Analysis On Changing Trend And Influential Factors Of Fasting Plasma Glucose And Serum Lipids After Renal Transplantation

ObjectiveThe aim of the present clinic survey was to observe the long-term fluctuation of fasting plasma glucose (FPG) and lipid durling the long follow-up period after transplantation, explore the incidence of PTDM and associated risk factors and determine whether complications, patient survival and graft function differ in patients with PTDM from those without PTDM.Materials and MethodsWe studied 709 patients receiving kidney transplant at our institution between 1 January,1993 and 31 December,2008. Patients with uncompleted data, graft failure or death within 1 year post-transplant, multi-organ transplant recipients or transplant more than once, were excluded. An analysis was performed among 446 adult patients, with 18 previously known diabetes and 428 non-diabetic patients before transplantation. The end date of this study was 31 December,2009.1. According to FPG level pre-transplantation, combining history, patients were divided into Pre-DM, IFG, NFG groups, we analyzed data of FPG and lipids (TC, TG, HDL, LDL) before and at different predefined time points after transplantation to observe the changing trend of FPG and lipids.2. For non-diabetic patients before surgery, we analyzed the prevalence of PTDM at different predefined time points after transplantation according to FPG. By the age of the different immunosuppressive treatment, patients were divided into three groups 1993-1996,1997-2000,2001-2008, and the incidence of PTDM was compared between different ages. Then we analyzed different outcomes of PTDM.3. We perform univariate analysis to examine a number of clinical characteristics to determine whether they were associated with the presence of PTDM. Paired t test was used to investigate the effect of conversion from cyclosporine A (CSA) to tacrolimus (FK506)-based immunosuppressive regimen on FPG and serum lipid profile in patients with immunosuppression conversion. Display the characteristics of the patients with persistent P-TDM (P-PTDM) and of the patients with transient PTDM (T-PTDM) to identify risk factors for the onset of P-PTDM and T-PTDM. In a stepwise logistic regression model, multivariate analysis was performed to identify risk factors independently associated with the onset of PTDM.4. The incidence of complications and mean serum creatinine levels were compared between the PTDM group and the N-PTDM group. Determine the relationship between PTDM and long-time survival after renal transplantation. Kaplan-Meier method and log-rank test were used for survival analysis.Results1. Within 1 month after kidney transplantation, FPG in Pre-DM, IFG and NFG three groups showed the trend of increased firstly and then decreased. FPG fluctuated significantly within 1 week posttransplant, much higher than pre-transplant, and gradually stabilized after 1 week. FPG level in Pre-DM group was the highest, IFG group followed, and NFG group the lowest.Within 10 years after renal transplantation, NFG group at each predefined time points were within the normal range, FPG level in the Pre-DM group and the IFG group began to increase within 3 months, fluctuated significantly within 12 months, and decreased gradually to converge in 36 months.The level of TC, TG, LDL show the similar trend posttransplant:significantly increased within 3 months, reached a peak between 3 and 6 months, and attained stability at a high price level of pre-transplant between 24 and 36 years. HDL showed no constant change.2. Of the 428 Patients,87 developed PTDM (20.3%) durling a mean follow-up of 6 years. The onset of PTDM occurred in 57 patients (in 65.5% of total PTDM) primarily during the first year after transplantation. The prevalence of PTDM at 1,3 and 10 year posttransplantation was 11.45%,17.20% and 25.45% respectively. There was no difference in the incidence of PTDM among three transplantation ages. Among 87 PTDM patients,15 T-PTDM patients (in 17.2% of total PTDM) eventually recovered to NFG or IFG.3. Univariate analysis identified variables to be associated with the onset of PTDM:older age, a higher body mass index (BMI), smoking history, positive family history of diabetes mellitus, deceased donor transplantion, hepatitis C virus infection, cytomegalovirus infection, FPG pre-transplantion and 1 week after transplantion, TC and TG pre-transplantion, a switch from CSA to FK506-based immunosuppressive regimen, peak plasma concentration of CSA in the first 6 and 12 months. FPG level, daily dose of insulin, the prevalence of PTDM were markedly elevated (P<0.05)in the group who were converted to FK506 but TC and TG statistically reduced. In the group who were converted to RAM, FPG level and the prevalence of PTDM remained unchanged, while TC, TG levels and daily dose of insulin statistically elevated (P<0.05). Older recipient age, a high BMI, positive family history of diabetes mellitus, deceased donor transplantion, FPG, TC and TG level at pre-transplantation and 1 year posttransplantation were higher risk factors for P-PTDM (P<0.05), whereas acute rejection episodes were higher risk factors for T-PTDM (P=0.043). By multivariate analysis, five factors were independently associated with the onset of PTDM:FPG pre-transplantation (OR=1.48, P=0.036), older recipient age (OR=1.10, P=0.044), BMI (OR=1.05, P=0.029), hepatitis C virus infection (OR=2.72, P=0.008), and deceased donor transplantation (OR=1.18, P=0.035).4. The incidence of following complications was higher in PTDM group compared with N-PTDM group:infections requiring hospitalization, antihypertensive drugs, dyslipidaemia durling the first year, but patient survival and mean serum creatinine levels at different predefined time points from transplantation were not different. In Cox proportional-hazard models adjusted for established risk factors, such as age, transplant age, tumor, infection, deceased donor transplant, PTDM was not an independent predictor of death(HR 1.216,95%CI 0.804-1.840, P=0.354).Conclusion1. The incidence of PTDM was 20.3% in patients suviving for more than 1 year durling a mean follow-up of 6 years, and the onset of PTDM occurred primarily (65.5% of total PTDM) durling the first year after transplantation.2. Main independent risk factors of PTDM included higher FPG levels, older recipient age, BMI, hepatitis C virus infection, deceased donor transplantation. Acute rejections were associated with the onset of T-PTDM.3. Conversion from CSA to FK506 in selected renal transplant recipients appears associated with a significant improvement in lipid profile, but with worsening abnormal glucose metabolism. Conversion from CSA to RAM increases lipid metabolism disorders, but has no significant effect on glucose metabolism.4. The overall patient and graft function are not adversely affected by PTDM durling a mean follow-up of 6 years, although complications, such as infections, hypertention and hyperlipemia are more frequently encountered in PTDM patients.