Renal Transplant Alıcılarında Gelişen Posttransplant Diabetes Mellitus Seyrinde Mikrovasküler Komplikasyonların Değerlendirilmesi

Abstract

Ozdemir Aybi O., Evaluation of Microvascular Complications in the Course of Post-transplant Diabetes Mellitus in Renal Transplant Recipients, Hacettepe University School of Medicine, Internal Medicine Thesis. Ankara, 2020. Hyperglycemia is a well documented complication occurring after solid organ transplantation. As grafts and recipients survival rates have increased in recent decades because of a better understanding and management of posttransplant immunological and infection complications, the incidence of PTDM has also increased leading to the need for a better understating of disease clinical course in the long term. It remains unclear if the progression of chronic diabetic complications in transplant recipients is similar to that of patients with other types of diabetes; therefore, the aim of the current study was to evaluate the clinical course of diabetic microvascular complications in kidney transplant recipients with five years of PTDM diagnosis. Forty three patients with the following criteria were included in the study; age >18 years, no history of diabetes before transplantation and with at least five years of PTDM. Most of recipients were male 27 (62,8%) and recipients’ mean age was 50,12±12,2 years. All transplanted patients included for fundus photographs and optic coherance tomography (OCT) for the evaluation of diabetic retinopathy. Spot urine albumin/creatinin ratio (mg/g) and glomerular filtration rate (GFR) were calculated for diabetic nephropathy screening. Michigan Neuropathy Screening Instrument (MNSI) was performed on the patients for the evaluation of peripheral neuropathy. In the neuropathy examination, the appearance of the feet and ankle reflex were examined. The toe vibration sense was measured with a neurothesiometer. 10 g monofilament test was applied. Quantitative sensory tests were performed with CASE-IV device, small fiber neuropathy was evaluated. Heart rate variability data was analyzed with ELA Medical SpiderView Holter Device for cardiac autonomic neuropathy screening. The majority of patients (58,1%) received organs from lived donors. The main immunosuppressive regimen was prednisone (93%), mycophenolate mofetil (83,7%), cyclosporine (44,2%) and tacrolimus (30,2%), respectively. At the end of follow-up, mean diabetes duration was 8,4±4 years and mean HbA1c was 6,5%. Fifty-five percent of patients with PTDM reported insulin use at least one doses/day and 41,9% used oral antihyperglycemic medications. Although patients with PTDM had an average diabetes duration of eight years, only two (4,7%) of them presented findings of diabetic retinopathy at fundus photograph and nine (20,9%) of them presented thinning of internal retinal layers on OCT. In biochemical tests, the mean creatinin was 1,9±2,1 mg/dl, mean GFR was 48,8±16,8 ml/dk/1,73 m² and mean albumin/creatinin ratio was 285,9±478,8 mg/g. There were 23 (57,5%) patients with albumin/creatinin ratio between 30-300 mg/g and eight (20%) patients with ≥ 300mg/g. In our study, there were three (7%) patients with a score of ≥4 MNSI questionnaire and nine (20,9%) patients with score of ≥2,5 from the physical examination and were considered diabetic neuropathy. Decreased response was obtained in five (11,6%) patiens and no response was obtained in one (2,3%) patient with 10 gr monofilament test. In the evaluation with quantitative sensory testing, diabetic small fiber neuropathy was detected in five (11,9%) patients. The mean heart rate of the recipients was 84 ± 14.6 beats/min. When the heart rate variability data were examined, parasympathetic system involvement was found in 55% of patients and sympathetic system in 67%. In conclusion, it has been shown that microvascular complications developing in renal transplant recipients with PTDM are less frequent and milder than expected complications in the course of Type 2 diabetes.