death. Drugs may induce hyperglycaemia through a variety of mechanisms, including alterations in insulin secretion and sensitivity, direct cytotoxic effects on pancreatic cells and increases in glucose production. Antihypertensive drugs are not equally implicated in increasing serum glucose levels. Glycaemic adverse events occur more frequently with thiazide diuretics and with certain beta-blocking agents than with calcium-channel blockers and inhibitors of the renin-angiotensin system. Lipid-modifying agents may also induce hyperglycaemia, and the diabetogenic effect seems to differ between the different types and daily doses of statins. Nicotinic acid may also alter glycaemic control. Among the anti-infectives, severe life-threatening events have been reported with fluoroquinolones, especially when high doses are used. Protease inhibitors and, to a lesser extent, nucleoside reverse transcriptase inhibitors have been reported to induce alterations in glucose metabolism. Pentamidine-induced hyperglycaemia seems to be related to direct dysfunction in pancreatic cells. Phenytoin and valproic acid may also induce hyperglycaemia. The mechanisms of second-generation antipsychotic-associated hyperglycaemia, diabetes mellitus and ketoacidosis are complex and are mainly due to insulin resistance. Antidepressant agents with high daily doses seem to be more frequently associated with an increased risk of diabetes. Ketoacidosis may occur in patients receiving beta-adrenergic stimulants, and theophylline may also induce hyperglycaemia. Steroid diabetes is more frequently associated with high doses of glucocorticoids. Some chemotherapeutic agents carry a higher risk of hyperglycaemia, and calcineurin inhibitor-induced hyperglycaemia is mainly due to a decrease in insulin secretion. Hyperglycaemia has been associated with oral contraceptives containing high doses of oestrogen. Growth hormone therapy and somatostatin analogues may also induce hyperglycaemia. Clinicians should be aware of medications that may alter glycaemia. Efforts should be made to identify and closely monitor patients receiving drugs that are known to induce hyperglycaemia.
Collapse
|
30
|
Brooks E, Tett SE, Isbel NM, Staatz CE. Population Pharmacokinetic Modelling and Bayesian Estimation of Tacrolimus Exposure: Is this Clinically Useful for Dosage Prediction Yet? Clin Pharmacokinet 2016; 55:1295-1335. [DOI: 10.1007/s40262-016-0396-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
31
|
Tacrolimus for children with refractory nephrotic syndrome: a one-year prospective, multicenter, and open-label study of Tacrobell®, a generic formula. World J Pediatr 2016; 12:60-5. [PMID: 26684309 DOI: 10.1007/s12519-015-0062-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/04/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cyclosporine A and tacrolimus (TAC) are often used as a second-line treatment for children with refractory nephrotic syndrome (NS). This study was undertaken to investigate the efficacy and safety of Tacrobell®, a locally produced generic form of TAC. METHODS This study was a one-year prospective, open-label, single-arm, multicenter trial. Fourty-four children with steroid-dependent NS (SDNS) and 33 children with steroid-resistant NS (SRNS) were enrolled. The primary endpoints were defined as the remission rates, whereas the secondary endpoints were recognized as the duration of remission and adverse effects of TAC. RESULTS After one-year treatment, 34 (77.3%) of the 44 patients with SDNS were in complete remission, and 6 (13.6%) were in partial remission. Nineteen (43.2%) patients did not relapse during the study; for those who did relapse, the mean duration of remission was 4.6±2.9 months. The number of relapse episodes during the study period (0.90 per patient-year) was significantly lower than that in the preceding year (2.8 per patient-year). After treatment for 3 and 6 months, 12 (36.4%) of the 33 patients with SRNS were in remission, and after treatment for 12 months, the number of patients had increased to 13 (39.4%). The mean time to achieve remission was 4.0±3.2 months. After remission (duration, 3.7±2.7 months), 12 (54.5%) of 22 patients relapsed. The fasting blood glucose and blood pressure levels during the therapy were similar to those at the time of study entry. CONCLUSIONS Treatment with Tacrobell® was effective and safe for children with refractory NS. The efficacy of this generic form of TAC was better than that of the original TAC formula.
