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Background Post-transplant prediabetes (PreDM) and diabetes (PTDM) are common and have an impact on cardiovascular events. We sought to investigate the pathogenesis and best approach for prediction. Methods We prospectively studied 115 waitlisted patients from a single center without manifest diabetes. An oral glucose tolerance test (OGTT) was performed yearly until transplantation and 12 months later. Insulin secretion, insulin sensitivity (IS) and disposition index (DI) were derived from the OGTT. Results PreDM and PTDM were observed in 27% and 28.6% of patients, respectively. Pretransplant age, body mass index (BMI), 120 min glucose, IS, DI, and prediabetes or undiagnosed diabetes were significantly associated with these alterations. In multivariate analysis, pretransplant age [odds ratio (OR) 1.5; 95% confidence interval (CI) 1.04–2.1], BMI (OR 1.16; 95% CI 1.04–1.3) and cumulative steroids (OR 1.5; 95% CI 1.02–2.2) were predictors of PreDM or PTDM. Receiver operating characteristic curve analysis showed that pretransplant BMI and 120 min glucose had the highest area under the curve (0.72; 95% CI 0.62–0.8; and 0.69; 95% CI 0.59–0.79, respectively). The highest discrimination cut-off for BMI (≥28.5 kg/m2) and 120 min glucose (≥123.5 mg/dL) yielded a similar number needed to diagnose (2.5). Conclusions PreDM or PTDM develops in waitlisted patients with an ineffective insulin secretion and BMI shows a similar diagnostic capacity to OGTT. Pretransplant interventions may reduce post-transplant glucose alterations.

Background In living kidney transplantation there are two different individuals, a healthy donor and a renal transplant recipient. This is an excellent human model to study factors that influence kidney function in the context of reduced renal mass and the adaptation of two comparable kidneys to different metabolic demands. Methods We analyzed the changes in measured glomerular filtration rate (GFR, iohexol) from pretransplantation to 12 months after transplantation in 30 donor–recipient pairs. Each donor was compared with his/her recipient. We defined a priori three different groups based on GFR differences at 12 months: donor > recipient (Group A; 78 ± 8 versus 57 ± 8 mL/min), donor Results In Group A donors were mostly male and recipients were female (75% each). Donors had a higher baseline weight than their recipients. During follow-up, weight remained stable in donors but increased 7% in recipients. In Group B donors were mostly female (60%) and recipients male. At baseline, donors had a lower weight than recipients. At 12 months, weight was stable in donors but increased in recipients. In Group C donors were mostly (75%) female and recipients male. At baseline, donors had a higher BMI than their recipients. At 12 months, BMI was stable in donors but increased 14% in recipients. In multivariable analysis, higher GFR at 12 months was associated with higher baseline weight and GFR in donors and with male gender and higher baseline weight in recipients. Conclusions Kidneys from living donors are more ‘plastic’ than originally thought and respond to metabolic demands and weight changes of their new host. These changes should be taken into account when assessing GFR outcomes in this population.

Background Diabetes is a risk factor for cancer in the general population. However, few data are available on the association between post-transplant diabetes mellitus (PTDM) and cancer after transplantation. Methods We analyzed this issue in a Spanish cohort of patients without diabetes before transplantation. PTDM was diagnosed with consensus criteria at 12 months after transplantation and 12 months before the diagnosis of cancer. The association between PTDM and cancer (overall and specific types) was evaluated with regression analysis. Results During a follow-up of 12 years (interquartile range 8–14), 85 cases of 603 developed cancer (829/100 000/year) and 164 (27%) PTDM. The most frequent cancers were renal cell cancer (RCC) n = 15, 146/cases/100 000/year), lung (n = 12, 117/cases/100 000/year), colon (n = 9, 88/cases/100 000/year) and prostate (n = 9, 88/cases/100 000/year). In logistic regression, PTDM was not associated with cancer. Eight of the 164 patients with PTDM (4.9%) vs 7 of the 439 without PTDM developed RCC (1.6%) (P = .027). In multivariate analysis, PTDM was independently associated with RCC [odds ratio (OR) 2.92, confidence interval (CI) 1.03–8.27], adjusting for smoking (OR 4.020, 95% CI 1.34–12.02) and other covariates. PTDM was not associated with other types of cancer. Conclusions Patients with PTDM must be considered a population at risk for RCC and accordingly, the subject of active surveillance.

Prediabetes and post-transplant diabetes mellitus affect about 20-30% of renal transplant patients. The latter is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. To study this we analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated oral glucose tests for up to five years and a long term survival evaluation. Prediabetes and post-transplant diabetes mellitus were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was significantly higher in patients with either prediabetes, (17%; 0.023 person/year) or post-transplant diabetes mellitus (20%; 0.028 person/year) than in normal individuals, (7%; 0.0095 person/year). The incidence of events was comparable between prediabetes and post-transplant diabetes mellitus. Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate Cox survival analyses (hazard ratio 2.24, 95% confidence interval 1.11-4.52). Prediabetes at three months and hemoglobin A1c at 12 months were not significantly associated with cardiovascular disease. Thus, prediabetes is a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Since prediabetes is potentially a reversible condition, there is an opportunity to prevent cardiovascular disease in this population.

