Undiagnosed diabetes can be dangerous, and a diagnosis of post-transplant diabetes (PTDM) is especially critical following a bone marrow or solid organ transplantation because it can directly affect the patient’s outcome.

“[PTDM] is a term that is reserved for when the disease is diagnosed after transplantation. That doesn’t mean that the diabetes would not have existed pretransplant. It’s just undiagnosed,” said Archana R. Sadhu, MD, FACE, Weill Cornell Medicine. “Or maybe it was in an early stage, but it gets unmasked after transplant.”           

Dr. Sadhu opened the Sunday, June 23, symposium Diabetes and Organ Transplantation—Pathophysiology, Inpatient, and Outpatient Management. The session can be viewed on-demand by registered meeting participants on the virtual meeting platform. If you haven’t registered for the 84^th Scientific Sessions, register today to access the valuable meeting content through Aug. 26.

PTDM is the most common metabolic complication following a liver transplant. It can result in complications due to adhesions, infections, and bleeding, said Palak Choksi, MD, University of Colorado Anschutz Medical Campus.         

“We also know that post-transplant diabetes affects survival,” Dr. Choksi said. “This is similar to data in liver transplant as well, where preexisting diabetes and PTDM will affect survival compared to those individuals who do not have diabetes.”

However, the prevalence or incidence of PTDM is highly variable in the literature, Dr. Sadhu said.

“It is reported to be up to 30 percent in kidney transplants, and even up to 40–50 percent for liver transplant, and that has to do with underlying metabolic states of the patients,” she said.     

The discrepancies in the statistics could be attributed to a lack of consensus in diagnostic criteria, Dr. Sadhu explained. Risk factors for PTDM can be categorized into those related to transplantation and those unrelated to transplantation.

“Unrelated to transplantation is everything for type 2 diabetes, as you would imagine: age, ethnicity, BMI, presence of glucose intolerance or prediabetes, all the things that we normally categorize for patients who are not transplants,” Dr. Sadhu said. “There are some unique things that happen with transplantation.”

Other risk factors for type 2 diabetes unrelated to transplantation are male gender, sedentary lifestyle, and genetic factors.

Among the risk factors associated with transplantation are different types of immunosuppressants, such as glucocorticoids and calcineurin inhibitors; coinfections and viral infections, such as hepatitis C; and post-transplant weight gain.     

“Weight gain is a very common occurrence after transplant, particularly if you do the steroids,” Dr. Sadhu said. “But also, the patients are now healthier, eating more, and becoming more generalizable patients.”          

PTDM typically peaks one year after transplantation and is ongoing after that. Around the 12-month mark is when clinicians are more vigilant in terms of what they change for the patient to facilitate appropriate screening, early diagnosis, and early treatment.

While there’s potential benefit in lifestyle changes for post-transplant patients, what happens after the patient goes home is important to consider, as well as patient goals and any regimen changes.

“As much as we talk about all this, you really don’t know what a patient is going to need, and the only way to find that out is by looking at the patient,” said Robert J. Rushakoff, MD, University of California, San Francisco, who discussed diabetes and kidney transplantation.

He shared observational findings of sodium-glucose cotransporter-2 (SGLT2) inhibitor use after renal transplantations. SGLT2 inhibitors are generally used for kidney disease and heart failure, and to reduce the risk of those complications.

“The theory of SGLT use is they should be the best drug, right off the bat, because in renal transplantation you have post-transplanters increase glomerular hyperfiltration and that causes glomerular injury. And hyperfiltration is clearly an adverse effect that leads to unfavorable long-term kidney outcomes,” Dr. Rushakoff said. “What about SGLT2s? Well, they reduce glomerular hyperfiltration. It’s a no-brainer, and so it’s possible these are going to improve long-term allograft outcomes.”