6. A potential female donor who is 31-year-old has normal fasting and post-prandial blood sugar test. She has excellent kidney function with no evidence of haematuria, proteinuria, or microalbuminuria. She gave a history of abnormal blood sugar during her last pregnancy which resolved after delivery. She is keen to donate to her daughter, 111 mismatch and no DSA
- How do you proceed?
- Substantiate your answer
Individuals at high risk of type 2 diabetes because of a positive family history, gestational diabetes, and/or obesity should undergo an OGTT. For individuals with a normal OGTT, the risk of developing type 2 diabetes within 5 years is around 1% and is modulated by ethnicity and obesity.
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 strict Medical history and family history
clinical examination
FBS and OGT
HbA1C
Life style modification
Strict blood sugar control
Avoiding of any risk factors obesity , smoking and hypertension
excluding of end organ damage
References :
BTS
This donor needs to be investigated for DM2 because have a history of gestational diabetes. So, Oral Glucose Tolerance Test should be performed.
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
Potential donor with history of gestational Dm ,positive FH of DM ,should go For OGTT ,if impaired fasting glucose or IGT> Risks of post donation DM should be considered
BTS 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)
History of gestational diabetes increases risk of future diabetes to the tune of 19% to 35% in few studies (1,2).
Further management in this case includes
References:
A 31 year potential female donor with history of GDM and normal fasting blood sugar ,renal profile and urinalysis still place the patient at high risk of developing diabetes, and cardiovascular diseases. According to one survey, around 35% of GDM patients develop diabetes later by 15 years. So, this case needs to be thoroughly evaluated for all the risk factors like family history of diabetes, ethnicity,BMI,hypertension and cardiovascular status which increase the future risk of diabetes. Family also to be completed as chances of having GDM in future pregnancies high with poor maternal and fetal outcomes. OGTT should be done and if normal ,then proceed for donation only after detailed counseling of all the future outcomes and then a collective decision should be made. Ideally young age patients should not be taken for donation, however, elderly patients without risk factors can be considered.
Keeping in view the above factors, such donors can be accepted if no risk factors present and OGTT is normal and patient counseled in detail of all the risks.
REFERENCES:
1-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)
Gestational diabetes increases the risk of developing diabetes 37 folds risk than the general population and those who developed diabetes are exposed to more risk of ESRD that’s why some kidney societies like CARI guidelines prohibited donation from female patients with a history of gestational diabetes. On the other hand, those with Gestational diabetes who never develop diabetes have a similar risk of CKD and ESRD to those with uncomplicated pregnancies.
It’s better to reject such a patient but if she insists on donation so further evaluation includes
If all the results within normal maybe I will accept after proper counseling
If labs showed prediabetic or diabetic I will reject this lady from the donation
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).
She need more investigation for DM as it recommended like FBS,HbA1C,GTT,ACR and lipid profile before donation because her history of gestation DM make her liable to DM at any time post donation
The potential donor has a history of gestational diabetes and now she has normal fasting and postprandial blood sugar test.
According to KDIGO and BTS guidelines
the donor should investigated with HBA1c and oral glucose tolerance test.
If there is impaired glucose tolerance test , the risk for developing diabetes after donation should be considered. the annual relative risk of a patient developing diabetes 6 times compared to whom with normal test.
Impaired glucose tolerance test is also associated with an increased risk of premature mortality and increased cardiovascular risk.
She needs to do an OGTT because of her past history of gestational diabetes that puts her at risk of development of T2DM. If OGTT is abnormal, she should preclude donation. But, if OGTT is normal she should have consulted about the risk of developing T2DM which is about 1% within 5 years and depends on obesity and ethnicity. She needs to reduce other CVD risk factors such as HTN, smoking, hyperlipidemia and control them. In addition, the risk of future pregnancies are increased.
DM II can develop within 9 years in 19 % of females with previous gestational DM.
Other risk factors like hypertension, and maternal age can contribute to DM II development.
In the current clinical scenario, I would arrange for OGTT and check if has criteria for pre-DM or DM, or normal.
I would arrange for HbA1C as well for diagnosis of DM if it equals or more than 6.5%.
Values between 6-6.5% need to be repeated and it might predict the likelihood of developing DM.
There are no clear guidelines about the decision of accepting donors with previous history of gestational DM. every decision should be individualized after counselling of the donor and explaining all the available risks and their evidence.
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 .
How do you proceed?
Substantiate your answer
We can proceed for donation if :
Proper counseling is still required about her risks of developing T2DM, renal and cardiovascular complications, keeping in mind that she is still in the childbearing period, and donation may impact her family planning and increase pregnancy related complications like preterm delivery, gestational diabetes, gestational hypertension and preeclampsia.
