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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 5  |  Page : 842-845
Post-transplantation diabetes mellitus; frequency and related risk factors: A single center study


Urmia University of Medical Sciences, Department of Internal Medicine, Imam Khomeini Training Hospital, Urmia, Iran

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Date of Web Publication31-Aug-2010
 

   Abstract 

Post-transplantation Diabetes Mellitus (PTDM) is a serious complication after organ transplantation, which could lead to cardiovascular morbidity and mortality. The rate of PTDM increased in recent years, probably due to new immunosuppressive drugs such as Tacrolimus. In this study, we retrospectively evaluated the frequency of PTDM and related risk factors in 644 non diabetic patients who underwent renal transplantation. Data was analyzed by chi-square and Fisher's exact test in SPSS software ver11.5. Among 644 patients PTDM developed in 10.2% similar to literature. PTDM was significantly correlated to age (P value = 0.000), positive familial history (P= 0.003) and HBV infection (P= 0.046). In conclusion, PTDM is not uncommon in Iranian patients and a positive family history of diabetes, HBV infection and older age increases the likelihood to develop PTDM.

How to cite this article:
Ghafari A, PourAli R, Sepehrvand N, Hatami S, Modarres V. Post-transplantation diabetes mellitus; frequency and related risk factors: A single center study. Saudi J Kidney Dis Transpl 2010;21:842-5

How to cite this URL:
Ghafari A, PourAli R, Sepehrvand N, Hatami S, Modarres V. Post-transplantation diabetes mellitus; frequency and related risk factors: A single center study. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Sep 21];21:842-5. Available from: http://www.sjkdt.org/text.asp?2010/21/5/842/68877

   Introduction Top


Improvement of graft survival after transplan­tation in the last decade has increased the car­diovascular disease as the major cause of morbi­dity and mortality in the post transplant period.

Some studies demonstrated that PTDM is a strong, independent predictor of graft failure and mortality. [1]

Risk factors for post-transplant diabetes mel­litus (PTDM) in kidney transplant recipients are classified into two groups: A group of risk fac­tors similar to those in the non-transplant popu­lation, such as aging, obesity, and race. Where­as immunosuppressive medications are specific for the transplant recipients.

The incidence of PTDM has changed over the past decade with changes in definition, immu­nosuppressant regimens, and patient demogra­phics. [1],[2],[3],[4],[5],[6],[7],[8]

This study aimed to review the incidence of post-transplantation diabetes mellitus (PTDM) and risk factors for its development among renal transplant recipients in Urmia, Iran.


   Material and Method Top


All consecutive, non-diabetic, End-Stage Renal Disease (ESRD) patients who underwent renal transplantation (644 graft recipients) from in­ception of transplantation in our center (Urmia, Iran) until 2007 were enrolled in a retrospective cross-sectional descriptive study.

PTDM was defined in patients with no prior history of diabetes mellitus and having the following:

  • Symptoms of diabetes (Polyuria, polydipsia and unexplained weight loss) plus random plasma glucose > 200 mg/dL.
  • Fasting plasma glucose > 126 mg/dL (7.1 mmol/L)
The patients with these criteria defined as PTDM if there is no history of DM before renal trans­plantation.

The factors investigated in our study are inclu­ding: age, sex, pre-transplant CMV-Ab, sessions of transplantation, family history of DM among near relatives, duration of HD before renal transplant, duration of post transplant period be­fore PTDM, immunosuppressive regimen, func­tion of graft, post-transplant, pulse therapy, BMI, HBsAg, HCVAb. Data extracted from patient's medical records.

Collected data were analyzed by means of des­criptive statistics, Chi-square and Fisher's exact test in the statistical software of SPSS ver11.5.


   Results Top


Among 644 renal allograft recipients, 350 pa­tients (54.3%) were male and the mean Age was 41 ± 13.8 years (12 - 82). The frequency of post-transplant diabetes mellitus was 10.2% (66). Various factors were associated with the deve­lopment of PTDM, [Table 1]. Subjects were cla­ssified by age into three categories: < 40 years old, 40-69 years, and > 70 years old. Frequency of PTDM in these groups was 3.8%, 15.6% and 20.3% respectively. The difference between these groups was significant and PTDM was more prevalent among elderly (P< 0.001),

Forty subjects transplanted for the second time, however no significant relationship between num­ber of transplant and development of PTDM (P= 0.957).
Table 1 :Various factors related to the development of post transplant diabetes mellitus.