Collapse
|
32
|
Shivaswamy V, Boerner B, Larsen J. Post-Transplant Diabetes Mellitus: Causes, Treatment, and Impact on Outcomes. Endocr Rev 2016; 37:37-61. [PMID: 26650437 PMCID: PMC4740345 DOI: 10.1210/er.2015-1084] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Post-transplant diabetes mellitus (PTDM) is a frequent consequence of solid organ transplantation. PTDM has been associated with greater mortality and increased infections in different transplant groups using different diagnostic criteria. An international consensus panel recommended a consistent set of guidelines in 2003 based on American Diabetes Association glucose criteria but did not exclude the immediate post-transplant hospitalization when many patients receive large doses of corticosteroids. Greater glucose monitoring during all hospitalizations has revealed significant glucose intolerance in the majority of recipients immediately after transplant. As a result, the international consensus panel reviewed its earlier guidelines and recommended delaying screening and diagnosis of PTDM until the recipient is on stable doses of immunosuppression after discharge from initial transplant hospitalization. The group cautioned that whereas hemoglobin A1C has been adopted as a diagnostic criterion by many, it is not reliable as the sole diabetes screening method during the first year after transplant. Risk factors for PTDM include many of the immunosuppressant medications themselves as well as those for type 2 diabetes. The provider managing diabetes and associated dyslipidemia and hypertension after transplant must be careful of the greater risk for drug-drug interactions and infections with immunosuppressant medications. Treatment goals and therapies must consider the greater risk for fluctuating and reduced kidney function, which can cause hypoglycemia. Research is actively focused on strategies to prevent PTDM, but until strategies are found, it is imperative that immunosuppression regimens are chosen based on their evidence to prolong graft survival, not to avoid PTDM.
Collapse
Affiliation(s)
- Vijay Shivaswamy
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Brian Boerner
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| | - Jennifer Larsen
- Division of Diabetes, Endocrinology, and Metabolism (V.S., B.B., J.L.), Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198; and VA Nebraska-Western Iowa Health Care System (V.S.), Omaha, Nebraska 68105
| |
Collapse
|
33
|
Improved Tacrolimus Target Concentration Achievement Using Computerized Dosing in Renal Transplant Recipients--A Prospective, Randomized Study. Transplantation 2016; 99:2158-66. [PMID: 25886918 DOI: 10.1097/tp.0000000000000708] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early after renal transplantation, it is often challenging to achieve and maintain tacrolimus concentrations within the target range. Computerized dose individualization using population pharmacokinetic models may be helpful. The objective of this study was to prospectively evaluate the target concentration achievement of tacrolimus using computerized dosing compared with conventional dosing performed by experienced transplant physicians. METHODS A single-center, prospective study was conducted. Renal transplant recipients were randomized to receive either computerized or conventional tacrolimus dosing during the first 8 weeks after transplantation. The median proportion of tacrolimus trough concentrations within the target range was compared between the groups. Standard risk (target, 3-7 μg/L) and high-risk (8-12 μg/L) recipients were analyzed separately. RESULTS Eighty renal transplant recipients were randomized, and 78 were included in the analysis (computerized dosing (n = 39): 32 standard risk/7 high-risk, conventional dosing (n = 39): 35 standard risk/4 high-risk). A total of 1711 tacrolimus whole blood concentrations were evaluated. The proportion of concentrations per patient within the target range was significantly higher with computerized dosing than with conventional dosing, both in standard risk patients (medians, 90% [95% confidence interval {95% CI}, 84-95%] vs 78% [95% CI, 76-82%], respectively, P < 0.001) and in high-risk patients (medians, 77% [95% CI, 71-80%] vs 59% [95% CI, 40-74%], respectively, P = 0.04). CONCLUSIONS Computerized dose individualization improves target concentration achievement of tacrolimus after renal transplantation. The computer software is applicable as a clinical dosing tool to optimize tacrolimus exposure and may potentially improve long-term outcome.
