Diabetes and organ transplantation are a familiar combination that can lead to further complications for patients. Whether transplantation is a result of organ failure stemming from diabetes, a continuing comorbidity, or a new condition following transplantation, both diabetes and organ transplantation can increase risks for cardiovascular disease and other unwanted metabolic complications.

“Diabetes is very common in organ transplantation,” said Archana R. Sadhu, MD, FACE, Associate Professor of Clinical Medicine, Houston Methodist Academic Institute and Weill Cornell Medicine. “Depending on the organ, rates of post-transplant diabetes range from 20% to 30% for kidney and up to 40% and 50% for liver, with other organs somewhere in between. Diagnosis and treatment of diabetes has nuances that are unique to this population.”

Dr. Sadhu will open Diabetes and Organ Transplantation: Pathophysiology, Inpatient, and Outpatient Management on Sunday, June 23, from 8:00 a.m. – 9:30 a.m. ET in Room W208 of the Orange County Convention Center. Palak Choksi, MD, Associate Professor of Endocrinology, Metabolism, and Diabetes at the University of Colorado Anschutz Medical Campus, will focus on management of diabetes following liver transplantation. Robert J. Rushakoff, MD, Medical Director, University of California, San Francisco, Diabetes Clinic at Mount Zion, will discuss diabetes and kidney transplantation.

Diabetes is one of the leading causes of kidney failure leading to transplantation, Dr. Sadhu noted, but having diabetes does not affect organ allocation and a patient’s likelihood of receiving a new kidney. At the same time, having diabetes before transplantation increases a patient’s risk score and predicts less favorable transplantation outcomes compared to similar patients who do not have pre-existing diabetes.

Similarly, patients who do not have pre-existing diabetes before transplantation and develop it afterward tend to have poor outcomes. Immunosuppressive agents given post-transplantation can contribute to the development of diabetes. Both high-dose steroids and calcineurin inhibitors commonly used to prevent organ rejection can lead to, or exacerbate, hyperglycemia.

Weight gain following transplantation can also impact diabetes control whether the disease began before or after transplantation.

“This is a challenging patient population when it comes to managing diabetes,” Dr. Sadhu said. “The challenges are highly dependent on the type of organ, the function of the organ, and the clinical metabolic changes of the patient after transplantation.”

Management can also depend on what has happened before transplantation.

Patients with diabetic kidney disease who go on dialysis may actually feel as though their diabetes has improved, perhaps even resolved, because they can use fewer medications, sometimes none, to achieve adequate glucose control, Dr. Sadhu explained.

In reality, neither failing kidneys nor dialysis can reverse the insulin deficiency of the beta-cells but can lead to higher circulating insulin levels, decreased glucose production, and ultimately improved glucose control. Kidney failure is temporarily masking the insulin deficiency.

However, after the new kidney is transplanted and begins excreting insulin into the urine at normal rates, the underlying insulin deficiency resurfaces, and the patientʻs previous diabetes re-emerges. The insulin deficiency is even exacerbated from the hyperglycemic effects of the new immunosuppressive medications, Dr. Sadhu explained.

In order to maximize the benefits of transplantation while minimizing the harm of treatment plans, and to ensure the best possible outcomes for the patient, clinicians need to familiarize themselves with the unique differences post-transplant patients face.

“We need to be screening all of our post-transplant patients for diabetes very early if they did not have it pretransplant,” Dr. Sadhu added. “Additionally, we must be cognizant of contraindications and side effects of common diabetes medications that may affect the function of the transplanted organ.”

For those unable to attend the 84^th Scientific Sessions in person, this session will be available on-demand on the ADA virtual meeting platform following the meeting for registered participants.