If she is still willing to donate her kidney to her mother and made a lot of effort to modify cardiovascular risk factors, we will consent her, and proceed for donation.
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)
2) British Transplantation Society. Renal Association Guidelines for Living Donor Kidney Transplantation, 4th ed.; British Transplantation Society: Macclesfield, UK, 2018.
Our potential donor is in need for :
-Illustrative history taking , regarding the gestational diabetes , family history
-Full examination
-BMI
-HbA1C , OGTT
-Fundus examination
-Echo
Proper counseling regarding the potential risk , and the importance of diet control , body weight control , avoidance of smoking , diet control , potential cardiovascular and future diabetes risk before acceptance for donation
This female lady with previous history suggestive of gestational diabetes, after thorough history taking, family history of DM exclusion, BMI evaluation, OGTT and HBA1c testing, lifestyle evaluation, symptoms suggestive of DM as polyuria, polydipsia, retinopathy, peripheral neuropathy fully evaluated.
Proper counselling of the donor based on the fact that gestational DM may be associated with increased risk of DM and progression to diabetic kidney diseases in about 40 % of cases.
Although this donation is for the sake of precious family member, I would preferably decline this donation. Searching for another living donor or even deceased donation may be successful solutions for this scenario.
According to BTS/RA Living Donor Kidney Transplantation Guidelines 2018.
Patients who had gestational Diabetes before in her pregnancies are not contraindicated per se as renal donor…..
The occurrence of GDM in a pregnant lady is a life time risk factor for the development of type 2 diabetes mellitus from 40-60% across various observational studies…The risk of Type 2 diabetes mellitus is directly linked to the presence of obesity, ethnicity, family history of diabetes mellitus…
This patient has normal fasting and post prandial blood sugar with normal renal function and no proteinuria….we need to know the current BMI of this donor and will need to do HbA1c and Oral glucose tolerance test also….I would counsel this donor for the life time risk of development of type 2 diabetes mellitus…And after the onset of type 2 diabetes mellitus the risk of development of micro albuminuria or macro albuminuria is nearly doubled after a nephrectomy…
After appropriate counselling and knowing the risk of development of type 2 diabetes mellitus and initiating the needs for life style modifications I will take this patient for renal donation
*This potential young donor , with excellent kidney function tests , has history of
Gestational diabetes which is a risk factor for development of mature onset diabetes later on.
1.Proper history taken including family history, full examination, exclude of all others risk factors like hypertension , obesity, dyslipidemia before acceptance this donor.
2.OGTT should be done and HBA1c.
*Gestational diabetes females at higher risk up to 10 folds of developing T2DM later on and renal complications and cardio-vascular events
*this candidate donor has higher risk of CKD post-kidney donation , so better to be excluded as a donor, unless insisted so , life style modifications will be needed and counselling her regarding risk of developing overt T2DM ,risk of CVD and risk of preeclampsia, gestational HTN, and preterm birth in coming labours.
References
1. Evans M, Kublickas M, Perry IJ, Stenvinkel P, et al. Does gestational diabetes increase the risk of maternal kidney disease? A Swedish national cohort study. PLoS ONE(2022) ;17(3): e0264992.
2.UpToDate: gestational diabetes mellitus.
Gestational diabetes is risk factor for future development of diabetes and diabetic renal disease.
A patient with suspected GDM should be investigated further with HbA1c, OGTT, FBS twice to confirm.
She should be counselled thoroughly for future cones and prone after donation.
KDIGO 2022.
This patient is keen to donate, but she is a female and young and has the chance of multiple pregnancies. This will have the additive risk of sensitization and risk of DM later. If she was 50 years or so, I might accept, but for this young, even with normal OGTT, I would not.
many studies showed the increased risk persistence of DM after GDM (one is: Mary V. Diaz-Santana, Katie M. O’Brien, Yong-Moon Mark Park, Dale P. Sandler, Clarice R. Weinberg; Persistence of Risk for Type 2 Diabetes After Gestational Diabetes Mellitus. Diabetes Care 1 April 2022; 45 (4): 864–870. https://doi.org/10.2337/dc21-1430)
1)Enquire history of polyurea, polydipsia and polyphagia. Family history of DM.
2)Detail history of diabetic control during the last pregnancy.
3)Systemic examination for target organ damage due to diabetes mellitus. BMI.
4)Investigation : HBA1C. lipid profile. ECG/ Echo specifically for cardiovascular status assessment.
The decision to approve donor candidates with prediabetes should be individualized based on demographic and health profile in relation to the transplant program’s acceptance threshold.