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Eighty five patients had a positive familial his­tory for DM, which was significantly associated with PTDM (20% vs 8.8%; P= 0.003).

Duration of HD in the pre transplant period had no impact on the development of PTDM (P= 0.143).

Twelve cases (18.2%) of PTDM cases deve­loped new onset diabetes mellitus in the first month after Tx, 24 (36.4%) between 2 nd and 12 th months, eight cases (12.1%) between 12 th and 24 th months and finally 22 (33.3%) cases developed PTDM after two years post-trans­plant.

One hundred eighty nine patients took Cell­cept in their immunosuppressive regimen and the PTDM did not develop as frequently (12.2% vs to 9.6%; P= 0.175).

Graft recipients were classified by BMI into four categories: < 18.5, 18-25, 25-29 and > 30, with a frequency of PTDM 5.4%, 8.8%, 11.1% and 13% respectively (P= 0.405).

Fourteen recipients were HBsAg+ having more likelihood of development of PTDM (P= 0.046).

HCVAb was present in seven cases with PTDM (P= 0.55).

There was no significant relationship between sessions of pulse therapy and development of PTDM in our study (P= 0.193).

Among patients who developed DM after trans­plant, 44 (66.7%) were treated by insulin, 16 (24.2%) were treated with oral agents, and fi­nally plasma glucose was controlled by nutri­tional regimen and physical activity in 6 (9.1%) patients.


   Discussion Top


The frequency of post-transplant diabetes mel­litus in this study was 10.2% (66 patients), which is similar to the literature. A meta-analysis per­formed by Heisel et al to assess the incidence of new onset diabetes mellitus (NODM) reported incidence of 13.4% after solid organ transplan­tation. [2]

A comparative analysis with renal transplant waiting-list patients noted that NODM occurred among approximately six percent per year among dialysis patients. [3] While Woodward et al found the incidence of NODM of approximately 6% per year among wait-listed dialysis patients, compared to 18% over the first two years post­transplant. [3]

Varied definitions in the literature have made it difficult to assess the true incidence of post­transplant diabetes or to assess the importance of different risk factors for its development. [2] Different follow up periods in these studies can explain the difference in the prevalence of PTDM in different studies. We applied the 2003 American Diabetes Association and World Health Organization experts committee definition to identify PTDM in our study.

The literature confirms correlation between several factors and the development of PTDM. Some factors mentioned in the literature such as ethnicity [4] are permanent. Some of these factors are potentially modifiable, such as obesity. [5],[6],[7],[8] We however did not find significant relation­ship between BMI and PTDM in this study.

The PTDM is more prevalent among senior recipients [1],[4],[5],[6],[7] similar to the prevalence of DM in the general population.

Despite the correlation revealed in several stu­dies among HCV infection and PTDM, [1],[8],[9] there was no significant difference between the HCV Ab level among two groups with and without PTDM. This may be due to the small number of HCV patients in our study. But we found a cor­relation between HBsAg positivity and deve­lopment of PTDM.

A significant relationship between positive fa­mily history for diabetes mellitus and develop­ment of PTDM, was noted in our study as well as by others. [10],[11]

As mentioned in the literature, Tacrolimus (TRL) increases the incidence of new-onset diabetes mellitus after transplantation. [1],[8],[12],[13] All of our patients received cyclosporine (CsA) and prednisone as their immunosuppressive therapy.

Some of our patients received Mycophenolate Mofetil (Roche), which was demonstrated in some studies to have a protective effect against PTDM. [1] We however did not find any signi­ficant relation.

New-onset diabetes after transplantation has been identified as one of the most important factors, being associated with reduced graft function and patient survival, and increased risk of graft loss. [14]

In conclusion, our study demonstrated age, fa­mily history for DM, and HBsAg positivity as significant risk factors for the development of PTDM. In patients with these risk factors one should remain vigilant in detection and ma­nagement of DM to avoid long term compli­cations.


