Original Investigation
Transplantation
Associations of Pretransplant Diabetes Mellitus, New-Onset Diabetes After Transplant, and Acute Rejection With Transplant Outcomes: An Analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing (OPTN/UNOS) Database

https://doi.org/10.1053/j.ajkd.2010.06.027Get rights and content

Background

Diabetes and acute rejection are major contributors to morbidity and mortality in kidney transplant recipients. Immunosuppressive medications decrease acute rejection, but increase the frequency of new-onset diabetes after transplant. Our objective was to investigate the joint associations of diabetes (pretransplant diabetes and new-onset diabetes after transplant) and acute rejection with transplant outcomes in a recent transplant cohort.

Study Design

Historical cohort study.

Setting & Participants

37,448 recipients (age ≥18 years; 2004-2007) surviving with a functioning transplant for longer than 1 year were identified in the Organ Procurement and Transplant Network/United Network for Organ Sharing (OPTN/UNOS) database as of May 22, 2009.

Predictors

Recipients were stratified into 6 mutually exclusive groups according to status of diabetes and acute rejection at 1 year: group 1, neither (reference; n = 20,964); group 2, new-onset diabetes alone (n = 2,140); group 3, pretransplant diabetes alone (n = 10,730); group 4, acute rejection alone (n = 2,282); group 5, new-onset diabetes and acute rejection (n = 361); and group 6, pretransplant diabetes and acute rejection (n = 1,061). Analyses were adjusted for other recipient, donor, and transplant characteristics.

Outcomes Measurements

Multivariate Cox regression analysis of time to transplant failure (overall and death censored) and mortality (all-cause and cardiovascular).

Results

Median follow-up after 1 year was 548 days (25th-75th percentiles, 334-752 days). During this time, there were 3,047 outcomes of overall transplant failure. New-onset diabetes alone (group 2) was not associated significantly with any study outcomes. Groups 3-6 were associated with higher overall transplant failure risk. However, only groups 4-6 were associated with higher death-censored transplant failure risk. Group 3, 4, and 6 were associated with higher all-cause mortality risk, whereas only groups 3 and 6 were associated with higher cardiovascular mortality risk.

Limitations

Potential information bias with exposure, covariable, or outcome misclassification; relatively short follow-up.

Conclusions

Pretransplant diabetes is the major predictor of all-cause and cardiovascular mortality, and acute rejection during the first year is the major predictor of death-censored transplant failure in kidney recipients surviving with a functioning transplant for at least 1 year. The influence of new-onset diabetes on long-term outcomes needs further observation.

Section snippets

Study Design, Setting, and Population

Adult recipients (aged ≥18 years) who had received their primary kidney transplant between July 1, 2004, and December 31, 2007, with at least 1 follow-up report with a clear record of DM status during follow-up were identified in the OPTN/UNOS database as of May 22, 2009. Multiorgan transplant recipients and recipients without clear reports of pretransplant diabetic status were excluded. Recipients surviving with a functioning transplant for at least 1 year posttransplant were identified and

Demographic Data

In the original sample of 45,989 adult recipients who received a primary kidney transplant alone between July 2004 and December 2007, the prevalence of pretransplant DM was 32.3% (14,857 of 45,989). NODAT was identified during the first year after transplant in 4,449 of 31,132 recipients (14.3%) who did not have DM before transplant, which corresponds to 9.7% of all study patients. Cumulative incidences of NODAT at 12, 24, and 36 months posttransplant were 9.7%, 13.3%, and 16.4%, respectively.

Discussion

In the present study, we analyzed the differential impacts of acute rejection, pretransplant DM, and NODAT on transplant and patient survival in the recent cohort (underwent transplant between 2004 and 2007) of kidney transplant recipients who survived with a functioning transplant for at least 1 year in the United States. In our study population, the reported rate of pretransplant DM was 31.5%. The reported rate of acute rejection at 1 year posttransplant was 9.7%, and that of NODAT at 1 year

Acknowledgements

The data and analyses reported in the 2008 Annual Report of the US OPTN and the Scientific Registry of Transplant Recipients have been supplied by UNOS and Arbor Research under contract with the Department of Health and Human Services/Health Resources and Services Administration (contract 231-00-0115). The authors alone are responsible for reporting and interpreting these data; the views expressed herein are those of the authors and not necessarily those of the US Government.

Support: None.

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    Originally published online as doi:10.1053/j.ajkd.2010.06.027 on October 11, 2010.

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