5. Urine dipstick showed 1+ of glucose on investigation of a potential female donor who is 31-year-old. She has normal fasting but abnormal post-prandial blood sugar test. She has excellent kidney function with no evidence of haematuria, proteinuria or microalbuminuria. She is keen to donate to her daughter, 111 mismatch and no DSA
- How do you proceed?
- Substantiate your answer
The above example is a young donor who has glycosuria due to diabetes mellitus with normal fasting sugar and abnormal post prandial blood sugar… The donor has normal renal function with no evidence of proteinuria, hematuria or microalbuminuria ….
When considering organ donation from diabetics it is important that they don’t have any end organ damage and no proteinuria and no renal dysfunction
It is also important to exclude obesity, dyslipidemia, hypertension, smoking and family history pre mature heart diseases…this donor has very early onset diabetes..I will warn her about the long term complication of diabetes including diabetic nephropathy after few decades…Her daughter must be very young, so if there are no other donors, I will proceeed after informed risk consent
Diabetes risk calculator can be used to give a perfect risk estimate after donation in a diabetic individual….
Type I DM is absolute contraindication
Type II DM
The perception of a danger of acquiring diabetes after donation and perhaps developing diabetic nephropathy that progresses to end-stage renal disease (ESRD) is what raises concerns regarding the acceptability of live kidney donors with impaired glucose metabolism
In these donors, one concern is that compensatory hyperfiltration from donating a kidney will combine with the hyperfiltration observed in DM and lead to a rapidly progressive deterioration of kidney function
Most transplant programs regard established diabetes mellitus as a contraindication to living donation, and many centers exclude individuals deemed high-risk
Individuals with IFG and IGT should be counseled on lifestyle modifications, including weight control, diet, exercise, and tobacco avoidance.
Donation is not advised for those who have mild or borderline IGT as well as additional risk factors Like HTN , Obesity , smoking and hyperlipidemia
or presence of end organ damage diabetic retinopathy , cardiac affection and peripheral blood vessels affections
So I will accept the donor after
Life style modification
Strict blood sugar control
Avoiding of any risk factors obesity , smoking and hypertension
excluding of end organ damage
Ref
BTS
This donor needs to be investigated for a family history of DM2 and personally for the possibility of having DM, because although she has a normal fasting test, no change in postprandial would be expected. I would perform the Oral Glucose Tolerance Test in an attempt to make the diagnosis.
This investigation would be carried out to optimize post-donation management, since, due to the fact that it does not present target organ damage, it may be a donor.
there is a high risk to develop DM
f she knows the risks and want to proceed I will go for the work up to exclude any micro vascular or macro vascular diabetic complications
I will ask about family history of diabetes, history of obesity, history of gestational diabetes and the ethnicity.
Repeat the post-prandial blood sugar test, if still high, OGTT and HbA1c should be done.
If OGTT reveals a persistent impaired fasting glucose and/or an
impaired glucose tolerance, then the risks of developing diabetes after
donation must be carefully considered.
Diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a
single kidney.
Reference:
BTS (2018)
31 year old donor with 1+ glucose in urine and impaired post prandial blood glucose is at a high risk of developing overt DM
Risks should be assessed accurately including full history for the patient including gestational diabetes and FH of diabetes
Full examination and investigation to exclude micro or macrovascular complications of diabetes and proper risk evaluation for the patient.
Type 1 DM absolute CI to donation
Type 2 relative CI according to risk calculation as with impaired glucose tolerance.
If no complications of diabetes either micro or macrovascular are present and pt is counselled for the risks of diabetes we shall proceed with Tx
she is young and pre diabetic, as per kdigo , the decision should be individualized , as per BTG type 2 with obesity , hypertension should be avoided as a donor. though she has good renal function but she is young and the weight is not mentioned but if she is obese, that will increase her risk and there is a chance she can progress to CKD .
In the case of abnormal postprandial sugar tests, the oral glucose tolerance test and HbA1c are initiated. If these tests are found to be above normal, she is more likely to develop diabetes in the future.(1)
Pre-diabetes can progress to diabetes over time. Intervention with diet and lifestyle changes during the pre-diabetes stage can halt or even reverse this progression and prevent diabetes.
A diabetes risk calculator estimates an individual’s risk for diabetes based on age, waist circumference, history of gestational diabetes, height, race/ethnicity, hypertension, family history, and exercise (2).
Look for diabetes-related end organ damage as well.
Ensure that cardiovascular risk factors such as obesity, hypertension, and dyslipidemia are well managed (1).
She should be counselled about the long-term risk of cardiovascular and kidney disease in view of an abnormal OGTT or HbA1c.
With pre-diabetes, she has increase chance of gestational diabetes and needs counselling for the same
Absence of end organ damage with controlled cardiovascular risk factors, she can proceed for donation
References:
In the above case,a 31 year potential donor with 111 mismatch and no DSA and normal fasting but abnormal post-prandial blood sugar test should be thoroughly evaluated for all the risk factors for increasing future diabetic risk like obesity,family history of diabetes,cardiovascular status and obesity,then subjected to OGTT –value equal to or greater than 11.1 mmol/L indicates diabetes and between 7.8 and 11.1 mmol/L indicates (IGT).She should also be counseled in detail about the risk of developing GDM in future pregnancies and maternal and fetal consequences which can occur. The risks and benefits of donation and transplantation, for both the donor and recipient should also be explained in detail. Risk calculators are also available which can help us in estimating risk of diabetes over the subsequent 10 years..
