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Insulin requirement much higher for post-transplant diabetes mellitus after liver transplant
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American Association of Clinical Endocrinologists 18th Annual Meeting
Patients who underwent liver transplant and were treated with high-dose steroids required a significant increase in insulin requirements to achieve glycemic targets, according to data presented at the American Association of Clinical Endocrinologists 18th Annual Meeting and Clinical Congress.
Post-transplant diabetes mellitus is a significant comorbid disease in liver transplant recipients, according to the researchers.
Researchers identified 50 patients who underwent liver transplantation from July 2005 to May 2006. All patients were on a standard immunosuppressive regimen (steroid, tacrolimus and/or mycophenolate mofetil).
Intraoperative methylprednisone (1 g) was administered, and then tapered to 200 mg per day to 20 mg per day for the first six days after transplant.
"The effect of 200 mg of steroids on postoperative day one resulted in five times the insulin needs as compared with the 20-mg dose administered on postoperative day six," presenter Garry Tobin, MD, associate professor of medicine and medical director of the Washington University Diabetes Center at Barnes-Jewish Hospital, St. Louis, told Endocrine Today. "Additionally, the insulin requirements on postoperative day one predicted the subset of patients that had persistent diabetes at one year following liver transplantation."
Mean blood glucose was 218 mg/dL among patients with pre-existing diabetes, and 180 mg/dL among those with stress/steroid hyperglycemia.
Post-correction, patients with pre-existing diabetes required 1.7 U/kg insulin per day compared with 1.4 U/kg for patients with stress/steroid hyperglycemia on the day patients received 200 mg methylprednisone. Insulin requirements decreased in the pre-existing diabetes group from to 0.7 U/kg when steroids were tapered to 80 mg and 0.4 U/kg when tapered to 20 mg. The decrease was also observed in the stress/steroid hyperglycemia group: from 0.45 U/kg with the 80-mg dose to 0.3 U/kg with the 20-mg dose.
"The effect of the immunosuppressive regimen on the beta cells is a factor present in all solid organ transplants. Steroids clearly have a predominant effect with the persistence of the diabetic state resolving in a large proportion of patients as the steroids are tapered," Tobin said.
A significant subset of the cohort had persistent diabetes at 1 year — 33% of the stress/ steroid hyperglycemic group. This group had a higher insulin requirement on postoperative day one (1.9 U/kg vs/ 1.2 U/kg), which suggests an unmasking of a beta cell defect, according to Tobin.
These data suggest a possible treatment algorithm for post-liver transplant patients.
“Although the data are not definitive, it gives us a handle on proper dosing and can be used to prospectively study other populations,” researcher Umadevi Muthyala, MD, said in a press release. – by Katie Kalvaitis
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