Donor candidates with prediabetes should be counseled that their condition may progress over time and may lead to end-organ complications.
Living Kidney Donor. KDIGO 2017.
References:
# It is difficult to predict who will develop diabetes.
Gestational diabetes along with obesity, ethnicity and family history are all risk factors for development of mature onset diabetes.
Better tests are needed but the most predictive available tests are the fasting blood glucose, insulin levels, and the 2 hour glucose tolerance test.In one study 35% of women who have gestational diabetes developed type 2 diabetes by 15 years after delivery.(1)
A study of 241 diet treated women with GDM diagnosed between 1978 – 85 in Copenhagen found that 2-11 years later 34% had abnormal glucose (3.7% IDDM, 13.7% NIDDM, 17%IGT) in contrast to a control group where none had diabetes and 5.3% had IGT (2).
So clearly there is a risk. Importantly diet, excercise can modify this risk.
The exclusion of the donors must depend on the basis of GDM and to look at their current risk based on BMI at time of evaluation, and laboratories (fasting glucose, oral glucose tolerance and HbA1,c).
The other question is what if the donor does develop diabetes. The existing data would suggest that the risk of micro and macro-albuminuria are increased. One of the most widely known studies is that of Silveiro (3). Importantly microalbuminuria was noted an average of 23 years after nephrectomy, but was present as soon as five years after nephrectomy. The conclusions that can be drawn are that nephrectomy in an individual with diabetes, normal renal function and no dipstick identifiable proteinuria is likely not going to cause problems in the short term. However with time increasing proteinuria is common, and this may ultimately lead to loss of renal function and perhaps an increase in cardiovascular disease.
Putting all of this together – the key considerations are the age of your donor and an assessment of their current risk based on BMI and laboratory tests. If they are young, the risk may preclude donation, if they are older and their other risk factors are low – this may be acceptable with informed consent.
#Results from other studies indicated donors who had gestational hypertension were at greater risk for developing hypertension (HR = 2.06) and diabetes (HR = 2.92) after donation, while those who had gestational diabetes were at greater risk for developing diabetes (HR = 4.17)(4).
References
1)Linne Y et al. Br J obst and Gyne 58:193-200, 2002
2)Damm P. Dan Med Bull. 1998 Nov;45(5)495-509
3)Silviero Diabetes Care 21: 1521-24, 1998.
John Gill, MD, MS
University Of British Columbia
St. Paul’s Hospital
Member, AST Education Committee
(4)Speaker: Pregnancy complications should be part of informed consent for kidney donors
ByMelissa J. Webb, MA
Gestational diabetes greatly increases the risk of diabetes mellitus in the future. Add to that the context of a young patient, still of childbearing age and who does not have other risk factors (obesity, ethnicity, family history).
At first, I would not proceed with the donation. There is a need for a broad investigation regarding metabolic findings, oral glucose tolerance test, and glycated hemoglobin.
There should be extensive discussion and advice regarding long-term post-nephrectomy-related risks.
In this scenario of a potential kidney donor of a 31 yrs old female with excellent kidney function, normal fasting blood glucose but abnormal post prandial with no evidence of haematuria or proteinuria…
▪︎ We can proceed by taking a careful history and clinical examination plus laboratory investigations to exclude all of the risk factors for DM type 2
and ask about the history for smoking, family history of diabetes. Her age when she developed the gestational diabetes
The life style of the pt and if she is obese or not and what is her BMI.
Investigation should include OGTT and HbA1c.
I will not accept this donor but if she is still willing to donate. It is better to inform her about her risk of developing DM and the impact of diabetes on the kidneys.
___________________
Ref:
Eoin Noctor and Fidelma P Dunne et.al.Type 2 diabetes after gestational diabetes: The influence of changing diagnostic criteria
https://doi.org/10.4239/wjd.v6.i2.234
First, I will do OGTT and HbA1C for this young risky patient.
Long-term consequences of gestational DM (GDM):
●GDM is a strong marker for maternal development of type 2 diabetes, including diabetes-related vascular disease
●GDM increases the offspring’s risk for developing obesity, impaired glucose tolerance, and diabetes.
Secondly, if the patient is diabetic, she still young and has high risk for progression of nephropathy. So, I will exclude her from donation.
If the patient has normal OGTT and HbA1C, she still has risk to develop DM. This due to history of GDM, and the risk may increase if she has obesity or family history of DM. So, she has no absolute contraindication for donation, but she should be informed about the risk of developing DM after donation, with also increased risk for nephropathy.
1)BTS/RA Living Donor Kidney Transplantation Guidelines 2018
2)https://www.uptodate.com/contents/gestational-diabetes-mellitus-obstetric-issues-and-management?