One of the study quoted relative risk 3.0 of developing diabetes with a positive family history (first degree relative) of type 2 diabetes .For individuals with a normal OGTT, the risk of developing type 2 diabetes within 5 years is around 1% and is affected by ethnicity and obesity. A patient with IFG and IGT has 4.7 times and 6 times relative risk of developing diabetes more than a normal person respectively according to one of the study.
Regarding the above case, the patient should not donate as pre-diabetic as chances of developing diabetes later and can be considered if no target organ damage and after counseling of all consequences and also about the risk of GDM in future pregnancies and advise to adopt a healthy lifestyle, with life-long follow-up. In case she is found diabetic on OGTT, then contraindicated for donation.
REFERENCES:
1- Okamoto M, Suzuki T, Fujiki M, et al. The consequences for live kidney donorsnwith preexisting glucose intolerance without diabetic complication: analysis at a single Japanese center. Transplantation 2010; 89: 1391-5
2- KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors; August 2017; Volume 101; pg. 17
31-year-old potential donor which has normal fasting but abnormal post-prandial blood sugar test.
To make the decision for such patients more details should be evaluated
1. History taking: Family history of diabetes, and smoking. and chronic kidney disease
2. Examination: including hypertension measurement, BMI, and hyperlipidemia.
3. Investigations: includes glycated hemoglobin, liver functions, kidney functions, and fundus examination.
The patient will be diagnosed as a prediabetic or diabetic patient.
Prediabetic: normal fasting and glycated hemoglobin with IGT especially with the presence of a positive family history of DM she is exposed to 6 folds risk of developing diabetes than the general population. Some transplant centers don’t accept such patients but with proper counseling about the risk, lifestyle modification, and with correction of all possible risk factors she can be accepted as a potential donor.
Diabetic patient: approved with glycated hemoglobin and after lab repetition. The old population with controlled diabetes with no evidence of any organ damage (up to kidney biopsy) can be accepted as the potential donor but this young lady which is 31 years old will be exposed to a high risk of diabetes complications including ESRD related to diabetes.
References:
1) Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PK, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017 Aug;101(8S Suppl 1):S1-S109. doi: 10.1097/TP.0000000000001769. PMID: 28742762; PMCID: PMC5540357.
2) British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018; Available online: https//bts.org.uk/wp-content/uploads/2018/07/FINAL_LDKT-guidelines_June-2018.pdf (accessed on 18 September 2022).
3) Ibrahim HN, Kukla A, Cordner G, Bailey R, Gillingham K, Matas AJ. Diabetes after kidney donation. Am J Transplant. 2010 Feb;10(2):331-7. doi: 10.1111/j.1600-6143.2009.02944.x. Epub 2009 Dec 23. PMID: 20041863; PMCID: PMC3565834.
I will proceed for donation after proper screening for DM ,like GTT ,HbA1c ,lipid profile and BMI measurement
The potential kidney donor has +1 glucose in dipstick,normal fasting but abnormal post-prandial blood sugar.
Workup
1.Family history, history of gestational diabetes,physical examination to detect complications
2.fasting blood sugar, oral glucose tolerance test,HBA1c
3.BMI
4.Assessment of presence of complication albumin/creatine ratio,fundus examination
,Cardiovascular evaluation and assessment of risk factors as hyperlipidemia, hypertension and obesity.
After that according to BTS guidelines
1.Type1 diabetes is absolute contraindication for kidney donation.
2.In type 2 diabetes, presence of hypertension,obesity or diabetic complications is a contraindication for kidney donation.
If there is no diabetic complication or other CV risk factor and GFR more than 80 ml/minute and age more than 60 ( relative contraindication)
and can be considered for donation after the assessment of the life time risk of CV and progressive kidney disease in the presence of a single kidney.
According to KDIGO : the decision for donation in pre-diabetic or type 2 DM should be individualized based on health profile.
This young female should be excluded, DM is a risk factor for ESRD.
· A comprehensive history and physical exam about gestational diabetes, family history of DM, her BMI and other CVD risk factors such as hyperlipidemia, smoking or hypertension is necessary. If her postprandial glucose is high but normal FBS, OGTT should be done. If OGTT is above 200 mg/dL and HSB A1C is equal or more than 6.5%, the donation shouldn’t happen.
This donor is a young woman with possible future pregnancies that
puts her in a future risk. Hence, it is better to preclude her from donation.
How do you proceed?
Substantiate your answer.
Potential donor with impaired abnormal post prandial blood glucose should be worked up via:
1- Family history of DM, history of gestational DM, Previous history of DM or pre-DM.
2- Full examination including BMI, BP, end-organ damage.
3- Investigations: Fasting blood sugar, OGTT, HBA1C, urine PCR, lipid profile, ECHO.
