New-onset diabetes after transplantation

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Abstract

For many years new-onset diabetes after transplantation has been recognized as a complication of solid-organ transplantation, although its importance has been greatly underestimated. Studies have shown that the cumulative incidence of this condition in heart transplant recipients may reach 32% at 5 years, similar to that reported in kidney and liver transplant patients. Several factors predispose to increased risk for developing new-onset diabetes after transplantation, including age, ethnicity, family history of diabetes, obesity and immunosuppressive therapy. Corticosteroids are associated with the greatest risk of developing the condition. Tacrolimus is more diabetogenic than cyclosporine in kidney and liver transplant patients, but there are few data reporting the effects of these agents in heart transplant patients. In kidney transplant patients, diabetes is known to be a significant risk factor for cardiovascular disease post-transplant. Although this has yet to be demonstrated clearly in heart transplant patients, evidence suggests that new-onset diabetes after transplantation may play a role in the development of cardiac allograft vasculopathy (CAV). Because CAV is the major limitation to long-term survival in this population, it is clear that efforts should be made to reduce the risk of diabetes and treat this condition appropriately. Management of transplant recipients with new-onset diabetes after transplantation has been assisted by the recent publication of International Consensus Guidelines. The guidelines were developed to establish a standard definition and describe risk factors for new-onset diabetes after transplantation. Use of these guidelines will help to prospectively identify those at risk of developing new-onset diabetes after transplantation so that therapeutic strategies can be individualized early in the treatment regimen. These management approaches should help to lower the risk of new-onset diabetes after heart transplantation and reduce the possible long-term consequences of the condition.

Section snippets

Incidence of new-onset diabetes after transplantation

The precise incidence of new-onset diabetes after transplantation has been difficult to determine due to the lack, until recently, of a consensus regarding the definition of the condition. Furthermore, the incidence of the condition in many studies is underestimated, because the observation periods are too short (<1 year). Indeed, the risk of developing new-onset diabetes has been shown to increase progressively post-transplant, and patients may still develop the condition up to 15 years after

Risk factors for the development of new-onset diabetes after transplantation

There are no well-established risk factors for new-onset diabetes after heart transplantation; however, a number of characteristics have been identified for kidney and liver transplant patients that appear to predispose individuals to the development of the condition (Table 1). 17, 18, 19, 20 In particular, there is good evidence that patients with a family history of diabetes among first-degree relatives and those of Hispanic or African American ethnicity have a greater risk of developing

Impact of new-onset diabetes after transplantation

The precise impact of new-onset diabetes on the outcome of heart transplant patients is difficult to assess as few studies have described the condition in this population. Some reports have shown that patients with diabetes at the time of heart transplantation have a poorer outcome than those without the condition.6, 7, 43 In particular, heart transplant patients with diabetes have an increased risk of serious infection; within 3 months post-transplant, the infection rate among patients with

Guidelines for the management of new-onset diabetes after transplantation

It is now recognized that the prevention of new-onset diabetes after transplantation, and early detection and appropriate treatment of patients who develop diabetes, are key considerations for the management of transplant recipients and can ameliorate the long-term consequences of the condition. Until recently, precise guidance on the management of transplant recipients at risk of developing diabetes was lacking. However, in 2003, International Consensus Guidelines (ICG) on new-onset diabetes

Conclusions

New-onset diabetes after transplantation is a serious complication of organ transplantation. Its cumulative incidence in heart transplant recipients may reach 32% at 5 years, similar to that reported in kidney and liver transplant patients. Despite the paucity of data reporting the impact of new-onset diabetes after transplantation in heart transplant patients, it would appear reasonable that early detection and appropriate treatment may have an impact on transplant outcomes in this population.

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