Issue: 2014 > April > review

Prevention and management of new-onset diabetes mellitus in kidney transplantation

M. Juan Khong, Ch. Ping Chong


New-onset diabetes mellitus after transplantation
(NODAT) is one of the complications that is increasingly
occurring among kidney transplanted patients. It is associated with the risk of cardiovascular disease, graft
failure and mortality. The risk of NODAT development
increases with time from transplantation. Therefore, early detection and prompt action are essential in reducing the risk of NODAT and its complications. This paper aims to review the screening parameters, prevention and management strategies for NODAT in both pre- and post-transplantation conditions. The pre-transplant patient should be screened for diabetes and cardiometabolic risk factors. Blood glucose evaluation for the pre-transplantation period is important for early detection of impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), which are highly associated with the incidence of NODAT. Post-kidney transplant patients
should have periodical blood glucose monitoring with
more frequent assessment in the initial phase. As early
hyperglycaemia development is a strong predictor for
NODAT, prompt intervention is needed. When NODAT
develops, monitoring and control of blood glucose profile,
lipid profile, microalbuminuria, diabetic complications and
comorbid conditions is recommended. Immunosuppressive regimen modification may be considered as suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) guideline to reverse or to improve the diabetes after weighing the risk of rejection and other potential adverse effects. Strategies for modifying immunosuppressive agents include dose reduction, discontinuation, and selection of calcineurin inhibitor (CNI), anti-metabolite agents, mammalian target of rapamycin inhibitors (mTORi), belatacept and corticosteroids. Lifestyle modification and a conventional anti-diabetic approach, as in the type 2 diabetes mellitus guidelines, are also recommended in NODAT management.