She needs an OGTT and if this shows diabetes she would probably be not suitable for transplant donation. In patients with gestational diabetes it is difficult to predict who will develop diabetes.
Gestational diabetes is a risk factor for development of mature onset diabetes. However, we need to know if the patient has other risk factors for development of mature onset diabetes such as ethnicity, obesity and family history.
The most predictive available tests are the fasting blood glucose, insulin levels, and the 2 hour glucose tolerance test. One interesting study has showed that 35% of women with gestational diabetes developed type 2 diabetes within 15 years after delivery.
Another study involving 241 diet treated women with GDM diagnosed over a period of seven years found that 2-11 years later 34% had abnormal glucose (3.7% IDDM, 13.7% NIDDM, 17%IGT) in contrast to a control group where none had diabetes and 5.3% had IGT. These studies indicate an increased risk of diabetes in patient with GDM, however lifestyle (diet, exercise) can modify this risk.
Therefore we should not exclude the patient only considering their GDM but we should consider other risk factors too, such as BMI at time of evaluation, fasting glucose and oral glucose tolerance before excluding them from donation.
The key factors for the donation include donor’s age and their risk factors based on BMI and laboratory tests. If they are young, the risk may preclude donation, if they are older and their other risk factors are low this may be acceptable with informed consent.
In this case if the patient has no other risk factors with normal OGTT and Fasting blood glucose I would consider her suitable for donation. However, she will need counseling abut lifestyle to reduce the risk factors.
American Society of Transplantation: Is a history of gestational diabetes a contraindication to later living kidney donation?
UK Guidelines for Living Donor Kidney Transplantation 2018.
2- if prediabtes can proceed with donation after explaining
the future risk of having DM , CVD , CKD ,, etc
3- if diabetic : donation is contraindication
thanks
patients with a history of gestational diabetes are considered at high risk for developing DM in the future.
detailed assessment of the risk of developing DM and cardiovascular complications should be done
-family history
-BMI,body weight
-lipid profile
-HBA1C,OGTT,fasting and 2 hpp blood glucose level all must be evaluated trying to detect daily glucose variablility.
– family histoty of Chronic kidney disease.
If no positive data except gestational diabetes i will inform her about potential risks of developing Dm And that she must adopt healthy life style and avoid risk factors and i will accept her as a donor
Positive points: young lady, excellent kidney function, good immunological match, normal fasting and post-prandial blood sugar.
Issue for further assessment: history of abnormal blood sugar during her last pregnancy
Assessment: detailed history of obstetric history, gestational diabetes history, family history of DM, hypertension, hyperlipidaemia, obesity.
Oral glucose tolerance test (OGTT) + HbA1c should be undertaken.
A history of gestational diabetes is an independent risk factor for later diabetes. Even with a normal OGTT, the risk of developing type 2 diabetes within 5 years is around 1% and is modulated by ethnicity and obesity.
So considering her risk of diabetes it’s better to recruit another donors .
We agree that DM and HT are the most important causes of ESRD .
DM is considered an absolute contraindicated for kidney donation .
So , regarding the young lady in this scenario aiming to donate for her daughter, she has history of GDM which carry a 37% risk of developing T2DM or even T1DM in the next few years .
In order to make a decision regarding accepting her as donor or not we need first :
Detailed history of her past pregnancy
Detailed history of the GDM
Family history of DM
GHT
The presence of risk factors that lead to the development of DM in future like obesity, minor ethnicity, family history of DM ,metabolic syndrome,dyslipidemia ,GHT
Then we should proceed with investigation like FBG,and
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 is a must[3].
I’ll explain and discuss all the issues to her and accept her as a potential donor with regular follow up.
[1] UpToDate- gestational diabetes mellitus: Screening, diagnosis, and prevention.
[2] Mack LR, Tomich PG. Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstet Gynecol Clin North Am. 2017 Jun;44(2):207-217. doi: 10.1016/j.ogc.2017.02.002. PMID: 28499531.
[3] Chen P, Wang S, Ji J, Ge A, Chen C, Zhu Y, Xie N, Wang Y. Risk factors and management of gestational diabetes. Cell Biochem Biophys. 2015 Mar;71(2):689-94. doi: 10.1007/s12013-014-0248-2. PMID: 25269773
GDM in addition to BMI, ethnicity & family history are risk factors for mature onset DM.. It was found that 35% of patients with GDM developed type 2 diabetes15 years following delivery, so not excluded as donors, but current risk factors including BMI, fasting glucose and oral glucose tolerance testing should be considered.
Considering index case age, and current risk based on BMI and laboratory test, I think it is better to preclude donation hoping for another more favorable donor.