Collapse
|
34
|
Galindo RJ, Fried M, Breen T, Tamler R. HYPERGLYCEMIA MANAGEMENT IN PATIENTS WITH POSTTRANSPLANTATION DIABETES. Endocr Pract 2015; 22:454-65. [PMID: 26720253 DOI: 10.4158/ep151039.ra] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Posttransplantation diabetes (PTDM) is a common occurrence after solid-organ transplantation and is associated with increased morbidity, mortality, and health care costs. There is a limited number of studies addressing strategies for hyperglycemia management in this population, with a few articles emerging recently. METHODS We performed a PubMed search of studies published in English addressing hyperglycemia management of PTDM/new-onset diabetes after transplant (NODAT). Relevant cited articles were also retrieved. RESULTS Most of the 25 publications eligible for review were retrospective studies. Insulin therapy during the early posttransplantation period showed promise in preventing PTDM development. Thiazolidinediones have been mostly shown to exert glycemic control in retrospective studies, at the expense of weight gain and fluid retention. Evidence with metformin, sulfonylureas, and meglitinides is very limited. Incretins have shown promising results in small prospective studies using sitagliptin, linaglitpin, and vildagliptin and a case series using liraglutide. CONCLUSION Prospective randomized studies assessing the management of hyperglycemia in PTDM are urgently needed. In the meantime, clinicians need to be aware of the high risk of PTDM and associated complications and current concepts in management.
Collapse
|
35
|
Pimentel AL, Bauer AC, Camargo JL. Renal posttransplantation diabetes mellitus: An overview. Clin Chim Acta 2015; 450:327-32. [DOI: 10.1016/j.cca.2015.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 12/25/2022]
|
36
|
Ji SM, Xie KN, Chen JS, Wen JQ, Cheng DR, Cheng DP, Li X, Ni XF, Liu ZH. Retrospective evaluation of the effect of mycophenolate mofetil dosage on survival of kidney grafts based on biopsy results. Transplant Proc 2015; 46:3383-9. [PMID: 25498056 DOI: 10.1016/j.transproceed.2014.09.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 08/21/2014] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Plasma concentration monitoring is commonly used to adjust immunosuppressant dosage in transplant recipients, but adjustment is often based on clinical experience rather than rigorous quantitative indicators. METHODS We examined the effect of mycophenolate mofetil (MMF) dosage on graft survival by pathologic and immunologic analysis of 88 kidney recipients who were given a postoperative immunosuppressive regimen of tacrolimus (FK506), MMF, and corticosteroids. Patients were given a conventional dosage (≥1.5 g/d; n = 40) or a reduced dosage (n = 48) of MMF owing to postoperative adverse side effects. RESULTS The reduced-dose group included patients given low doses (≤1.0 g/d; n = 27), ultra-low doses (≤0.5 g/d; n = 15), and those who discontinued MMF (n = 6). The dose reduction group had increased acute rejection, chronic rejection, and graft dysfunction, poorer pathologic scores, and increased cell infiltration of graft tissue (CD4, CD8, CD68, and CD138 positivity) and expression of interleukin-2R and HLA-DR. Finally, hazard analysis indicated that patients given low doses and ultra-low doses of MMF had poorer long-term kidney grafts survival (hazard ratios of 1.52 and 1.78, respectively). CONCLUSIONS These results indicate the importance of using an appropriate dosage of MMF in kidney transplant recipients.
