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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2000  |  Volume : 11  |  Issue : 4  |  Page : 559-562
Post-Transplant Diabetes Mellitus in Kidney Transplant Recipients with Special Reference to Association with HLA Antigens


Transplant Unit, Armed Forces Hospital, Southern Region, Khamis Mushayt, Saudi Arabia

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   Abstract 

One hundred fifty three kidney transplant recipients whose grafts functioned for longer than one year were evaluated for evidence of post-transplant diabetes mellitus (PTDM). Twenty-six patients (17%) developed PTDM. Patients with PTDM were older than controls (mean age 49.4 vs 37.9 years). There was no demonstrable association between sex of patients and PTDM. The body mass index (BMI) was persistently higher in patients with PTDM compared to controls, although the difference did not amount to statistical significance. The association of PTDM with HLA-A28, A30 and B8 observed in other studies was not seen in our patients. Similarly, neither the positive association of HLA-DR3 and DR4, nor the negative association of HLA-B7 and DR2 seen in population­based studies of insulin dependent diabetes mellitus, were seen in our patients with PTDM. To our knowledge, this is the first report that has looked into the association of HLA antigens and PTDM in Saudi Arabia.

Keywords: Post-transplant diabetes mellitus, Kidney transplantation, HLA antigens.

How to cite this article:
Addous A, Mohamed A S, Ismail G, Al-Hashemy A. Post-Transplant Diabetes Mellitus in Kidney Transplant Recipients with Special Reference to Association with HLA Antigens. Saudi J Kidney Dis Transpl 2000;11:559-62

How to cite this URL:
Addous A, Mohamed A S, Ismail G, Al-Hashemy A. Post-Transplant Diabetes Mellitus in Kidney Transplant Recipients with Special Reference to Association with HLA Antigens. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2019 Nov 20];11:559-62. Available from: http://www.sjkdt.org/text.asp?2000/11/4/559/36643

   Introduction Top


Post-transplant diabetes mellitus (PTDM) is a well-recognized complication of organ transplantation that has a prevalence rate ranging from 3 to 20%. [1] The prevalence of diabetes mellitus (DM) in the adult population of Saudi Arabia is 7 to 14% which is amongst the highest in the world. [2] The reported prevalence of PTDM in kidney transplant recipients from Saudi Arabia ranges from 9.2 to 41.4%. [3],[4] We undertook this study to determine the prevalence rate, clinical characteristics and risk factors of PTDM in kidney transplant recipients in our region.


   Materials and Methods Top


The records of all patients who underwent kidney transplantation at the Armed Forces Hospital, Southern Region, between March 1989 and September 1997 were reviewed. During this period, a total of 190 (119 living related and 71 cadaveric) kidney transplant operations were performed in our unit. For the purpose of this study, patients with history of diabetes mellitus prior to transplantation, recipients under 18 years of age and patients whose graft functioned for less than one year were excluded. Thus, a total of 153 patients, who constituted the subjects of this study, were evaluated for evidence of PTDM, which was defined as the finding, on more than two occasions, of fasting blood sugar of > 7.8 mmol/L or random blood sugar of >11.1 mmol/L.

Our immunosuppression protocol consisted of triple therapy with cyclosporine (10 mg/kg/day initially, which was later adjusted according to cyclosporine blood levels), prednisolone (0.5 mg/kg/day) and azathioprine (2 mg/kg/day). Acute rejection episodes were treated with pulse methyl­prednisolone (0.5 to 1 gm/day for 3-5 days). Anti-thymocyte globulin was used in steroid resistant rejections only.

Time of onset of PTDM since transplant, the clinical presentation as well as the modality of treatment used for control of diabetes were noted. We analyzed the association of age, body mass index (BMI) (weight in kg/height in m 2 ), sex, and HLA antigens with PTDM.


   Results Top


Of the 153 kidney recipients whose grafts functioned for over one year, 26 (17%) developed PTDM. Seventeen of the 26 patients (65%) developed PTDM within the first three months following transplantation while 20 of the 26 patients (76.9%) developed PTDM within one year after transplantation. The majority of patients with PTDM (24/26, 92.8%) were asympto­matic and diagnosis was made on the basis of finding elevated blood sugar levels during routine follow-up. Two patients presented with diabetic ketoacidosis. Seven patients (26.9%) required insulin for proper control of the diabetes, 11 (42.3%) were on oral hypoglycemics, while eight others (30.7%) could be managed on diet alone. The mean age of patients with PTDM was signifi­cantly higher than that of the non-diabetic controls (49.4 ± 11.7 years versus 37.9 ± 11.8 years) [Table - 1]. There was no association between sex of the patient and PTDM [Table - 1]. The BMI at the time of transplantation, as well as three, six and 12 months after transplantation, were all higher in patients with PTDM than the controls, although the difference did not amount to statistical significance [Table - 1]. There was no association between the HLA antigens A28, A30, B7, B8, DR2, DR3 or DR4 and PTDM [Table - 2].


