Management of metabolic alterations in adult kidney transplant recipients: A joint position statement of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID)

Abstract

Chronic metabolic alterations such as post-transplant diabetes mellitus (PTDM), dyslipidaemias and overweight/obesity significantly impact on kidney transplant (KT) outcomes. This joint position statement is based on the evidence on the management of metabolic alterations in KT recipients (KTRs) published after the release of the 2009 KDIGO clinical practice guideline for the care of KTRs. Members of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID) selected to represent professionals involved in the management of KTRs undertook a systematic review of the published evidence for the management of PTDM, dyslipidaemias and obesity in this setting. The aim of this work is to provide an updated review of the evidence on the prevention, diagnosis and treatment of metabolic alterations in KTRs, in order to support physicians, patients and the Healthcare System in the decision-making process when choosing among the various available options.

Obesity and Post-Transplant Diabetes Mellitus in Kidney Transplantation

“…Concerning lifestyle interventions for the management of obesity and PTDM in kidney transplant recipients, the joint position statement of the Italian Societies of Nephrology Organ Transplantation and Diabetes, suggest to follow the nutritional recommendations developed for the general population with diabetes [ 78 , 79 ]. They also recommend encouraging physical exercise and, in overweight/obese patients, weight loss by offering a weight-reduction program or bariatric surgery if required [ 79 ]. In a study comparing 22 morbidly obese kidney transplant patients who underwent bariatric surgery, with 44 moderate to severely obese patients on lifestyle management, significant reductions in mean BMI at 6 months were observed only in the group with bariatric surgery.…”

“…In addition to insulin treatment, anti-diabetic drugs for PTDM such as metformin, sulfonylureas, meglitinides, and dipeptidyl peptidase IV inhibitors (DPP4-i) have been used in kidney transplant patients according to patient characteristics and renal function as shown in Table 3 [ 41 , 79 ] with no substantial interaction being seen in terms of the pharmacokinetics of tacrolimus, cyclosporine, or m-TOR inhibitors [ 42 ]. In a study that included 14,144 kidney transplant patients with type 2 diabetes mellitus, low risk for all-cause mortality was described in regimens that included metformin compared with those with insulin [ 81 ], something similar to what had been described in the general population [ 82 ].…”

Supporting physicians in the management of metabolic alterations in adult kidney transplant recipients: a comment on the joint position statement of the Italian Society of Nephrology (SIN), the Italian Society for Organ Transplantation (SITO) and the Italian Diabetes Society (SID)

“…Similar to previous guidelines, repeat evaluation of lipid profile is suggested after starting or adjusting treatment, until the target is achieved and annually thereafter, unless otherwise clinically indicated. While an LDL goal of < 100 mg/dL (< 2.6 mmol/L) was previously recommended for all KTRs [1], the joint position statement suggests achieving at least a ≥ 50% LDL-C reduction from baseline in all KTRs, but sets different LDL goals based on the cardiovascular risk profile, suggesting that a lower goal of < 70 mg/dL [< 1.8 mmol/L] for KTRs at very high cardiovascular risk. These goals appear to be realistic and of potential benefit.…”

Obesity and Lifestyle Habits among Kidney Transplant Recipients

“…Obesity is an independent risk factor for the development and progression of CKD, and poses significant challenges in the management of CKD patients [ 6 ]. Of note, obesity often represents a barrier to kidney transplant (KT), and may impact KT outcomes [ 7 , 8 , 9 ]. The prevalence of obesity and obesity-associated chronic metabolic alterations is constantly growing among KT recipients, mirroring and even exceeding the prevalence in the general population [ 7 ].…”

“…Of note, obesity often represents a barrier to kidney transplant (KT), and may impact KT outcomes [ 7 , 8 , 9 ]. The prevalence of obesity and obesity-associated chronic metabolic alterations is constantly growing among KT recipients, mirroring and even exceeding the prevalence in the general population [ 7 ].…”