Yes Dr Ben, I agree this is a case-control study. Hence, it provides level 3b evidence.
Case-control studies are longitudinal studies (other being cohort). In case-control studies (always retrospective), we find out the end-point (DM in donors) and one looks back for underlying factors. While in cohort studies (with prospective or retrospective) we start with factors and follow these patients to look for the end-point,
case control series cross sectional with level of evidence 3
Balaji Kirushnan
2 years ago
The Study assessed the risk of development of type 2 Diabetes in donors as compared to the general population…. It also compared the renal function, proteinuria an blood pressure in such donors with age, gender and BMI…..
The study was actually a survey conducted by asking the donors about the onset of diabetes mellitus, hypertension and proteinuria.
This was conducted at the University of Minnesota, Minneapolis…
Only 154 out of 2954 (5%) developed type 2 diabetes mellitus with a mean of 17.7 years after donation… The above incidence is like that of general population itself…The risk factors for development of diabetes included donating to a family member of type1 diabetes, males, age more than 45 years and BMI >30. There was no relation with smoking or serum creatinine at the time of donation..
> 70% of the donors who developed diabetes had hypertension and around 18% developed proteinuria… The rate of eGFR change in diabetic donors and matched non diabetic donors were similar…
They concluded that the development of diabetes in renal donors is similar to those in general population. Diabetic donors have increased hypertension and proteinuria than non diabetic donors, but they concluded that the frequencies were similar to diabetics with 2 kidneys..
Case control study providing level 3 evidence
Post donation development of diabetes in our population is related to increased BMI, lack of hypertension control and the family history of diabetes in the donors…
Wee Leng Gan
2 years ago
This is a retrospective study with level 3 evidence to study the prevalence and risks of T2DM among kidney donors. The prevalence was 4% in the entire pool of 3777 donors. with the mean time of 17.7 ± 9.0 years post transplantation. The risk factors include family history of type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07. A BMI greater than 30; HR 2.97 (95% CI 1.93–4.56), p < 0.001 and male gender; HR 1.76 (95% CI 1.12–2.76). Age more than 45 year old HR 1.46 (95% CI 0.97–2.19). Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM. The limitations include , survival bias (do not have information on type 2 diabetes in the majority of donors who have passed away), and also response bias. In conclusion, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors. Therefore, declining donors with positive family history of type 2 diabetes may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
Naglaa Abdalla
2 years ago
This study done between January 1, 1963 and March 31, 2009. There are 3825 donor nephrectomies were performed at the University of Minnesota. At several times in the last three decades, the authors attempted to contact all donors to ascertain their health status. In the last 7 years, they begun a comprehensive multistep approach to locate all kidney donors (including review of medical records, utilizing phone and internet directories and also the help of the recipients). Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation.
The results:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, 48 also donated a partial pancreas and, therefore, were not included in the analyses. Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys. In total, 154 donors reported
developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors
with available information prior to death and 8 of the 555 donors with no recent health
updates reported having T2DM, as well. Therefore, there is diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact). The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%. Only two donors were listed to have died of diabetes-related complications. In addition, 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
Dalia Ali
2 years ago
Introduction Diabetes mellitus is the leading cause of end-stage renal disease . Its prevalence will more than likely increase as the prevalence of type 2 diabetes mellitus (T2DM) increases in parallel with the rise of obesity in the general population . T2DM has a strong genetic component and 30% of those afflicted with it develop kidney damage.Therefore, some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass . Yet it is unknown whether development of T2DM after donating a kidney leads to a higher risk of experiencing acceleration in glomerular filtration rate (GFR) decay when compared to nondiabetic donors or diabetics with two kidneys. Risk factors for diabetes The Cox regression analysis assessing the various risk factors (at time of donation) for diabetes development revealed that donating to a family member with type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07, were associated with the future risk of developing T2DM (Table 2). A BMI greater than 30; HR 2.97 (95% CI 1.93–4.56), p < 0.001 and male gender; HR 1.76 (95% CI 1.12–2.76), were also strongly associated with the development of diabetes.
Donors with diabetes For the 154 donors who developed diabetes, mean age (±SD) at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation. Characteristics of these donors are shown in Table 3; the majority were white and 47% donated to a sibling or other family member (Table 3). The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
Longitudinal eGFR change Of the 154 donors who developed diabetes, 64 donors had multiple serum creatinine measurements available after the diagnosis of diabetes was made. To address whether these 64 donors were different than the rest of the diabetic donors, they were compared to the remaining 90 diabetic donors with no serial measurements on baseline demographics that included age, gender, time from donation, BMI and relation to the recipient, among others, and they were not different (data not shown). They, however, were more likely to be hypertensive (91%), 19% were proteinuric, their BMI at the time of last follow-up was 31.6 ± 7.0 kg/m2 and an average of 15.5 ± 8.8 years had elapsed from donation to the development of T2DM. The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2 (range −2.99–1.63). The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year, range (−4.99–2.19, p = 0.43, vs. those with diabetes). To strengthen this analysis, we matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year.
Uninephrectomy is followed by a rapid increase in renal plasma flow and GFR. In fact, GFR increases by 70% within 1 week of donation .In addition, a substantial proportion of subjects with either types 1 and 2 diabetes undergo hyperfiltration The compensatory increase in GFR observed in the setting of reduced renal mass and diabetes has been linked to the progressive nature of kidney disease Of concern is the possibility of a multiplicative adverse action of the hyperfiltration from donating a kidney and the hyperfiltration observed in diabetes. However, in case series of diabetic patients with either unilateral agenesis or unilateral nephrectomy, none suffered accelerated kidney function in the remaining kidney Silveiro et al. studied type 2 nonliving donor diabetic patients who had undergone uninephrectomy (single-kidney diabetes, n = 20; duration of diabetes, 8.5 ± 7 years) comparing renal function versus nondiabetics who had undergone uninephrectomy (single-kidney nondiabetic, n = 17) and versus type 2 diabetics having 2 kidneys (n = 184; duration of diabetes, 10 ± 7 years) (15). The single-kidney and two-kidney type 2 diabetic patients were matched for age, sex and BMI. Mi-croalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
The prevalence of proteinuria in 128 donors with available measurements was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio obtained in 20/154 donors. This prevalence is higher than the usual rates of albuminuria encountered in kidney donors but similar to subjects with diabetes with two kidneys. Garg et al. quantified the pooled incidence of proteinuria in 42 studies of kidney donors comprising 4793 donors and found it to be 12% (95% CI 8–16%) (25). In addition, we have recently measured the urinary albumin/creatinine ratio in 255 kidney donors, of whom only 3.1% have T2DM, who were at least 12.2 ± 9.2 years after donation and found that 12.7% were albuminuric (26). These observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself, but probably represents the presence of underlying diabetic renal involvement and possibly hypertension. While the proportion with normoalbuminuria was similar between diabetic and non-diabetic donor controls, only 3.9% of nondiabetic donors reported proteinuria suggesting that diabetes is responsible for the higher prevalence (18.8%) of proteinuria. This finding needs to be confirmed in a larger group of individuals. We, unfortunately, do not have information on retinopathy, kidney biopsy information or other end organ damage from diabetes which would make diabetic renal involvement a more likely reason for this increased albuminuria. In addition, quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls.
Our population consisted of mainly white kidney donors and therefore we could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation and information on family history of type 2 DM in nondiabetic donors was not captured. Most importantly, reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria. In summary, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed. All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
level 3
Mohammed Sobair
2 years ago
Introduction:
Report on the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster. Materials and Methods:
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota.
Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation. Results:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys .
In total, 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well.
Therefore, we have diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact). The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%. Risk Factors for DM:
Donating to a family member with type 1 diabetes less T2dm.
A BMI greater than 30Male gender.
Donors who were over the age of 45ys. Donors with DM:
When compared to the age, gender, duration after donation and BMI-matched nondiabetic donor controls, its found that donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.00.
GFR, Prior to development of T2DM, it was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and after developing the condition it was −1.10 ± 5.6 mL/min/year (range −10.8–7.3), p = 0.93. Discussion:
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys in the first few years of type 2 diabetes development.
Diabetic donors, however, are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls but this frequency of hypertension is, again, similar to type 2 individuals with two kidneys (2,3,24). The prevalence of proteinuria in 128 donors with available measurements was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio obtained in 20/154 donors. This prevalence is higher than the usual rates of albuminuria encountered in kidney donors but similar to subjects with diabetes with two kidneys. In summary:
the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
Level of evidence 3B.
Please reflect on the guidelines provided above and on your practice
We investigate donors at least twice. those with strong family history are counselled
regarding possible risk of develop of DM and ESRD.
Hinda Hassan
2 years ago
This is a study of 2954 kidney donors regarding the development of T2DM (2929 + 17 deceased + 8 with no recent contact). a survey regarding development of T2DM after donation was sent to the donors donated between January 1, 1963 and March 31, 2009 who are alive. The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%. Only two donors were listed to have died of diabetes-related complications. In addition, 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease. 154 developed T2DM 17.7 ± 9.0 years after donation; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well. Donors with diabetes were more likely to
1. be smokers
2. have a BMI greater than 30
3. their serum creatinine measurements at the time of donation were slightly higher than those of their non-diabetic counterparts.
Non-responders donated more recently, were least likely to have ever smoked cigarettes and least likely to have donated to a recipient with T2DM. The majority, 80% of nondiabetic responders, donated prior to 2002, when glucose tolerance testing was required in high risk individuals.
Risk factors for diabetes
1. donating to a family member with type 1 diabetes; and to a lesser extent, but not statistically significant T2DM;
2. A BMI greater than 30;
3. male gender;
4. age of 45
For the 154 donors who developed diabetes:
1. mean age (±SD) at time of donation was 39.8 ± 11.4 years
2. the majority were white
3. 47% donated to a sibling or other family member
4. The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%.
5. 20% had a positive family history for T2DM
6. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8%
7. a third were receiving oral hypoglycemic agents.
8. 71% developed hypertension requiring treatment
9. Actual blood pressure readings were available in 126 donors and they were 128 ± 16 mmHg for systolic blood pressure and 75 ± 10 mmHg for diastolic blood pressure.
10. Serum creatinine was available in 126 of the diabetic donors (following diagnosis) and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes .
11. 29 donors (18.8%) were told they have proteinuria.
12. 20 local diabetic donors who were able to come back to the University of Minnesota, measured urinary albumin/creatinine ratio was 68.7 ± 176.85 mg/g, 75% were normoalbuminuric (using ACR <17 mg/g creatinine for men and 25 mg/g creatinine for women), 20% were microalbuminuric and 10% were macroalbuminuric . Time from development of type 2 diabetes to ACR measurement in these 20 donors was 5.1 ± 7.2 years.
In conclusion, donors who developed T2DM had an increased prevalence of hypertension and proteinuric. The annual eGFR change in diabetic versus non diabetic donors was almost indistinguishable.
level of evidence is 3
Post donation DM was not attracting much attention in Sudan. We have started small surveillance programm for the general population but the population response is poor. we need to focus on enhancing population awareness.
CARLOS TADEU LEONIDIO
2 years ago
1. Please summarise this article in your own words
After nephrectomy for kidney donation, there is a temporary physiological adaptation of increased plasma flow and Glomerular Filtration Rate (GFR), which in a patient with reduced renal mass and diabetes would be associated with worsening renal function, especially if it is already diabetic.
Several studies have tried to assess the relationship between diabetes and different markers such as: proteinuria, urinary albumin/creatinine ratio, estimated glomerular filtration rate (eGRF) that would be followed up after donation.
After several attempts to cross populations with various risk factors related to the prevalence and risk factors for the development of DM2 in living kidney donors are not different when compared to the general population. And even those donors who developed diabetes, when better analyzed in relation to albuminuria rates, larger curves were noticed than non-diabetic donors, which may be suggestive of early diabetic kidney disease.
2. What is the level of evidence provided by this article?
This is a retrospective case control study, which is looking for risk factors for the development of diabetes in living kidney donors – Level 03
3. Please reflect on the guidelines provided above and on your practice
Some reflections can be made:
– Need for long-term studies to really elucidate the risk of developing the most diverse pathologies in living donor patients;
– A significant percentage of the population has criteria for diagnosing the most prevalent diseases in the general population and is not aware of it. Therefore, investigation of screening protocols should be performed in all proposed living donors.
– Diabetic donors in the first decade will not present an increased risk of evolving with accelerated kidney disease, so they can join the donor queue.
– importance of donor follow-up after donation.
Asmaa Khudhur
2 years ago
Diabetes after Kidney Donation
Introduction :
T2DM is a genetic disease with 30 % of those affected by it developed kidney damage.
Kidney donors with strong family history of DM are declined from donation by some centers because of the additional risks of hyperfiltration and small size kidneys.
This study report the donor risk of developing T2DM compared with non diabetic donors in regard to age , bendy, duration after donation and BMI and GFR decline.
Materials and Methods :
3825 donors were taken from 1963 to 2009,at university of Minnesota .
Survey including questions regarding the presence of DM , age at its development, type of treatment, presence of HT , presence of protein in urine.
Potential donors with 2 parents with DM , multiple siblings with DM in edition to one parent with DM , more than one family member with diabetic kidney disease are strongly discouraged from donating.
After 2002 , those with more than one family member with DM , those with gestational DM and those with fasting blood sugar more than 99 are subjected to GTT.
Donors with BMI > 35 kg/m2 not accepted as donors.
Serum creatinine, urinary protein, GFR are estimated.
Diabetic donors were matched with the non diabetic donors in regard to age , gender , years from donation and BMI at donation.
Serial measurement of serum creatinine in donors who develop DM after donation and at 1 year apart to assess for the rate of GFR decay.
Results : 3825 underwent uninephrectomy for kidney donation.
48 of them were excluded .
3777 remain , 293 of them have died, 555 lost ,
2929 remaining, 129 are alive , 154 developed T2DM , 293 are deseased donor.
Cause of death is unknown in 40% of the donors , 19% Cardiovascular, and 20% cancer. Only 2 died due to DM complications.
Risk factors for diabetes :
Positive family history, BMI greater than 30 , male gender , donor age more than 45 .
Donors with diabetes : 154 with DM Mean age was 39 years
The majority were white
47% donating to sibling or other family members
The cause of ESRD was type 1 DM 33%
T2DM 10% , HT 35%, PCK in 5% and others are 15% .
71% developed HT requiring treatment.
29 donors developed proteinuria .
Comparing between the donors with and without DM in regard to age , gender , duration after donation and BMI we found that donors who developed T2DM have increased prevalence of hypertension and proteinuria .
Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
Level of evidence 3
Mahmud Islam
2 years ago
This is a retrospective case-control study with a level of evidence (III). a total of 3825 was scanned. 293 dead, but 17 were reported to have DM before death. 8 out of 555 patients not followed in the last four years reported DM. In this study, 2929 patients were analyzed, and 129 DM was reported. As shown in figure 1, the ratio of obese patients (MBI>30 was higher in those who developed DM 25.3 vs 17.2% with a significant p-value of 0.02. Smoking had a hazard ratio of 1.22, but this was not statistically significant (p=0.31). In the 154 who developed DM, the mean value of developing DM was 17.7 years (± 9.0 ), age at developing DM was 57 ( ± 12.6 ). HT in DM (post-donation) was around 70%. This group was found to have more proteinuria. In this study, factors related to DM were not very much different from the general population.
Nasrin Esfandiar
2 years ago
The aim of this study was determining the risk of T2DM after donation compared with a matched control group. Donors were asked about T2DM, HTN or proteinuria and taking medicine regarding them.
Their GFR was estimated using their last serum creatinine based on MDRD formula. Of 3777 donors only 2954 responded to survey, T2DM was developed in 154 donors with a mean duration of 17/7 ± 9 years after donation.
Risk factors for development of T2DM post-donation includes:
1- donation to a family member with type 1DM
2- BMI over 30
3- male gender
4- donors over 45 years of age
Mean age of donors with diabetes was 39.8±11.8 years and occurred 17.7±9 years after donation.