Linne Y et al. Br J obst and Gyne 58:193-200, 2002
Gestational diabetes is increase risk factors for development of diabetes in the future
.Follow up with fasting blood glucose, insulin levels, and OGT is recommended .
Follow up in previous study shows 35% of women who have gestational diabetes
developed type 2 diabetes by 15 years after delivery.(1)
so patient with GSDM not excluded on the basis of GDM , look at their current risk
based on BMI at time of evaluation, and laboratories (fasting glucose and oral glucose
tolerance).
so main considerations are the age of your donor and an assessment of their current
risk based on BMI and laboratory tests.
If they are young, the risk may preclude donation, if they are older and their other risk
factors are low – this may be acceptable with informed consent.
References:
1-Linne Y et al. Br J obst and Gyne 58:193-200, 2002.
How do you proceed?
This 31 year old potential donor has normal fasting and post prandial sugars and normal urine testing. There is history of abnormal sugars in last pregnancy .
Those with history of gestational diabetes may develop glucose intolerance and risk of developing full diabetes can ten folds. In one study the risk of diabetes Mellitus after gestational diabetes was 3.7% at 9 months and 18.9% after delivery1. Risk factors leading to full diabetes after gestational diabetes are Obesity, Diagnosis of gestational diabetes in second trimester , need for insulin in pregnancy and higher fasting sugars.
This potential donor will need further assessment and risk prediction for development of diabetes. If there is higher risk of development of diabetes then cardiovascular risks also increase.
I will arrange a oral glucose tolerance test to see impaired glucose tolerance.
If there is impaired glucose tolerance then kidney donation will be risk in this donor as she is very young . This will increase her risk of CKD and cardiovascular risks.
However if there is no impaired glucose tolerance then she should be educated and counselled in detail. She has to modify life style and understand the situation fully and after that she can be accepted donation.
References
1-Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes mellitus after diagnosis of gestational diabetes. CMAJ. 2008 Jul 29;179(3):229-34.
The patient base on her history had Gestational diabetes. Currently her condition is normal and all functions are intact. But gestational DM is accompanied or may develop into full blown DM type 2. With this in mind. The patient must be investigated and advice must be given to ensure she doesn’t fall into T2DM
1) The patient must have life style modification
a) Diet
b) Exercise
c) Weight loss
d) Avoid stress
e) Proper follow-ups
f) Avoid toxic habits
2) Once that is done studies must be conducted to do a diagnosis and to see if there is any organ that sis damaged.
3) OGGT test
4) HbA1c
5) Fasting glucose test
6) Pancreatic investigation
7) Rule out infection
8) EKG
9) ECHO
In one study conducted by the CDC if was found that 50% of women with gestational DM go on to develop T2DM. It continues by suggesting that the risk can be lowered by routine blood test and lifestyle modification. Post-delivery, blood sugar test must be done 6-12 weeks after delivery and posterior every 1-3 years.
references:
www.cdc.gov/diabetes/basics/gestational.htm
detailed history (the managmet she recieved during pregnancy, duartion and folow up)
and family hx of type 2 DM, kidney diseases
check wight , bp
fasting plasma glucose, OGTT
*the use of a diabetes risk calculator to inform the discussion of potential kidney donation.
*to inform the donor about that females who develop gestational diabetes are more likely to have type 2 DM and experience early stages of kidney damage later in life
*in the current study, we observed that women with a history of GDM were more likely to have increased levels of eGFR, which could indicate early stages of glomerular hyperfiltration and renal damage
29.Palatini P. Glomerular hyperfiltration: a marker of early renal damage in pre-diabetes and pre-hypertension. Nephrol Dial Transplant 2012;27:1708–1714[PubMed]
Google ScholarCrossref
This 31 years old girl with history of gestational diabetes.
Previous systematic reviews and meta analysis showed that women with a history of GDM have a sevenfold risk of being diagnosed as T2Dm.
So the patient have a high risk to develope DM.
detailed history about wieght, bmi ,hieght, waist circumference, physical activity,diet ,blood pressure, family history of diabetes
Pregnancy history or plan.
kindey nephropathy should also roll out (albumin/creatinine _ GFR _kidney biobsy ).
OGT should be done.
Blood pressure measurement.
inform the patient about the high risk of developing DM in future and being a patient with one kidney and diabetes ,esrd risk ,CV risk ,her future plan of getting pregnancy again ,all these things should be discussed with the donor.
gestational diabetes is a relatively contraindication as prediabetes patient for kidney donation
the yong age of the patient is the most important factor here (put her in more probability of developing complication).
the wiling of the patient to donate after inform her of risk also important .
so it is individualized desision after discussing and wightened the risk and benefits to accept or decline.
