57 the lifestyle intervention reduced the incidence

57
The lifestyle intervention reduced
the incidence of type 2 diabetes by 58% (95% confidence interval 48–66%) and
metformin by 31% (95% confidence interval 17–43%) as compared with placebo.
The goals for the lifestyle modification involved achieving and maintaining a weight
reduction of at least 7% of initial body weight through a healthy low-calorie, low-fat
diet and at least 150 min of physical activity per week.
Pre-transplant treatment of HCV-infected renal transplant candidates should be
considered. Selection of an immunosuppressive regimen should be tailored to each
individual patient, weighing the risk of developing diabetes after transplantation
against the risk of acute rejection. Suggested pre-transplant baseline evaluation of
potential transplant candidates is shown in Fig. 16.2.

16 Diabetes Mellitus and Transplantation: Risks for Post-transplant Diabetes 267
PRE-TRANSPLANT BASELINE EVALUATION
• Complete medical care and family
history
• Glucose history
• Fasting plasma glucose
• 2-hour oral glucose tolerance test 1
• Counseling:
• Weight control
• Diet
• Exercise
• Consider pre-transplant treatment
of HCV-infected candidates
• Diabetogenicity of immunosuppressive agents:
Corticosteroids > Tac > CSA Sirolimus 2
• Individualization of immunosuppressive
agents 3
• Steroid-sparing or withdrawal regimen
• Tac to CSA switch
• CNI minimization protocol
• Management of established NODAT: please
refer to Table 2
Identify high-risk candidates
Pre-transplant Post-transplant
1 Please see text; 2 Further studies are needed, see text; 3 Modification of immunosuppressive regimen should be done at the
discretion of the transplant physician
Abbreviations: Tac: tacrolimus, CSA: cyclosporine, CNI: calcineurin inhibitor
Fig. 16.2 Pre-transplant baseline evaluation
Early Detection of NODAT After Transplantation
Studies investigating the best predictive tool for identifying patients at risk for devel-
oping NODAT early after transplantation are currently lacking. In a single-center
prospective study consisting of 359 de novo renal transplant recipients, Kuypers
et al.
44
demonstrated that a normal (vs. diabetic) OGTT on day 5 was associ-
ated with a significantly reduced risk for NODAT (odds ratio 0.03, P = 0.0002).
A similar reduction in the risk of NODAT was conferred by a normal FPG on
day 5 (odds ratio 0.06; P < 0.0001). [NODAT was defined as the uninterrupted
need for glucose-lowering therapy for at least 3 months following transplanta-
tion. The up-to-date American Diabetes Association criteria were used to define
impaired glucose tolerance (IGT), impaired fasting glucose (IFG), and diabetes
mellitus (DM).] Although an OGTT at 5 days after transplantation might prove
to be a clinically useful predictive diagnostic tool for the eventual development of
NODAT, Kuypers et al.’s study results should be interpreted with caution. The study
included predominantly white patients (91.4%), negligible number of black (1.4%),
and no Hispanics. The inclusions of more blacks or Hispanics or both would most
probably have increased the percentage of patients destined to develop NODAT,
thereby increasing the positive predictive values of both OGTT and FPG on day 5,
while decreasing their negative predictive values. Furthermore, baseline evaluation