Post-Transplantation Diabetes: Strategies Needed

Post-transplantation diabetes (PTDM) is a common occurrence after solid-organ transplantation. Between 4 and 25% of transplant recipients develop this problem.

PTDM increases the risk of death from cardiovascular and infectious complications and is associated with increased morbidity, mortality, and health care costs. Few studies have addressed strategies for hyperglycemia management in the post-transplant population.

Selecting therapy is complicated by the need to find drugs and biologics that do not interact with immunosuppressant agents.

Patients' fluctuating renal/end-organ function and nutritional status are also important factors.

The journal Endocrine Practice began to fill the information void with an analysis of available studies. These researchers — a group from Icahn School of Medicine at Mount Sinai, New York, New York – addressed hyperglycemia management of PTDM/new-onset diabetes after transplant (NODAT).

In most cases, patients with PTDM develop β-cell dysfunction and sensitivity in liver, muscle and adipose tissue. Some studies have identified calcineurin inhibitors as increasing risk, and reported that switching from tacrolimus to cyclosporine A could reduce risk of NODAT.

Among the 25 publications that studied glucose-lowering therapies eligible for review, most were retrospective studies.

These researchers found that insulin therapy during the early post-transplantation period seemed to prevent PTDM development. This is especially important in hospitalized patients, and clinicians should target blood glucose levels of less than 180 mg/dL while avoiding levels lower than 70 mg/dL.

Retrospective studies discovered that thiazolidinediones address hyperglycemia well. However, this class of drugs has been associated with weight gain and fluid retention.

The researchers found little evidence that considered or supported metformin, sulfonylureas, or meglitinides directly.

Incretins have shown promising results in small prospective studies using sitagliptin, linaglitpin, and vildagliptin and a case series using liraglutide. The DPP-inhibitors have few interactions with immunosuppressant drugs.

Evidence-based treatment regimens used in patients with type 2 diabetes mellitus are useless in patients with PTDM. More good-quality studies are needed, and the need is pressing.