But with this high risk, i prefer to refuse this donor.
History of GDM increasing risk of developing DM later on ( 10 folds ) also high risk for recurrence of GDM in the coming pregnancies
Proper history regarding family history , with proper assessment of BMI , smoking , diet , exercise
Also can be evaluated by OGTT and HbA1C
This pt must be counseled regarding high risk of developing overt diabetes with complications
A history of GDM is predictive of an increased risk of developing type 2 diabetes, metabolic syndrome, cardiovascular disease (CVD), and even type 1 diabetes.
These risks appear to be particularly high in patients with both GDM and a hypertensive disorder of pregnancy
GDM has been called a “marker,” “stress test,” or “window” for future diabetes and CVD
patients with GDM were at an almost 10-fold higher risk of developing subsequent type 2 diabetes than patients with normoglycemic pregnancies , high risk for recurrent GDM and developing prediabetes (impaired glucose tolerance or impaired fasting glucose) or overt diabetes over the subsequent five years.
GDM in one pregnancy is a strong predictor of recurrence in a subsequent pregnancy
Other major risk factors for development of type 2 DM are:-
1-gestational requirement for insulin
2-early gestational age at the time of diagnosis (ie, less than 24 weeks of gestation)
3-Additional risk factors for impaired glucose tolerance and overt diabetes later in life include autoantibodies (eg, glutamic acid decarboxylase, insulinoma antigen-2)
4-high-fasting blood glucose concentrations during pregnancy and early postpartum, higher-fasting plasma glucose at diagnosis of GDM and high glucose levels in the GTT, the number of abnormal values on the glucose tolerance test
5- neonatal hypoglycemia
6-GDM in more than one pregnancy
Patients with GDM are at higher risk of developing CVD and developing it at a younger age than those with no history of GDM
Even mild glucose impairment (defined as an abnormal 50 g one-hour GTT followed by a normal 100 g three-hour GTT) appears to identify individuals at increased risk of future development of CVD, usually myocardial infarction or stroke
Much but not all of this excess risk is related to development of type 2 diabetes later in life
Finally the decision will depend on the age of our donor and an assessment of their current risk based on BMI,risk factors and laboratory tests. If they are young, the risk may preclude donation, if they are older and their other risk factors are low this may be acceptable with informed consent.
references
1-up to date
This young lady with hx gestational diabetes with no end organ damage must be assessed very well before giving her the agreement to be potentially living donor as the prediction of development diabetes is very difficult.
And my opinion I will exclude her and consider her unsuitable for donation as AST published >>> the key considerations are the age of your donor and an assessment of their current risk based on BMI and laboratory tests. If they are young, the risk may preclude donation, if they are older and their other risk factors are low – this may be acceptable with informed consent.
>>> history of gestational diabetes is an independent risk factor for later diabetes.
Gestational diabetes along with obesity, ethnicity and family history are all risk factors for development of mature onset diabetes all should undergo an OGTT. For individuals with a normal OGTT, the risk of developing type 2 diabetes within 5 years is around 1% and is modulated by ethnicity and obesity.Also individuals with pre-diabetes, and at increased risk of developing diabetes and cardiovascular disease in the future
We therefore do not exclude patients simply on the basis of GDM but also look at their current risk based on BMI at time of evaluation, and laboratories (fasting glucose and oral glucose tolerance)
Gestational diabetes refers to diagnosis of diabetes at 24-28 weeks of gestation.
Diagnosis of diabetes in early pregnancy is more consistent with previously undiagnosed type II diabetes.
Gestational DM is strong marker for maternal development of type II diabetes includes diabetes related vascular discuses.
History of gestational diabetes is a predictive of increasing risk of type II diabetes , metabolic syndrome, cardiovascular diseases and even typeI diabetes.
Gestational diabetes has been called a marker, stress-test or window for further diabetes.
* this young female 31 years old with normal fasting and post-prandial blood sugar test, excellent kidney function, no proteinimas micro-albuminuna or haematuria
1- requires a comprehensive history regard to ( family history, previously diagnosed pre-diabetic or history of gestational DM.
2- calculate BMI for obesity.
3- tight Control of blood pressure and lipid profiles.
4- consider life style.
* female with gestational diabetes carries high risk for developing type II diabetes from 50-70% in some series and this risk increasing in 5 years with plateau risk 10 years after delivery.
* OGTT with stimulated insulin level other than OGTT alone in female with history of gestational diabetes cam predict the risk for overt diabetes INSHALLAH.
* so it is hardly for acceptance that female for donation and counselling for high future risk.