Twenty percent had positive family history. Seventeen percent off diabetic donors developed
hypertension and 18.8% proteinuria. Rate of GFR decline was not different in diabetic donors.
Type of study: This is a case-control (cohort) study with the level of evidence of 3b.
Our local practice:
1) Individuals with a history of diabetes or fasting blood glucose of ≥ 126 mg/dL on at least
two occasions or 2-h glucose with OGTT ≥ 200 mg/dL or HbA1c ≥ 6.5% should not
donate.
2) In the presence of FBS< 100 mgr/dl, OGTT and HbA1c should be performed in the
following prospective donors:
a) BMI≥ 30 kg/m2
b) History of diabetes in 1° relatives
c) History of GDM > 10 years ago
3) Donation in potential donors with FBS between 100-126 mgr/dl (impaired fasting
glucose) is not recommended except in related donors with normal OGTT.
Ahmed Fouad Omar
2 years ago
Introduction: DM is the most common cause of ESRD worldwide. 30% of T2DM has a strong genetic component . Some Transplant centers exclude kidney donors with a strong family history of type 2 diabetes. Kidney donors are at risk of DM like the general population. Aim of the study: To compare kidney function in diabetic donors to that of age, gender, and BMI-matched non-diabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR, hypertension and Proteinuria when compared to non-diabetic donors.
Materials: Single center study(University of Minnesota) which included > 3825 donors Results: 5% developed type 2 diabetes mellitus after donation, which was like the incidence in general population. Risk factors for developing DM are: donating to a family member with type 1 DM, males, age >45 years, and BMI > 30 71% of the donors who developed diabetes had hypertension (2 times of the non-diabetics, but similar to diabetics with 2 kidneys) 18.8% developed proteinuria (4.5 times more than the non-diabetics, but similar to diabetic patients with 2 kidneys) The rate of eGFR change in the diabetic donors and matched non-diabetic donors was similar.
Conclusion: The prevalence of type 2 DM in kidney donors after the donation is the same prevalence in the general population. The risk factors for development of diabetes in renal donors are similar to those in the general population. Diabetic donors have increased hypertension and proteinuria than non-diabetic donors, but the frequencies are similar to diabetics with 2 kidneys.
What is the level of evidence provided by this article? Level 3, case control study.
Please reflect on the guidelines provided above and on your practice. In our center we screen all potential donors with FBS, HBA1c. We don’t exclude potential donor with positive FH or DM unless having impaired an abnormal blood sugar level( fasting blood sugar or GTT).
Hamdy Hegazy
2 years ago
This is a cross sectional study with level of evidence IIIB.
Some transplant centers exclude donors with strong family history of DM because of their high genetic risk to develop DM later in their life.
Risk factors of developing DM after kidney donation include: age, gender, BMI, and duration after kidney donation.
Method: Post donation survey, asking donors if they developed DM, age of onset and treatment received. Donors renal function test and e-GFR was measured at the nearest medical practice.
Results and discussion: 2929 donors participated in the survey. 154 donors admitted of developing DM II. 2 donors died because of DM related complications. 11 donors developed ESRD who required dialysis or transplantation, none of them was related to diabetic nephropathy.
Donors with post donation DM were found to be smokers, obese, BMI>30, high serum creatinine at the time of donation, donors with family history of DM I, and aged above 45 years.
Donors with DM: mean age 39.8 years, diagnosed 17.7 years after donation, HbA1C 8 +/- 7.8%. 2/3 of them were treated with insulin. 71 % developed Hypertension. 18% were found to have proteinuria with average urine ACR 61.8 +/- 18.1 mg/g.
One-week post nephrectomy, GFR increases by 70%. DM is associated with hyperfiltration as well. Macro-albuminuria was found in 30% of single kidney Diabetics than23% in single kidney non-diabetics. Prevalence of proteinuria was 25% by urine ACR.
Limitations of this study: 1- 40% of cases, the cause of death was not found. 2- DM incidence was not correctly determined. 3- Survival Bias. 4- Response Bias. 5- No detailed information about family history. 6- No assessment of ethnicity as a risk factor.
Jamila Elamouri
2 years ago
Diabetes after Kidney Donation
Diabetes mellitus is a major cause of ESRD. It has strong association with family history of the disease, there for many transplant centers exclude donors with strong family history of diabetes. age, gender, duration after donation and body mass index (BMI) are risk factors for its development.
Method
Donors have send survey to determine if they develop diabetes, in addition to other question regarding age of onset and treatment use.
Donors are asked to measure the serum creatinine at their near medical office and their GFR were estimated. The collected data were categorized and analyzed with appropriate test.
Results:
2929 have responded to our surveys. In total, 154 donors reported developing T2DM; only 2 donors listed to have died of diabetes-related complications. 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
Total population
Donors who develop DM are more likely to be smoker, obese with BMI > 30, and have higher serum creatinine at time of donation as compared with non diabetic donors.
Risk factors for diabetes:
1- Donation to a family member with type 1 diabetes
2- BMI >30
3- Donor age >45 years
Neither s. creatinine nor smoking status at donation were predictive of future risk of T2DM.
Donors with diabetes:
Mean age was 39.8± 11 years. Diagnosis occurred 17.7 ±9 years after donation. The majority was white and 47% donate to their sibling or family member.
The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
Of the diabetic donors, 71% develop hypertension requiring treatment at the same time they were told to have diabetes. Serum creatinine was 1.26±0.4 mg/dl with e GFR of 58.8 ±16.7 Ml//min/1.73 m2, 7.7±7.0 years after the development of diabetes. 18.8% told to have proteinuria. 20% were microalbuminuria and 10% were macroalbuminuria. Time to development of type 2 diabetes to ACR measurement in these 20 donors was 5.1± 7.2 years.
When compared to the age, gender, duration after donation and BMI-matched nondiabetic donor controls, we found that donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.0001. Quantitative proteinuria information was available in 14 nondiabetic controls. The average ACR was 61.8 ± 181.1 mg/g and a similar proportion (i.e. 71%) was normoalbuminuric.
Longitudinal e GFR change:
Donors who have multiple e GFR measurements were compared in the two group. Those who develop diabetes, they were more likely to be hypertensive (91%), 19% were proteinuric, their BMI at the time of last follow-up was 31.6 ± 7.0 kg/m2 and an average of 15.5 ± 8.8 years had elapsed from donation to the development of T2DM. The annual eGFR change in these donors was -0.80 ± 0.9 mL/min/ 1.73m2 (range -2.99–1.63). The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was -0.70 ± 0.86 mL/min/year, range (-4.99–2.19, p = 0.43, vs. those with diabetes).
Seven diabetic donors had multiple e GFR before and after diabetes, the lope in e GFR before diabetes was –0.88±0.67 ml/min/1.73m2 (range -1.96 to 0.21) and after diabetes the slop in e GFR was –1.10±5.6 ml/min/1.73m2.
Discussion
Post- nephrectomy there is rapid increase in plasma flow and GFR. GFR increased by 70% 1 week after donation. Also diabetic patients undergo hyperfiltraion.
The compensatory increase in GFR observed in the setting of reduced renal mass and diabetes has been linked to the progressive nature of kidney disease.
The single-kidney and two-kidney type 2 diabetic patients were matched for age, sex and BMI. Microalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%). Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys in the first few years of type 2 diabetes development.
The prevalence of proteinuria in donors was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio. This prevalence is higher than the usual rates in kidney donors but similar to subjects with diabetes with two kidneys.
The mean time from donation to development of T2DM in our donor population was 17.7 ± 9.0 years. the median time with normoalbuminuria before progressing to microalbuminuria is 19 years; the median time with microalbuminuria before progressing to macroalbuminuria is 11 years and the median time with macroalbuminuria before progressing to nephropathy is 10 years.
One would expect that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be reflective of a drop in their renal function.
Limitations
1- The cause of death was missing in 40%.
2- The incidence of diabetes could not be precisely determined.
3- Survival bias and response bias.
4- Ethnicity as risk could not assessed as majority was white donor.
5- Information on family history was not captured.
amna khalifa alhadari
2 years ago
Diabetes after kidney donation
Kidney donors are at risk for developing diabetes type 2, and 30% of diabetic can develop CKD.
1. The study estimate the risk of donors of developing T2DM,
2. comparing diabetic donors with matched non diabetic donors in renal function, age, gender, duration after donation and BMI.
3. comparing the progression rate of GFR between diabetic donors and non diabetic donors. Method and statistics
All the donors between (Jan 1963-march 2009) were attempted to contact (total of 3825).
A survey were send to those who were contacted to ascertain their health status. and regarding development of T2DM after donation.
Also they were requested to check their serum creatinine and check urine protein measurements at their Primary care provider. GFR were estimated using MDRD equation.
The comparison were tested statistically using chi square or fisher’s exact test.
Continuous variables were compared using unpaired t test.
A cox proportional hazard model was used to study the predictors for the development of type 2 diabetes. Discussion
As a result of uni-nephrectomy post kidney donation, GFR increases to 70% within 1 week. This is as a compensation to the reduced renal mass, similar to hyperfiltration observed in diabetes type 1 or 2.
The result of the study showed that the prevalence and risk factors for T2DM in kidney donors are similar to general population.
More over they found that type 1 DM considered associated factor for the development of T2DM in the donor and this might be due to wrong identification of type 1 diabetes.
The author also found that smoking was not a significant risk factor for T2DM in both the adjusted and unadjusted analyses, though there was a higher prevalence of smoking in the donors who developed diabetes. But the authors suggested this result could be due to small studied population inspite of similar results in other studies.
Also it was found that higher prevalence of proteinuria in the diabetic donors is unrelated to donation rather it might be due to the presence of underlying diabetic renal involvement and possibly hypertension.
normoalbuminuria was similar in diabetic and non-diabetic donor, but only 3.9% of nondiabetic donors reported proteinuria hence they suggested that diabetes is responsible for the higher prevalence of proteinuria. But afurther studies needed for confirmation.
One of the limitations of this study that, retinopathy other diabetic complications including kidney biopsy information were not which would confirm diabetic renal involvement being responsible for the increased albuminuria.
Other finding of the study was the rate of GFR decline is not accelerated when compared to nondiabetic donors,
diabetic donors had a urinary albumin excretion rate of 68.7 ± 176.8 mg/g; comparable to other studies.
In the study The mean time from donation to development of T2DM in the donor population was 17.7 ± 9.0 years.
the author suggested that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be reflective of a drop in their renal function.
Other limitations to the study was that the cause of death was missing in 40% of all donors. And no information available about type 2 diabetes in the majority of donors who have passed away
The prevalence of diabetes in our donors (5.2%) is lower than the 9.8% that is observed in non-Hispanic whites which coud be attributed to the fact that donors were screened at the time of donation and so may be a selected subgroup. Conclusion:
the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease.
Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes
All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
level of evidence 3b
in our center we do routinely check for fasting blood sugar and hba1c for the donors and if both normal we do accept the donor if not we refer him to the diabetologist to assess for further complications and accordingly we decide but we try to avoid diabetics as a donor even those with impaired glucose test.
Ahmed Abd El Razek
2 years ago
Introduction
Diabetes mellitus is the first leading cause of end-stage renal disease development worldwide. That is why some transplant centers decline kidney donors with a strong family history of type 2 diabetes owing to the fact of possible additive effect of hyperfiltration afterwards.
It is also crucial to exclude whether development of T2DM post donation can result in higher risk of acceleration in glomerular filtration rate decline over years.
This study aims to compare renal function decline in diabetic donors versus those non diabetic donors, to assess the donors’ risk if T2DM was developed later on and whether diabetic donors are vulnerable to an accelerated decline in GFR when compared to nondiabetic donors.
Materials and Methods
The study was carried out for established donors between January 1963 and March 2009 included 3825 donors based on a survey.
Statistical method
Chi-square or Fisher’s exact test were the principle tools for studying variables and further comparisons. A Cox proportional hazard model was successfully used to study the predictors for the development of type 2 diabetes. The main determining variables were age, gender, BMI, type 1 DM in the recipient, type 2 DM in the recipient, serum creatinine and smoking status. Results are expressed as adjusted hazard ratio and their 95% confidence intervals. p < 0.05 was considered significant.
Results
A number of 154 donors reported developing T2DM. Two donors only have died of diabetes-related complications. A number of 11 donors have developed ESRD requiring dialysis or transplantation and none was attributed to diabetic kidney disease. Donors with diabetes were smokers, with BMI exceeding 30, and their serum creatinine measurements at the time of donation were slightly higher than those of their nondiabetic controls.
Risk factors for diabetes
Among the important risk factors were donating to a family member with type 1 diabetes, accompanied with substantial risk for developing T2DM, BMI exceeding 30,as well as male gender.
Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM.
Donors with diabetes
Among 154 donors who developed diabetes, mean age (SD) at time of donation was 39.8 years and the diagnosis of diabetes occurred 9.0 years post donation. HbA1c was available in 51 donors and it was around 8.0 to 7.8%, with some of them were receiving oral hypoglycemic agents.
Regarding albuminuria; urinary albumin/creatinine ratio (ACR) was around 68.7 to 176.85 mg/g, 75% were normoalbuminuric (using ACR <17 mg/g creatinine for men and 25 mg/g creatinine for women), 20% were microalbuminuric and 10% were macroalbuminuric. These donors have developed type 2 diabetes from the time of ACR measurement in these 20 donors was 5.1 to 7.2 years.
Donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.0001).
Longitudinal eGFR change
Only 64 donors had multiple serum creatinine measurements available after the diagnosis of diabetes was established. These donors were more likely to be hypertensive (91%), 19% were proteinuric, their BMI exceeded 30 at the time of last follow-up. The annual eGFR change in these donors was −0.80 to 0.9 mL/min/1.73m2 (range −2.99–1.63) while those donors without diabetes after donation was −0.70 to 0.86 mL/min/year.
Seven diabetic donors had multiple serum creatinine measurements pre and post development of diabetes that allowed to compare pre- and post-diabetes eGFR slopes concluding that Prior to development of T2DM, it was −0.88 to 0.67 mL/min/year (range −1.96 to −0.21) while after being DM was −1.10 to 5.6 mL/min/year (range −10.8–7.3),of estimated p = 0.93.
Discussion
The compensatory increase in GFR post donation in the setting of reduced renal mass and diabetes has been strongly linked to the progressive nature of kidney disease. Astonishingly, in case series of diabetic patients presented with either unilateral agenesis or unilateral nephrectomy, none suffered accelerated kidney function in the remaining kidney.
Chang et al. found no difference between the mesangial matrix volume; the hallmark of diabetic nephropathy, in diabetic subjects with one kidney compared to those with two kidneys. Okamoto et al. reviewed the records of 444 kidney donors who donated in the era between 1985 and 2000, seven of 65 survivors with impaired glucose tolerance at the time of donor evaluation became frankly diabetic while no ESRD was reported as well as their survival was similar to the other donors.
A higher prevalence of smoking in the donors who developed diabetes was reported, stating that known smokers were 40% more likely to develop diabetes of 95% CI.
Diabetic donors are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls, however it is also similar to type 2 individuals with two kidneys.
The prevalence of proteinuria is 18 % which is higher than the common rates of albuminuria reported in kidney donors but again it was similar to subjects with diabetes with two kidneys.
According to Garg et al. who quantified the incidence of proteinuria in 42 studies of kidney donors, the estimated incidence was only 12%.
All these data preclude that; the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself, but probably represents the presence of underlying diabetic renal involvement and possibly hypertension.
Limitations of the study, are mainly the lack of sufficient information on retinopathy, renal biopsy or other associated end organ damage from diabetes which would make diabetic renal involvement a more likely reason for this currently increased albuminuria. Also quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls.
It takes many years to develop diabetic renal changes and this study was limited to the first decade after type 2 diabetes development which is also one of the drawbacks. The cause of death was missing in 40% of all donors as well, so true incidence of diabetes could not be precisely determined. The population of the study consisted of mainly white kidney donors, thus it can’t be applied to other ethnicities.