Collapse
Affiliation(s)
- S-M Ji
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - K-N Xie
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J-S Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J-Q Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | | | - D-P Cheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - X Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - X-F Ni
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Z-H Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China. zhihong--
| |
Collapse
|
37
|
Pirsch JD, Henning AK, First MR, Fitzsimmons W, Gaber AO, Reisfield R, Shihab F, Woodle ES. New-Onset Diabetes After Transplantation: Results From a Double-Blind Early Corticosteroid Withdrawal Trial. Am J Transplant 2015; 15:1982-90. [PMID: 25881802 DOI: 10.1111/ajt.13247] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/09/2015] [Accepted: 01/31/2015] [Indexed: 01/25/2023]
Abstract
New-onset diabetes after transplantation (NODAT) is an important complication following kidney transplantation. Data from the 5-year early steroid withdrawal double-blind randomized trial were analyzed to determine if steroid avoidance reduced the NODAT risk. Incidence, timing and risk factors for NODAT were evaluated using eight definitions. By American Diabetes Association definition, 36.3% of patients on chronic corticosteroids (CCS) and 35.9% on early corticosteroid withdrawal (CSWD) were diagnosed with NODAT by 5 years. The definition combining fasting blood glucose ≥126 mg/dL on two occasions or treatment identified slightly more cases of NODAT: CCS (39.3%) and CSWD (39.4%). Through 5 years posttransplant, the proportion of NODAT patients requiring treatment were similar (CSWD 22.5% vs. CCS 21.5%); however, insulin therapy was lower with CSWD (3.7% vs. 11.6%; p = 0.049). By multivariate analysis, only age, but not corticosteroid use, was a significant risk factor for NODAT for more than one definition. Numerical, but not statistically significant trends toward lower NODAT rates with CSWD were observed through 5 years for insulin use, HbA1c ≥6.0% and ≥6.5% on two occasions. This prospective, randomized trial of CSWD indicates that CSWD has a limited impact in reducing NODAT when compared to low-dose prednisone (5 mg/day from month 6 to 5 years).
Collapse
Affiliation(s)
| | | | - M R First
- Astellas Pharma Global Development, Northbrook, IL
| | | | - A O Gaber
- The Methodist Hospital, Houston, TX.,Weill Cornell Medical College, New York, NY
| | - R Reisfield
- Astellas Pharma Global Development, Northbrook, IL
| | - F Shihab
- University of Utah, Salt Lake City, UT
| | - E S Woodle
- University of Cincinnati, Cincinnati, OH
| |
Collapse
|
38
|
New-onset diabetes after kidney transplant in children. Pediatr Nephrol 2015; 30:405-16. [PMID: 24894384 DOI: 10.1007/s00467-014-2830-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 04/01/2014] [Accepted: 04/11/2014] [Indexed: 02/08/2023]
Abstract
The development of new-onset diabetes after kidney transplantation (NODAT) is associated with reduced graft function, increased cardiovascular morbidity and lower patient survival among adult recipients. In the pediatric population, however, the few studies examining NODAT have yielded inconsistent results. Therefore, the true incidence of NODAT in the pediatric population has been difficult to establish. The identification of children and adolescents at risk for NODAT requires appropriate screening questions and tests pre- and post-kidney transplant. Several risk factors have been implicated in the pathogenesis of NODAT and post-transplant glucose intolerance, including African American race, obesity, family history of diabetes and the type of immunosuppressant regimen. Moreover, uremia per se results in a state of insulin resistance that increases the risk of developing diabetes post-transplant. When an individual becomes glucose intolerant, early lifestyle modification and antihyperglycemic measures with tailoring of the immunosuppressant regimen should be implemented to prevent the development of NODAT. For the child or adolescent with NODAT, antihyperglycemic therapy should be prescribed in order to achieve optimal glycemic control, ultimately reducing complications and improving overall allograft and patient survival. In this article, we review the risk factors, screening methods, diagnosis, management and outcome of children and adolescents with NODAT and post-kidney transplant glucose intolerance.
Collapse
|
39
|
Gaynor JJ, Ciancio G, Guerra G, Sageshima J, Hanson L, Roth D, Goldstein MJ, Chen L, Kupin W, Mattiazzi A, Tueros L, Flores S, Barba LJ, Lopez A, Rivas J, Ruiz P, Vianna R, Burke GW. Multivariable risk of developing new onset diabetes after transplant-results from a single-center study of 481 adult, primary kidney transplant recipients. Clin Transplant 2015; 29:301-10. [PMID: 25581205 DOI: 10.1111/ctr.12510] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Understanding the relative contributions of baseline demographics and immunosuppressive therapy on NODAT risk may help in developing preventive strategies. METHODS Using our prospectively followed cohort of 481 adult, primary kidney transplant recipients without pre-transplant diabetes, we determined the significant baseline predictors for the hazard rate of developing NODAT via Cox stepwise regression. The multivariable influence of first BPAR (defined as a time-dependent covariate) was also tested. RESULTS Median follow-up was 57 mo post-transplant; the overall percentage who developed NODAT was 22.5% (108/481). Four baseline predictors of a greater NODAT hazard rate were found (by order of selection): higher BMI (p < 0.000001), planned maintenance with SRL (p = 0.0003), non-white recipient (p = 0.0004), and older recipient age (p = 0.0004). Approximately one-half of the 106 patients in the highest demographic risk category (BMI ≥25 kg/m(2) , non-white race, and age at transplant ≥40 yr) developed NODAT; actuarial NODAT risk ranged from 10% to 30% in the lower demographic risk categories. First BPAR was also associated with significantly higher NODAT in multivariable analysis (p = 0.02)-the highly elevated NODAT rate observed during the first few months post-transplant and following first BPAR appears to demonstrate the diabetogenic effect of using high-dose (intravenous) corticosteroids. CONCLUSIONS The disturbingly high NODAT rate found among patients having multiple demographic risk factors is still an important problem that awaits a better solution.
