Friday, July 16, 2010

Transplant/Immunology Quiz 3 answers

Which one of these are risk factors for Post Transplant New Onset Diabetes Mellitus ( NODAT)?
HLA Mismatch 20%
CMV infection 40%
Hep C infection 40%
Sirolimus 40%
Calcium Channel Blockers  10%
Hypomagnesemia 20%
Elevated uric acid 30%
CNI use 70%
Metabolic syndrome 70%

Most of you got it right, all above are risk factors except Calcium Channel Blockers.
NODAT is a common metabolic complication seen in post transplant patients as we are seeing these patients living longer and longer.
It has been linked independently as a risk factor for cardiac disease post transplant.
Lot of research has been done in this field and numerous physicians have done work on identifiable risk factors and hoping to decrease its
The list I am going to put below is from a recent review in Nature Review Nephrology and might not be wholesome but covers most of the
known risk factors.
The non modifiable ones are: Age, African american race, Family history of DM, DM as a cause of ESRD. Interestingly, patients with
Glomerulonephritis and ADPKD leading to ESRD had increased risk of NODAT, male gender, HLA mismatch( weak association),
genetic, innate immunity( alteration in it post transplant), cadaveric donor, male donor, education.
The modifiable risk factors are: Previous stress related diabetes, obesity, metabolic syndrome, post transplant high TG level, CMV infection
(affecting the Beta cells directly), Hep C infection, tacrolimus > cyclosporine( direct pancreas effect), sirolimus, steroids, rejection episodes( perhaps
due to more steroid use), anti hypertensives( beta blockers, HCTZ), hypomagnesemia( 2 studies so far), hyperurecemia( one study so far), decreased

This is interesting to me personally and we have showed ( in a very small study) that hypomagnesemia might be related to RAPID NODAT, within the
first three months of transplant. There is one large study out of Europe that showed this link before and there is animal and human data on direct
association of insulin resistance and hypomagnesemia as well.

Some good references:

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