According to the United Kingdom Prospective Diabetes Study (UKPDS); it takes an average of 10 years from the diagnosis of type 2 diabetes for 25% of subjects with diabetes to frankly develop microalbuminuria.
So, longer follow-up is required emphasizing that level of eGFR seen in diabetic and nondiabetic donors as an early sign of progressive renal disease in the diabetic individuals. One would expect that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be indicative of further decline in their renal function.
Finally, the risk factors for the development of T2DM in kidney donors is similar to the general population, particularly those donors who have albuminuria as it might be suggestive of early diabetic kidney disease.
At last we recommend that larger studies and, more importantly, longer follow-up are needed for all donors especially those with a positive family history for diabetes with advisable strict weight control and healthy lifestyle adoption.
Level of evidence 3
In our practice, proper selection of the living donor with meticulous assessment to avoid the risk of development of diabetic kidney disease is a must. HBA1C is one of the parameters to exclude the evidence of DM in candidate donors as well as the albumin quantification in 24 urinary measurement, it is performed at least twice. Donors with high BMI exceeding 30, or those with significant albuminuria as well as positive family history of DM are excluded from donation.
Abhijit Patil
2 years ago
Introduction:
Kidney donors, similar to the general population, are at risk for development of type 2 diabetes mellitus (T2DM) as in general population.
The aim of the study was to evaluate the course of donors who develop T2DM
Material and methods:
Between January 1, 1963 and March 31, 2009
3825 donor nephrectomies were performed
At the University of Minnesota
finally, 3777 kidney donors evaluated regarding the development of T2DM.
it was a survey based analysis
Results
Of the 2954 who responded, 154 developed T2DM after donation
17.7 ± 9.0 years after donation.
The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls;
diabetic donors were more likely to have
hypertension (70.8% vs. 36.2%, p = 0.005),
proteinuria (18.8% vs. 3.9%, p < 0.0001)
similar serum creatinine.
eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors
Conclusion
Carefully selected donors at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Please reflect on the guidelines provided above and on your practice.
So, donor with family history of DM can be accepted as donor provided the OGT is normal and healthy lifestyle is maintained.
Abdullah Raoof
2 years ago
Diabetes after Kidney Donation
Q1- Please summarise this article in your own words.
type 2 diabetes mellitus (T2DM) development risk in donors are similar to general population.
Abstract
The risk factors for developing T2DM are
· Recipient with type 1 DM,
· male gender
· body mass index >30 kg/m2 at time of donation.
Compared to non-diabetic donor controls; diabetic donors have more hypertension , proteinuria, but had a similar serum creatinine.
The available data showed that factors associated with T2DM in kidney donors are similar to that in the general population and these donors has no accelerated diabetic kidney nephropathy . Introduction
Diabetes mellitus is the leading cause of ESRD.
T2DM is a genetic disease . and 30% of those patient develop kidney damage.
some centers decline kidney donors in the presence of a strong family history of type 2 diabetes, because of the possible additive effect of hyperfiltration of diabetes and reduction in renal mass . Risk factors for diabetes at the time of donation .
· donating to a family member with type 1 diabetes.
· A BMI greater than 30 .
· male gender .
· over the age of 45 y .
Of the diabetic donors,
· 71% developed hypertension .
· 18.8% develop proteinuria.
This means that patient with T3DM has more chance for developing hypertension and proteinuria than non diabetic .
Silveiro et al . demonstrate that
· Mi-croalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
· Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
The study suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself only , but may be due to the presence of diabetic renaldisease t and hypertension. While the proportion with normoalbuminuria was similar between diabetic and non-diabetic donor controls, only 3.9% of nondiabetic donors reported proteinuria suggesting that diabetes is responsible for the higher prevalence of proteinuria.
the degree of GFR decline is not accelerated when compared to nondiabetic donors, and is similar to patients with two kidneys.
The mean time from donation to development of T2DM is around 21 y .
Based on statisticaldata ,
· the median time till microalbuminuria is 19 years.
· the median till macroalbuminuria is 11 years .
· the median time till nephropathy is 10 years .
In summary, 1. the risk factors for the development of T2DM in kidney donors is similar to the general population and 2. donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. 3. when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. 4. declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified . 5. All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
Q2- what is the level of evidence provided by this article?
Level of evidence is 3 – retrospective – case control study.
Q3- Please reflect on the guidelines provided above and on your practice.
The donor is assessed by FBS, HB AIC , if needed OGT , if high sugar level in these study , the will declined .
Tahani Ashmaig
2 years ago
Diabetes after Kidney Donation Introduction Some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass. This study reported the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI). Results: This study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation. The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation. Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was -0.80 ± 0.94 mL/min/year, -0.70 ± 0.86 in nondiabetic donors with similar duration after donation and -0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls. Limitations of the study: 1. The finding needs to be confirmed in a larger group of individuals. 2. No information on retinopathy, kidney biopsy or other end organ damage from diabetes which would make diabetic renal involvement a more likely reason for this increased albuminuria. 3. Quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls. 4. The cause of death was missing in 40% of all donors. 5. The true incidence of diabetes could not be precisely determined. 6. Survival and response bias 7. The study population consisted of mainly white kidney donors and therefore they could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation. 8. Information on family history of type 2 DM in nondiabetic donors was not captured. 9. Reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria. Conclusion: Factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease When compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. So, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed. All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
amiri elaf
2 years ago
# Please summarise this article in your own words
# The objectives:
*Report on the donors’ risk of developing T2DM.
*Compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched non diabetic donors.
*To assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to non diabetic donors.
# Introduction
*DM is the leading cause of ESRD. Its prevalence will more than likely increase as the prevalence of (T2DM) increases in parallel with the rise of obesity in the general population.
*T2DM has a strong genetic component and 30% of those afflicted with it develop kidney damage. So, some transplant centers decline kidney donors with a strong family history of T2DM.
#Method:
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota. They attempted to contact all donors to ascertain their health status. In the last 7 years, they have begun a comprehensive multistep approach to locate all kidney donors. Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation. The survey included several questions.
#Result
*They surveyed 3777 kidney donors regarding the development of T2DM.
* Of the 2954 who responded, 154 developed T2DM 17.7 +/- 9.0 years after donation.
*The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
* Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine.
* e-GFR change after T2DM development was −0.80 + /- 0.94 mL/min/year, −0.70 +/- 0.86 in non diabetic donors with similar duration after donation and −0.61 + /- 0.76 mL/min/year in age, gender, BMI and duration after donation matched non diabetic donor controls.
*These preliminary and short term data demonstrate that factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
# The limitation:
*The cause of death was missing in 40% of all donors therefore, true incidence of diabetes could not be precisely determined.
*Survival bias (do not have information on type 2 diabetes in the majority of donors who have passed away).
*Response bias as responders are certainly different and in this analysis were more likely to have ever smoked and were heavier at donation.
# Concolution:
*The risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than non diabetic donors, which may be suggestive of early diabetic kidney disease.
*When compared to non diabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
*Declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
* All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
# What is the level of evidence provided by this article?
*Level of evidence is 3
# Please reflect on the guidelines provided above and on your practice.
*In our practice for donors that have family history of DM, we do full evaluation with GTT, FBS HbA1c, abnormal BMI and proteinuria, if there any possibility for DM we exclude the donor.
Eusha Ansary
2 years ago
Summary:
Kidney donors are similar to the general population regarding the risk of development of type 2 diabetes mellitus (T2DM).
This study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation.
The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in non diabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched non diabetic donor controls.
These preliminary and short term data demonstrate that factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Level of evidence: 3
Nandita Sugumar
2 years ago
Summary
This study is about kidney donors developing diabetes mellitus type 2. There are many centers that take donors who have a family history of diabetes. This study reports that the incidence of diabetes mellitus and the course it takes is similar in both kidney donors and the general population. The lifetime risk in kidney donors in terms of diabetes type 2 remains the same as general population, irrespective of donation.
Some of the characteristics common between diabetic donors were found to be :
smoking
BMI above 30, i.e., overweight
serum creatinine higher than non-diabetics
Following kidney donation, the following changes take place within 1 week of donation :
increase in renal plasma flow
increase in GFR due to possible hyper filtration
DIabetic donors can have significant hypertension and albuminuria in comparison with diabetics in the general population. In addition, diabetic donors have twice the risk of hypertension compared to the general population.
Diabetes in kidney donors can develop anywhere between the first 2 decades following kidney donation. There did not appear to be an increased risk for accelerated kidney disease in diabetic donors in comparison with non-diabetic donors.
Limitations of study include the following :
no cause of death was clearly estimated
Restricted ethnic variation – this study mainly involved white donors
family history of diabetes was not included
proteinuria was assessed by self report and dipstick measurement which is inferior to quantitative methods
The study concludes with a recommendation not to reject kidney donors based on positive family history of diabetes type 2, and to maintain longer follow up post donation. Counseling patient for weight management and smoking abstinence in crucial.
Level of evidence
Case control study – level of evidence 3.
Filipe prohaska Batista
2 years ago
This is a single-center retrospective case-control study between 1963 and 2009 with 3825 living donors evaluating the correlation of diabetes mellitus after kidney donation and its consequences, being considered an evidence study 3b.
Potential donors are discouraged when they have both diabetic parents, multiple siblings, or obese (BMI greater than 35), especially when they are Hispanic or African American. In this study, all patients were Caucasian, assessing the prevalence of systemic arterial hypertension, eGFR, proteinuria, age, gender, and age at donation.
Of the 3825 patients, 48 underwent kidney-pancreas, 293 died and 555 did not receive feedback through the voice questionnaire, leaving 2929 patients. In 40% of patients, the cause of death was unknown and only two donors had a death related to diabetes complications.
When calculating risk factors for diabetes, the Hazard Ratio found was:
Family members with DM1 – 2.97
Future risk of developing DM 2 – 3.07
BMI > 30 – 2.97
Male gender – 1.76
> 45 years old at the time of donation – 1.46
Serum creatinine and smoking status at the time of donation were not predictive of T2DM. Donors who developed DM2 had a high prevalence of systemic arterial hypertension, proteinuria, and BMI around 31.
This study suggests that risk factors for the development of T2DM are not different between donors and the general population. Smoking appears to be an important factor, but the study number was not sufficient to generate statistically significant data. On the other hand, the lack of data related to retinopathy, renal biopsy, or end-organ damage findings from diabetes.
This study was exclusively aimed at a Caucasian population, outside the reality of Brazil, where we have an extremely mixed population with very different genetic characteristics. Obesity, smoking, and physical inactivity must be proactively reversed to improve the donor’s quality of life.
Theepa Mariamutu
2 years ago
DM is the leading cause of ESKD, T2DM has a strong genetic component and 30% its patients mostly develop kidney disease. Transplant centers exclude kidney donors with a strong family history of type 2 diabetes.
This study was done to compare kidney function in diabetic donors to that of age, gender, duration after donation and BMI-matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR when compared to nondiabetic donors.
2929 responders were included, 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM
Donors with diabetes
154 donors (majority were white and 47% donated to a sibling or other family member) who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation.
20% had a positive family history for T2DM. Current HbA1c was available in 51 donors, and it was 8.0 ± 7.8% and a third were receiving oral hypoglycaemic agents
71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; at the same time they were told have diabetes
Serum creatinine was available in 126 of the diabetic donors and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes
29 donors (18.8%) were told they have proteinuria
donors who developed T2DM had an increased prevalence of hypertension and were also more likely to have proteinuria
risk factors for the development of T2DM in kidney donors similar to general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early DKD
eGFR change
The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2
The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year
matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI, and duration after donation and found rate of eGFR change to be almost indistinguishable: 0.61 mL/min/ year.
For diabetic donors pre- diabetes was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and post diabetes eGFR slopes −1.10 ± 5.6 mL/min/year (range −10.8–7.3)
Silveiro et al found that microalbumiuria -higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
Chang et al.found no difference between the mesangial matrix volume; in subjects with one kidney type 1 diabetes who received renal transplants compared to those with two kidneys. Data suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
Diabetic donors are twice more likely to be hypertensive but this frequency of hypertension is, similar to type 2 individuals with two kidneys.
Observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself.
The study is case control level of evidence III, case-control study
In our practise we usually will not take pre diabetic and diabetic patients for living kidney donation.
Huda Al-Taee
2 years ago
Please summarise this article in your own words
Aim of the study:
To report on the donors’ risk of developing T2DM
To compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index-matched non-diabetic donors.
To assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to non-diabetic donors.
Methods:
Survey-based study including questions about diabetes, hypertension and proteinuria.
Results:
3777 kidney donors were survyed regarding the development of T2DM.
Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation.
The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at the time of donation. Compared to age, gender, duration after donation and body mass index-matched non-diabetic donor controls; diabetic donors were more likely to have hypertension and proteinuria but had a similar serum creatinine.
eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched non-diabetic donor controls.
Conclusion:
factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
What is the level of evidence provided by this article?
Level 3 ( case-control study ).
Rahul Yadav rahulyadavdr@gmail.com
2 years ago
Please summarize this article in your own words
DM in one of the leading causes of Kidney Damage and affects 30% of those affected. It has a strong genetic association with prevalence rising due to increase in obesity in general population.
This study assesses
a) Donor’s risk of developing T2DM
b) Compare Kidney function in diabetic Donors to matched Non-Diabetic Donors (age, gender, duration after donation and BMI matched)
c) Vulnerability of faster Decay of GFR in diabetic versus non-diabetic donor
Risk factor for development of diabetes found in this study:
1. Donation to family member with T1DM (HR 2.97)
2. BMI >30(HR 2.97)
3. Male gender (HR 1.76)
4. Donor>45 years, slightly more likely to develop DM(HR 1.46),not statistically significant
Donor with Diabetes:
As compared to matched nondiabetic donor controls, donors who developed T2DM had an
a)increased prevalence of HTN (71% versus 36.3%), in second decade after donation
b)more likely to be proteinuric (18% versus 2.9%), in second decade after donation
Annual eGFR change:
Rate of annual eFGR decline in donors with or without Diabetes when compared longitudinally doesn’t show an accelerated pattern
Prevalence and risk factors for T2DM in kidney donors
Same as general population
United Kingdom Prospective Diabetes Study (UKPDS) suggests:
25% of subjects diagnosed for more than a decade with T2DM develop microalbuminuria
Median time in progressing microalbuminuria is 19 years
Median time in progressing macroalbuminuria from microalbuminuria is 11 years
Median time to nephropathy with macroalbuminuria is 10 years
Avoid :
· Potential Donors with both Diabetic parents
· Potential Donor who has multiple siblings with T2DM with one parent diabetic
· Potential Donor who has multiple siblings with T2DM with one immediate family member with diabetes, especially African American or Hispanic
What is the level of evidence provided by this article?
Retrospective case control study, Level of evidence 3
Please reflect on the guidelines provided above and on your practice.
In my practice,
FBS, PPBS, HbA1c done twice.
If impaired FBS/PPBS, will proceed for OGTT.
If found diabetic, will look for end organ damage like albuminuria, Diabetic retinopathy/Neuropathy.
If no evidence of end organ damage and not significant family history of Diabetes/Diabetic Nephropathy and age at the time of assessment more than 40years, we select such diabetic as prospective Donor with well informed consent
Mu'taz Saleh
2 years ago
Level 3
Mu'taz Saleh
2 years ago
Please summaries this article in your own words
DM is the most common cause of ESRD , so its very important to study the risk of developing DM post donation , and to compare the effect of diabetes between donor and non donor population .
This study aims to determine the risk of development of T2DM in kidney donors and to compare rate of kidney function decline in diabetic donors and matched non diabetic donors. It included 3825 kidney donors who had nephrectomy between 1963 and 2009. Potential donors with family history of T2DM were accepted if their age at time of assessment was 10 years beyond the age at which parent developed T2DM, those with >1 immediate family member with DKD are discouraged from donation. Potential donors with BMI >35 are advised to lose weight and to donate when BMI <30. They found no increased risk of having diabetes in donors, whom experienced diabetes were smokers , having a BMI >30, and the serum creatinine at the time of donation was higher than non diabetic donors.
risk factors for diabetes according to study was:
Donating to a family member with type 1 diabetes.