Collapse
Affiliation(s)
- Jeffrey J Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Chen QJ, Li J, Zuo SR, Zhang YP, Jia SJ, Yuan H, Liu SK, Cheng K, Ming YZ, Zuo XC, Luo AJ, Xie WZ, Cai JJ, Yang M, Wang JL. Tacrolimus decreases insulin sensitivity without reducing fasting insulin concentration: a 2-year follow-up study in kidney transplant recipients. Ren Fail 2015; 37:601-6. [PMID: 25644968 DOI: 10.3109/0886022x.2015.1007833] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
New Onset Diabetes after Transplantation (NODAT) is defined as sustained hyperglycemia developing in patients without diabetes history before transplantation. A cohort study was performed to access the effects of tacrolimus on insulin secretion and insulin sensitivity and consequently in the development of NODAT in kidney transplant recipients. Then, we further investigated the association between NODAT and single-nucleotide polymorphisms of IRS-1 and IRS-2 in renal allograft recipients. One hundred and fifty-eight kidney transplant patients, receiving tacrolimus as the base immunosuppressant, were divided into two groups: with or without NODAT. Plasma levels of fasting insulin concentration (FINS) and C-peptide were determined by enhanced chemiluminescence immunoassay and ADVIA Centaur C peptide assay, respectively. The genotypes of Gly1057Asp in IRS-2 and Gly972Arg in IRS-1 were detected through polymerase chain reaction fragment length polymorphism in NODAT and non-NODAT patients. It was found that the concentrations of fasting plasma insulin and C-peptide in NODAT and non-NODAT patients treated with tacrolimus were higher than that in healthy volunteers (p < 0.05). Fasting plasma insulin concentration in NODAT was significantly elevated compared with than that in non-NODAT group (p < 0.05). But there are no statistical differences in fasting plasma C-peptide concentrations between NODAT and non-NODAT groups. The allele and genotype frequencies of IRS-2 Gly1057Asp and IRS-1 Gly972Arg in NODAT patients were not significantly different from non-NODAT patients (p > 0.05). In conclusion, insulin resistance is the primary cause of tacrolimus-induced NODAT. The IRS-2 Gly1057Asp and IRS-1 Gly972Arg genotypes are not related to NODAT.