Donors with DM I should be excluded from donation.
Donors with impaired fasting glucose or impaired glucose tolerance can develop DM 5 times more than normal population. However, they can donate after discussing the risks of DM post donation.
Donors with DM II without any target organ damage can go for donation after assessment of cardio-vascular risks.
As per KDIGO guidelines, older donors with DM II with well controlled blood sugar without insulin and without target organ damage can proceed for donation.
In summary:
If this donor (young female) is pre-DM–à> control blood sugar and risk factors—à> proceed for donation.
If this donor (young female) is DM—-à> not to proceed for donation
A donor with suspected diabetes should be managed as follows :
1- This donor must have a fasting plasma glucose level checked.
2- A fasting plasma glucose concentration between 6.1-6.9 mmol/L (110-125mg/dl) is indicative of an impaired fasting glucose state and (OGTT) should be undertaken.
3- this donors may has high risk of type 2 diabetes if
o family history,
o a history of gestational diabetes,
o ethnicity or
o obesity
should also undergo an OGTT.
4- diabetes as donors requires very careful evaluation
· In the absence of evidence of target organ damage.
· other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed,
diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease .
An important consideration for kidney donor is the risk of developing nephropathy when they subsequently develop type 2 diabetes. It is known that There is increase in the incidence of type 2 diabetes after the age of 50 and the median age at diagnosis is around 60 years.
– Less than 1% of Europeans with type 2 diabetes develop ESRD but the incidence is higher in other ethnic groups .
– There is, a 50% cumulative incidence of proteinuria after type 2 diabetes has been present for 20 years which may become an issue for kidney donors who have an above average life expectancy and who may expect to live into their 80s .
In a large survey of living kidney donors in the United States, Ibrahim et al , found the eGFR and the rate of decline of eGFR were not significantly different between diabetic and matched non-diabetic donors. In this study, 11 donors developed ESRD requiring dialysis or transplantation, of which none were due to diabetic kidney disease .
1- Andrews PA, Burnapp L. British Transplantation Society / Renal Association UK Guidelines for Living Donor Kidney Transplantation 2018: Summary of Updated Guidance. Transplantation. 2018 Jul;102(7):e307
References:
1) Lentine KL et al. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017 Aug;101(8S Suppl 1):S1-S109
2) BTS Guidelines for Living Donor Kidney Transplantation; Fourth Edition. 2018
Our potential donor is :
-31 years old
-high post prandial glucose test
-evidence of + glucose urine dipstick which is sensitive
Further evaluation is needed regarding full history taking , family and obstetric history
Full examination
OGTT , repeat Fasting , 2HPP , HBA1C
Fundus examination
Echocardiography
BMI
Individualized acceptance of type 2 DM donor is well known after assessment of the potential risk as well as proper counselling
This 31 year old lady with +1 glycosuria with marked abnormal post prandial blood sugar, thorough history taking regarding family history of DM , clinical examination with special emphasis on BMI ,dietary habits ,urine frequency ,thirst sensation.
Further strict testing including OGTT is mandatory along with HBA1c is a must to rule out the diagnosis of DM. in case of diagnosis of DM, this donation must be rejected according to British transplantation society guidelines.
The risk of developing further diabetic kidney disease is highly probable.
Even if not diabetic, tubular affection is also contraindication for donation.
*This potential young donor has excellent kidney function with abnormal post-prandial blood sugar test and +1 glycosuria.
1.More detailed history should be taken ( includes: dyslipidemia , obesity , family history of DM, gestational diabetes.
2. OGTT if > 11.1 mmol/l so, DM confirmed. IF, IGT documented; donor will be at risk of diabetes after kidney donation, so risk should be assessed after six months.
3.HBA1c.
If , Diabetes confirmed so, this donor should be rejected for donation, so she should be counselled about modification of risk factors.
-According to KDIGO Guidelines: Donors with T2DM or Pre-diabetic state should be counselled about their progression of their condition and target organ damage in the coming future.
-References:
*KDIGO Guidelines.
*BTS Living Donor Kidney Transplantation Guidelines 2018.
Glycosuria could be from tubulopathy, drugs, and if blood sugars above the reabsorption threshold that is >200mg/dl.
In this patient need to confirm via FBS minimum twice, HbA1c, and OGTT. if impaired or diabetic should avoid donation.
I will try to make sure about glycosuria. tubulopathy may be a reason, but here we are concerned about diabetes. from this point of view, we need detailed evaluation, including evaluation of family history about DM etc.
We need to check both FBG and postprandial. If Fs is not less than 100 or in case of doubt, 75 mg OGTT and A1c will help. Still, the patient is young. In case his family history is strong, I may hesitate because the donor is 31 years old with multiple risks (as child bearing age related problems that may ensue with one kidney)
1) History enquire symptoms of diabetes : polyurea, polydipsia, polyphagia.
2) systemic examination for target organ damage.
3) Investigation : HBA1C. ECG.
4) Advice healthy lifestyle and diabetic diet control.
Donor candidates with type 1 diabetes mellitus should not donate.