BMI >30.
Males.
Age at donation > 45 year old.
Conclusion: Exclusion of potential donors due to presence of positive family history of T2DM and negative oral glucose tolerance test is not justified but further studies with longer follow up are still needed All kidney donors especially with positive family history for DM should be advised to keep weight control.
Please reflect on the guidelines provided above and on your practice.
in our trasnplantation center we ordered FBS two times with HbA1c if normal we accept the patient if one of them is abnormal we refer him to endocrinologist and do OGTT
thanks
Mohamed Ebrahim Abosaeed
2 years ago
– Diabetes mellitus is the leading cause of end-stage renal disease .
– some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass . Yet it is unknown whether development of T2DM after donating a kidney leads to a higher risk of experiencing acceleration in glomerular filtration rate (GFR) decay when compared to nondiabetic donors or diabetics with two kidneys.
– This study repots on the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to nondiabetic donors
– this study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation. The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Results :
Compared to age, gender, duration after donation and body mass index (BMI) , matched non-diabetic donor controls;
– diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls.
Conclusions:
– the risk factors for the development of T2DM in kidney donors is similar to the general population
– donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease.
– Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
– Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
– All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
– level of evidence>>>III ( case controls study )
– in our practice , we are doing Fasting & post prandial plasma glucose & HBA1C for screening for DM
– if DM>>exclude from donation
-if impaired FPG >>so will do OGTT >>if impaired also>>will be excluded
– if normal OGTT & after reduction of weight & life style modification >> can be accepted with counselling regarding the risk .
Marius Badal
2 years ago
. Diabetes after Kidney Donation 1.
The study was about DM and that it is the most frequent cause of kidney failure worldwide. The major risk factors are obesity and a strong family history of DM especially type 2. Due to the major risk that are frequent with DM should it be a liable or viable candidate for kidney transplantation especially when it comes to rapid decrease in kidney functions and that itself will have a great impact on the donor kidney. The study was conducted at the university of Minnesota of about 3777 kidney donors as it relates to DM type 2. They were looked into closely to see if there was DM, proteinuria, HTN, the number of medications taken and etc. Based on the study the results showed that the risk of developing DMT2 was related with DMT 1 in the recipient, male patients, and a BMI of greater than 30 kg/m2. Micro albuminuria was grater single DM kidney than non DM kidneys and the prevalence of albuminuria and HTN was similar in DM donors and DM patients with 2 kidneys, however the HTN risk was greater when compared with the non DM donors. It was found that patients who are DM donors were more likely to have HTN, proteinuria, but their serum creatinine was similar but the GFR changed after developing DMT2 as it relates to non-DM donors. It was found that smoking was not a risk factor for DMT2. The study had some imitations and they are: the follow-up was too short, the cause of death of 40 % of donors were missing, and the self-support urine test assessments. 2. What is the level of evidence provided by this article? I think the level of evidence is level 3 3. Please reflect on the guidelines provided above and on your practice. Well currently there is not kidney transplantation in my country but I would like to ensure that the patients are properly screen and studied to ensure all pathologies are diagnosed and treated base on the international guidelines.
Shereen Yousef
2 years ago
◇Summary of the article
This article discusses the incidence of DM post kidney donation
Diabetes mellitus is the leading cause of end-stage renal disease, T2DM has a strong genetic component and 30% iv its patients mostly develop kidney disease.
some transplant centers decline kidney donors with a strong family history of type 2 diabetes.
This study was done to compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI)-matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR when compared to nondiabetic donors.
2929 responders were included , 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM,
Donors with diabetes
-For the 154 donors who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation.
-the majority were white and 47% donated to a sibling or other family member
-20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
-Of the 154 diabetic donors, 71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; almost at the same time they were told they have diabetes.
-Serum creatinine was available in 126 of the diabetic donors and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes.
-29 donors (18.8%) were told they have proteinuria.
-it was found that donors who developed T2DM had an increased prevalence of hypertension and were also more likely to be proteinuric .
-the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease
▪︎Longitudinal eGFR change
Of the 154 donors who developed diabetes
The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2 .
The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year .
To strengthen this analysis, we matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year.
-For diabetic donors pre- and postdiabetes eGFR slopes. Prior to development of T2DM, it was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and after developing the condition it was −1.10 ± 5.6 mL/min/year (range −10.8–7.3).
-Silveiro et al found that microalbumiuria
was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
-Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
-Chang et al.found no difference between the mesangial matrix volume; in subjects with one kidney type 1 diabetes who received renal transplants compared to those with two kidneys
data suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
-Diabetic donors, however, are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls but this frequency of hypertension is, similar to type 2 individuals with two kidneys.
observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself.
*Limitations of the study
-longer follow-up is needed as it takes an average of 10 years from the diagnosis of type 2 diabetes for 25% of subjects with diabetes to develop microalbuminuri amedian time before progressing to macroalbuminuria is 11 years and the median time before progressing to nephropathy is 10 years.
-The cause of death was missing in 40% of all donors.
-true incidence of diabetes could not be precisely determined.
-limited by survival bias and by response bias.
-could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation.
The study is case contol level of evidence III
In my practice we ask for fasting, 2 hours post prandual blood Glucose and HBA1C diabetic donors are declined ,
Prediabetics are asked to controll weight ,smoking and other risk factors and counseled about the potential risk after donation
Abdul Rahim Khan
2 years ago
Please summarise this article in your own words
Kidney donors are at risk of developing Type 2 diabetes as general population. The course of donors who develop diabetes has not been studied. In this study 3777 donors were surveyed regarding development of diabetes. 2954 responded.
In this study following variables were assessed.
Frequency of development of diabetes
Risk factors of developing diabetes
Comparing those who develop diabetes with matched non donors (Regarding proteinuria, hypertension and creatinine)
Evaluate consensus of excluding donors with strong family history of diabetes mellitus.
Results-
154 Developed type 2 diabetes 17.7+-9.0 years post donation
Risk of development of Diabetes included male gender, time duration post donation, BMI>30. smoking, Type 1 diabetes in recipient.
Risk of development of hypertension was almost twice than non diabetics (70.8% vs. 36.2%)
Proteinuria -18.8% vs. 3.9%, but had similar serum creatinine
Conclusion
Factors associated with T2DM in kidney donors are similar to those in the general population
Donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Albuminuria is more in those who develop diabetes as compared to non diabetic donors
Kidney donors with strong family history should be advised for strict weight control
Kidney donation does not contribute to added risk of development of diabetes.
What is the level of evidence provided by this article?
Cross sectional study Level 1V
Please reflect on the guidelines provided above and on your practice.
In my practice we use fasting and post prandial sugars and HbA1C.
Pre diabetics are advised lifestyle changes and reassessed later
Diabetic donors to be excluded
Amit Sharma
2 years ago
Please summarise this article in your own words
The study assessed risk of developing type 2 diabetes mellitus in donors, the comparison of renal function, proteinuria, and blood pressure in such donors with age-, denger-, BMI- and duration after donation-matched donors who did not develop diabetes post-donation and whether such donors have increased risk of faster decline in GFR.
The study was done by conducting a survey of the donors asking them regarding diabetes mellitus, hypertension and proteinuria.
154 out of 2954 (5%) developed type 2 diabetes mellitus with a mean of 17.7 years after donation, which was like the incidence in general population. Risk factors for developing DM included donating to a family member with type 1 DM, males, age more than 45 years, and BMI more than 30. There was no relation with smoking or serum creatinine at donation.
71% of the donors who developed diabetes had hypertension (2 times of the non-diabetics, but similar to diabetics with 2 kidneys) and 18.8% developed proteinuria (4.5 times more than the non-diabetics, but similar to diabetic patients with 2 kidneys) while the serum creatinine was similar to non-diabetics. 20% of the diabetic donors had family history of DM. The rate of eGFR change in the diabetic donors and matched non-diabetic donors was similar. The difference in the pre- and post-diabetic eGFR slopes in the diabetic donors was not significant.
The limitations of the study include: non-availability of cause of death of 40% of the donors; survival bias and response bias; the donors were screened at time of donation, hence they are a selected subgroup of the population; role of ethnicity not assessed as the population mainly consisted of whites; family history of diabetes was not captured; Proteinuria was self-reported.
So, risk factors for development of diabetes in renal donors are similar to those in general population. Diabetic donors have increased hypertension and proteinuria than non-diabetic donors, but the frequencies are similar to diabetics with 2 kidneys. It implies that these higher prevalences are unrelated to the act of donation and are more due to the diabetes itself.
What is the level of evidence provided by this article?
Level of evidence: Level 3 – Case-control study.
Please reflect on the guidelines provided above and on your practice.
We perform an HbA1C and Fasting blood sugar with post-prandial blood sugar in all our prospective living donors. In cases with abnormal readings, we perform OGTT before going any further in donor evaluation
Wael Jebur
2 years ago
As diabetes mellitus DM is a prevalent disease in the community, this study tried to assess the impact of DM on the renal function in kidney donors, as the potential hyperfiltration inflict of DM is theoretically fortified by reduced nephron mass and compensatory nephronal hyperfiltration. Based on this assumption, most of the transplant centers strongly advocate against kidney donation from relatives of DM, especially 2 parents, or more than one sibling.
To verify whether Diabetic kidney donors are increasingly prone to complication of DM that they attracted post donation, in particular, proteinuria. renal failure and hypertension. all diabetic donors were surveyed in comparison to non donor diabetics and non diabetic donors.
Between 1963 and 2009, more than 3000 nephrectomies where done.
154 donors reported to have type 2 DM. The result showcased seemingly common risk factors for developing T2DM with the non-donor’s population with matched risk factors of age, BMI. Nevertheless, the rate of albuminuria was earlier in donor diabetic DD, however GFR changes were comparable between DD and non-DD, concluding that, the donation dose not negatively impact the incidence or course of T2DM in DD. Henceforth, loosening the stringent criteria to involve Donors with family history of DD is advocated.
This study was case control study with level of evidence 3.
In our practice donors with normal blood sugar, fasting, post prandial and HbA1c are considered suitable even if he is of a strong family history of diabetes Mellitus.
Ramy Elshahat
2 years ago
Diabetes after Kidney Donation
Am J Transplant. 2010 February
This is a cross-sectional (prevalence) study (level of evidence III) in which 3825(2954 responded) renal donations are done in the University of Minnesota between Jan 1, 1963- March 31 2009 screened regarding the prevalence of type 2 DM, evaluation of its risk factors and comparing diabetic donors after donation to matched non-diabetic donor as controls regarding creatinine, proteinuria, and hypertension. Results:
The prevalence of type 2 DM post kidney donation is 5%,17.7 ± 9.0 years after donation which similar to the incidence of DM2 in the general population
Risk factors: for development of DM2 including obesity (BMI>30 kg/m2), male sex, and smoking.
HTN: 2 times more frequent in donors who developed diabetes post donation when compared to donors who didn’t develop diabetes, with the same frequency in diabetic patients with 2 kidneys.
Proteinuria: 5 times more frequent in donors who developed diabetes post donation compared to donors who didn’t develop diabetes post donation with the same frequency in the diabetic patient with 2 kidneys.
Creatinine and eGFR decline not fastened in diabetic donors when compared to non-diabetic donors & 2 kidneys with diabetes.
Conclusion
The prevalence of type 2 DM in kidney donors after the donation is the same prevalence in the general population, and if DM develop donor are exposed to a 2fold risk of developing hypertension and 5 folds the risk of developing proteinuria but eGFR is stable with no difference in relation to the donor who didn’t develop diabetes post-donation, so kidney donation as per this study (level of evidence III) is not associated with any added risk regarding development and complication of DM2
Please reflect on the guidelines provided above and on your practice.
In our center’s experience regarding DM screening in potential donors, we used to do FBG,2HPP, and HBA1c for screening.
For donors with risk factors for developing DM post-donation, we try to control before donation like weight reduction and smoking cessation
Finally, we used to counsel patients before donation about the risk of developing DM post-transplant, especially with +ve family history but we do not reject them
Mohamed Saad
2 years ago
Diabetes after Kidney Donation .
Introduction:
Type I and II DM is considered one of the most common cause of ESRD worldwide, risk of developing DM post kidney donation will be reported here, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched nondiabetic donors and assess whether diabetic donors are liable to a faster decay in GFR when compared to nondiabetic donors. Materials and Methods.
The University of Minnesota surveyed 3777 kidney donors regarding the development of T2DM by contact them and asked if there have DM, duration of diagnosis, on medications or diet control, proteinuria development, HTN developed or not, with medications or not. Results
2929 have responded to the survey, 154 donors reported developing T2DM 17.7 ± 9.0 years after donation,129 from the 2929 currently alive donors, 17 of 293 deceased donors, only two donors were listed to have died of diabetes-related complications and11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
The risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Diabetic donors were more likely to have hypertension, proteinuria but had a similar serum creatinine. eGFR change after T2DM development comparing to non-diabetics donors with similar duration after donation. Donors with diabetes.
For the 154 donors who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation, 154 diabetic donors, 71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; almost at the same time they were told they have diabetes.
Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age. Summary:
The risk for the development of T2DM in kidney donors is similar to the general population.
Donors who develop DM have rates of albuminuria that are higher than nondiabetic donors.
Risk factors for developing type II DM
1.Donating to a family member with type 1 diabetes
2.BMI greater than 30.
3.Male gender
4.Donors over the age 45 years old.
Diabetics and nondiabetics donors had a similar serum creatinine. What is the level of evidence provided by this article?
Level 3 B (retrospective cohort study). Please reflect on the guidelines provided above and on your practice.
We should be more caution in selection our kidney donors with strong family history of DM, old age, obesity with BMI>30.
We should keep our patients with these criteria to be strictly observation.
More large studies with long term follow up are needed to more clarification of this point.
Muntasir Mohammed
2 years ago
Introduction
Diabetes mellitus is number one cause of ESRD worldwide. Its prevalence increases with the increase of obesity. T2DM had a genetic predisposition, and since it could cause ESRD, potential kidney donors with strong family history of DM could be excluded from donation. Aim of the study:
To assess whether post donation development of DM is associated with increased risk of acceleration of eGFR decline when compared to non-diabetic donors or not.
Materials & methods:
Between Jan 1st 1963- March 31st 2009, 3825 renal donation done in the University of Minnesota. Attempts to contact the donor in the last 3 decades to confirm health status, & in last 7 years comprehensive multistep approach used to locate all donors, those who were a life with available contact information were sent survey regarding T2DM development.
The survey included the following questions: 1. Were you ever told you have diabetes? If you answered yes, please answer the following questions: a. How old were you when you were diagnosed with diabetes? b. Are you currently taking insulin, a pill to lower your blood sugar (glucose) or both? c. Are you controlling your blood sugars by diet only? 2. Do you have hypertension (high blood pressure)? If yes, are you taking medications
to lower your blood pressure and when did you start taking them? 3. Were you ever told you have protein in the urine? When?
Donors with 2 diabetic parents, multiple siblings with T2DM in addition to 1 parent with T2DM or >1 immediate family member with type 2 diabetic kidney disease are excluded from donation especially if they are of African American or Hispanic descend.
eGFR (MDRD) done for all donor with comparison to the matched nondiabetic donor (age, BMI, gender & years from donation).
Results & discussion:
Of the 3777 who responded to the survey, 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys In total, 154 donors reported
developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors
with available information prior to death and 8 of the 555 donors with no recent health
updates reported having T2DM, as well. Risk factors for diabetes development were: 1. Donating to a family member with type 1 diabetes; HR 2.97. 2. BMI greater than 30; HR 2.97. 3. Male gender; HR 1.76. 4. Donors over the age of 45 were slightly more likely to develop diabetes; HR 1.46
• Micro-albuminuria was higher in single diabetic kidney (40%) than single non diabetic kidney(18%) & 2 diabetic kidney(20%).