Collapse
Affiliation(s)
- Qing-Jie Chen
- Clinical Pharmacy and Pharmacology Research Institute, The Third Xiangya Hospital of Central South University , Changsha, Hunan , PR China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Ruiz R, Kirk AD. Long-Term Toxicity of Immunosuppressive Therapy. TRANSPLANTATION OF THE LIVER 2015. [PMCID: PMC7152453 DOI: 10.1016/b978-1-4557-0268-8.00097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
42
|
Einollahi B, Motalebi M, Salesi M, Ebrahimi M, Taghipour M. The impact of cytomegalovirus infection on new-onset diabetes mellitus after kidney transplantation: a review on current findings. J Nephropathol 2014; 3:139-48. [PMID: 25374883 PMCID: PMC4219616 DOI: 10.12860/jnp.2014.27] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/28/2014] [Indexed: 01/12/2023] Open
Abstract
CONTEXT New onset diabetes mellitus after transplantation (NODAT) increases the risk of cardiovascular disease, rate of infections, graft rejection and graft loss as well as decreases patient and graft survival rates. There is a controversy surrounding the impact of cytomegalovirus (CMV) infection in the development of NODAT. This meta-analysis aims to identify the role of CMV infection leading to the development of NODAT in kidney recipient patients. EVIDENCE ACQUISITIONS We searched several electronic databases, including PubMed, Embase, Medline, Scopus, Trip Database and Google Scholar for studies that completely fulfill our criteria between January 1990 and January 2014 RESULTS: Seven studies with 1389 kidney transplant patients were included in this metaanalysis.The mean age of patients ranged from 42.8 to 48.8 years and males made up 53% to 75% of patients in the cohort studies. The incidence of NODAT varies from 14.3% to 27.1% in these studies. Overall adj OR was 1.94 [exp (0.66)] with a 95% CI of 1.26-2.98 [exp (0.23) and (1.09)]. There was no significant publication bias based on the Begg's and Egger's test (p value = 0.17 and 0.54, respectively). CONCLUSIONS Our study showed that CMV infection is a risk factor for increasing incidence of NODAT. Thus, prophylaxis against CMV infection after kidney transplantation is strongly suggested. However, further clinical trials and cohorts are needed to confirm this association.
Collapse
Affiliation(s)
- Behzad Einollahi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohsen Motalebi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mahmood Salesi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehrdad Ebrahimi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taghipour
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
43
|
Rangel EB. Tacrolimus in pancreas transplant: a focus on toxicity, diabetogenic effect and drug–drug interactions. Expert Opin Drug Metab Toxicol 2014; 10:1585-605. [DOI: 10.1517/17425255.2014.964205] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
44
|
Kim Y, Park S, Kim H, Han S. Actual 10-year Outcomes of Tacrolimus/MMF Compared with Cyclosporin/MMF in Kidney Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yaerim Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Sungbae Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Keimyung University Kidney Institute, Daegu, Korea
| | - Hyoungtae Kim
- Keimyung University Kidney Institute, Daegu, Korea
- Department of General Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
- Keimyung University Kidney Institute, Daegu, Korea
| |
Collapse
|
45
|
Wissing KM, Pipeleers L. Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: prevention and treatment. Transplant Rev (Orlando) 2013; 28:37-46. [PMID: 24507957 DOI: 10.1016/j.trre.2013.12.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/18/2013] [Indexed: 02/06/2023]
Abstract
The prevalence of the metabolic syndrome in dialysis patients is high and further increases after transplantation due to weight gain and the detrimental metabolic effects of immunosuppressive drugs. Corticosteroids cause insulin resistance, hyperlipidemia, abnormal glucose metabolism and arterial hypertension. The calcineurin inhibitor tacrolimus is diabetogenic by inhibiting insulin secretion, whereas cyclosporine causes hypertension and increases cholesterol levels. Mtor antagonists are responsible for hyperlipidemia and abnormal glucose metabolism by mechanisms that also implicate insulin resistance. The metabolic syndrome in transplant recipients has numerous detrimental effects such as increasing the risk of new onset diabetes, cardiovascular disease events and patient death. In addition, it has also been linked with accelerated loss of graft function, proteinuria and ultimately graft loss. Prevention and management of the metabolic syndrome are based on increasing physical activity, promotion of weight loss and control of cardiovascular risk factors. Bariatric surgery before or after renal transplantation in patients with body mass index >35 kg/m(2) is an option but its long term effects on graft and patient survival have not been investigated. Steroid withdrawal and replacement of tacrolimus with cyclosporine facilitate control of diabetes, whereas replacement of cyclosporine and mtor antagonists can improve hyperlipidemia. The new costimulation inhibitor belatacept has potent immunosuppressive properties without metabolic adverse effects and will be an important component of immunosuppressive regimens with better metabolic risk profile. Medical treatment of cardiovascular risk factors has to take potential drug interactions with immunosuppressive medication and drug accumulation due to renal insufficiency into account.
