New-Onset Diabetes After Transplantation 2003 International Consensus Guidelines
An endocrinologist’s view
Article Figures & Tables
Figures
- Figure 1—
Incidence of diabetes before and after transplantation in patients receiving tacrolimus (—) or cyclosporine (- - -). At 1 year posttransplant, the incidence of new-onset diabetes was significantly lower in patients receiving cyclosporine than in those receiving tacrolimus (14.1 vs. 22.9%; P < 0.0001). (From Woodward RS, Schnitzler MA, Baty J, et al.: Incidence and cost of new onset diabetes mellitus among U.S. waitlisted and transplanted renal allograft recipients. Am J Transplant 3:590–598, 2003, with permission from Blackwell Publishing Ltd.)
- Figure 2—
Algorithm summarizing the recommended management for transplant recipients with new-onset diabetes. (From Davidson JA, Wilkinson A, Dantal J, et al.: New-onset diabetes after transplantation: 2003 international consensus guidelines. Transplantation 75:SS3–SS24, 2003, with permission from Lippincott Williams & Wilkins.)
Tables
- Table 1—
RR for ischemic heart disease among transplant recipients >1 year after kidney transplantation (8)
Risk factor Men Women Control Transplant recipient Control Transplant recipient Age (years) 1.05 1.06* 1.40 1.10 Cholesterol (mg/dl) <160 0.52 0.00† 0.77 0.00† 160–199 1.00‡ 1.00‡ 1.00‡ 1.00‡ 200–239 1.19 2.39 1.23 2.07 240–279 1.66 2.02 1.28 2.44 >280 1.93 2.25 1.71 1.84 Blood pressure (mmHg) <120 and <80 1.00 0.25 0.59 0.56 120–129 or 80–84 1.00‡ 1.00‡ 1.00‡ 1.00‡ 130–139 or 85–89 1.33 1.05 0.93 1.26 140–159 or 90–99 1.68 1.19 1.30 1.63 ≥160 or ≥100 1.86 1.47 1.59 0.31 Diabetes 1.53 2.78* 1.82 5.40* Smoking 1.69 1.95* 1.34 1.82 A RR of ≥1.00 indicates a higher or lower risk for ischemic heart disease, respectively. Control subjects are from the Framingham Heart Study.
- *
↵* P < 0.05 compared with reference risk values for transplant recipients;
- †
↵† too few patients were available to reliably assess this risk;
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↵‡ reference risks for cholesterol levels and blood pressure are indicated by 1.00.
- Table 2—
Different aspects of the management of transplant recipients with new-onset diabetes and differences from management of patients with diabetes in the general population
Management aspect Recommendation/frequency of testing Comments/similarity with general management of type 2 diabetes FPG testing • Weekly for first month posttransplant • Used to identify patients with abnormal glucose regulation • At 3, 6, and 12 months • Annually after the first year OGTT testing • Consider for patients with normal FPG or those with IGT • Utility of test not validated in this population Tailoring immunosup-pressive therapy • Decrease corticosteroids as soon as possible • Complete withdrawal of corticosteroids not recommended due to risk of acute rejection • Consider switch to cyclosporine in poorly controlled tacrolimus-treated patients Self-monitoring of blood glucose • Essential component of management for patients receiving oral agents/insulin • Similar to recommendation for patients with type 2 diabetes • Useful for patients on nonpharmacologic therapy Lipid levels • Evaluate annually • Similar to recommendation for patients with type 2 diabetes A1C • Measure every 3 months; intervention for A1C ≥6.5% • Same target as IDF and ACE • Interpret test with care in patients with anemia/kidney impairment Diabetic complications • Screen annually • Similar to recommendation for patients with type 2 diabetes Microalbuminuria • Consider annual screening • Not validated in this population Oral agent monotherapy • Make choice of agent mainly on safety • Comparative efficacy of agents not investigated in this population • Consider possibility of serious adverse events in patients with kidney impairment Combination therapy • Use same combinations as used for patients with type 2 diabetes • No combinations tested in this patient population Insulin + oral agents • Consider for patients poorly controlled with com-bination therapy • Not tested in this patient population Dyslipidemia • Aggressive lipid-lowering as detailed by NCEP • All patients considered at high risk of CHD Hypertension • Reduction of blood pressure <130/80 mmHg • Same target recommended by ADA • Value of blood pressure lowering not tested in this population CHD, coronary heart disease; NCEP, National Cholesterol Education Program.
In this Issue
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- Article
- INCIDENCE OF NEW-ONSET DIABETES AFTER TRANSPLANTATION
- IMPACT OF NEW-ONSET DIABETES AFTER TRANSPLANTATION
- PREDICTIVE FACTORS FOR NEW-ONSET DIABETES AFTER TRANSPLANTATION
- SIMILARITIES BETWEEN NEW-ONSET DIABETES AND TYPE 2 DIABETES
- MANAGEMENT OF PATIENTS WITH NEW-ONSET DIABETES AFTER TRANSPLANTATION
- SUMMARY
- APPENDIX
- Footnotes
- References
- Figures & Tables
- Info & Metrics