Poor Outcome in Patients With Diabetes Mellitus Undergoing Liver Transplantation.

Shields, PL; Tang, Howard; Neuberger, James; Gunson, Bridget K.; McMaster, P; Pirenne, Jacques

doi:10.1097/00007890-199908270-00015

Cited by 77 publications

(72 citation statements)

References 4 publications

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“…Post-OLT survival of liver transplant recipients with DM had been reported to be less than the survival of those without DM in 1 series, 13 but the rest of the series reported to date did not find significant differences. 12,14-17 Our patients with DM had greater survival and it was even greater in those who required pharmacological treatment to achieve metabolic control.…”

Section: Discussionmentioning

confidence: 87%

See 1 more Smart Citation

Liver transplantation in cirrhotic patients with diabetes mellitus: Midterm results, survival, and adverse events

et al. 2001

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Liver cirrhosis is frequently associated with diabetes mellitus (DM), and this metabolic complication is also frequent after orthotopic liver transplantation (OLT). The aim of our study is to investigate which factors are associated with DM before and after OLT and their impact on post-OLT evolution. We evaluated the prevalence of DM among 115 liver transplant candidates with cirrhosis and assessed their evolution after OLT (median follow-up, 41 months). Sixteen candidates had DM requiring pharmacological therapy (group A), 45 candidates had DM controlled with diet (group B), and 54 candidates did not have DM (group C). One-year and 3-year actuarial survival rates were 100% and 100% for group A, 91% and 85% for group B, and 77% and 74% for group C, respectively (P < .03). Post-OLT DM was more frequent in group A. The incidence of other metabolic complications, major infections, rejection, and arterial hypertension; the need for hospitalization; and renal and graft function of patients in groups A, B, and C were similar. The only risk factor for DM 1 year after OLT on multivariate analysis was pre-OLT DM requiring pharmacological treatment. L iver cirrhosis is frequently associated with impaired glucose metabolism. 1-3 Insulin resistance has been found in most patients with cirrhosis. 4-6 It seems to be caused mainly by a deficiency in insulin-stimulated glycogen synthesis in the muscle. 4 This insulin resistance increases the demand for pancreatic insulin secretion and may lead to overt diabetes mellitus (DM), 7 found in 10% to 30% of the patients with cirrhosis.Glucose intolerance and insulin resistance of patients with cirrhosis are reversed after orthotopic liver transplantation (OLT), 8 but the use of such immunosuppressive drugs as cyclosporine, tacrolimus, or prednisone can alter glucose metabolism either by direct effect on pancreatic ␤-cells or by contributing to insulin resistance. 9-11 Thus, the global effect of OLT on glucose metabolism may be both prodiabetogenic and antidiabetogenic.Some studies have reported the evolution of transplant recipients with DM after OLT. [12][13][14][15][16][17] In 1 study, 13 liver transplant recipients with DM had a lower survival rate than those without DM. Conversely, other studies did not show a difference between patients with and without DM. 12,[14][15][16][17] In these studies, DM had been diagnosed according to serum fasting glucose levels, probably underestimating the incidence of liver cirrhosis-related DM.The aim of this study is to investigate the prevalence of pre-OLT DM in end-stage liver cirrhosis and assess the evolution of patients with DM after OLT. In addition, factors predisposing to post-OLT DM were studied. Patients and Methods Study Design and PopulationFrom February 1990 to October 1998, a total of 115 adult patients with liver cirrhosis undergoing OLT at a single institution were studied before OLT by means of an oral glucose tolerance test (OGTT) to rule out DM, unless they had a previous reported diagnosis of DM. According to the 1997 recommen...

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Section: Discussionmentioning

confidence: 87%

“…[12][13][14][15][16][17] In 1 study, 13 liver transplant recipients with DM had a lower survival rate than those without DM. Conversely, other studies did not show a difference between patients with and without DM.…”

mentioning

confidence: 99%

Liver transplantation in cirrhotic patients with diabetes mellitus: Midterm results, survival, and adverse events

et al. 2001

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“…[13][14][15][16][17] In a more recent investigation, the prevalence of diabetes in cirrhotic patients was 53%, as defined by formal glucose tolerance testing. 18 The reason for the 3-fold variability in the earlier series is not clear.…”

Section: Prevalence Of Diabetes In Liver Transplant Recipientsmentioning

confidence: 99%

“…These optimistic results were not observed in three other studies. 14,15,17 In one of these studies, 15 the death rate among diabetics was 4-fold greater than among matched nondiabetic liver recipients; insulin-dependent diabetics fared worse than those controlled by diet alone. Patients with alcoholic liver disease and insulintreated diabetes fared worst of all, and hepatitis C was more prevalent in the diabetics than the nondiabetics.…”