• Macro-albuminuria was higher in single diabetic kidney (30%) than single non diabetic kidney but comparable to 2 diabetic kidneys.
• No difference in prevalence risk factors of T2DM in kidney donor than general population.
• Smoker is not a strong risk factor for T2DM which may be due to clustering of other habits in smokers.
• Prevalence of albuminuria & hypertension was similar in diabetic donor & diabetic patient with 2 kidneys, but hypertension risk was more when compared to matched non diabetic donors.
• eGFR decline was not faster in diabetic donor when compared to non diabetic donor & 2 kidney with diabetes. Limitations:
· Follow-up done just for first decade after development of diabetes.
· Missing of death cause in 40% of donors.
· Survival bias.
· Inability to assess the role of ethnicity in diabetes development( most donors were white).
· Self-report & dipstick protein assessment
1. What is the level of evidence provided by this article? Level 3, case control study. 2. Please reflect on the guidelines provided above and on your practice.
In our centre we screen all potential donors with FBS, HB A1c. Donors with family history of DM or obese we do OGTT.
saja Mohammed
2 years ago
Introduction
Diabetes mellitus is the common cause of ESRD worldwide and its prevalence increases with the increased rate of obesity, around 30% of patients with Type2DM have a genetic susceptibility to CKD and in some centers, they don’t accept a donation from those with a strong family history of DM due to the additional risk of hyperfiltration with nephrectomy. Kidney donors are at risk of DM like the general population, however, still, we don’t know if the diabetic donor compared to non-diabetic donors’ aim of this study is to address the long-term consequences of the donation including the risk of DM. Material and setting
A single-center study reviews the donors from 1963-2009 from the University of Minnesota, they included > 3825 donors whose nephrectomies, they don’t exclude donors with Positive FH of T2DM, and all donors were contacted and assessed their health status and FU them over 7 years by full multistep style included reviewing their medical records, phone call, and internets connection or through the recipients, also send them to survey about the type2 DM development after kidney donation of three questionnaires ( if you have been told that you have DM at which age after donation are you on treatment ( insulin, pills, or both are under control with diet, any associated hypertension if yes are you under control with medications and when did you start? And Proteinuria.
for determination of e GFR by MDRD formula, and annual change in was calculated and compared between the two groups, proteinuria screen, and blood pressure all matched by 1-1 between the two groups to age and sex. Time form donation by years, BMI at time of donation
all donor and nondiabetic control groups are white populations Results In this study, they top diabetes information on 2945out of 3777 donors (2929 + 17 deceased + 8 with no recent contact)
IN 40% of the donors the cause of death was unknown, CVD in 19%, and cancer in 20%, while from diabetic patients only two only
11% progress to ESRD and none have DM
154 donors developed DM with an average age of 39 + The mean time for donation till the development of DM is 17+/-9 years
71% OF diabetic donors were found to be hypertensive, while only 18.8 % reported having proteinuria
Donors with DM are smokers with BMI > 30s and they have higher baseline creatinine, more than 80% of nondiabetic donors, donate prior to 2002 when the high-risk donor should be tested with OGTT. Risk factors for DM 1. donation to a family member with a T1DM with HR2.9(95%CI 1.9-4.5) and in lower range donation to a Family member with T2DM.
2. BMI>30
3. Male gender
4. donor aged above 45 years
The diabetic donors tend to be more hypertensive 71% vs 34% compared to non-diabetic control and more proteinuria 18.8 vs 3.4 % after adjustment to the age, sex, BMI, and duration of the donation
Longitudinal change in GFR over the FU period is more in DM however did not reach statistical significance. Discussion
After donor nephrectomy, the GFR will increase due to increased renal plasma flow, up to 70% after the first-week post-donation, so both reduced renal mass and occurrence of DM will have an additive hyperfiltration effect and increased GFR but on long-term fU, this can contribute to progressive CKD
This study suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population. smoking did not show statistical significance as risk factor for DM post-donation (small sample size) Limitation of the study
They include only the white population, exclusion of another ethnicity may affect the results, especially for black ethnicity
Missing data about the FH of DM in nondiabetic donor
Cause of death missing in 40% of the donors
Proteinuria records by self-reporting and by UDS analysis can be misleading and few patients have quantitative urine a/c ratio
Survival bias (Missing data about the DM in the majority of donors who died)
Response bias
Underestimation of the presence of DM, and HTN in the general population
Short follow up
The level of evidence provided by this article?
retrospective cohort with the control group, level 3B
Please reflect on the guidelines provided above and on your practice.
Being practicing in the gulf area with a higher rate of DM and DKD which is the leading cause of ESRD in Oman around 66% of patients on dialysis due to DKD so excluding donor with DM and those with impaired fasting will do OGTT IF impaired GTT also we exclude them, metabolic syndrome with high HBAIC , fatty live hyperuricemia and BMI> 30 we decline them for donation.
KAMAL YOUSIF ELGORASHI ADAM
2 years ago
The kidney donor have the same risk as general population of having diabetes , the risk factors ; as obesity , male gender, age, and body mass index >30 .
In survey done in Menissota university by medicine and surgery department , they found that among 2954 donor , 154 develop t2 DM after 17.7 +-9 yrs after donation.
Diabetic donor have more incidence rate of developing HTN (70.8 vs 36.2) P<0.005, and proteinurea (18.8 vs 3.9%) P <0.0001. with similar s.cr. eGFR change was -0.80+-0.94 in diabetic vs -0.70+-0.86 in non-diabetic donors, so this short term survey noted that factor associated with T2DM in kidney donors, is same as for general population .
Survey done have no exclusion criteria, from 3777 , 2929 share in the survey .
The rsult of the survey was; 293 died, 555 no feed back during the last 4 yrs, 154 develop T2 DM.
T2 DM donors post transplant have previuos risk factor thann non diabetic ( smoking, BMI> 30 , and their s.cr was slightly higher pre donation ., also notced that 80% of donors undewent donation before 2002, when GTT is moadatory for high risk donors.
Charecteristic of diabetic, non-diabetic, and non-responder;-
diabetics: No, 154, whie; 50%, women;49.4% Duration of follow up 24.4+-8.4 Age at dination; 18-45 yrs (68.2%) History of smoking 54.6& S.Cr at donation 0.95+-0.19 BMI at donation >30% 25.3% Type 1 DM in recipient ; 22.1%
non diabetics; No. 2914, white; 97%, women; 56.75 Duration; 14.0+-11.1yrs Age at duration; 18-45 yrs (67%) History of smoking 38.8% Serum Cr at donation; 0.9 +-18 MBI at donation; 17.2% T1 DM in recipient; 23.7%
Risk factors for development of T2 DM;
variables at donation HR;
Unadjusted group;
MBI >30 T1 DM in rcipient 3.07
T2 DM in recipient 2.46
Men 1.35
Donor age > 45 yrs 1.53
S.Cr 0.95
Smoking 1.22
Adjusted group;
BMI; 2.9
T1 DM 2.27
T2Dm 3.07
Men 1.76
Donor age >45 1.46
S.Cr 0.79
Smoking 1.22
Level of eidence ((3)).
Reflection of guidelines on local practice;
Diabetic patient with risk factor such as uncontrolled, obses, with microvascular complication e.g micro albuminurea , are always excluded from donation .
Heba Wagdy
2 years ago
DM is one of the commonest causes of ESKD, 30% of patients with T2DM may develop renal impairment, so potential donors with strong family history of T2DM may be excluded for fear of GFR decline after donation as donor nephrectomy induce hyperfiltration leading to increased GFR, the compensatory increase in GFR in presence of reduced renal mass and DM may accelerate the deterioration of diabetic kidney disease.
The concern is raised about adverse effect of hyperfiltration after donation and hyperfiltration due to DM.
This study aims to determine the risk of development of T2DM in kidney donors and to compare rate of kidney function decline in diabetic donors and matched non diabetic donors.
It included 3825 kidney donors who had nephrectomy between 1963 and 2009.
Potential donors with family history of T2DM were accepted if their age at time of assessment was 10 years beyond the age at which parent developed T2DM, those with >1 immediate family member with DKD are discouraged from donation.
Potential donors with BMI >35 are advised to lose weight and to donate when BMI <30. The study showed that:
prevalence and risk factors for T2DM after kidney donation are similar to that in general population.
Smoking was more prevalent in diabetic donors but was not a significant risk factor for T2DM unlike previous studies, this may be due to small number of donor included and clustering of other habits in smokers that were not included in the survey.
Diabetic donors in the first decade of DM have the same degree of albuminuria and hyperfiltration as in T2DM patients with 2 kidneys.
Diabetic donors are more likely to be hypertensive than matched nondiabetic donor controls.
Frequency of HTN in diabetic donors was similar to that in T2DM with 2 kidneys.
The prevalence of proteinuria was higher than usual rates in nondiabetic kidney donors but was similar to patients with T2DM with 2 kidneys, the increased proteinuria wasn’t related to donation but to the renal affection by DM and HTN.
The rate of GFR decline in diabetic donors was similar to that in both nondiabetic donors and diabetic patients with HTN and microalbuminuria.
T2DM developed within 17.7+/- 9years after donation.
Limitations:
Short term follow up of diabetic donors
The cause of death was missing in 40% of donors, missing information may lead to survival bias.
Presence of response bias about DM and HTN as patients with DM or HTN may be unaware of their presence.
Only included white donors.
Small proportion of donors had quantified method for assessment of proteinuria, majority was assessed. Conclusion:
Exclusion of potential donors due to presence of positive family history of T2DM and negative oral glucose tolerance test is not justified but further studies with longer follow up are still needed
All kidney donors especially with positive family history for DM should be advised to keep weight control.
Level of evidence: 3 Case control study
In our practice, potential donors with impaired oral glucose tolerance test are excluded.
Mohammad Alshaikh
2 years ago
Please summarise this article in your own words
The study try to figure out the risk for diabetes occurrence among donors, conducted by University of Minnesota, from January,1, 1963 -nMarch 31, 2009, cohort case control study, using a questionnaire.
They found no increased risk of having diabetes in donors, whom experienced diabetes were smokers , having a BMI >30, and the serum creatinine at the time of donation was higher than non diabetic donors.
risk factors for diabetes according to study was:
Donating to a family member with type 1 diabetes.
BMI >30.
Males.
Age at donation > 45 year old.
The mean time to have diabetes after donation was 17.7 -/+9 years, 71% of diabetic patients found to have HTN requiring treatment.
The eGFR decline was comparable in diabetic and non diabetic donors.
Microalbuminuria was higher single kidney diabetic(40%), than single kidney no diabetic(18%), or two kidney diabetic(20%), it takes 19 years to occur.
Macroalbuminuria was the same in single kidney diabetic and non diabetic(30%), and lesser in two kidney diabetic(23%). it takes 11 years to occur and 10 years to progrees to nephropathy.
There was higher prevalence of smoking among diabetic donors, but not of clinical significance.
Measurement of OGTT in donors, with family history of diabetes is justified to refuse donation!.
Conclusion:
The incidence of diabetes post kidney donation was not different among donors and non donors.
Diabetic donor is not at higher risk to progress to nephropathy and end stage renal disease.
Kidney donors with strong family history for diabetes, should not smoke and maintain a normal weight.
What is the level of evidence provided by this article? Level of evidence is III b case control cohort study.
Please reflect on the guidelines provided above and on your practice.
In our practice we perform twice FBS and Hba1c in the evaluation of patients and ask about the clinical signs of diabetes.
If FBS >126 mg/dl in two occasions, or HbA1c > 5.8% we consider OGTT.
usually we decline the donor if he has an impaired glucose tolerence.
Ibrahim Omar
2 years ago
Please summarise this article in your own words :
T2DM has a strong genetic component. 30 % of diabetic patients develop kidney disease.
this study was for evaluation of the risk of T2DM in living kidney donors, compared with matched living non-donors. It also compared kidney functions in diabetic donors versus matched non-donors.
the survey included 3777 living kidney donors who donated their kidneys many years ago.
the results were as following :
1- 293 of donors were died. the cause of death was unknown in 40% of them, cardio-vascular causes accounted to 19% and cancer causes accounted to 20% of their mortality. diabetic complications accounted to only 2 % of mortality.
2- 555 of donors were not responding to the survey questionnaire.
3- there were remaining 2929 who responded to the questionnaire.
4- 154 donors developed T2DM over a post-donation period of 17.7+/-9 years. 129 of them were out of the 2929 donors,17 of them were out of the 293 dead donors and 8 of them were out of the 555 non-responding donors with no recent contact.
5- hypertension was developed in 70.8% of donors versus 36.2% of non-donors.
6- proteinuria was developed in 18.8 % of donors versus 3.9 of non-donors.
7- serum creatinine was not changed between donors and non-donors.
the conclusion was as following :
1- the risk and associated factors of T2DM development in kidney donors are similar to these of the general population.
2- living kidney donors who were screened carefully at the time of donation have no acceleration of diabetic kidney disease in the first decade post-donation. therefore, declining donors with +ve family history of T2DM may not be fully justified. however, all donors should be advised to maintain their ideal body weight.
3- larger and longer studies are still needed for more evaluation.
What is the level of evidence provided by this article?
this is a retrospective cohort study.
level of evidence is III
Please reflect on the guidelines provided above and on your practice.
as there is no added risk of kidney donation on development of T2DM, I will fully explain this to candidate donors to help to freely donate without such fears.
even in those with family history of T2DM, they can donate with no extra risks. however, they should maintain healthy lifestyle and diet habits for proper functioning of both pancreas and kidney.
Assafi Mohammed
2 years ago
Diabetes after Kidney Donation Summary
This retrospective study analyzed KT donors with perspective to T2DM in the period from 1963 to 2007 at the university of Minnesota.
1. No policy that excludes donors with family history of T2DM.
2. Potential donors with multiple siblings having T2DM in addition to diabetic parent or one immediate family member are strongly discouraged from donation.
3. All potential donors have a normal GTT which was performed in the followings:
i. more than one immediate family member with T2DM.
ii. women with history of gestational diabetes.
iii. those with fasting blood sugar ≥99 mg/dL.
4. Accepted BMI is less than 30 kg/m2. Risk factors for diabetes in LKDT:
1. Family member with type 1 diabetes.
2. Family member with type T2DM (to a lesser extent, but not statistically significant).
3. A BMI greater than 30.
4. Male gender.
5. Donor age > 45 y.
6. Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM. Study Conclusion:
1. The risk factors for the development of T2DM in kidney donors is similar to the general population.
2. Donors who develop it have rates of albuminuria that are higher than nondiabetic donors.
3. Diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Suggestions by the study’s group:
1. Declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
2. Potential donors with FH of DM should be strongly advised to maintain weight control.
The level of evidence provided by this article: level III
Please reflect on the guidelines provided above and on your practice.
We don’t exclude potential donor with positive FH od DM unless having impaired an abnormal blood sugar level( fasting blood sugar or GTT).
Wadia Elhardallo
2 years ago
Observational study aimed to address possible risk factors of diabetes in kidney donors, and thereafter check the influence of diabetes in development of other complications (hypertension, proteinuria, the rate of eGFR change/decline in renal function) compared to matched non diabetic donors.
Single centre study was conducted Between January 1963 and March 2009, at the University of Minnesota. 3825 donor nephrectomies were performed * exclude patients also donated a partial pancreas: remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded. In total, 154 donors reported developing T2DM.
Risk factors for diabetes include:
1. BMI>30; HR2.97 (95% CI 1.93–4.56), p<0.001
2. male gender; HR 1.76 (95% CI 1.12–2.76),
3. family member with type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07, were associated with the future risk of developing T2DM
4. Donors who were over the age of 45 were slightly more likely to develop diabetes; HR 1.46 (95% CI 0.97–2.19), p = 0.07
* serum creatinine and smoking status at donation not predictive of the future risk of T2DM.