The decision to approve donor candidates with prediabetes or type 2 diabetes should be individualized based on local protocol.
reference
1)Living Kidney Donor. KDIGO 2017.
References:
*This 31 young female, and potential donor for kidney transplantation, with 1+glucose in urine dipstick and abnormal post prandial blood sugar test, however, she had normal fasting sugar test, kidney function, with no evidence of haematuria, proteinuria or microalbuminuria and acceptable immunological risk, we needs to know the history of gestational diabetes, smoking, life style, BMI, lipid profile family history of diabetes and the OGTT, HbA1C should be done.
* A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
* Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT.
* If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
*Impaired glucose tolerance was initially defined in terms of an increased future risk of diabetes, but it is now appreciated that it is also associated with an increased risk of premature mortality and increased cardiovascular risk.
*Diabetes may also be diagnosed based upon HbA1c criteria, a result >48 mmol/mol being sufficient to diagnose diabetes if confirmed by repeat testing. An HbA1c <48 mmol/mol may be used to predict the future likelihood of developing diabetes; for example, an HbA1c result of 42-48 mmol/mol indicates a 5-year incidence risk of diabetes of 25-50%, 20 times higher than that associated with a HbA1c of 31 mmol/mol. An OGTT should be strongly considered when the HbA1c is in this range. It is reasonable to consider HbA1c values between 39 and 46 mmol/mol as identifying individuals with pre-diabetes, and at increased risk of developing diabetes and cardiovascular disease in the future.
# Postprandial hyperglycemia in nondiabetic populations is a stronger predictor of insulin resistance and CVD than fasting glucose. The combined 20-year mortality data some studies showed that the upper quintile compared with the lower for the 2-h postplasma load glucose was associated with a 2.7 times increased risk of CVD mortality.
The fasting glucose values were less discriminatory for CVD, with only the upper 2.5% values conferring a 1.8-fold increased mortality risk.
Over a 7-year period, elderly women in a study with isolated postprandial hyperglycemia, 2-h value > 11.1 mmol l−1 and fasting value < 7.0 mmol l−1 on a 75-g OGTT had an approximately three fold increased risk of heart disease when compared with women whose 2-h values were below 11.1 mmol l−1.
In established diabetes post prandial glycemia appears to have a stronger relationship with microvascular and mscrovasculat disease than fasting blood glucose. Similarly, in gestational diabetes adverse pregnancy outcome is more closely related to postprandial glycemia than fasting and premeal glycemic values.
*BTS/RA Living Donor Kidney Transplantation Guidelines 2018
*Postprandial Hyperglycemia
Postprandial hyperglycemia and lipemia result in vascular oxidative vascular stress, endothelial dysfunction, and inflammatory response even in healthy individuals,44,45 which means that these short-term metabolic stimuli and their effects are apparently physiological.
From: Diabetes (Second Edition), 2020
She is a young donor, with a finding in a screening test. I would request an oral glucose tolerance test and glycated hemoglobin in an attempt to close the criteria for diabetes mellitus, which would contraindicate donation in most transplant centers.
In addition to an extensive metabolic investigation, lifestyle changes should be suggested, such as a balanced diet, physical exercise, avoiding alcohol and smoking, and aiming for a body mass index between 25 and 30.
If glycated hemoglobin and oral glucose tolerance test are normal, I would proceed with the donation
.
Sorry I uploaded case scenario 6 here by mistake and deleted it.
· As long as she has glucosuria and abnormal post-prandial sugar, I should go ahead for OGTT and HbA1c
· If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered
· We can use HbA1c criteria, as a result >6.5% is sufficient to diagnose diabetes if confirmed by repeat testing
· We may use the diabetes risk calculator to inform the discussion of potential kidney donation
· We should exclude target organ damage and ensure that other cardiovascular risk factors such as obesity, hypertension or hyperlipidemia are optimally managed
· younger donors have enough time to develop risk factors for kidney disease, such as hypertension or diabetes which may lead to progressive kidney disease
Glycosuria may be due to either:
– the inability of the kidney to reabsorb filtered glucose in the proximal tubule despite normal plasma glucose concentration
– or an overflow scenario related to high plasma glucose concentrations overwhelming the capacity of the renal tubules to reabsorb glucose.
· In patients with normal kidney function, significant glycosuria does not generally occur until the plasma glucose concentration exceeds 180 mg/dL (10 mmol/L).
· When glycosuria occurs with a normal plasma glucose, a primary defect of proximal tubule reabsorption needs to be considered. glycosuria may coexist with additional manifestations of proximal tubular dysfunction, including phosphaturia, uricosuria, renal tubular acidosis, and aminoaciduria (Fanconi syndrome)
· Glycosuria with normal plasma glucose will also be evident in patients receiving sodium-glucose cotransporter 2 inhibitors.