References:.
– uptodate.
– handbook of kidney transplantation 6th edition,Gabriel M. Danovitch.
Gestational diabetes is a risk factor for development of mature onset diabetes. Obesity, ethnicity & family history are all other risk factors.
I should further evaluate this potential donor before acceptance or denial for donation.
History & examination should include FH of DM, the ethnic background, & measurement of BMI.
Oral glucose tolerance test would be needed to diagnose pre-diabetes.
Women who develop GDM & subsequent T2DM are at increased risk of developing CKD & ESRD; however, those with GDM who never develop overt T2DM have similar risk of future CKD/ESRD to those with uncomplicated pregnancies.
There is 10-fold increased risk of developing T2DM among women who experience GDM; and T2DM is a risk factor for CKD. However, about half of GDM-diagnosed women will never develop T2DM.
GDM-diagnosed women have persistent markers of endothelial dysfunction in the years following pregnancy predisposing them to a range of cardiovascular and renal diseases compared to women who remained normo-glycaemic in pregnancy.
Black women have an increased risk of T2DM compared with white women; this may increase their risk of future CKD irrespective of previous GDM.
References
1. Barrett PM, McCarthy FP, Evans M, Kublickas M, Perry IJ, Stenvinkel P, et al. (2022) Does gestational diabetes increase the risk of maternal kidney disease? A Swedish national cohort study. PLoS ONE 17(3): e0264992. https://doi.org/10.1371/ journal. pone.0264992
Gestational diabetes along with obesity, ethnicity and family history are risk factors for development of diabetes.
The most predictive available tests are the fasting blood glucose which was normal , insulin levels, and the 2 hour glucose tolerance test.
In one study 35% of women who have gestational diabetes developed type 2 diabetes by 15 years after delivery.
Another population-based study from Ontario, Canada, found that type 2 diabetes developed within 9 years after pregnancy in nearly 19% of women with previous gestational diabetes.
Therefore there is a certain risk but is modified by life style modification ,exercise and diet control.
In this case OGTT need to be done
-If <140nmg/dl ,the DM risk can be evaluated including age and ethnicity to assess the possibility of donation
-If 140-199 mg/dl so it is IGT likely unsuitable donor also DM risk can be checked
-if>200 mg/dl then she isnot a suitable donor.
Reference
-Vigneault CB etal, Should Living Kidney Donor Candidates with Impaired Fasting Glucose Donate? CJASN August 2011, 6 (8) 2054-2059
Well done.
_ The current donor is young age with history if gestational diabetes which is considered contraindication for donation.
As the risk of overt type 2 DM will be higher especially if she gets pregnant again and especially with single kidney.
_ the current donor has higher risk of ESKD after donation , so better excluded.
_ if she is willing to donate, she must be counseled regard the risk of ESKD in addition to counseleing regarding life style modification with weight loss and exercise.
_ oral glucose tolerance test can differentiate prediabetic state from overt DM., Prediabetes has blood glucose between 140_199 while value more than 200 indicates type 2 DM
Very good Mai but you usually substantiate more.
A 31 year old female donor to her daughter with 111 mismatch and no DSA, excellent kidney function with no evidence of haematuria, proteinuria, or microalbuminuria.BUT gave a history of abnormal blood sugar during her last pregnancy which resolved after delivery..
How do you proceed?
The patient highlights history of Gestational diabetes (occurs in 6% of pregnancies), that increases risk of diabetes mellitus type 2,and indicates long term risk of cardiovascular events, and hypertensive disorders of pregnancy (ie, preeclampsia, gestational HTN, and preterm birth)[1].
Will measure her BMI, blood pressure and lipid profile, encourage life style modification measures and treat. smoking history and abstinence encouragement[2,3].
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 is a must[3].
I’ll explain and discuss all the issues to her and accept her as a potential donor with regular follow up.
[1] UpToDate- gestational diabetes mellitus: Screening, diagnosis, and prevention.
[2] Mack LR, Tomich PG. Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstet Gynecol Clin North Am. 2017 Jun;44(2):207-217. doi: 10.1016/j.ogc.2017.02.002. PMID: 28499531.
[3] Chen P, Wang S, Ji J, Ge A, Chen C, Zhu Y, Xie N, Wang Y. Risk factors and management of gestational diabetes. Cell Biochem Biophys. 2015 Mar;71(2):689-94. doi: 10.1007/s12013-014-0248-2. PMID: 25269773.
Very good.
A case of GDM has every chance to develop Diabetes subsequently. If she again become pregnant, which can enhance the development of diabetes as well.
