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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 583-586
Morbidity and mortality in Tunisian patients with post-transplant diabetes mellitus


1 Department of Internal Medicine A, Charles Nicolle Hospital, Tunis, Tunisia
2 Department of Internal Medicine A; Research Laboratory of Immunology LR03SP0, Charles Nicolle Hospital, Tunis, Tunisia

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Date of Web Publication24-Apr-2013
 

How to cite this article:
Ali IH, Abderrahim E, Barbouch S, Abdelghani KB, Khiari K, M'chirgui N, Romdhane N, Abdallah NB, Abdallah TB, Kheder A. Morbidity and mortality in Tunisian patients with post-transplant diabetes mellitus. Saudi J Kidney Dis Transpl 2013;24:583-6

How to cite this URL:
Ali IH, Abderrahim E, Barbouch S, Abdelghani KB, Khiari K, M'chirgui N, Romdhane N, Abdallah NB, Abdallah TB, Kheder A. Morbidity and mortality in Tunisian patients with post-transplant diabetes mellitus. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Dec 10];24:583-6. Available from: http://www.sjkdt.org/text.asp?2013/24/3/583/111073
To the Editor,

New-onset diabetes mellitus after organ transplantation is associated with significant impairment of patient and organ survival. [1],[2],[3] It is a frequent complication in kidney transplant recipients and its occurrence poorly affects the morbidity and mortality of these patients. The aim of this retrospective study was to analyze the morbidity and mortality of patients with post-transplant diabetes mellitus (PTDM).

In this case-control study, 51 patients with PTDM were compared with 49 control sub­jects (renal transplant recipients without im­pairment of glucose tolerance). PTDM was de­fined according to the 2003 international con­sensus guidelines. We excluded patients with early graft loss. The two groups were matched for age, gender, period of transplantation, and initial nephropathy. The groups were com­pared regarding the length of stay in hospital, occurrence of hypertension, coronary insuffi­ciency, and other cardiovascular complications including ischemic heart disease, arrhythmia, stroke and peripheral vascular disease. They were also compared regarding the occurrence of hyperlipidemia, infections, neoplasm, urological and iatrogenic complications, as well as mortality.

The mean period of follow-up of patients with PTDM was 8.5 ± 5.5 years versus 6.4 ± 4.6 years in controls. The rate of annual hospitalization in diabetic patients was 43% versus 39% in controls. However, the median dura­tion of hospitalization was 60 days in diabetic patients versus 40 days in non-diabetics (P <0.03).

Complications related to diabetes were rare, but cardiovascular complications including ischemic heart disease, arrhythmia, stroke, and peripheral vascular disease were more frequent in diabetics (29.4% vs. 10.2%, P <0.02).

The different complications encountered in the two groups are shown in [Table 1]. Pseudo­monas urinary infection and cytomegalovirus infection were predominant. The neoplasms seen in patients with PTDM included Kaposi's sar­coma in two cases and gastric adenocarcinoma and cutaneous lymphoma in one patient each. In controls, neoplasms were seen in three patients, and cerebral lymphoma, Kaposi's sarcoma, and pancreas tumor in one patient each.
Table 1: Morbidity among patients with post-transplant diabetes mellitus.

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The annual rate of graft lost was 3.1% in pa­tients with PTDM versus 1.9% in controls [Figure 1]. Global mortality was 16% in pa­tients with PTDM and 18.4% in controls, corresponding to an annual rate of 1.9% in diabetics versus 2.86% in controls (P = NS) [Figure 2].
Figure 1: Actuarial graft survival in patients with and without post-transplant diabetes mellitus.

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Figure 2: Actuarial patient survival in recipients with and without post-transplant diabetes mellitus.

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PTDM is currently considered an important complication of renal transplantation. Its pre­sence is correlated with reduced survival as well as higher frequency of infections ranging from 38% to 53%, [4] rejection, and organ failure. [5],[6],[7] Saleem et al [8] reported that the risk of recurrent infections is 2.57-fold higher in pa­tients with PTDM versus controls, and some authors have shown that infection is the most common cause of mortality in patients with PTDM. [9] In our study, there was no statistically significant difference in the incidence of infec­tions in the two groups. Cardiovascular com­plications are frequent in transplant recipients, especially in diabetic patients. In fact, the risk of mortality by myocardial infarction is 6.4­fold higher in patients with PTDM than in the general population and increases to 20-fold higher in elderly diabetic patients. [10]

