Perioperative glucose management and outcomes in liver transplant recipients: A qualitative systematic review

Paka, Prani; Lieber, Sarah R.; Lee, Ruth-Ann; Desai, Chirag S.; Dupuis, Robert E.; Barritt, A. Sidney

doi:10.5500/wjt.v8.i3.75

Cited by 11 publications

(9 citation statements)

References 31 publications

(63 reference statements)

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“…Previous studies have reported worse survival outcomes for diabetic patients post‐LT presumably due to higher rates of infections, chronic rejections, and late onset hepatic artery thrombosis . A qualitative systematic review of perioperative glucose control also confirmed worse transplant outcomes associated with hyperglycemia . Our results demonstrated higher rates of graft rejection among PTDM individuals with trends toward worse overall survival also suggesting a unique relationship between glucose dysregulation, graft viability, and patient survival.…”

Section: Discussionsupporting

confidence: 78%

The impact of post‐transplant diabetes mellitus on liver transplant outcomes

Lieber¹,

Lee

Jiang³

et al. 2019

Clinical Transplantation

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Background Post‐transplant diabetes mellitus (PTDM) is common after liver transplantation (LT). Yet, how PTDM relates to graft outcomes and survival needs elucidation as more individuals are transplanted for nonalcoholic fatty liver disease (NAFLD). Methods This single‐center, retrospective study of adult LT recipients (2003‐2016) identified PTDM incidence and associations with graft steatosis, rejection, and post‐LT patient survival. Multivariable analysis investigated predictors of PTDM. Kaplan‐Meier curves depicted patient survival 5 years post‐LT. Results Among 415 adult LT recipients, 23% had pre‐LT DM and 13% were transplanted for NAFLD. PTDM incidence was 34.7%, 46.9%, and 56.2% and overall survival was 90%, 80.9%, and 71.7% at 1, 3, and 5 years, respectively. Over a third of non‐NAFLD patients developed PTDM. Half of PTDM cases developed by 6 months and 75% by 12 months. The PTDM group had more rejection episodes compared to no PTDM (31.9% vs 21.8%, P = 0.055), with trends toward worse patient survival 5 years post‐LT (log‐rank test P = 0.254). Age was the only significant predictor of PTDM. Conclusions Post‐transplant diabetes mellitus occurs rapidly in the post‐LT period and is a significant problem for both NAFLD and non‐NAFLD LT recipients. Age is a significant risk factor for PTDM. Outcomes trended toward increased rejection and worse survival among PTDM individuals, suggesting the benefit of early strategies targeting glucose control.

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Section: Discussionsupporting

confidence: 78%

The impact of post‐transplant diabetes mellitus on liver transplant outcomes

Lieber¹,

Lee

Jiang³

et al. 2019

Clinical Transplantation

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“…Some guidelines and studies recommend maintaining blood glucose below 200 mg/dL in the perioperative period between surgical procedures, including liver transplantation. 2,12 However, other targets for glucose maintenance have been suggested: 150 to 200 mg/dL by the World Health Organization, 15 150 mg/dL by Paka et al, 16 and 140 to 180 mg/dL in the guideline proposed by the American Association of Clinical Endocrinologists and the American Diabetes Association. 17 A review of the literature, concurrent with the guidelines, suggests that further studies evaluating the optimal glycemic value that may act as a protective factor against SSI in liver transplant recipients in the perioperative period are required.…”

Section: Discussionmentioning

confidence: 99%

A Retrospective Cohort Study of Risk Factors for Surgical Site Infection Following Liver Transplantation

Oliveira

Mancero²,

Faria³

et al. 2019

Prog Transpl

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Background: Surgical site infection is an important complication in the postoperative period among liver transplant recipients. However, little is known about the risk factors in this patient group. Therefore, the objective of this study was to analyze the incidence and risk factors for surgical site infections among adult liver transplant recipients. Methods: Medical records of adult liver transplant recipients from January 1, 2009, to December 31, 2015, were analyzed in this retrospective cohort study. Results: We enrolled 156 recipients' medical records. Forty-two (26.9%) cases of surgical site infections were identified. The main isolated microorganisms were methicillin-resistant Staphylococcus species, extended spectrum b-lactamase-producing Klebsiella species, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii, and vancomycin-susceptible Enterococcus faecalis. We found that long operative times (487 minutes) and differences in body mass index between donor and recipient (1.3 kg/m 2) increased the risk for surgical site infections by approximately 5 times (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.5-11.8), and capillary glycemia 175 mg/dL in the first 96 postoperative hours increased the risk by approximately 3 times (OR, 2.97; 95% CI, 1.43-6.17). Conclusions: There was a high incidence of surgical site infections among the studied population and that some risk factors identified differ from those reported in the scientific literature.

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“…Posttransplant hyperglycemia has been associated with an increased risk of ACR as well as other comorbidities. ( 46 ) In addition, hyperglycemia management after LT uses significant resources ( 47 ) and can result in additional laboratory testing, office and emergency room visits, and hospital admissions. Improvement in glycemic control after LT can result in better clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Budesonide for Liver Transplant Immune Suppression: Results of a Pilot Phase 2a Trial

et al. 2020

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Earn MOC for this article: www.wileyhealthlearning.com/aasld.aspx Despite adverse effects like hyperglycemia, new-onset diabetes after transplant (NODAT), and infectious complications, corticosteroid use remains an important part of liver transplantation (LT) immune suppression. Budesonide, a synthetic corticosteroid, undergoes extensive first-pass hepatic metabolism with only 10% systemic bioavailability, providing an opportunity for an improved toxicity-therapeutic ratio. Although effective in the treatment of autoimmune hepatitis, the effects of budesonide for LT immune suppression are unknown. We conducted a single-center phase 2a trial to study the safety and efficacy of budesonide immunosuppressive therapy. From July 2017 to November 2018, 20 patients undergoing a first LT received budesonide tapering doses (from 9 to 3 mg) for 12 weeks. Patients were compared with matched control patients who received prednisone from the same time period. Additionally, both groups received calcineurin inhibitors and mycophenolate mofetil. Outcome measures at week 24 included rates of biopsy-proven acute cellular rejection (ACR), NODAT (hemoglobin A1c >6.4%), and infectious complications. In the budesonide arm, 1 patient developed ACR at week 5 and was removed from the study. Another patient stopped the study drug at week 8 due to persistent nausea. Rates of ACR were similar between the budesonide and control groups (5% versus 5%, P = 1.00). Three patients in the control group developed NODAT versus none in the budesonide group (15% versus 0%; P = 0.23). There were 6 infections in the control group compared with none in the budesonide group (30% versus 0; P = 0.02). These pilot data suggest that budesonide has the potential to be a safe and effective alternative to prednisone for LT immune suppression while reducing steroid-induced infections and NODAT. Randomized controlled trials are required to validate these findings.

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Perioperative glucose management and outcomes in liver transplant recipients: A qualitative systematic review

Cited by 11 publications

References 31 publications

The impact of post‐transplant diabetes mellitus on liver transplant outcomes

The impact of post‐transplant diabetes mellitus on liver transplant outcomes

A Retrospective Cohort Study of Risk Factors for Surgical Site Infection Following Liver Transplantation

Safety and Efficacy of Budesonide for Liver Transplant Immune Suppression: Results of a Pilot Phase 2a Trial

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