In conclusion if this patient is diabetic, I think she should be precluded from donation because she is young and has increased risk for progression of nephropathy
1)BTS/RA Living Donor Kidney Transplantation Guidelines 2018
2)https://www.uptodate.com/contents/urinalysis-in-the-diagnosis-of-kidney-disease/contributors
This 31 year potential kidney donor with abnormal postprandial blood sugar test and +1 glucosuria
OGTT equal to or greater than 11.1 mmol/L indicates diabetes
between 7.8 and 11.1 mmol/L indicates (IGT)
Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation
in our potential donor
If laboratory results refers to impaired glucose intolerance, donor may undergo renal transplant but after assessment of the lifetime risk of cardiovascular and progressive renal disease
BTS GUIDELINE
KDIGO Guidelines :
2-hour glucose tolerance or HbA1c testing should be performed in donor candidates with elevated fasting blood glucose, history of gestational diabetes, or family history of diabetes in a first-degree relative, and results should be used to classify diabetes or prediabetes status using established criteria for the general population.
Donor candidates with prediabetes or type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complications
thanks
She has glycosuria and an abnormal post-prandial blood sugar therefore we need to know if there is any family history of diabetes, ethnicity, previous history of gestational diabetes, dyslipidemia, BMI (obesity) and we should also assess her cardiovascular risk.
If OGTT confirm diabetes this patient should not be considered for donation. If OGTT shows impaired fasting glucose or impaired glucose tolerance, she will be at increased risk of diabetes post donation. She should be informed that if she has pre-diabetes this may progress into diabetes therefore it is paramount to comply with lifestyle (lose weight, exercise, dietary measures, smoking cessation) in order to prevent the progression of her pre-diabetes (if she has pre-diabetes).
If the donor is able to correct her pre-diabetes she may be considered suitable for donation after excluding target organ damage and others risk factor (hypertension, BMI, hyperlipidemia etc) are satisfactory.
KDIGO Guidelines
British Transplantation Society Living Donor Kidney Transplantation Guidelines 2018
The presented case is young lady wishes to donate to her daughter no data bout her age.
she has glucosuria and abnormal Post prandial blood sugar test with normal kidney functions and no other abnormalities.
History should include:
-family history of Dm.
-gestational diabetes.
-dietary habits, BMI,history of PCO and irregular menses as part of metabolic syndrome with insulin resistance.
-if she had completed her family or she still wishes to become pregnant as she is young and the future pregnancy with single kidney is challenging.
-OGTT, HBA1C,should be done if abnormal refer yo endocrinologist for evaluation of type of diabetes.
If diagnosed to be diabetic at this ago so long term diabetic renal complications is of high incidence so i wont accept her as a donor
If not she will be asked to control body weight adopt healthy life style and to be reevaluated 6 months later
KDIGO Guidelines :
2-hour glucose tolerance or HbA1c testing should be performed in donor candidates with elevated fasting blood glucose, history of gestational diabetes, or family history of diabetes in a first-degree relative, and results should be used to classify diabetes or prediabetes status using established criteria for the general population.
Donor candidates with prediabetes or type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complications
– We start by history taking: family history, H/O pre-diabetes or history of gestational DM and examination mainly to calculate BMI.
– OGTT to be performed in presence of one or more of those items.
-OGTT showing impaired fasting glucose and/or impaired glucose tolerance ,post donation risk of developing diabetes must be considered.
– With established diabetes, kidney donation is contraindicated.
-On the other hand, patients with IFG and IGT need to modify life style through weight control, diet, exercise, tobacco-avoidance and reassessed.
References
BTS guidelines.2018.
How do you proceed?
This female is 31 with Glucose 1+ on urine dip . Fasting sugar is normal but post prandial is abnormal.
I will like to explore further to find the cause of glucose in urine
I will like to detailed medical history. It will include history of including history of gestational diabetes as she is young. I will asses her in detail regarding risk factor for diabetes and cardiovascular risks. It will include family history of diabetes, any history of dyslipedemia , smoking , high BMI and hypertension.
I will repeat urine test, and do oral glucose tolerance test, HBA1c
If She turns out to be pre diabetic then she cannot donate . She will need life style modifications including exercise, dietary measures, avoidance of smoking and lose weight.
She will need repeat assessment. If there is no further glucosuria and no end organ damage and no cardiovascular risks then she can donate
BTS Guidelines on living kidney donation 2018 .
Patient female with history of having glucose 1+ on a urine dipstick. With no other risk factor as a donor. The patient must be properly interviewed to look for a cause for the glucose in the urine. Medical and family history, gestational history and also risk of metabolic syndrome and obesity in the family must be identify. One that is done, the patient must be further investigated by doing the following:
1) Repeat the urine dipstick
2) Must do OGTT
3) HbA1c must be done
4) Do pancreatic test
5) Investigate to see is there is any tubulopathy.
Once that is done it is noted that the patient is pre diabetic then care must be taken and recommend life style modification to ensure there is adequate metabolic or glucose control.
These include:
1) Exercise
2) Avoid stress
3) Weight loss
4) Avoid toxic habits
5) Dieting,etc.
Once that is done and the patient glucose level is well controlled and there is no sigh of organ affectation based on KDIGO guidelines patient can proceed as a donor.
female donor who is 31-year-old1+ of glucose + abnormal post-prandial blood sugar test
detailed history including, history of gestational diabetes, ethnicity or obesity and family history of type 2 diabetes
check the wight and bp
check for eGFR, Hb1 c and OGTT
if OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
but In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed,
This patient 31 age old with glucoseurea and impaired post prandial blood sugar test .
