Approach to the Patient with New-Onset Diabetes after Transplant (NODAT)

Abstract

New-onset diabetes after transplantation (NODAT) refers to the occurrence of diabetes in previously nondiabetic persons after organ transplantation. The incidence rates of NODAT vary by organ transplanted and posttransplant interval. The estimated rates at 12 months posttransplant are 20-50% for kidney transplants, 9-21% for liver transplants, and approximately 20% for lung transplants. NODAT is associated with increased risks of graft rejection, infection, cardiovascular disease, and death. Besides the traditional risk factors for type 2 diabetes (age, family history, obesity, and ethnicity), exposure to immunosuppressive agents often precedes the occurrence of NODAT. Identification of risk factors through pretransplant screening is desirable, as is prompt diagnosis and appropriate treatment. NODAT is consistent with type 2 diabetes and responds to the usual antidiabetes agents. However, severe hyperglycemia during the early posttransplant period may necessitate the use of iv insulin infusion. Also, high-dose glucocorticoid therapy for induction of immunosuppression (or treatment of acute rejection) may require the use of insulin therapy for glycemic control. After hospital discharge, close monitoring of blood glucose during the first month and every 3 months for the first year is recommended. Consideration should be given to drug toxicities or interactions when prescribing antidiabetes agents in the posttransplant patient. In addition to hyperglycemia, the control of comorbidities such as dyslipidemia and hypertension needs to be optimized. Future areas of investigation include the development of immunosuppressive regimens with minimal diabetogenic effects, determination of the role of glycemic control on graft survival, and interventions for primary prevention of NODAT.