Management of the hospitalized transplant patient.

Significant hyperglycemia is commonly observed immediately after solid organ and bone marrow transplant as well as with subsequent hospitalizations. Surgery and procedures are well known to cause pain and stress leading to secretion of cytokines and other hormones known to aggravate insulin action. Immunosuppression required for transplant and preexisting risk are also major factors. Glucose control improves outcomes for all hospitalized patients, including transplant patients, but is often more challenging to achieve because of frequent and sometimes unpredictable changes in immunosuppression doses, renal function, and nutrition. As a result, risk of hypoglycemia can be greater in this patient group when trying to achieve glucose control goals for hospitalized patients. Key to successful management of hyperglycemia is regular communication between the members of the care team as well as anticipating and rapidly implementing a new treatment paradigm in response to changes in immunosuppression, nutrition, renal function, or evidence of changing insulin resistance

Efficacy and safety of sitagliptin for the treatment of new-onset diabetes after renal transplantation.

New-onset diabetes after transplantation (NODAT) is a common comorbidity after renal transplantation. Though metformin is the first-line agent for the treatment of type 2 diabetes, in renal transplant recipients, metformin is frequently avoided due to concerns about renal dysfunction and risk for lactic acidosis. Therefore, alternative first-line agents for the treatment of NODAT in renal transplant recipients are needed. Sitagliptin, a dipeptidyl-peptidase-4 (DPP-4) inhibitor, has a low incidence of hypoglycemia, is weight neutral, and, in a small study, did not affect immunosuppressant levels. However, long-term sitagliptin use for the treatment of NODAT in kidney transplant recipients has not been studied. We retrospectively analyzed renal transplant recipients diagnosed with NODAT and treated with sitagliptin to assess safety and efficacy. Twenty-two patients were started on sitagliptin alone. After 12 months of followup, 19/22 patients remained on sitagliptin alone with a significant improvement in hemoglobin A1c. Renal function and immunosuppressant levels remained stable. Analysis of long-term followup (32.5 ± 17.8 months) revealed that 17/22 patients remained on sitagliptin (mean hemoglobin A1c \u3c 7%) with 9/17 patients remaining on sitagliptin alone. Transplant-specific adverse events were rare. Sitagliptin appears safe and efficacious for the treatment of NODAT in kidney transplant recipients

Efficacy and Safety of Sitagliptin for the Treatment of New-Onset Diabetes after Renal Transplantation

New-onset diabetes after transplantation (NODAT) is a common comorbidity after renal transplantation. Though metformin is the first-line agent for the treatment of type 2 diabetes, in renal transplant recipients, metformin is frequently avoided due to concerns about renal dysfunction and risk for lactic acidosis. Therefore, alternative first-line agents for the treatment of NODAT in renal transplant recipients are needed. Sitagliptin, a dipeptidyl-peptidase-4 (DPP-4) inhibitor, has a low incidence of hypoglycemia, is weight neutral, and, in a small study, did not affect immunosuppressant levels. However, long-term sitagliptin use for the treatment of NODAT in kidney transplant recipients has not been studied. We retrospectively analyzed renal transplant recipients diagnosed with NODAT and treated with sitagliptin to assess safety and efficacy. Twenty-two patients were started on sitagliptin alone. After 12 months of followup, 19/22 patients remained on sitagliptin alone with a significant improvement in hemoglobin A1c. Renal function and immunosuppressant levels remained stable. Analysis of long-term followup (32.5 ± 17.8 months) revealed that 17/22 patients remained on sitagliptin (mean hemoglobin A1c < 7%) with 9/17 patients remaining on sitagliptin alone. Transplant-specific adverse events were rare. Sitagliptin appears safe and efficacious for the treatment of NODAT in kidney transplant recipients

An altered spatiotemporal gait adjustment during a virtual obstacle crossing task in patients with diabetic peripheral neuropathy

This study investigates spatiotemporal gait adjustments that occur while stepping over virtual obstacles during treadmill walking in people with/without diabetic peripheral neuropathy (DPN). Eleven adults with Type 2 diabetes mellitus, ten DPN, and 11 age-matched healthy adults (HTY) participated in this study. They stepped over forthcoming virtual obstacles during treadmill walking. Outcomes such as success rate, spatiotemporal gait characteristics during obstacle crossing, and correlations between these variables were evaluated. The results partially supported our hypotheses that when comparing with HTY and DM, people with DPN adopted a crossing strategy which decreased obstacle crossing success rate and maximal toe elevation, and increased stride time and stance time during virtual obstacle crossing. This might be due to the compromised somatosensory functions of their lower extremity which may increase the risk of falling. This study also found an inter-leg relationship which may be applied to future stepping or obstacle crossing training that incorporates both legs as a means for improving outcomes of the trailing leg during daily obstacle negotiation