As this potential donor is young with history of GDM; there is every chance to develop diabetes over time. She can donate with appropriate counselling regarding her future risks of comorbidities and risky future pregnancies as well.
Thankyou
The index donor is a young female with history of gestational diabetes mellitus.
Gestational diabetes is a strong risk-factor for subsequent diabetes, and is associated with increased risk of ESRD. She should undergo OGTT. An OGTT in conjunction with stimulated insulin levels may be more helpful in determining risk than an OGTT alone because some women with a history of gestational diabetes may have evidence of insulin resistance that may portend a higher risk for future development of overt diabetes.
Additional risk factors for developing diabetes or cardiovascular complications should be evaluated:
Women with a history of gestational diabetes have a high lifetime risk for developing type 2 diabetes—as high as 50% to 70% in some series with the greatest increase in risk in the first 5 years after delivery, and a plateau in risk after 10 years. Therefore, acceptance for donation and counseling for future risk can be dictated by these time frames.
Dear ALL
Going through your responses to this issue of GD in this lady obviously there is no strict algorithm that is compulsory to follow and this gives space for the different decisions at the end of the day showing different very respectable mostly WISE opinions. Thankyou
How do you proceed?
-A recent large, population-based study from Ontario, Canada, found that type 2 diabetes developed within 9 years after the index pregnancy in nearly 19% of women with previous gestational diabetes (the comparable rate for women without gestational diabetes was 2%) . Furthermore, although several risk factors, such as maternal age, presence of hypertension, and presence of comorbid conditions, contributed to the development of type 2 diabetes, gestational diabetes imparted the greatest risk (adjusted hazard ratio 37) .
-This is young ,female donor has past history of gestational diabetes mellitus with normal fasting and post-prandial blood sugar tests.
– She needs detail history about family history of DM, BMI, and to know her ethnicity because gestational diabetes along with obesity, ethnicity and family history are all risk factors for development of mature onset diabetes.
–An oral glucose tolerance test (OGTT) : A 2-hour value between 7.8 – 11.1 mmol/L indicates impaired glucose tolerance (IGT) . A 2-hour glucose value ≥ 11.1 mmol/L indicates diabetes .
-A study of 241 diet treated women with GDM diagnosed between 1978 – 85 in Copenhagen found that 2-11 years later 34% had abnormal glucose (3.7% IDDM, 13.7% NIDDM, 17%IGT) in contrast to a control group where none had diabetes and 5.3% had IGT.
– HbA1c :Diabetes may also be diagnosed based upon HbA1c criteria, a result 6.5% being sufficient to diagnose diabetes if confirmed by repeat testing . An HbA1c between 6.0-6.5% may be used to predict the future likelihood of developing diabetes. HbA1c 5.7% – 6.4% as identifying individuals with pre-diabetes, and at increased risk of developing diabetes and cardiovascular disease in the future
-In one study 35% of women who have gestational diabetes developed type 2 diabetes by 15 years after delivery.
-The existing data would suggest that the risk of micro and macro-albuminuria are increased ,if the donor develop diabetes. One of the most widely known studies is that of Silveiro .
-Prior recommendations regarding candidacy of persons with prediabetes for kidney donation are conflicting. The European
Best Practice Guideline states that impaired glucose tolerance
is not an absolute contraindication to donation, other guidelines consider prediabetes a relative contraindication, or a condition warranting careful consideration,while CARI considers prediabetes as well as past history of gestational diabetes to be absolute contraindications.
– Given the lack of current data specific to the donor population, they endorse individualizing the decision to approve donation in persons with prediabetes based on their predicted long-term risk in relation to the transplant program’s acceptable risk threshold.
-If the donor found to be diabetic, she will be excluded from donation.
-If her investigations are normal and after proper counselling ,she can proceed for donation .
References:
-Feig DS, Zinman B, Wang X, Hux JE: Risk of development of diabetes mellitus after diagnosis of gestational diabetes. CMAJ 179: 229–234, 2008.
-KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors August 2017 . Volume 101 . Number 8S-1.
-BTS/RA Living Donor Kidney Transplantation Guidelines 2018
-Linne Y et al. Br J obst and Gyne.AST. 58:193-200, 2002
-Damm P. Dan Med Bull. AST.1998 Nov;45(5)495-509
-Silviero Diabetes Care.AST. 21: 1521-24, 1998.
Well done thankyou for taking the effort to display different opinions and then giving yours.
Gestational diabetes has increased risk of development of diabetes in future.
Here, I will do an OGTT and will do according to results.
If found IFG or IGT or DM then assess risk factors.
As she is young, she need detailed counselling regarding future risk of renal involvement.
Short ,clear but you need to clarify.. who do you allow to donate .What about the index case.