Diabetes mellitus after renal transplantation: as deleterious as non-transplant-associated diabetes?

BACKGROUND: Despite use of lower doses of corticosteroid hormones after renal allotransplantation in the era of cyclosporine and tacrolimus, posttransplant diabetes mellitus remains a common clinical problem. METHODS: We prospectively investigated the effect of posttransplant diabetes on long-term (mean follow-up, 9.3+/-1.5 years) graft and patient survival in the 11.8% of our renal transplant population (n = 40) who developed diabetes after kidney transplantation, and we compared outcome in 38 randomly chosen nondiabetic control patients who had received transplants concurrently. RESULTS: Twelve-year graft survival in diabetic patients was 48%, compared with 70% in control patients (P = 0.04), and Cox's regression analysis revealed diabetes to be a significant predictor of graft loss (P = 0.04, relative risk = 3.72) independent of age, sex, and race. Renal function at 5 years as assessed by serum creatinine level was inferior in diabetic patients compared to control patients (2.9+/-2.6 vs. 2.0+/-0.07 mg/dl, P = 0.05). Two diabetic patient who experienced graft loss had a clinical course and histological features consistent with diabetic nephropathy; other diabetes-related morbidity in patients with posttransplant diabetes included ketoacidosis, hyperosmolar coma or precoma, and sensorimotor peripheral neuropathy. Patient survival at 12 years was similar in diabetic and control patients (71% vs. 74%). CONCLUSIONS: Posttransplant diabetes mellitus is associated with impaired long-term renal allograft survival and function, complications similar to those in non-transplant-associated diabetes may occur in posttransplant diabetes, and, hence, as in non-transplant-associated diabetes, tight glycemic control may also be warranted in patients with posttransplant diabetes.

Unemployment in inner-city renal transplant recipients: predictive and sociodemographic factors.

Studies of dialysis patients report unemployment rates of 60% to 75%; however, it is generally believed that following transplantation, improvement in well-being and removal of time constraints imposed by the dialytic regimen afford improvement in employment status. We studied 58 stable renal transplant recipient attending an outpatient transplant clinic by questionnaire, administered anonymously. Only 25 (43%) of the patients were currently employed. Employed and unemployed patients did not differ when compared for age, gender, race, cause of renal disease, type of transplant or prior dialysis, time on dialysis or time since transplantation, years of education, or prestige score or classification ("blue collar" v "white collar") of prior job. In the employed group, 24 (96%) patients had worked before developing kidney disease compared with 23 (70%) patients in the unemployed group (P < 0.05). While on dialysis, 19 (79%) of the employed patients continued working compared with 10 (30%) of the unemployed patients (P < 0.005). Major reasons for discontinuing work after starting dialysis for both groups were subjective illness (feeling too sick, 51%), followed by interference of the dialysis regimen with time necessary for work (32%). Only 15% of the previously employed patients did not work after transplantation because of feeling too sick. By multiple logistic regression, the strongest predictors of employment posttransplant were being more than 1 year posttransplant (odds ratio, 2.35; 95% confidence interval, 1.01 to 5.5) and having been employed before transplantation (odds ratio, 3.79; 95% confidence interval, 1.60 to 9.02). Over half of the unemployed patients (20 [61%]) expressed interest in job training. Eighty percent to 90% of patients in both groups were insured by Medicare, with the second greatest number insured by Medicaid. Of the 15 unemployed patients insured by Medicaid, 67% reported that their decision not to work was related to fear of losing Medicaid benefits because they could not afford medications without it. Despite no difference in actual type of insurance carried, 17 (51%) of the unemployed patients believed their health insurance coverage was inadequate compared with four (12%) of the employed patients (P = 0.005, chi-squared test). Unemployment remains a significant problem for our population of inner-city renal transplant recipients. Attention to job retention or retraining during the early renal disease and dialysis therapy period may promote better rehabilitation following transplantation. However, for this population, with limited employment opportunities, removal of disincentives to work, including loss of Insurance and Inability to pay for medications, will be necessary before we can provide optimal rehabilitation for renal transplant recipients from all social strata.

The effect of kidney size on cadaveric renal allograft outcome.

Chronic rejection is the commonest cause of long-term renal allograft loss. Though immunologic factors are thought dominant in its pathogenesis, nonimmunologic factors, in particular, hyperfiltration damage related to reduced renal mass, have also been proposed as factors in the causation of chronic allograft rejection. We assessed the influence of renal size on graft survival and function in all cyclosporine-treated cadaver donor adult renal allograft recipients engrafted at a single center between June 1989 and July 1994, whose grafts functioned for > or = to 3 months (n=169). Patients were divided into 4 groups based on the ratio of kidney volume to recipient body surface area (volume/BSA) (ml/m2), and outcome in groups compared by methods including Cox's proportional hazards and Kaplan-Meier analysis. No significant differences between groups existed for serum creatinine levels, presence of significant proteinuria, or 1- and 5-year graft survival. There was no correlation between volume/BSA and either serum creatinine or degree of proteinuria at 3, 6, 12, 36, and 60 months posttransplant. Volume/BSA was similar in patients with good or poor renal function (58 +/-21 vs. 56 +/- 28 ml/m2), with or without significant proteinuria (57 +/- 24 vs. 60 +/- 25 ml/m2) or in patients who lost their grafts to chronic rejection compared with those with stable allograft function (64 +/- 34 vs. 59 +/- 24 ml/m2). Volume/BSA was not a predictor of graft survival on multivariate regression. We conclude that donor kidney size has no apparent effect on cadaveric renal allograft outcome in the short and intermediate-term, suggesting that close matching of donor kidney size to recipient size is not presently indicated.