For the 154 donors who developed diabetes, mean age (±SD) at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation. the majority were white and 47% donated to a sibling or other family member. The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM.
Then for the determination of the prevalence of hypertension, eGFR and proteinuria, diabetic donors were matched (1:1) on age, gender, years from donation and BMI at donation to donors who did not develop diabetes. All diabetic and nondiabetic controls were white.diabetic donors were more likely to have hypertension
(70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine.
In a matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year (eGFR change after T2DM development was -0.80 ± 0.94 mL/min/year, -0.70 ± 0.86 in nondiabetic donors with similar duration after donation and -0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls)
What is the level of evidence provided by this article?
Observational, Case control study (retrospective controlled), level 3
Please reflect on the guidelines provided above and on your practice.
Practice: All potential donor assessed in details clinically (history, examination, lab) for diabetes
impact: carefully address possible risk factors: BMI, family history of diabetes specially in older male
may retrieve data of previous donors already at risk: follow up more frequent for possibility of diabetes
Abdulrahman Ishag
2 years ago
The aim o the study ;
The prevalence and risk factors for T2DM in kidney donors.
The type of the study;
Case control study .
The study area ;
The University of Minnesota.
Ethical approval ;
approval by the University of Minnesota Institutional Review Board.
Population;
The study surveyed 3777 kidney donors regarding the development of T2DM.
Inclusion criteria ;
Alive donors and with available contact information.
The method ;
A comprehensive multi step approach to locate all kidney donors (including review of medical records, utilizing phone and internet directories and also the help of the recipients). The included donors were sent a survey regarding development of T2DM after donation.
Statistical method;
1-Categorical variables were compared using the chi-square or Fisher’s exact test. Continuous variables were compared utilizing the unpaired t-test.
2-A Cox proportional hazard model was used to study the predictors for the development of type 2 diabetes, utilizing variables ascertained at the time of donation.
3-All other results are expressed as mean ± SD, unless otherwise specified. p < 0.05 was considered significant. SAS 9.1 (SAS Institute Inc., Cary, NC) was used for all analyses.
Results;
The prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
There study limitations ;
1-The cause of death was missing in 40% of all donors.
2 -The population of the study consisted of mainly white kidney donors and therefore we could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation.
3- The information on family history of type 2 DM in non diabetic donors was not captured.
4- Reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria.
2-What is the level of evidence provided by this article?
Level III.
3-Please reflect on the guidelines provided above and on your practice.
1- All potential donors should be screened for diabetes and categorized according to their risks for developing diabetes in the future .
2-All potential donors should be screened for diabetes or IFG using an OGTT.
3-Those,who have diabetes ,(IFG/IGT and family history of diabetes ) should be excluded from donation .
4- Life style modification before and post donation for donors .
5-Post donation screening for diabetes should be based on the pre donation risk assessment and follow the standard guidelines of general population .
6- This information help in counseling potential donors .
Hussein Bagha baghahussein@yahoo.com
2 years ago
Summary
This is a case control study looking at the incidence of diabetes post kidney donation. It was a retrospective survey that looked at 2 outcomes:
Donors risk of developing T2DM
Compare kidney function in diabetic donors to that of age, gender, duration after donation and BMI – matched non-diabetic donors and whether diabetic donors are vulnerable to a faster decay in in GFR compared to non-diabetic donors. All the records donors who donated a kidney between the period of January 1963 to March 2009 were looked. The donors were traced and those that could be contacted were asked questions regarding the development of diabetes, hypertension and proteinuria. This already introduces a recall bias.
They had data for 3777 kidney donors out of which 2954 responded. 154 donors developed diabetes after donation – 129 were currently alive and 17 had died.
Of the 154 donors who developed diabetes after donation, the mean age at the time of donation was 39.8 years and the diagnosis of diabetes occurred 17.7 years after donation.
Compared to the non-diabetic donors matched for age, gender, duration post-donation and BMI, diabetic donors were more likely to have hypertension (70.8% versus 36.2%, p=0.005), and proteinuria (18.8% vs 3.9%, p< 0.0001) but had similar GFR decay.
The risk factors for the development of T2DM included:
T1DM in the recipient
Male gender
BMI > 30 kg/m2
The authors concluded that the risk of developing T2DM post-donation was similar to that of general population and the decline in GFR was similar to the non-diabetic donors,
The limitations of these study:
Unavailable data – cause of death in 40% of donors was not known
Survival bias
Recall bias
Majority of the donors were Caucasian
Level of Evidence
It is level III as this is a case control study
In my practice we take a detailed history of the potential donor. All potential donors are screened for diabetes or IFG using an OGTT. If the potential donor has IFG/IGT and a family h/o diabetes then he /she is excluded from being a donor and counselled on lifestyle and diet and followed up in the diabetic clinic. If there is no family h/o diabetes and the potential donor is obese, he/she is advised on lifestyle and diet and weight loss
Manal Malik
2 years ago
Summary of Diabetes after Kidney DonationDM is the major cause of ESRD .
T2DM has strong genetic component and 30% of these affect with it develop kidney damage.
METHOD AND MATERIAL
Between jan/ 1963 to 3/2009 3825 donor nephrectomies done at university of MINNESTRA ,all these donor available for more information.
there are 2 group to evaluate eGFR change in these diabetics donors :
1- 522 non diabetics donors who also had multiple serum creatinine available.
2-56 non DM donors matched an age ,gender,BMI and duration after donation who had multiple creatinine measurement available .
RESULT
In total 154 donors reported developing T2DM
129 from alive donor.
two donors were listed to have died of DM related complication .
11donors develop ESRD requiring dialysis or transplantation.
Risk factors for SM :
BMI >30 .
male Gender .
Age >45 y.
Fmily history of type1DM .
but neither smoking nor serum creatinine were predictive of the future risk of T2DM.
Discussion:
In case series of DM patients with either unilateral agenesis or unilateral nephrectomy,none suffered accelerated kidney function in the remaining kidney .
Microalbuminurea was noted in ahigher proptipon of single kidney DM than non-DM but both have normal kidney function
type1 DM associtted factor for the development of T2dm in the donor and marginal nonstatistical association with type 2 DM in the recipient .
summary:
The risk factors for the T2DM in kideny donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than non diabetics donors,which may be suggestive of early diabetic kidney disease,there is accerlated risk of kidny disease in DM donors.
Donor with impaired GTT and postive family history for DM should be declined.
2- level of evidence 111
3- in our practize donor with postive family history are not excluded
but donor with impaired GTT and DM are excluded from donation.
Hadeel Badawi
2 years ago
Diabetes mellitus is the leading cause of ESRD and has a strong genetic component, and some transplant centers preclude donors with a family history of diabetes. The course of donors who develop T2DM has not been studied well.
Aim of the study: – Report on the donors’ risk of developing T2DM. – Compare kidney function in diabetic donors to matched nondiabetic donors – Assess the decline in GFR when comparing diabetic to nondiabetic donors.
Materials and Methods – Reviewing kidney donation at the University of Minnesota Between January 1, 1963, and March 31, 2009. – Surveyed 3777 kidney donors regarding the development of T2DM post-donation. – 293 have died, 555 lost follow-up in the last 4 years, and 2929 have responded to the surveys – Diabetic donors were matched (1:1) on age, gender, years from donation and BMI at donation to donors who did not develop diabetes. – All diabetic and nondiabetic controls were white.
Results:
Diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact)
Of 2954 who responded, 154 developed T2DM 17.7 +- 9.0 years after donation
Donors with diabetes were more likely to be smokers, have a BMI greater than 30, and have slightly higher serum creatinine at the time of donation compared to their non-diabetic counterparts.
Risk factors for diabetes development (at time of donation); donating to a family member with T1DM, a lesser extent T2DM, BMI greater than 30, male gender, and age of over 45.
Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM, possibly due to the small number of donors studied
The diabetic donors had an increased prevalence of HTN (71% vs. 36.3%) and were also more likely to be proteinuric 18.8%.
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys
The frequency of hypertension in diabetic donors is twice nondiabetic donors; however, it is similar to type 2 individuals with two kidneys.
The rate of GFR decline is not accelerated when compared to nondiabetic donors ( 0.8ml/min vs 0.7 ml/min) and is similar to the rate observed in two kidney diabetic subjects with hypertension and microalbuminuria. Comparing pre- and post-diabetes eGFR slopes, it was not statistically significant.
Silveiro et al.
Studied T2DM with uni-nephrectomy (single-kidney diabetes), versus nondiabetics who had undergone uni-nephrectomy (single-kidney nondiabetic) and versus T2DM having 2 kidneys with similar renal function at the time of the study.
Microalbuminuria was noted in a higher proportion of single-kidney diabetics, followed by 2 kidneys diabetic compared to single-kidney nondiabetics. Macro-albuminuria was also higher in single-kidney diabetics with similar degrees in two-kidney diabetics.
Chang et al, showed no difference in histological findings in kidney biopsy of T1DM recipients compared with diabetics with 2 functioning kidneys.
Data from UKPDS indicate that it takes; – the median time with normoalbuminuria before progressing to microalbuminuria is 19 years – the median time with microalbuminuria before progressing to macroalbuminuria is 11 years. – and the median time with macroalbuminuria before progressing to nephropathy is 10 years
limitations.
– The cause of death was missing in 40% of all donors.
– The true incidence of diabetes could not be precisely determined.
– Survival bias (missing information about T2DM in most donors who have passed away.
– Response bias to the survey, information self-reported
– Study included only white donors, so generalizability to other ethnicity is difficult.
In conclusion, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
What is the level of evidence provided by this article?
Retrospective case-control study level III.
Please reflect on the guidelines provided above and on your practice.
– Screen with GTT to all potential donors. – If GTT is impaired and the potential donor has a family history of diabetes, to be excluded. – If GTT is impaired and no FHx of DM, they need to control their weight and be re-evaluated.
Rihab Elidrisi
2 years ago
This is a cross sectional study (level of evidence III) evaluating 2954 kidney donors regarding the frequency of development of type 2 DM, with assessment of risk factors associated with the development of this disease, and comparing those who develop DM to matched non-diabetic donor controls regarding creatinine, proteiniuria and hypertension.
Also it evaluates a common consensus of excluding donors with strong family history of DM since the occurrence of 2 cause of hyper filtration (single kidney and DM) may theoretically harm the kidney.
Materials and Methods
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota. Attempts to contact the donor in the last 3 decade to confirm health status and in last 7 years comprehensive multistep approach used to locate all donors, those who were a life with available contact information were sent survey regarding T2DM development
The survey included the following questions:
1. Were you ever told you have diabetes? If you answered yes, please answer the
following questions:
a. How old were you when you were diagnosed with diabetes?
b. Are you currently taking insulin, a pill to lower your blood sugar (glucose)
or both?
c. Are you controlling your blood sugars by diet only?
2. Do you have hypertension (high blood pressure)? If yes, are you taking medications
to lower your blood pressure, and when did you start taking them?
3. Were you ever told you have protein in the urine? When?
To address whether the rate of eGFR change is accelerated in diabetic donors, they studied diabetic donors who had multiple serum creatinine measurements obtained after T2DM development and that were at least 1 year apart. eGFR change in these diabetic donors was compared to two groups:
1. Five hundred and twenty-two nondiabetic donors who also had multiple serum creatinines available in the same time frame the diabetic donors’ onset of T2DM (i.e. ≥15 years after donation).
2. Fifty-six nondiabetic donors matched on age, gender, BMI and duration after donation who also had multiple creatinine measurements available. This group is a subset of the 522 nondiabetic donors mentioned earlier.
Result:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, 48 also donated a partial pancreas and, therefore, were not included in the analyses. Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys (Figure 1). In total, 154 donors reported developing T2DM; 129 of 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well.
In our practice we declined donor with diabetes and even the one who is border line
Sahar elkharraz
2 years ago
Diabetes mellitus cause ESRD and there’s genetic cause & obesity contribute to develop T2DM. All patients with family history T2DM are declined for donation of kidney because risk of DM after donation and hyper-filtration effects on kidney due to compensatory factor and diabetic kidney lead to reduce renal mass.
This article focus on donor risk to develop T2DM and compare with kidney function in diabetic donor to age/ gender/ BMI and duration of donation.
This study done between January 1963 to March 2009 for all nephrectomy were performed at university of minnesota.
Survey done with detailed history regarding DM / age/ race of patients and duration of DM, medication and controlling of DM.
History of hypertension and medication; history of micro albuminuria.
Family history of T2DM. All donated with family history of DM has normal glucose tolerance test / women with history of gestational DM & blood sugar > 99 mg/dl should underwent GTT. Donor with BMI > 35 kg/m2 should maintain body weight less than 30kg/m2.
Serial S. Cr and protein creatinine ratio and measurement of eGFR by MDRD study equation.
Risk factors of DM:
Age > 45, family history of DM + BMI > 30. smoking history and slightly increase of s. Cr not contribute to develop of T2DM.
This study shows mean age at time of donation 39.8 years and diagnosis of DM occur after 17.7 years post donation. Majority are white donated to siblings or family members.
Cause of ESRD in recipient T1DM 33% / hypertension 35% / T2DM 10% / ADPKD 5% / positive family history of T2DM and HBA1C between 8-7.8.
In this study 71% diabetic donor develops hypertension and requires treatment 17.6 years post donation with target blood pressure 126/75 and S. Cr 1.2, eGFR 58.8 ml/min. 18% has proteinuria and PCR between 68-176 mg/dl. 75% normoalbuminuria and 20% micro albuminuria and 10% macro albuminuria.
Prevalence of hypertension increase with diabetic donor in comparison to non diabetic donor.
Uninephrectomy undergoing to compensatory matching with increase renal blood flow and GFR lead to compensatory hyper filtration with presence of DM and it’s effects on kidney and further hyper filtration lead progress kidney disease and reduce renal mass. So prevalence of micro albuminuria and macro albuminuria more in single diabetic kidney in comparison to single non diabetic kidney.
There’s high prevalence of smoking in donor who develop DM and smoking was not significant factor for T2DM. in this prospective cohort study shows 40% of smoking develop T2DM. but there’s lack of data to show associations between smoking and DM.
The observational study shows higher prevalence of proteinuria in diabetic donor is unrelated to donation itself but it may due to presence of underlying diabetic renal involvement and hypertension.
The mean time for donation to develop T2DM is 17 years.
UKPDS: there’s average 10 years of diabetic donor to develop micro albuminuria. Median time with normoalbuminuria for progress to micro albuminuria is 19%. median time with micro albuminuria to progress macro albuminuria 11%. median time from macro albuminuria to progress to nephropathy needs 10 years. So fallow up is mandatory.
Notice that diabetic donor undergoing to hyper filtration and eGFR increase as same to non diabetic donor may reflect a drop in their renal function.
Limitations of this study is lack cause of death and incidence of DM in donation is missing because lack of fallow up and also because random sample.
Risk factors for developing T2DM in kidney donor similar to general population.
Incidence of micro albuminuria is higher in comparison to non diabetic donor.
Diabetic donor is not exhibit increase accelerated kidney disease in first decade. All kidney donor with positive family history of DM should strongly maintain weight control and decline all donor with positive family history of DM and positive GTT.
What is the level of evidence provided by
this article? Level 3
Please reflect on the guidelines provided above and on your practice.
The criteria to select kidney donor is healthy donor with well control hypertension and tight control of blood sugar Hba1c less than 7% and fasting blood sugar less than 99 mg/dl.
In those of positive family history of DM should be excluded from donation
BMI less than 30 kg/m2.
Normal protein creatinine ratio
Normal level of creatinine level
renal biopsy shows no evidence of diabetic kidney and no sign of hyper filtration.