   Acknowledgment Top


The authors would like to thank Urmia Uni­versity of Medical sciences for the grants pro­vided for our study.

 
   References Top

1.Kasiske BL, Snyder JJ, Gilbertson D, Matas AJ. Diabetes mellitus after kidney transplantation in the United States. Am J Transplant 2003;3(2): 178-85.  Back to cited text no. 1      
2.Heisel O, Heisel R, Balshaw R, Keown P. New onset diabetes mellitus in patients receiving calcineurin inhibitors: a systematic review and meta-analysis. Am J Transplant 2004;4(4):583-­95.  Back to cited text no. 2      
3.Woodward RS, Schnitzler MA, Baty J, et al. Incidence and cost of new onset diabetes mel­litus among U.S. wait-listed and transplanted renal allograft recipients. Am J Transplant 2003; 3(5):590-8.  Back to cited text no. 3      
4.Montori VM, Basu A, Erwin PJ, Velosa JA, Gabriel SE, Kudva YC. Post-transplantation diabetes: a systematic review of the literature. Diabetes Care 2002;25(3):583-92.  Back to cited text no. 4      
5.Cosio FG, Pesavento TE, Kim S, Osei K, Henry M, Ferguson RM. Patient survival after renal transplantation: IV. Impact of post-transplant diabetes. Kidney Int 2002;62(4):1440-6.  Back to cited text no. 5      
6.Cosio FG, Pesavento TE, Osei K, Henry ML, Ferguson RM. Post-transplant diabetes mellitus: increasing incidence in renal allograft recipients transplanted in recent years. Kidney Int 2001;59 (2):732-7.  Back to cited text no. 6      
7.Foo SM, Wong HS, Morad Z. Risk factors and incidence of post-transplant diabetes mellitus in renal transplant recipients. Transplant Proc 2004; 36(7):2139-40.  Back to cited text no. 7      
8.Shah T, Kasravi A, Huang E, et al. Risk factors for development of new-onset diabetes mellitus after kidney transplantation. Transplantation 2006; 82(12):1673-6.  Back to cited text no. 8      
9.Bloom RD, Rao V, Weng F, Grossman RA, Cohen D, Mange KC. Association of hepatitis C with post-transplant diabetes in renal transplant patients on tacrolimus. J Am Soc Nephrol 2002; 13(5):1374- 80.  Back to cited text no. 9      
10.Romagnoli J, Citterio F, Nanni G, et al. Inci­dence of post-transplant diabetes mellitus in kidney transplant recipients immunosuppressed with sirolimus in combination with cyclos­porine. Transplant Proc 2006;38(4):1034- 6.  Back to cited text no. 10      
11.Romagnoli J, Citterio F, Violi P, Cadeddu F, Nanni G, Castagneto M. Post-transplant diabetes mellitus: a case-control analysis of the risk factors. Transplant Proc 2005;18(3):309-12.  Back to cited text no. 11      
12.Bouchta NB, Ghisdal L, Abramowicz D, et al. Conversion from tacrolimus to cyclosporin is associated with a significant improvement of glucose metabolism in patients with new-onset diabetes mellitus after renal transplantation. Transplant Proc 2005;37(4):1857-60.  Back to cited text no. 12      
13.Ghisdal L, Bouchta NB, Broeders N, et al. Conversion from tacrolimus to cyclosporine A for new-onset diabetes after transplantation: a single-centre experience in renal transplanted patients and review of the literature. Transplant Int 2008;21(2):146-51.  Back to cited text no. 13      
14.Wilkinson A, Davidson J, Dotta F, et al: Guide­lines for the treatment and management of new­onset diabetes after transplantation. Transplant 2005;19(3):291-8.  Back to cited text no. 14      

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Correspondence Address:
Nariman Sepehrvand
Students' Research Committee, Urmia University of Medical Sciences, Urmia, West-Azerbaijan
Iran
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PMID: 20814117

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    Abstract
    Introduction
    Material and Method
    Results
    Discussion
    Acknowledgment
    References
    Article Tables
 

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