Post-Operative Hyperglycemia after Kidney Transplant: Estimating Insulin Requirements and the Role of IV Insulin

Presentation Number: MON 584
Date of Presentation: April 3rd, 2017

Margaret Spinosa*, Shelby Steffen, Clifford Miles, Alexander Maskin, Vijay Shivaswamy and Brian P Boerner
University of Nebraska Medical Center, Omaha, NE

Abstract

Introduction: Inpatient post-operative hyperglycemia (POH) immediately after kidney transplant (KTx) is common and related to many factors including corticosteroid use and a high rate of diabetes (DM) in this population. POH has been associated with worse outcomes, including increased rejection risk. No specific blood glucose (BG) goals have been established for the immediate post-KTx period, though tight control (BG 70-110 mg/dl) in this setting was associated with increased rejection risk (1). We have proposed that BG goals for KTx recipients should reflect the American Diabetes Association recommendations for any hospitalized patient (2). Though algorithms have been proposed to estimate insulin doses for steroid-induced hyperglycemia, little data exists to guide insulin management in the post-KTx setting.

Methods: We performed a retrospective analysis of KTx alone recipients at UNMC between 1/1/2013 and 12/31/2014 to investigate the frequency of immediate POH, predictors of post-KTx insulin dose requirements (including steroid dose, renal function, weight, and pre-KTx insulin doses), and the safety and efficacy of IV insulin in this setting.

Results: A total of 256 subjects were analyzed (age 52.5 ± 12.7 years); 82 had pre-operative DM (type 1 DM, n=7; type 2 DM, n=75). Subjects received basiliximab or alemtuzumab plus high-dose steroids for induction, and were started on tacrolimus at time of KTx. POH, defined as persistent BG >180 mg/dl and/or requiring insulin therapy, developed in 80/256 subjects, 72 of whom had pre-KTx diagnosis of DM (daily mean BG of POH vs. No POH = 167 ± 41 vs. 119 ± 25 mg/dl, P<0.0001). Insulin therapy was utilized in 76/80 subjects with POH. The only significant predictor of post-KTx insulin dose was pre-KTx insulin dose (P<0.0001). Renal function, steroid dose, and weight were poor predictors of post-KTx insulin dose (P = NS). In 52/76 subjects who required insulin, IV insulin was used at least one day (mean duration 3.5 ± 1.4 days). Mean daily insulin dose was higher in subjects who received any IV insulin (+IV) compared to subjects who received only SQ insulin (–IV) (51.3 ± 44.8 vs. 10.0 ± 11.5 units/day, P<0.0001). Daily mean BG were maintained in the goal range, with modestly better BG control in +IV versus –IV (165±40 vs. 172±42 mg/dl, P=0.043). Hypoglycemia rates were very low in both groups (+IV=0.51% vs. –IV=0.37%, P=NS). Length of stay did not differ between +IV and –IV (6.4±2.4 vs. 5.8±2.2 days, P=NS).

Conclusions: POH requiring insulin therapy is common amongst KTx recipients with pre-transplant DM. Only pre-KTx insulin dose correlated with post-KTx insulin dose. Thus, utilizing steroid dose, weight, or renal function is unlikely to yield an accurate estimate of insulin dose requirements. IV insulin by our protocol was safe and effective, indicating this is a useful therapy for POH in KTx recipients, especially those with higher insulin requirements.

 

Nothing to Disclose: MS, SS, CM, AM, VS, BPB