Mohamed Mohamed
2 years ago
IV. Diabetes after Kidney Donation Please summarise this article in your own words
To study the course of donors who develop T2DM, the authors surveyed 3777 kidney donors. Out of 2954 (2929 + 17 deceased + 8 with no recent contact) responders, 154 developed T2DM 17.7 ± 9.0 years post- donation. The cause of death in donors:
Unknown (40%)
CVD (19%)
Cancer (20%)
Diabetes-related complications (2 donors)
ESRD developed in 11 donors; none was due to DKD. Risk factors for development of T2DM:
T1DM in the recipient
Male gender
BMI >30 at time of donation. Donors with diabetes (154 donors)
Mean age at donation: 39.8 ±11.4 years
Diagnosis of T2DM: 17.7 ± 9.0 years after donation.
Prevalence of hypertension: 71% vs. 36.3% (p = 0.005)
Prevalence of proteinuria: 18.8% vs. 3.9% (p < 0.0001).
eGFR: no significant change. Discussion
In a study by Silveiro et al, macro-albuminuria was seen more among single-kidney diabetics (30%) than single-kidney nondiabetics; however, there was no difference between single-kidney diabetics (30%) & two-kidney diabetics (23%).
Chang et al. found no difference between the mesangial matrix volume in biopsies from subjects with T1DM & those with DM & 2 functioning kidneys.
The current study suggests that the prevalence & risk factors for T2DM in kidney donors are not different than that seen in the general population.
Diabetic donors had a degree of albuminuria & HTN in the 1st decade of diabetes comparable to that seen in subjects with DM & 2 kidneys in the 1stfew years of T1DM.
Diabetic donors are twice more likely to be hypertensive than matched non-diabetic donor controls; however, this frequency of HTN is, also, similar to T2DM with 2 kidneys.
Prevalence of proteinuria in 128 donors was 18.8% by self-report & 25% UACR in 20/154 donors; a prevalence is higher than the usual rates seen in kidney donors but similar to those with DM with 2 kidneys. Garg et al.(42 studies, 4793 donors) reported an incidence of proteinuria of 12% (95% CI 8–16%).
Summary:
Risk factors forT2DM in kidney donors is similar to the general population & donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early DKD.
Compared to nondiabetic donors, diabetic donors in the 1stdecade of DM development didn’t show increased risk for accelerated kidney disease; thus, no good reasons to decline donors with positive FH of T2DM, if screened with OGTT.
Kidney donors (especially if FH of diabetes) should be strongly advised to maintain weight control.
======================= What is the level of evidence provided by this article? Level III ======================= Please reflect on the guidelines provided above and on your practice.
In concordance with guidelines stated above, in our center, we will exclude donors with strong FH of diabetes only if there are also other CV risk factors, such as hypertension & obesity.
We send potential donors for OGTT if HbA1c is between 6.1 to 6.9.
Thank you for your contribution. Please try to write it in your own words.
Dear All
What is the level of evidence Ban? What is the type of this study?
Yes Dr Ben, I agree this is a case-control study. Hence, it provides level 3b evidence.
Case-control studies are longitudinal studies (other being cohort). In case-control studies (always retrospective), we find out the end-point (DM in donors) and one looks back for underlying factors. While in cohort studies (with prospective or retrospective) we start with factors and follow these patients to look for the end-point,
Thank you professor for your explanation.
Thank you Professor Ajay
its cross-section (prevalence study) with level IIIb of evidence
case control series cross sectional with level of evidence 3
The Study assessed the risk of development of type 2 Diabetes in donors as compared to the general population…. It also compared the renal function, proteinuria an blood pressure in such donors with age, gender and BMI…..
The study was actually a survey conducted by asking the donors about the onset of diabetes mellitus, hypertension and proteinuria.
This was conducted at the University of Minnesota, Minneapolis…
Only 154 out of 2954 (5%) developed type 2 diabetes mellitus with a mean of 17.7 years after donation… The above incidence is like that of general population itself…The risk factors for development of diabetes included donating to a family member of type1 diabetes, males, age more than 45 years and BMI >30. There was no relation with smoking or serum creatinine at the time of donation..
> 70% of the donors who developed diabetes had hypertension and around 18% developed proteinuria… The rate of eGFR change in diabetic donors and matched non diabetic donors were similar…
They concluded that the development of diabetes in renal donors is similar to those in general population. Diabetic donors have increased hypertension and proteinuria than non diabetic donors, but they concluded that the frequencies were similar to diabetics with 2 kidneys..
Case control study providing level 3 evidence
Post donation development of diabetes in our population is related to increased BMI, lack of hypertension control and the family history of diabetes in the donors…
This is a retrospective study with level 3 evidence to study the prevalence and risks of T2DM among kidney donors. The prevalence was 4% in the entire pool of 3777 donors. with the mean time of 17.7 ± 9.0 years post transplantation. The risk factors include family history of type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07. A BMI greater than 30; HR 2.97 (95% CI 1.93–4.56), p < 0.001 and male gender; HR 1.76 (95% CI 1.12–2.76). Age more than 45 year old HR 1.46 (95% CI 0.97–2.19). Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM. The limitations include , survival bias (do not have information on type 2 diabetes in the majority of donors who have passed away), and also response bias. In conclusion, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors. Therefore, declining donors with positive family history of type 2 diabetes may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
This study done between January 1, 1963 and March 31, 2009. There are 3825 donor nephrectomies were performed at the University of Minnesota. At several times in the last three decades, the authors attempted to contact all donors to ascertain their health status. In the last 7 years, they begun a comprehensive multistep approach to locate all kidney donors (including review of medical records, utilizing phone and internet directories and also the help of the recipients). Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation.
The results:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, 48 also donated a partial pancreas and, therefore, were not included in the analyses. Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys. In total, 154 donors reported
developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors
with available information prior to death and 8 of the 555 donors with no recent health
updates reported having T2DM, as well. Therefore, there is diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact). The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%. Only two donors were listed to have died of diabetes-related complications. In addition, 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
Introduction Diabetes mellitus is the leading cause of end-stage renal disease . Its prevalence will more than likely increase as the prevalence of type 2 diabetes mellitus (T2DM) increases in parallel with the rise of obesity in the general population . T2DM has a strong genetic component and 30% of those afflicted with it develop kidney damage.Therefore, some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass . Yet it is unknown whether development of T2DM after donating a kidney leads to a higher risk of experiencing acceleration in glomerular filtration rate (GFR) decay when compared to nondiabetic donors or diabetics with two kidneys.
Risk factors for diabetes The Cox regression analysis assessing the various risk factors (at time of donation) for diabetes development revealed that donating to a family member with type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07, were associated with the future risk of developing T2DM (Table 2). A BMI greater than 30; HR 2.97 (95% CI 1.93–4.56), p < 0.001 and male gender; HR 1.76 (95% CI 1.12–2.76), were also strongly associated with the development of diabetes.
Donors with diabetes For the 154 donors who developed diabetes, mean age (±SD) at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation. Characteristics of these donors are shown in Table 3; the majority were white and 47% donated to a sibling or other family member (Table 3). The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
Longitudinal eGFR change Of the 154 donors who developed diabetes, 64 donors had multiple serum creatinine measurements available after the diagnosis of diabetes was made. To address whether these 64 donors were different than the rest of the diabetic donors, they were compared to the remaining 90 diabetic donors with no serial measurements on baseline demographics that included age, gender, time from donation, BMI and relation to the recipient, among others, and they were not different (data not shown). They, however, were more likely to be hypertensive (91%), 19% were proteinuric, their BMI at the time of last follow-up was 31.6 ± 7.0 kg/m2 and an average of 15.5 ± 8.8 years had elapsed from donation to the development of T2DM. The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2 (range −2.99–1.63). The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year, range (−4.99–2.19, p = 0.43, vs. those with diabetes). To strengthen this analysis, we matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year.
Uninephrectomy is followed by a rapid increase in renal plasma flow and GFR. In fact, GFR increases by 70% within 1 week of donation .In addition, a substantial proportion of subjects with either types 1 and 2 diabetes undergo hyperfiltration The compensatory increase in GFR observed in the setting of reduced renal mass and diabetes has been linked to the progressive nature of kidney disease Of concern is the possibility of a multiplicative adverse action of the hyperfiltration from donating a kidney and the hyperfiltration observed in diabetes. However, in case series of diabetic patients with either unilateral agenesis or unilateral nephrectomy, none suffered accelerated kidney function in the remaining kidney Silveiro et al. studied type 2 nonliving donor diabetic patients who had undergone uninephrectomy (single-kidney diabetes, n = 20; duration of diabetes, 8.5 ± 7 years) comparing renal function versus nondiabetics who had undergone uninephrectomy (single-kidney nondiabetic, n = 17) and versus type 2 diabetics having 2 kidneys (n = 184; duration of diabetes, 10 ± 7 years) (15). The single-kidney and two-kidney type 2 diabetic patients were matched for age, sex and BMI. Mi-croalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
The prevalence of proteinuria in 128 donors with available measurements was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio obtained in 20/154 donors. This prevalence is higher than the usual rates of albuminuria encountered in kidney donors but similar to subjects with diabetes with two kidneys. Garg et al. quantified the pooled incidence of proteinuria in 42 studies of kidney donors comprising 4793 donors and found it to be 12% (95% CI 8–16%) (25). In addition, we have recently measured the urinary albumin/creatinine ratio in 255 kidney donors, of whom only 3.1% have T2DM, who were at least 12.2 ± 9.2 years after donation and found that 12.7% were albuminuric (26). These observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself, but probably represents the presence of underlying diabetic renal involvement and possibly hypertension. While the proportion with normoalbuminuria was similar between diabetic and non-diabetic donor controls, only 3.9% of nondiabetic donors reported proteinuria suggesting that diabetes is responsible for the higher prevalence (18.8%) of proteinuria. This finding needs to be confirmed in a larger group of individuals. We, unfortunately, do not have information on retinopathy, kidney biopsy information or other end organ damage from diabetes which would make diabetic renal involvement a more likely reason for this increased albuminuria. In addition, quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls.
Our population consisted of mainly white kidney donors and therefore we could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation and information on family history of type 2 DM in nondiabetic donors was not captured. Most importantly, reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria. In summary, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed. All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
level 3
Introduction:
Report on the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster.
Materials and Methods:
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota.
Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation.
Results:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys .
In total, 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well.
Therefore, we have diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact). The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%.
Risk Factors for DM:
Donating to a family member with type 1 diabetes less T2dm.
A BMI greater than 30Male gender.
Donors who were over the age of 45ys.
Donors with DM:
When compared to the age, gender, duration after donation and BMI-matched nondiabetic donor controls, its found that donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.00.
GFR, Prior to development of T2DM, it was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and after developing the condition it was −1.10 ± 5.6 mL/min/year (range −10.8–7.3), p = 0.93.
Discussion:
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys in the first few years of type 2 diabetes development.
Diabetic donors, however, are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls but this frequency of hypertension is, again, similar to type 2 individuals with two kidneys (2,3,24). The prevalence of proteinuria in 128 donors with available measurements was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio obtained in 20/154 donors. This prevalence is higher than the usual rates of albuminuria encountered in kidney donors but similar to subjects with diabetes with two kidneys.
In summary:
the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
Level of evidence 3B.
Please reflect on the guidelines provided above and on your practice
We investigate donors at least twice. those with strong family history are counselled
regarding possible risk of develop of DM and ESRD.
This is a study of 2954 kidney donors regarding the development of T2DM (2929 + 17 deceased + 8 with no recent contact). a survey regarding development of T2DM after donation was sent to the donors donated between January 1, 1963 and March 31, 2009 who are alive. The cause of death is unknown for 40% of the donors, cardiovascular disease in 19% and cancer in 20%. Only two donors were listed to have died of diabetes-related complications. In addition, 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease. 154 developed T2DM 17.7 ± 9.0 years after donation; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well. Donors with diabetes were more likely to
1. be smokers
2. have a BMI greater than 30
3. their serum creatinine measurements at the time of donation were slightly higher than those of their non-diabetic counterparts.
Non-responders donated more recently, were least likely to have ever smoked cigarettes and least likely to have donated to a recipient with T2DM. The majority, 80% of nondiabetic responders, donated prior to 2002, when glucose tolerance testing was required in high risk individuals.
Risk factors for diabetes
1. donating to a family member with type 1 diabetes; and to a lesser extent, but not statistically significant T2DM;
2. A BMI greater than 30;
3. male gender;
4. age of 45
For the 154 donors who developed diabetes:
1. mean age (±SD) at time of donation was 39.8 ± 11.4 years
2. the majority were white
3. 47% donated to a sibling or other family member
4. The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%.
5. 20% had a positive family history for T2DM
6. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8%
7. a third were receiving oral hypoglycemic agents.
8. 71% developed hypertension requiring treatment
9. Actual blood pressure readings were available in 126 donors and they were 128 ± 16 mmHg for systolic blood pressure and 75 ± 10 mmHg for diastolic blood pressure.
10. Serum creatinine was available in 126 of the diabetic donors (following diagnosis) and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes .
11. 29 donors (18.8%) were told they have proteinuria.
12. 20 local diabetic donors who were able to come back to the University of Minnesota, measured urinary albumin/creatinine ratio was 68.7 ± 176.85 mg/g, 75% were normoalbuminuric (using ACR <17 mg/g creatinine for men and 25 mg/g creatinine for women), 20% were microalbuminuric and 10% were macroalbuminuric . Time from development of type 2 diabetes to ACR measurement in these 20 donors was 5.1 ± 7.2 years.
In conclusion, donors who developed T2DM had an increased prevalence of hypertension and proteinuric. The annual eGFR change in diabetic versus non diabetic donors was almost indistinguishable.
level of evidence is 3
Post donation DM was not attracting much attention in Sudan. We have started small surveillance programm for the general population but the population response is poor. we need to focus on enhancing population awareness.
1. Please summarise this article in your own words
After nephrectomy for kidney donation, there is a temporary physiological adaptation of increased plasma flow and Glomerular Filtration Rate (GFR), which in a patient with reduced renal mass and diabetes would be associated with worsening renal function, especially if it is already diabetic.
Several studies have tried to assess the relationship between diabetes and different markers such as: proteinuria, urinary albumin/creatinine ratio, estimated glomerular filtration rate (eGRF) that would be followed up after donation.
After several attempts to cross populations with various risk factors related to the prevalence and risk factors for the development of DM2 in living kidney donors are not different when compared to the general population. And even those donors who developed diabetes, when better analyzed in relation to albuminuria rates, larger curves were noticed than non-diabetic donors, which may be suggestive of early diabetic kidney disease.
2. What is the level of evidence provided by this article?
This is a retrospective case control study, which is looking for risk factors for the development of diabetes in living kidney donors – Level 03
3. Please reflect on the guidelines provided above and on your practice
Some reflections can be made:
– Need for long-term studies to really elucidate the risk of developing the most diverse pathologies in living donor patients;
– A significant percentage of the population has criteria for diagnosing the most prevalent diseases in the general population and is not aware of it. Therefore, investigation of screening protocols should be performed in all proposed living donors.
– Diabetic donors in the first decade will not present an increased risk of evolving with accelerated kidney disease, so they can join the donor queue.
– importance of donor follow-up after donation.
Diabetes after Kidney Donation
Introduction :
T2DM is a genetic disease with 30 % of those affected by it developed kidney damage.
Kidney donors with strong family history of DM are declined from donation by some centers because of the additional risks of hyperfiltration and small size kidneys.
This study report the donor risk of developing T2DM compared with non diabetic donors in regard to age , bendy, duration after donation and BMI and GFR decline.
Materials and Methods :
3825 donors were taken from 1963 to 2009,at university of Minnesota .
Survey including questions regarding the presence of DM , age at its development, type of treatment, presence of HT , presence of protein in urine.
Potential donors with 2 parents with DM , multiple siblings with DM in edition to one parent with DM , more than one family member with diabetic kidney disease are strongly discouraged from donating.
After 2002 , those with more than one family member with DM , those with gestational DM and those with fasting blood sugar more than 99 are subjected to GTT.
Donors with BMI > 35 kg/m2 not accepted as donors.
Serum creatinine, urinary protein, GFR are estimated.
