According to the guidelines an important step towards minimizing the risk of developing new-onset diabetes after transplantation is the close monitoring of the two modifiable risk factors for new-onset diabetes, obesity and immunosuppressive therapy. In addition to counseling patients on the importance of weight control and physical activity, the guidelines recommend that clinicians carefully consider the selection of immunosuppressive agents, at the time of the introduction of immunosuppression and at any time thereafter that diabetes develops. They should assess the individual's diabetes and cardiovascular risk profile in conjunction with the diabetes risk and immunosuppressive efficacy associated with each agent. Studies show that of the immunosuppressive drugs available, corticosteroids and tacrolimus have the greatest impact on the development of new-onset diabetes. Clinicians are also advised to actively assess risk factors such as: patient age, ethnic background, family or gestational history of diabetes, and hepatitis C infection when making these decisions and advising patients of their risk of becoming diabetic.
New-onset diabetes after transplantation increases the risk of organ failure by 63%, increases the long-term risk of cardiovascular disease and increases the risk of death by 87%.ii The prevalence has been largely underestimated due to the lack of consensus regarding the definition and management of the condition. Furthermore, patients are not routinely screened for hyperglycemia (high blood sugar) post transplantation.
To assist clinicians in the diagnosis and management of new-onset diabetes after transplantation the guidelines offer a number of management and treatment algorithms. They advocate the standardization of the definition of new-onset diabetes after transplant by adopting the currently accepted definition for diabetes mellitus that has recently been defined by WHO, IDF, ADA, and ACE.
"The new guidelines meet a real need amongst the medical community", commented Professor Jaime Davidson, Clinical Associate Professor of Medicine, University of Texas Southwestern Medical School, Texas, USA, and co-chair of the consensus guidelines expert panel. "It is vital that transplant recipients at risk of developing diabetes are appropriately monitored and managed - undergoing a transplant is a huge emotional and physical investment for the patient and it is essential that we do everything we can to ensure the survival of the organ and the patient."
"New-onset diabetes after transplantation is a serious complication which needs to be effectively controlled from the outset." commented Dr Wilkinson, Director of the UCLA Kidney and Kidney-Pancreas Transplant Programs, LA, USA, and also co-chair of the consensus guidelines expert panel. "It is one of the complications most feared by patients contemplating transplantation. I strongly urge transplant clinicians to adopt the management strategies that these guidelines recommend. Effective management could reduce the numbers of patients affected and proper care of diabetes can significantly help to ensure that the transplant is a success in the long term, that the patient's quality of life is maintained and that healthcare management costs are kept down. It is also important that the ADA/WHO guidelines are used in clinical research studies when reporting the incidence of new onset diabetes."
NOTE TO EDITORS
Contributors to the New-Onset Diabetes After Transplantation International Consensus Guidelines include:
Prof J Davidson (Chair) Endocrine & Diabetes Association of Texas, University of
Texas Southwestern Medical School USA
Prof A Wilkinson (Chair) UCLA School of Medicine, USA
Prof B Kiberd
Prof M Markell Dalhousie University, Canada
SUNY Downstate Medical Centre, USA
Prof B Kasiske University of Minnesota Medical School, USA
Dr P Marchetti University of Pisa, Italy
Prof F Dotta University of Rome, Italy
Prof C Legendre Hopital Saint Louis, France
Prof J Dantal Hopital Hotel Dieu, France
Dr H Haller Kliniken der Med Hochschule Nephrologie, Germany
Prof F Van der Woude Klinikum Mannheim, Germany
Dr A Krentz Southampton General Hospital, UK
Dr D Wheeler Centre of Nephrology, UK
Dr D Hernández Hospital Universitario de Canarias, Spain
The New-Onset Diabetes After Transplantation International Consensus Guidelines were sponsored by an unrestricted educational grant from Novartis Pharma AG.
[i] Montori VM, Velosa JA, Basu A, Gabriel SE, Erwin PJ, KudvaYC, Post transplantation diabetes. A systematic review of the literature. Diabetes Care 2002; 25:583-92
[ii] Kasiske BL, Snyder JJ, Gilbertson D, Matas AJ. Diabetes Mellitus after Transplantation in the United States. Am J Transplant 2003; 3:178
[iii] Lindholm A, Albrechtsen D, Frodin L, Persson NH, Lundgren G. Ischemic heart disease * major cause of death and graft loss after renal transplantation in Scandinavia. Transplantation 1995; 60: 451
[iv] World Health Organisation, International Diabetes Federation, American Diabetes Association, and the American College of Endocrinologists