Almost one 3rd of non-diabetic kidney transplant recipients may develop persistent impairment of glucose metabolism within 6 months’ post-transplant
New onset diabetes after transplant (NODAT) in renal transplant recipients
Almost one 3rd of non-diabetic kidney
transplant recipients (KTRs) may develop persistent impairment
of glucose metabolism within 6 months’ post-transplant. New Onset Diabetes After Transplantation (NODAT) has a negative impact on patient
and allograft outcome. NODAT may be developed any timing post-transplant with a
symptomatized patient in addition to a random blood glucose ≥ 200 mg/dl (11.1 mmol/l), fasting blood glucose ≥126 mg/dL (7.0 mmol/L) or a 2-h plasma glucose ≥ 200 mg /dL L (11.1 mmol/L) via
an oral glucose tolerance testing.
Pre-diabetic hyperglycemia can be diagnosed via a FBG (fasting
blood glucose) value of 100-125 mg/dL (5.6-6.9 mmol/L) or a 2-h. blood glucose value of 140-199 mg/dL (7.8-11.0 mmol/L) via an oral glucose tolerance testing (ADA
guide-lines). Glucocorticoids, CNI (calcineurin inhibitors) and sirolimus that usually included in the
post-transplant immunosuppressive protocol can increase the risk of NODAT development. As compared to CyA (cyclosporine) , tacrolimus is more diabeto-genic to the kidney
transplant recipient (KTRs). On the other hand, MMF (mycophenolate mofetil) and
Azathioprine are almost non-diabetogenic.
Screening work-up for the risk factors for NODAT, in addition to the history of
gestational diabetes should be assessed in the pre-transplant preparation.
Furthermore, fasting blood glucose, metabolic syndrome-related markers and
other cardiovascular-related risk factors. Patients’ counseling in regard to
the risk of NODAT evolution and the related necessary modifications to
limit this risk.
Dietitians should have their role in competing NODAT
evolution with timely referral of the high risk patients. ALL KTRs should have regular testing for
fasting plasma glucose on a weekly basis within the 1st 4 weeks after
transplantation, then 3-6 monthly basis post-transplantation, and then every
year forwards. In addition, HBA1c (hemoglobin A1c) can be revised after 3 months’
post-operative, particularly if obtaining a fasting blood-glucose level was
impractical.
MANAGEMENT OF NODAT
The attempt to manage and improve glucose tolerance is
currently endangered by an increased risk of graft rejection. Considering this
caution, the following approach has been suggested:
1]
In patients with NODAT, glucocorticoid doses should be lowered
early and as soon as possible. Complete holding of glucocorticoids is not
recommended.
2]
NO switch of tacrolimus to CyA is recommended unless other
tacrolimus-induced adverse effects was present. Tacrolimus dosage can be
reduced whenever possible.
3]
KTRs with uncontrolled diabetes despite reducing tacrolimus dose,
switching to CyA can be considered.
4]
A stepwise strategy has been advised for NODAT control,
as follows:
1)
Non-pharmacological approach,
2)
Oral single therapy (monotherapy),
3)
Combined oral therapy, and finally,
4)
Insulin therapy providing decompensated metabolic balance
was not present.
5]
Commencing oral therapy has been advised with glipizide at a dose of 2.5-5 mg/day and then increment
to 10 mg twice/day as required to keep the HbA1c at <7 %.
6]
On the other
hand meglitinides e.g., repaglinide (Prandin) have been advised by some
experts before sulfonylureas can be utilized, as sulfonylureas may induce
potential renal toxicity. In regard to thiazolinediones they must be discarded among KTRs due to their adverse untoward
effects.
7]
Insulin therapy is generally advised with:
1)
The presence of metabolic decompensation,
2)
The presence of adverse untoward effects with oral medications,
or
3)
HbA1c values
that are currently exceeding 7 %.
8]
Multiple medications and/or multiple-dosage,
intensive insulin dosages or insulin-pump technique may be all considered. KTRs requiring insulin therapy are
better referred early to a specialized endocrinologist.
N.B. This Blogger is created to declare the development of diabetes mellitus after transplantation (NODAT).
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