Numerous studies have confirmed the high frequency of graft loss in diabetic patients. [8],[11],[12],[13] Kasiske et al [4] observed an increase in rela­tive risk of graft loss of about 46% in diabetic patients. Previous observations confirmed this significant decrease of graft survival starting in the third year after transplantation. [9],[14] In con­trast, in 2007, Joss et al [15] reported no difference in graft survival between diabetic pa­tients and controls. In the present study, dia­betes did not seem to alter the graft survival. In fact, the analysis of actuarial graft survival curve shows no difference between diabetic patients and controls in the short and long run. Concerning the impact of PTDM on survival, many studies have confirmed the high rate of mortality among these patients. [1],[11],[14] However, in this study, we did not find any such impact of PTDM. In fact, global mortality was 16% in diabetic patients and 18.4% in controls, corres­ponding to an annual rate of 1.9% in diabetics versus 2.86% in controls (P = NS). Since it is widely accepted that chronic hyperglycemia itself is related to increased cardiovascular morbidity/mortality, it is important to identify the exposed patients to design the best thera­peutic approach. [16]

In our study, PTDM did not seem to influence either graft or patient survival rates. However, diabetics had greater morbidity as shown by increased rate and duration of hospitalization.

 
   References Top

1.Hjelmesaeth J, Hartmann A, Leivestad T, et al. The impact of early-diagnosed new-onset post­transplantation diabetes mellitus on survival and major cardiac events. Kidney Int 2006;69: 588-95.  Back to cited text no. 1
    
2.Cosio FG, Kudva Y, van der Velde M, et al. New-Onset hyperglycemia and diabetes are associated with increased cardiovascular risk after kidney transplantation. Kidney Int 2005; 67:2415-21.  Back to cited text no. 2
    
3.Eckhard M, Schindler RA, Renner FC, et al. New-Onset Diabetes Mellitus after renal trans­plantation. Transplant Proc 2009;41:2544-5.  Back to cited text no. 3
    
4.Kasiske BL, Snyder JJ, Gilbertson D, Matas AJ. Diabetes mellitus after kidney transplan­tation in the United State. Am J Transplant 2003;3:178-85.  Back to cited text no. 4
    
5.Elmagd MM, Bakr MA, Metwally AH, Wahab AM. Clinico-epidemiologic study of post-transplant diabetes after living-donor renal transplant. Exp Clin Transplant 2008;6:42-7.  Back to cited text no. 5
    
6.Wong YT, Del-Rio-Martin J, Jaques B, Shaw JA, Talbot D. Audit of diabetes in a renal transplant population. Transplant Proc 2005; 37:3283-5.  Back to cited text no. 6
    
7.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.  Back to cited text no. 7
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8.Saleem TF, Cunningham KE, Hollenbeak CS, Alfrey EJ, Gabbay RA. Development of diabetes mellitus post renal transplantation is associated with poor short-term clinical out­comes. Transplant Proc 2003;35:2916-8.  Back to cited text no. 8
    
9.Miles AM, Sumrani N, Horowitz R, et al. Diabetes mellitus after renal transplantation: As deleterious an non- transplant-associated diabetes? Clin Transplant 1998;65:380-4.  Back to cited text no. 9
    
10.Lindholm A, Albrechtsen D, Frödin L, Tufveson G, Persson NH, Lundgren G. Ischemic heart disease- major cause of death and graft loss after renal transplantation in Scandinavia. Transplantation 1995;60:451-7.  Back to cited text no. 10
    
11.Ravindran V, Baboolal K, Moore R. Post transplant diabetes mellitus after renal trans­plantation: The emerging clinical challenge. Yonsei Med J 2004;45:1059-64.  Back to cited text no. 11
    
12.González-Posada JM, Hernández D, Bayés Genís B, García Perez J, Rivero Sanchez M. Impact of diabetes mellitus on kidney transplant recipients in Spain. Nephrol Dial Transplant 2004;19:57-61.  Back to cited text no. 12
    
13.Bernieh B, Nezamuddin N, Sirwal IA, et al. Short-term post transplant follow-up at Madinah Al Munawarah. Saudi J Kidney Dis Transpl 1999;10:493-7.  Back to cited text no. 13
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14.Roth D, Milgrom M, Esquenazi V, Fuller L, Burke G, Miller J. Post transplant hyperglycemia. Increased incidence in cyclosporine-treated renal allograft recipients. Transplantation 1989;47:278-81.  Back to cited text no. 14
    
15.Joss N, Staatz CE, Thomson AH, Jardine AG. Predictors of new onset diabetes after renal transplantation. Clin Transplant 2007;21:136-43.  Back to cited text no. 15
    
16.Hathaway DK, Tolley EA, Blakely ML, Winsett RP, Gaber AO. Development of an index to predict post-transplant diabetes mellitus. Clin Transplant 1993;7:330-8.  Back to cited text no. 16
    

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Correspondence Address:
Insaf Hadj Ali
Department of Internal Medicine A, Charles Nicolle Hospital, Tunis
Tunisia
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DOI: 10.4103/1319-2442.111073

PMID: 23640638

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