Collapse
Affiliation(s)
- Karl Martin Wissing
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Nephrology and Dialysis Clinic, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Lissa Pipeleers
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
46
|
Hornum M, Lindahl JP, von Zur-Mühlen B, Jenssen T, Feldt-Rasmussen B. Diagnosis, management and treatment of glucometabolic disorders emerging after kidney transplantation: a position statement from the Nordic Transplantation Societies. Transpl Int 2013; 26:1049-60. [PMID: 23634804 DOI: 10.1111/tri.12112] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 02/11/2013] [Accepted: 04/06/2013] [Indexed: 12/16/2022]
Abstract
After successful solid organ transplantation, new-onset diabetes (NODAT) is reported to develop in about 15-40% of the patients. The variation in incidence may partly depend on differences in the populations that have been studied and partly depend on the different definitions of NODAT that have been used. The diagnosis was often based on 'the use of insulin postoperatively', 'oral agents used', random glucose monitoring and a fasting glucose value between 7 and 13 mmol/l (126-234 mg/dl). Only few have used a 2-h glucose tolerance test performed before transplantation. There is a huge variation in the literature regarding risk factors for developing NODAT. They can be divided into factors related to glucose metabolism or to patient demographics and the latter into modifiable and nonmodifiable. Screening for risk factors should start early and be re-evaluated while being on the waitlist. Patients on the waiting list for renal transplantation and transplanted patients share many characteristics in having hyperglycaemia, disturbed insulin secretion and increased insulin resistance. We present guidelines for early risk factor assessment and a screening/treatment strategy for disturbed glucose metabolism, both before and after transplantation. The aim was to avoid the increased cardiovascular disease and mortality rates associated with NODAT.
Collapse
Affiliation(s)
- Mads Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | | | | |
Collapse
|
47
|
|
48
|
Tatar E, Kircelli F, Demirci MS, Turan MN, Gungor O, Asci G, Ozkahya M, Ok E, Hoscoskun C, Toz H. Pre-transplant HbA1c level as an early marker for new-onset diabetes after renal transplantation. Int Urol Nephrol 2012; 45:251-8. [PMID: 23054321 DOI: 10.1007/s11255-012-0304-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/17/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND New-onset diabetes after transplantation (NODAT) is a common complication in renal transplant (RT) patients. The clinical significance of pre-transplant HbA1c level remains unclear in RT patients. Thus, we investigated the predictive role of pre-transplant HbA1c levels for the NODAT diagnosed in 1 year after renal transplantation. METHODS Two hundred and four RT patients older than 18 years were analyzed. NODAT diagnosis during the 1-year follow-up after RT was based on the 2003 modified criteria of the ADA. HbA1c level was measured at pre-transplantation period and every 3 months after RT. RESULTS Mean age was 39.3 ± 10.7 (20-73) years and 36 % were female. Mean pre-transplant HbA1c level was 4.9 ± 0.5 % (4.0-6.4 %). Pre-transplant HbA1c level was positively correlated with age, pre-transplant body mass index (BMI) and cholesterol level. Fifty-four patients (25.9 %) developed NODAT and 33.8 % had impaired fasting blood glucose levels. Patients with NODAT were significantly older and had higher pre-transplant BMI and HbA1c than those without. Use of Tacrolimus was also higher in patients with NODAT. In stepwise logistic regression analysis, pre-transplant HbA1c level was an independent predictor for the development on NODAT (OR = 4.63, 95 % CI: 2.09-10.2, p < 0.001) together with age, Tacrolimus-based regimen and pre-transplant fasting blood glucose level. CONCLUSIONS Assessment of pre-transplant HbA1c levels may be a valuable tool for early diagnosis of NODAT in RT recipients.
Collapse
Affiliation(s)
- Erhan Tatar
- Division of Nephrology, Ege University School of Medicine, 35100, Bornova, Izmir, Turkey.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Rangel EB. The metabolic and toxicological considerations for immunosuppressive drugs used during pancreas transplantation. Expert Opin Drug Metab Toxicol 2012; 8:1531-48. [DOI: 10.1517/17425255.2012.724058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
50
|
Phillips S, Heuberger R. Metabolic Disorders Following Kidney Transplantation. J Ren Nutr 2012; 22:451-60.e1. [DOI: 10.1053/j.jrn.2012.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/05/2012] [Accepted: 01/14/2012] [Indexed: 11/11/2022] Open
|