First the test must be done again if still positive the risk of developing diabetes should be calculated.
First detailed history about wieght, bmi ,hieght, waist circumference, physical activity,diet ,blood pressure, family history of diabetes
Pregnancy history or plan (gestational diabetes risk).
All these thing will help us calculat the risk of developing diabetes in future throughout the Q diabetes risk calculator.
Kidney nephropathy of diabetes should be assessed with albumin/creatinine ratio and calculation of GFR.
The donor shoul be informed about the risk of developing DM after donation and inform about the nephropathy esrd risk and CV risk
Blood pressure measurementin.
The precence of prediabetes doesn’t necessarily render a potential donor unacceptable
Prediabetes is a relatively contraindication to donation and policy is trying to increase kidney donation pool , so prospective donors with IFG ,IGT should be assessed on an individual basis.
Young Potential donor with positive urine stick for glucose and abnormal post prandial
Should be properly assessed by :
History taking of family history , previous gestational diabetes
Also assessing BMI , CV risk
Labs as Hb A1C , OGTT
If OGTT is positive for impaired fasting or impaired glucose tolerance , this pt has high risk of developing DM after renovation.
Confirmed Diabetics will be excluded by many centers .
While prediabetics should be counseled with wt loss , control diet and exercise
Ask about
1- Family history of type 2 diabetes
2- History of gestational diabetes
3- Ethnicity and obesity
Consideration of a diabetic as a potential donor requires a thorough evaluation of the risks and benefits of donation and transplantation, for both the donor and recipient.
Specifically, a careful search should be made for any evidence of target organ damage and assessment of cardiovascular risk factors such as obesity, hypertension and hyperlipidaemia.
The age of the donor, donor GFR, and the relationship to the potential recipient are critical factors.
After exclusion of preexisting diabetic nephropathy, possibly including renal biopsy, the potential risk of development of diabetic nephropathy should be discussed with the potential donor
The guidelines
1-All potential living kidney donors must have a fasting plasma glucose level checked.
2-A fasting plasma glucose concentration between 6.1-6.9 mmol/L is indicative of an impaired fasting glucose state and an oral glucose tolerance test (OGTT) should be undertaken.
3-Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT.
4- If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
5- Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation.
Reference
Guidelines for Living Donor Kidney Transplantation Fourth Edition March 2018
BTS/RA Living Donor Kidney Transplantation Guidelines 2018 United Kingdom Guidelines
Having Urine dipstick showed 1+ of glucose and abnormal post-prandial blood sugar test:
Importance in the Medical +/- Family History of a Potential Kidney Donor about DM, history of gestational diabetes, ethnicity or obesity.
Repeat urine test
Further assessment of diabetes in a form of HbA1c and 2-hour oral glucose tolerance test (OGTT).
The OGTT can be used either to diagnose diabetes or to predict the risk of
developing diabetes in the future. If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
Traditional guidance has suggested that individuals with diabetes should not donate
a kidney.
Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney.
Reference:
British Transplantation Society Living Donor Kidney Transplantation Guidelines 2018
The patient has glycosuria and impaired post prandial sugar.
A full history, risk factors, family history and diet history must be taken from the patient. OGTT and HbA1c must be ordered, and positive results must be explained to the patient as this will increase the risk of DM in future.
Hi Dr Salamah,
Your reply is too brief.
Ajay
How do you proceed?
Substantiate your answer
I will do oral glucose tolerance test (OGTT)
Pre-diabetes is diagnosed by any one of the following:
Elevated fasting glucose (>100 mg/dL by the ADA & >110 mg/dL by the WHO)
Elevated hemoglobin A1c
Elevated glucose on OGTT
Pre-diabetes may progress in severity over years to become frank diabetes.
Postprandial hyperglycemia in non-diabetic persons is a stronger predictor of insulin resistance & CVD than fasting glucose.
It is associated with 2.7 times increased risk of CVD mortality (Whitehall, Paris Prospective, & Helsinki Policemen studies).
The FBG is less discriminative for CVD; with only the upper 2.5% values conferring a 1.8-fold increased mortality risk.
Dietary & lifestyle changes intervention at the pre-diabetes stage can delay or even reverse this progression & prevent diabetes. These interventions need to be continue on long term.
Over a 7-year period, elderly women in a study with isolated postprandial hyperglycemia, 2-h value > 11.1 mmol & FBG < 7.0 mmol on a 75-g OGT test had a 3 fold increased risk of heart disease when compared with women whose 2-h values were <11.1 mmol.
This young lady may be declined as donor if proved to be pre-diabetic because of the continued risk for developing diabetes over many years, particularly if she does not maintain the lifestyle changes.
UNOS requires that potential kidney donors with DM be excluded from donation, thus the potential donor who is not able to correct their pre-diabetes may be declined from donation.
A small study reported that pre-diabetes who went on to donation had higher rates of progression to diabetes (15.6%) compared to donors with normal glucose levels (2.2%); however, there was no difference in remaining kidney function over the first 10 years following donation.