Section: Impact Of Diabetes On the Outcome Of Liver Transplantationmentioning

confidence: 99%

Long-term management of the liver transplant patient: Diabetes, hyperlipidemia, and obesity

Reuben

2001

Liver Transplantation

115

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Key Points 1. As long-term survival improves after liver transplantation, cardiovascular complications are emerging as a major cause of late morbidity and mortality. It seems reasonable to correct the potentially reversible cardiovascular risk factors of diabetes, hyperlipidemia, and obesity, in addition to hypertension. 2. The results of liver transplantation in diabetics are acceptable in terms of morbidity, mortality, and prevalence of posttransplant diabetes, but the poor outcomes described in some series suggest that more extensive testing for macro-and microvascular disease may become necessary. T he main aim of liver transplantation, besides the immediate goal of saving life, is to return the patient to productive community living with good quality of life. It is ironic, therefore, that many of the health problems that afflict successful liver transplant recipients long term are those of community living in the developed world, including diabetes mellitus, hyperlipidemia, and obesity. These three metabolic derangements, together with hypertension, constitute adverse cardiovascular risk factors for transplant recipients. The management of diabetes in liver transplant recipients is not substantially different from its management in

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“…Despite the lack of universal agreement, some studies have observed worsened short-and mid-term survival among diabetic LT recipients. [1][2][3][4][5][6][7] Furthermore, DM is a wellknown risk factor for cardiovascular disease, which is one of the leading causes of death of LT recipients in the long term. 8 Calcineurin inhibitors (CI) also predispose to DM through islet cell toxicity, diminished insulin synthesis or release, as well as decreased peripheral insulin sensitivity.…”

Section: D Abetes Mellitus (Dm)mentioning

confidence: 99%

Conversion from calcineurin inhibitors to mycophenolate mofetil in liver transplant recipients with diabetes mellitus

Herrero¹,

Quiroga²,

Sangro³

et al. 2003

Transplantation Proceedings

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Diabetes mellitus, a frequent metabolic complication in liver transplant recipients, may be produced by the diabetogenic effect of calcineurin inhibitors cyclosporine and tacrolimus. The aim of this study was to investigate the safety and metabolic effects of a gradual switch from cyclosporine or tacrolimus to mycophenolate mofetil among 12 diabetic liver transplant recipients. One patient was withdrawn from the study due to gastrointestinal side effects. Of the 11 remaining patients, cyclosporine or tacrolimus was completely withdrawn in five patients. Two patients developed suspected acute rejection episodes that were controlled by increasing the tacrolimus dosage. Glycosylated hemoglobin A1C and C-peptide levels were significantly lower at 3 and 6 months after the initiation of mycophenolate mofetil (P < .03 in all cases). Furthermore, urea and uric acid levels were significantly reduced after the change of treatment. In conclusion, a switch from cyclosporine/tacrolimus to mycophenolate mofetil may produce beneficial metabolic effects in diabetic liver transplant recipients, but poses a risk of graft rejection. I D ABETES MELLITUS (DM) is a frequent metabolic complication in liver transplant(LT) recipients. Despite the lack of universal agreement, some studies have observed worsened short-and mid-term survival among diabetic LT recipients. 1-7 Furthermore, DM is a wellknown risk factor for cardiovascular disease, which is one of the leading causes of death of LT recipients in the long term. 8 Calcineurin inhibitors (CI) also predispose to DM through islet cell toxicity, diminished insulin synthesis or release, as well as decreased peripheral insulin sensitivity. 9 Mycophenolate mofetil (MMF) has proven to be useful as a CI-sparing agent. The use of MMF has allowed physicians to reduce cyclosporine exposure in LT recipients with renal functional impairment. 10 Some patients have been maintained on MMF monotherapy, but this strategy poses the risk of graft rejection. 11 The aim of the present study was to examine whether conversion to MMF for stable LT recipients with DM allows the reduction/withdrawal of CI and results in improve metabolic control.From the Liver Unit (J.I.H., J.Q., B.S., J.P.) and

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Poor Outcome in Patients With Diabetes Mellitus Undergoing Liver Transplantation.

Abstract: Poorer outcome in the diabetics undergoing OLT, particularly in those with ALD, suggests the need for a more detailed pre-OLT assessment of these patients, particularly those with insulin and tablet controlled diabetes.

Cited by 77 publications

References 4 publications

Liver transplantation in cirrhotic patients with diabetes mellitus: Midterm results, survival, and adverse events

Liver transplantation in cirrhotic patients with diabetes mellitus: Midterm results, survival, and adverse events

Long-term management of the liver transplant patient: Diabetes, hyperlipidemia, and obesity

Conversion from calcineurin inhibitors to mycophenolate mofetil in liver transplant recipients with diabetes mellitus

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