Pioglitazone in the Treatment of Type 2 Diabetes: Safety and Efficacy Review

The increase in obesity and the aging of the population has lead to an increase in the incidence of type 2 diabetes. This has led to the development of new drugs such as thiazolidinediones (TZDs) which are Peroxisome Proliferator-Activated Receptor (PPAR-gamma) agonists, to treat type 2 diabetes. TZDs have recently been at the center of a controversy with regards to their cardiovascular safety. Pioglitazone is a TZD which has been shown to be effective in glycemic control by lowering insulin resistance. Pioglitazone also has beneficial effects on lipid metabolism and cardiovascular risk. The safety and efficacy of pioglitazone including its pleotropic effects are discussed at length in this article

Genetically Targeted Dipeptidyl Peptidase-4 Inhibitor Use in a Patient with a Novel Mutation of MODY type 4

Maturity onset diabetes of the young (MODY) is a rare form of diabetes mellitus typically seen in young adults that results from pancreatic beta-cell dysfunction. MODY4 is a rare subtype caused by a PDX1 mutation. In this case, we present a nonobese 26-year-old male with polyuria and polydipsia. Lab work showed a blood glucose of 511 mg/dL, no ketones or antibodies (insulin, islet cell, and glutamic acid decarboxylase [GAD]), C-peptide of 1.6 ng/mL, and A1c 9.3%. Genetic analysis revealed a novel nonsense mutation in the PDX1 gene, consistent with MODY type 4. Given this patient's particular genetic mutation affecting the incretin pathway, sitagliptin was substituted for glyburide, which led to significant improvement in glycemic control. Our case report identifies a unique mutation in a rare form of MODY and outlines management of ensuing diabetes through targeting its inherent genetic mutation

Adrenal oncoctyoma of uncertain malignant potential: a rare etiology of adrenal incidentaloma

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The impact of apathy on glycemic control in diabetes: A cross-sectional study

Objective: Diabetes mellitus is a major public health problem with a prevalence of 6–7%. Self-care behaviors play a major role in the control of diabetes. Apathy is characterized by loss of initiative and motivation. Apathy may interfere with self-care behavior and glycemic control. The primary objective was to determine the prevalence of apathy in patients with diabetes. The secondary objective was to determine if there was an association between clinically significant apathy and factors that affect glycemic control. Research design and methods: We conducted a cross-sectional study of 100 patients with diabetes who were assessed with the Apathy Evaluation Scale-Clinician version (AES-C), the Hamilton Depression Scale (HAM-D), and the Self-Care Inventory (SCI). For this study we defined clinically significant apathy as AES-C score of \u3e30. We excluded patients with a HAM-D score of \u3e14 (n = 19) to avoid confounding from depression. T-tests were used to compare clinical characteristics between subjects with and without apathy. Multiple linear regression modeling was used to investigate the association between clinically significant apathy and factors that affect glycemic control. Results: Fifty (61.7% of 81) patients had clinically significant apathy. Compared to the nonapathetic patients, those with apathy had a higher mean BMI (30.5 kg/m2 versus 34.1 kg/m2 (p = 0.03)) and were less likely to adhere to an exercise plan (p = 0.01) or insulin regimen (p = 0.003). After adjustment for age, BMI, cholesterol, mild depression and the average Self- Care Index score, the mean HbA1C level was 0.66% greater for apathetic compared to nonapathetic subjects (P = 0.08). Conclusion: Apathy is highly prevalent in patients with diabetes without depression. Apathy may have a negative impact on self-care behaviors and diabetes control

Dyslipidemia Can Be Controlled in Diabetic as well as Nondiabetic Recipients after Kidney Transplant

Background Patients with diabetes have been reported to have greater dyslipidemia after kidney transplant (KTX). As post-KTX management of diabetes has changed dramatically since those reports, we hypothesized that lipids can be controlled as well in diabetic as nondiabetic recipients. Methods We compared lipids up to two years after KTX (n=192) between diabetic and nondiabetic recipients. The cohort was subdivided into non-diabetic (nonDM-K; n=123), type 2 (DM2-K; n=33), or type 1 diabetes after KTX (DM1-K; n=14), or type 1 after kidney-pancreas (DM1-KP; n=22). Results Mean age and BMI of DM2-K were greater than the others (p\u3c0.01), and diabetes groups had a higher pre-transplant A1C than nonDM-K (p\u3c0.001). After KTX, lipids were not greater in diabetic than nondiabetic recipients, and didn’t increase in any group. Total and LDL-cholesterol decreased in DM1-K (p\u3c0.001), HDL decreased in DM1-KP (p=0.02), and triglycerides were unchanged after KTX for all groups. A1C improved in DM1-K and DM1-KP (p\u3c0.0001). There was less improvement in lipids with tacrolimus-sirolimus immunosuppression than other steroid-containing regimens (p\u3c0.05). Conclusions Multiple mechanisms may contribute to better lipids in both groups as well as the lack of difference between diabetic and nondiabetic recipients compared to what has been reported previously: greater use of and more effective lipid lowering agents, no significant weight gain, no difference in renal function between groups, and better control of glucose in the diabetic group. Thus, overall, lipids can be controlled as well in diabetic as nondiabetic KTX recipients