In diabetics, postprandial glycemia has a stronger relationship with micro- & macro-vascular disease than FBG; Similarly, in gestational diabetes adverse pregnancy outcome is more closely related to post-prandial glycemia than fasting & premeal glycemic values.
References
1. Author: S. Taler, Editor: J. Tan. AST. LIVE DONOR COMMUNITY OF PRACTICE Living Donors with Pre-diabetes
2. G. Frost. Encyclopedia of Food Sciences and Nutrition Second Edition. 2003
Thanks, Dr Mahamed, I agree with your reply.
Ajay
31 y/o female potential living donor with +1 glucose in urine and abnormal Post prandial glucose >>> IGT / pre diabetic must be evaluated well by hx taking regarding family hx of dm
Family hx cardiovascular diseases especially at young age
Family hx of ckd
Hx of gestational diabetes
Hx of smoking and sedentary life style
Examination mainly BMI
Laboratory findings in pre diabetic include elevated fasting glucose, elevated hemoglobin A1c and elevated glucose on an oral glucose tolerance test.
If IGT diagnosed so it is associated with an increased risk of premature mortality and increased cardiovascular risk which must be evaluated before transplant
Pre-diabetes may progress in severity over years to become classified as diabetes. Intervention at the pre-diabetes stage with diet and lifestyle changes can stall or even reverse this progression and prevent diabetes.
So our young donor must be advised to institute lifestyle changes to lose weight, increase exercise and thereby prevent the progression to diabetes mellitus. It is important to understand that the lifestyle changes that are effective to reverse pre- diabetes will need to be continued for the long term. Thus a program may decline a potential kidney donor with pre-diabetes who is young because of the continued risk for developing diabetes over many future years, particularly if they do not maintain the lifestyle changes.
UNOS requires that potential kidney donors with diabetes mellitus be excluded from donation, thus the potential donor who is not able to correct their pre-diabetes may be denied as a donor candidate.
——————————————————————————-
AST Living Donors with Pre-diabetes
Author: S. Taler, MD Editor: J. Tan, MD
RECOMMENDATION
1. The risk of diabetes mellitus in donors with pre-diabetes is higher than for a healthy donor with normal glucose metabolism. Pre-diabetes increases the future risk for diabetes-associated kidney disease for the donor.
2. UNOS requires that potential donors with diabetes mellitus be excluded from donation. Potential donors with pre-diabetes need to make lifestyle changes including diet change, increased exercise and weight loss to normalize their glucose metabolism and reduce their risk for future diabetes. These changes will need to be continued over the long term.
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
Recommendations
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT. (B1)
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered. (B1)
Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation. (B2)
Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
Thanks, Dr Huda, I agree with your answer.
Ajay
A potential female donor 31 y old
-Urine dipstick +1.
– fasting blood sugar is normal.
– abnormal post prandial.
– III mismatch and no DSA.
– this patient requires a comprehensive history regard to ( family history, previously diagnosed pre-diabetic or history of gestational DM and calculate BMI for obesity.
– the prospective donor with increase risk for type 2 diabetes because of family history, gestational diabetes, ethnicity or obesity must undergro OGTT.
-if OGTT showed pansistant impaired fasting glucose and/or impaired glucose tolerance., the risk of developing diabetes after donation must be considered.
– as regard to established diabetes, most of transplant centers considered as contraindication for living kidney donation.
-While patients with IFG and IGT must counseled to modify their life styles by weight control, diet, exercise, tobacco-avoidance
References
BTS guidelines
Thanks, Dr Amal Anan, I agree with your answer.
Ajay
Transplant centers are more likely to accept donors with potential risk factors for CKD likely explained by the ever-increasing demand for more kidneys as the transplant waiting list grows.
Meanwhile UNOS requires that potential donors with diabetes mellitus be excluded from donation and pre-diabetes need to make lifestyle changes.
IGT increases the risk for developing diabetes by 5% – 10% /year, along with other variables as ethnicity, weight, lipid profile, family history ,also it is associated with an increase in cardiovascular complications.
The patient need to be assessed regarding history of gestational DM , history of Impaired OGTT,first degree family member with DM , examination including high BMI>25 , signs of metabolic syndrome .
OGTT test ,Hba1c need to be assessed and DM risk can be calculated
These risks would be higher with younger candidates with features of the metabolic syndrome and lower if she were older, white, without features of metabolic syndrome, and absent a positive family history.
Lifestyle modifications can have a significant effect on altering the predicted risks
Reference
-Vigneault CB etal, Should Living Kidney Donor Candidates with Impaired Fasting Glucose Donate? CJASN August 2011, 6 (8) 2054-2059
-UNOS donor evaluation policy accessed at
http://optn.transplant.hrsa.gov/ContentDocuments/OPTN_Policies.pdf#nameddest=Policy_14
– this potential donor with glucosuria and abnormal post prandial blood glucose requires evaluation to determine the risk of DIabetes after donation.
– history of gestational diabetes, family history of diabetes.
-examination regarding BMI (obesity as a risk factor for type 2 DM), hypertension.