Background: Prediabetes and post-transplant diabetes mellitus (PTDM) affect about 20-30% of renal transplant patients. PTDM is a risk factor for cardiovascular disease. However, no clear evidence linking prediabetes and cardiovascular disease is available. Methods: We analyzed the impact of prediabetes on cardiovascular disease in 603 renal transplant patients followed with repeated OGTTs up to 5 years and a long term survival evaluation. Findings: Prediabetes and PTDM were defined at 12 months after transplantation to avoid their high reversibility rate before this period. 73 cardiovascular events were observed. The incidence of events was higher in patients with prediabetes, 28 (17%) or PTDM 20 (20%) than in normal subjects, 25 (7%), p = 0·001 and < 0·0001, respectively. The incidence of events was comparable between prediabetes and PTDM (p = 0·27). Prediabetes at 12 months was a risk factor for cardiovascular events in univariate and multivariate COX survival analyses (HR:2·24 95% CI 1·11-4·52). Prediabetes at 3 months and HbA1c at 12 months were not significant. Interpretation: Prediabetes was a risk factor for cardiovascular disease in renal transplantation, a population at high risk for cardiovascular events. Prediabetes is a potentially reversible condition, which offers the opportunity to prevent cardiovascular disease in this population. Funding Statement: Instituto de Salud Carlos III: The authors would like to acknowledge (a) the IMBRAIN project (FP7-RE6-POT-2012-CT2012- 31637-IMBRAIN) funded under the 7th Frameworks Programme (capacities), (b) the Instituto de Salud Carlos III (Fondo de Investigacioen Sanitaria: FIS) and Fondos FEDER for the following grants: PI 07/0732, the REDINREN RD/0021/0008 and PI10/02428 and (c) the funding of the Spanish Research Network for Kidney Diseases (REDINREN RD12/0021/0008). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the Ethics Committee of each hospital and followed the Declaration of Helsinki.

The number of renal transplantation of emigrants from Africa in Europe is increasing. However, there is little information about the results. The aim of this study was to compare the results of renal transplantation among this African emigrant population compared with a matched group of Spanish patients. From 1996-2006, 27 African emigrants (from Morocco, Guinea, and Nigeria) received renal transplants in Madrid. We compared their results with a matched cohort, including 69% who received a kidney from the same donors to 49 Caucasian Spanish patients. Demographic data were similar except that retransplantation was more frequent (32% vs 0%; P = .02) among Spanish patients and hepatitis B was more frequent among the African group (22% vs 2%; P = .004). For both groups the most frequent regimen was steroids, tacrolimus, and mycophenolate mofetil. Acute rejection incidence was similar (Africans 26% vs Spanish 22%), but rejection as a cause of graft loss was numerically more frequent in Africans (4 of 6). Patient and graft survival rates were identical in both groups (96% and 80%, respectively) at a mean follow-up of 76 months in Africans versus 68 months in Spanish people. Characteristically African patients required higher dose of tacrolimus to maintain the same levels; and notably, they suffered rare opportunistic infections, such as Phonopsis longicolla and visceral Leishmania. In summary, renal transplantation in African emigrant patients in Spain showed excellent results similar to those obtained with a Spanish population. However, these patients needed higher doses of Tacrolimus and experienced more rare opportunistic infections.

The aim of this study was to analyze the 30 third transplantations performed at our center since 1976. They were all from cadaveric donors. Recipient mean age was 40 years (range, 21-57 years). Twenty-one patients (70%) had hepatitis C virus infection and 16 (53%) were hypersensitized (panel-reactive antibodies [PRA] >50%), with a mean time on dialysis since second graft loss of 65 months (range, 1-250 months). The imaging tests showed iliac calcifications in 14 patients (47%). The graft was preferably placed in the iliac fossa (27/30). Twenty-five patients (83%) had prior graft nephrectomy and transplantectomy was performed at the same surgery in 2 cases. Immunosuppressive protocol was quadruple therapy in 23 patients (77%). At a mean follow-up of 43 months, 24 grafts were functioning. Mean serum creatinine was 1.5 mg/dL and Modification of Diet in Renal Disease (MDRD) clearance was 64.5 mL/min. Six grafts were lost: 3 due to acute rejection, 2 due to chronic allograft nephropathy, and 1 due to venous thrombosis. Four patients died: 2 due to infectious complications, 1 due to hepatic encephalopathy, and 1 to an accident with a functioning graft. The acute rejection rate was 30% and 4 patients had an acute humoral rejection episode. The main surgical complication was lymphocele in 7 cases (23%). Estimated survival at 5 years was 76% for grafts and 86% for patients. Graft survival worsened among patients with PRA > 80% and among those who had lost the previous grafts in the first month posttransplantation (P < .05). In conclusion, the outcomes of the third kidney transplantations encourage us to continue with this procedure. However, worse graft survival should be expected among hyperimmunized patients and among those who had lost previous grafts early in their course.