   Discussion Top


The 17% prevalence rate of PTDM observed in our unit is in keeping with the rates reported in literature. [1] The clinical presentation of PTDM in our patients is similar to what has been reported by others; the majority were symptom-free and were diagnosed on the basis of high blood sugar detected during routine follow-up. [5],[6] Two of our patients however, presented with diabetic ketoacidosis as the first manifes­tation of PTDM. One of these two patients was critically ill with aspiration pneumonia and had required prolonged stay in the intensive care unit because of respiratory failure needing ventilatory support. The second patient with ketoacidosis had no apparent precipitating factor for the ketoacidosis. At last follow-up the diabetic state of both these patients was well controlled with oral hypoglycemic agents. The onset of PTDM was within the first three months after kidney transplantation in 65.4% and within the first year in 76.9% of the patients as is the experience of others. [5],[6] In contrast to the finding of other workers, where insulin was required in majority of the patients with PTDM, only seven (26.9%) of our patients needed insulin therapy and 11 (42.3%) were controlled on oral hypoglycemics agents. [5] Eight patients (30.7%), who were initially on insulin or oral hypoglycemics agents, could sub­sequently be controlled on diet alone. Maintenance prednisolone was withdrawn in nine patients with PTDM. The long-term consequences of prednisolone withdrawal in this group of patients are being analyzed.

The association of PTDM with HLA-A28, A30 and B8 observed in some studies, was not seen in our patients. [7],[5],[8] The positive association of HLA-DR3 and DR4 and the negative association of HLA-B7 and DR2 seen in population-based studies of insulin dependent diabetes mellitus was also not seen in our patients with PTDM. [8] To our knowledge, this is the first report that has looked into the association of HLA antigens and PTDM in Saudi Arabia.

In summary, PTDM occurred in 17% of our kidney recipients, 65.4% of whom presented within the first three months. All but two of our patients, who presented with diabetic ketoacidosis as the first manifes­tation of PTDM, were asymptomatic. There was strong association between age and PTDM. There was no demonstrable association between BMI, sex of the patient or HLA antigens and PTDM. While seven patients needed insulin, others could be managed with oral hypoglycemic agents or dietary manipulation alone.

 
   References Top

1.Jindal RM. Post-transplant diabetes mellitus-a review. Transplantation 1994;58:1289-98.  Back to cited text no. 1  [PUBMED]  
2.Al-Nuaim AR. Prevalence of glucose intole­rance in urban and rural communities in Saudi Arabia. Diabet Med 1997;14:595-602.  Back to cited text no. 2  [PUBMED]  
3.Basri N, Aman H, Adiku W, Baraqdar A, Bonatero I, Nezamuddin N. Diabetes mellitus after renal transplantation. Transplant Proc 1992;24: 1780-1.  Back to cited text no. 3  [PUBMED]  
4.Onwubalili JK, Obineche EN. High incidence of post-transplant diabetes mellitus in a single-centre study. Nehprol Dial Transplant 1992; 7:346-9.  Back to cited text no. 4    
5.Sumrani NB, Delaney V, Ding Z, et al. Diabetes mellitus after renal transplantation in the cyclosporine era-an analysis of risk factors. Transplantation 1991;51:343-7.  Back to cited text no. 5    
6.Boudreaux JP, McHugh L, Canafax DM, et al. The impact of cyclosporine and combination immunosuppression on the incidence of post-transplant diabetes in renal allograft recipients. Transplantation 1987;44:376-81.  Back to cited text no. 6  [PUBMED]  
7.David DS, Cheigh JS, Braun DW Jr, et al. HLA-A28 and steroid-induced diabetes in renal transplant patients. JAMA 1980;243: 532-3.  Back to cited text no. 7  [PUBMED]  
8.von Kiparski A, Frei D, Uhlschmid G, Largiader F, Binswanger U. Post-transplant diabetes mellitus in renal allograft recipients: a matched-pair control study. Nephrol Dial Transplant 1990;5:220-5.  Back to cited text no. 8    

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Correspondence Address:
A Addous
Consultant Nephrologist, Armed Forces Hospital, P.O. Box 101, Khamis Mushayt
Saudi Arabia
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PMID: 18209345

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    Materials and Me...
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