_ oral glucose tolerance test and HbA1c to differentiate between IGT and type 2 DM.
_ as per KDIGo guidelines, donor with pre diabetes or type 2 DM can be accepted if he has no target organ damage (retinopathy, LVH or microalbuminuria ) and no other risk factors as obesity, hypertension and dyslipidemia.
_ the donor should be counseled regard the control of her diabetic state with diet, exercise ( life style modification)
I appreciate your approach, Dr Shawky.
Ajay
31 year old female donor to her daughter with 111 mismatch and no DSA, in urine dipstick +1 glucose, normal fasting glucose but abnormal post-prandial blood glucose.
How do you proceed?
First i will take a detailed family history of diabetes mellitus, if there is any history of gestational diabetes, and life style clarification.
Will measure her BMI if high would ask for life style modifications.
Then will repeat urinalysis if still +1 glucose will check for the cause, and will ask for pregnancy test (a potential cause of proteinuria), treat if ther is infection then repeat the test.
I will ask for OGTT :
And will ask for HbA1C > 6,5% – indicates diabetes, 5,7-6,4% indicates prediabetes and shluod be repeated if the same then OGTT is a must for cardiovascular risk stratification.
If impaired glucose tolerance then full cardiac evaluation will be done including ECG, stress ECHO and/or MPI, and cath if needed.
Substantiate your answer
BTS Guidelines :
Prospective donors with an increased risk of type 2 diabetes because of family history, a history of gestational diabetes, ethnicity or obesity should also undergo an OGTT.
If OGTT reveals a persistent impaired fasting glucose and/or an impaired glucose tolerance, then the risks of developing diabetes after donation must be carefully considered.
Consideration should be given to the use of a diabetes risk calculator to inform the discussion of potential kidney donation.
Consideration of patients with diabetes as potential kidney donors requires very careful evaluation of the risks and benefits. In the absence of evidence of target organ damage and having ensured that other cardiovascular risk factors such as obesity, hypertension or hyperlipidaemia are optimally managed, diabetics can be considered for kidney donation after a thorough assessment of the lifetime risk of cardiovascular and progressive renal disease in the presence of a single kidney. (Not graded)
KDIGO Guidelines :
2-hour glucose tolerance or HbA1c testing should be performed in donor candidates with elevated fasting blood glucose, history of gestational diabetes, or family history of diabetes in a first-degree relative, and results should be used to classify diabetes or prediabetes status using established criteria for the general population.
Donor candidates with prediabetes or type 2 diabetes should be counseled that their condition may progress over time and may lead to end-organ complications.
That is an excellent short write-up, dear Dr Alshaikh.
Need to cofirm her diagnosis. Need to take family history, history of gestational diabetes.
Need to do OGTT and HbA1C
As this potential donor is young with possibly prediabetic or IGT; there is every chance to develop diabetes over time. She can donate with appropriate counselling regarding her future risks of comorbidities.
Thank You
How would you advise her regarding the future risk?
How do you proceed?
Patient has gycosuria and IGT, but kidney function is normal. The patient should undergo, OGT, HbA1c and detailed history of family history of diabetes mellitus, prior history of gestational diabetes in female donors, prior diagnosis of pre-diabetes or diabetes (Type 1 or Type 2), ethnicity.
Additional risk factors for developing diabetes or cardiovascular complications should be evaluated:
KDIGO recommends that:
Ibrahim et al found that the self-reported prevalence of diabetes was 5.2% in the 2,954 patients who responded. The vast majority of kidney donors where white, about 50% were genetically related to the recipient. The eGFR and the rate of decline of eGFR were
not significantly different between diabetic and matched non-diabetic donors. In this
study, 11 donors developed ESRD requiring dialysis or transplantation, of which
none were due to diabetic kidney disease.
Organ Procurement and Transplantation Network and the Center for Medicare and Medicaid Services databases identified 126 cases of ESRD post-kidney donation from 56,458 living donors across the USA between 1987 and 2003. The median time to ESRD
after donation was 10.4 years and glomerulonephritis was considered to be the
cause in 33%, hypertension in 25%, and diabetes in 9%
The patient will be counselled about risk factors for prediabetes, the higher the likelihood that diabetes and subsequent kidney disease will develop in that person’s remaining lifetime.
If the patient has IGT without additional risk factor for developing DM or CV death, she can be donor.
Risk of future pregnancy and risk of developing GDM will also be counselled prior to transplant.
Thankyou Theepa how long was the follow up time in Ibrahim’ study.
oterwise well done.
The study surveyed 3777 kidney donors regarding the development of T2DM. Among 2954 who responded, 154 developed T2DM ,17.7 ± 9.0 years after donation
I will take family history, gestational diabetes history, will check BMI.
i will do OGTT..
Consideration of patients with diabetes as a donor requires very bcareful evaluation of risks and benefits. In the abscence of evidence of target organ damage and excluding other cardiovascular risk factors, diabetics can donate kidney after through assessment of lifetime risk of cardiovascular and progressive renal disease.
As our patient is young, if she had no risk factors, though she should be details councelled regarding risk of renal disease in future.
I hope you mean T2DM!!!