Diabetic donors were matched with the non diabetic donors in regard to age , gender , years from donation and BMI at donation.
Serial measurement of serum creatinine in donors who develop DM after donation and at 1 year apart to assess for the rate of GFR decay.
Results :
3825 underwent uninephrectomy for kidney donation.
48 of them were excluded .
3777 remain , 293 of them have died, 555 lost ,
2929 remaining, 129 are alive , 154 developed T2DM , 293 are deseased donor.
Cause of death is unknown in 40% of the donors , 19% Cardiovascular, and 20% cancer. Only 2 died due to DM complications.
Risk factors for diabetes :
Positive family history, BMI greater than 30 , male gender , donor age more than 45 .
Donors with diabetes :
154 with DM
Mean age was 39 years
The majority were white
47% donating to sibling or other family members
The cause of ESRD was type 1 DM 33%
T2DM 10% , HT 35%, PCK in 5% and others are 15% .
71% developed HT requiring treatment.
29 donors developed proteinuria .
Comparing between the donors with and without DM in regard to age , gender , duration after donation and BMI we found that donors who developed T2DM have increased prevalence of hypertension and proteinuria .
Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
Level of evidence 3
This is a retrospective case-control study with a level of evidence (III). a total of 3825 was scanned. 293 dead, but 17 were reported to have DM before death. 8 out of 555 patients not followed in the last four years reported DM. In this study, 2929 patients were analyzed, and 129 DM was reported. As shown in figure 1, the ratio of obese patients (MBI>30 was higher in those who developed DM 25.3 vs 17.2% with a significant p-value of 0.02. Smoking had a hazard ratio of 1.22, but this was not statistically significant (p=0.31). In the 154 who developed DM, the mean value of developing DM was 17.7 years (± 9.0 ), age at developing DM was 57 ( ± 12.6 ). HT in DM (post-donation) was around 70%. This group was found to have more proteinuria. In this study, factors related to DM were not very much different from the general population.
The aim of this study was determining the risk of T2DM after donation compared with a matched control group. Donors were asked about T2DM, HTN or proteinuria and taking medicine regarding them.
Their GFR was estimated using their last serum creatinine based on MDRD formula. Of 3777 donors only 2954 responded to survey, T2DM was developed in 154 donors with a mean duration of 17/7 ± 9 years after donation.
Risk factors for development of T2DM post-donation includes:
1- donation to a family member with type 1DM
2- BMI over 30
3- male gender
4- donors over 45 years of age
Mean age of donors with diabetes was 39.8±11.8 years and occurred 17.7±9 years after donation.
Twenty percent had positive family history. Seventeen percent off diabetic donors developed
hypertension and 18.8% proteinuria. Rate of GFR decline was not different in diabetic donors.
Type of study: This is a case-control (cohort) study with the level of evidence of 3b.
Our local practice:
1) Individuals with a history of diabetes or fasting blood glucose of ≥ 126 mg/dL on at least
two occasions or 2-h glucose with OGTT ≥ 200 mg/dL or HbA1c ≥ 6.5% should not
donate.
2) In the presence of FBS< 100 mgr/dl, OGTT and HbA1c should be performed in the
following prospective donors:
a) BMI≥ 30 kg/m2
b) History of diabetes in 1° relatives
c) History of GDM > 10 years ago
3) Donation in potential donors with FBS between 100-126 mgr/dl (impaired fasting
glucose) is not recommended except in related donors with normal OGTT.
Introduction:
DM is the most common cause of ESRD worldwide.
30% of T2DM has a strong genetic component . Some Transplant centers exclude kidney donors with a strong family history of type 2 diabetes. Kidney donors are at risk of DM like the general population.
Aim of the study:
To compare kidney function in diabetic donors to that of age, gender, and BMI-matched non-diabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR, hypertension and Proteinuria when compared to non-diabetic donors.
Materials:
Single center study(University of Minnesota) which included > 3825 donors
Results:
5% developed type 2 diabetes mellitus after donation, which was like the incidence in general population.
Risk factors for developing DM are: donating to a family member with type 1 DM, males, age >45 years, and BMI > 30
71% of the donors who developed diabetes had hypertension (2 times of the non-diabetics, but similar to diabetics with 2 kidneys)
18.8% developed proteinuria (4.5 times more than the non-diabetics, but similar to diabetic patients with 2 kidneys)
The rate of eGFR change in the diabetic donors and matched non-diabetic donors was similar.
Conclusion:
The prevalence of type 2 DM in kidney donors after the donation is the same prevalence in the general population.
The risk factors for development of diabetes in renal donors are similar to those in the general population. Diabetic donors have increased hypertension and proteinuria than non-diabetic donors, but the frequencies are similar to diabetics with 2 kidneys.
What is the level of evidence provided by this article?
Level 3, case control study.
Please reflect on the guidelines provided above and on your practice.
In our center we screen all potential donors with FBS, HBA1c.
We don’t exclude potential donor with positive FH or DM unless having impaired an abnormal blood sugar level( fasting blood sugar or GTT).
This is a cross sectional study with level of evidence IIIB.
Some transplant centers exclude donors with strong family history of DM because of their high genetic risk to develop DM later in their life.
Risk factors of developing DM after kidney donation include: age, gender, BMI, and duration after kidney donation.
Method:
Post donation survey, asking donors if they developed DM, age of onset and treatment received. Donors renal function test and e-GFR was measured at the nearest medical practice.
Results and discussion:
2929 donors participated in the survey.
154 donors admitted of developing DM II.
2 donors died because of DM related complications.
11 donors developed ESRD who required dialysis or transplantation, none of them was related to diabetic nephropathy.
Donors with post donation DM were found to be smokers, obese, BMI>30, high serum creatinine at the time of donation, donors with family history of DM I, and aged above 45 years.
Donors with DM: mean age 39.8 years, diagnosed 17.7 years after donation, HbA1C 8 +/- 7.8%. 2/3 of them were treated with insulin. 71 % developed Hypertension. 18% were found to have proteinuria with average urine ACR 61.8 +/- 18.1 mg/g.
One-week post nephrectomy, GFR increases by 70%. DM is associated with hyperfiltration as well. Macro-albuminuria was found in 30% of single kidney Diabetics than23% in single kidney non-diabetics. Prevalence of proteinuria was 25% by urine ACR.
Limitations of this study:
1- 40% of cases, the cause of death was not found.
2- DM incidence was not correctly determined.
3- Survival Bias.
4- Response Bias.
5- No detailed information about family history.
6- No assessment of ethnicity as a risk factor.
Diabetes after Kidney Donation
Diabetes mellitus is a major cause of ESRD. It has strong association with family history of the disease, there for many transplant centers exclude donors with strong family history of diabetes. age, gender, duration after donation and body mass index (BMI) are risk factors for its development.
Method
Donors have send survey to determine if they develop diabetes, in addition to other question regarding age of onset and treatment use.
Donors are asked to measure the serum creatinine at their near medical office and their GFR were estimated. The collected data were categorized and analyzed with appropriate test.
Results:
2929 have responded to our surveys. In total, 154 donors reported developing T2DM; only 2 donors listed to have died of diabetes-related complications. 11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
Total population
Donors who develop DM are more likely to be smoker, obese with BMI > 30, and have higher serum creatinine at time of donation as compared with non diabetic donors.
Risk factors for diabetes:
1- Donation to a family member with type 1 diabetes
2- BMI >30
3- Donor age >45 years
Neither s. creatinine nor smoking status at donation were predictive of future risk of T2DM.
Donors with diabetes:
Mean age was 39.8± 11 years. Diagnosis occurred 17.7 ±9 years after donation. The majority was white and 47% donate to their sibling or family member.
The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
Of the diabetic donors, 71% develop hypertension requiring treatment at the same time they were told to have diabetes. Serum creatinine was 1.26±0.4 mg/dl with e GFR of 58.8 ±16.7 Ml//min/1.73 m2, 7.7±7.0 years after the development of diabetes. 18.8% told to have proteinuria. 20% were microalbuminuria and 10% were macroalbuminuria. Time to development of type 2 diabetes to ACR measurement in these 20 donors was 5.1± 7.2 years.
When compared to the age, gender, duration after donation and BMI-matched nondiabetic donor controls, we found that donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.0001. Quantitative proteinuria information was available in 14 nondiabetic controls. The average ACR was 61.8 ± 181.1 mg/g and a similar proportion (i.e. 71%) was normoalbuminuric.
Longitudinal e GFR change:
Donors who have multiple e GFR measurements were compared in the two group. Those who develop diabetes, they were more likely to be hypertensive (91%), 19% were proteinuric, their BMI at the time of last follow-up was 31.6 ± 7.0 kg/m2 and an average of 15.5 ± 8.8 years had elapsed from donation to the development of T2DM. The annual eGFR change in these donors was -0.80 ± 0.9 mL/min/ 1.73m2 (range -2.99–1.63). The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was -0.70 ± 0.86 mL/min/year, range (-4.99–2.19, p = 0.43, vs. those with diabetes).
Seven diabetic donors had multiple e GFR before and after diabetes, the lope in e GFR before diabetes was –0.88±0.67 ml/min/1.73m2 (range -1.96 to 0.21) and after diabetes the slop in e GFR was –1.10±5.6 ml/min/1.73m2.
Discussion
Post- nephrectomy there is rapid increase in plasma flow and GFR. GFR increased by 70% 1 week after donation. Also diabetic patients undergo hyperfiltraion.
The compensatory increase in GFR observed in the setting of reduced renal mass and diabetes has been linked to the progressive nature of kidney disease.
The single-kidney and two-kidney type 2 diabetic patients were matched for age, sex and BMI. Microalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%). Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys in the first few years of type 2 diabetes development.
The prevalence of proteinuria in donors was 18.8% by self-report and 25% by the urinary albumin/creatinine ratio. This prevalence is higher than the usual rates in kidney donors but similar to subjects with diabetes with two kidneys.
The mean time from donation to development of T2DM in our donor population was 17.7 ± 9.0 years. the median time with normoalbuminuria before progressing to microalbuminuria is 19 years; the median time with microalbuminuria before progressing to macroalbuminuria is 11 years and the median time with macroalbuminuria before progressing to nephropathy is 10 years.
One would expect that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be reflective of a drop in their renal function.
Limitations
1- The cause of death was missing in 40%.
2- The incidence of diabetes could not be precisely determined.
3- Survival bias and response bias.
4- Ethnicity as risk could not assessed as majority was white donor.
5- Information on family history was not captured.
Diabetes after kidney donation
Kidney donors are at risk for developing diabetes type 2, and 30% of diabetic can develop CKD.
1. The study estimate the risk of donors of developing T2DM,
2. comparing diabetic donors with matched non diabetic donors in renal function, age, gender, duration after donation and BMI.
3. comparing the progression rate of GFR between diabetic donors and non diabetic donors.
Method and statistics
All the donors between (Jan 1963-march 2009) were attempted to contact (total of 3825).
A survey were send to those who were contacted to ascertain their health status. and regarding development of T2DM after donation.
Also they were requested to check their serum creatinine and check urine protein measurements at their Primary care provider. GFR were estimated using MDRD equation.
The comparison were tested statistically using chi square or fisher’s exact test.
Continuous variables were compared using unpaired t test.
A cox proportional hazard model was used to study the predictors for the development of type 2 diabetes.
Discussion
As a result of uni-nephrectomy post kidney donation, GFR increases to 70% within 1 week. This is as a compensation to the reduced renal mass, similar to hyperfiltration observed in diabetes type 1 or 2.
The result of the study showed that the prevalence and risk factors for T2DM in kidney donors are similar to general population.
More over they found that type 1 DM considered associated factor for the development of T2DM in the donor and this might be due to wrong identification of type 1 diabetes.
The author also found that smoking was not a significant risk factor for T2DM in both the adjusted and unadjusted analyses, though there was a higher prevalence of smoking in the donors who developed diabetes. But the authors suggested this result could be due to small studied population inspite of similar results in other studies.
Also it was found that higher prevalence of proteinuria in the diabetic donors is unrelated to donation rather it might be due to the presence of underlying diabetic renal involvement and possibly hypertension.
normoalbuminuria was similar in diabetic and non-diabetic donor, but only 3.9% of nondiabetic donors reported proteinuria hence they suggested that diabetes is responsible for the higher prevalence of proteinuria. But afurther studies needed for confirmation.
One of the limitations of this study that, retinopathy other diabetic complications including kidney biopsy information were not which would confirm diabetic renal involvement being responsible for the increased albuminuria.
Other finding of the study was the rate of GFR decline is not accelerated when compared to nondiabetic donors,
diabetic donors had a urinary albumin excretion rate of 68.7 ± 176.8 mg/g; comparable to other studies.
In the study The mean time from donation to development of T2DM in the donor population was 17.7 ± 9.0 years.
the author suggested that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be reflective of a drop in their renal function.
Other limitations to the study was that the cause of death was missing in 40% of all donors. And no information available about type 2 diabetes in the majority of donors who have passed away
The prevalence of diabetes in our donors (5.2%) is lower than the 9.8% that is observed in non-Hispanic whites which coud be attributed to the fact that donors were screened at the time of donation and so may be a selected subgroup.
Conclusion:
the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease.
Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. Therefore, declining donors with positive family history of type 2 diabetes
All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
level of evidence 3b
in our center we do routinely check for fasting blood sugar and hba1c for the donors and if both normal we do accept the donor if not we refer him to the diabetologist to assess for further complications and accordingly we decide but we try to avoid diabetics as a donor even those with impaired glucose test.
Introduction
Diabetes mellitus is the first leading cause of end-stage renal disease development worldwide. That is why some transplant centers decline kidney donors with a strong family history of type 2 diabetes owing to the fact of possible additive effect of hyperfiltration afterwards.
It is also crucial to exclude whether development of T2DM post donation can result in higher risk of acceleration in glomerular filtration rate decline over years.
This study aims to compare renal function decline in diabetic donors versus those non diabetic donors, to assess the donors’ risk if T2DM was developed later on and whether diabetic donors are vulnerable to an accelerated decline in GFR when compared to nondiabetic donors.
Materials and Methods
The study was carried out for established donors between January 1963 and March 2009 included 3825 donors based on a survey.
Statistical method
Chi-square or Fisher’s exact test were the principle tools for studying variables and further comparisons. A Cox proportional hazard model was successfully used to study the predictors for the development of type 2 diabetes. The main determining variables were age, gender, BMI, type 1 DM in the recipient, type 2 DM in the recipient, serum creatinine and smoking status. Results are expressed as adjusted hazard ratio and their 95% confidence intervals. p < 0.05 was considered significant.
Results
A number of 154 donors reported developing T2DM. Two donors only have died of diabetes-related complications. A number of 11 donors have developed ESRD requiring dialysis or transplantation and none was attributed to diabetic kidney disease. Donors with diabetes were smokers, with BMI exceeding 30, and their serum creatinine measurements at the time of donation were slightly higher than those of their nondiabetic controls.
Risk factors for diabetes
Among the important risk factors were donating to a family member with type 1 diabetes, accompanied with substantial risk for developing T2DM, BMI exceeding 30,as well as male gender.
Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM.
Donors with diabetes
Among 154 donors who developed diabetes, mean age (SD) at time of donation was 39.8 years and the diagnosis of diabetes occurred 9.0 years post donation. HbA1c was available in 51 donors and it was around 8.0 to 7.8%, with some of them were receiving oral hypoglycemic agents.
Regarding albuminuria; urinary albumin/creatinine ratio (ACR) was around 68.7 to 176.85 mg/g, 75% were normoalbuminuric (using ACR <17 mg/g creatinine for men and 25 mg/g creatinine for women), 20% were microalbuminuric and 10% were macroalbuminuric. These donors have developed type 2 diabetes from the time of ACR measurement in these 20 donors was 5.1 to 7.2 years.
Donors who developed T2DM had an increased prevalence of hypertension (71% vs. 36.3%; p = 0.005) and were also more likely to be proteinuric (18.8% vs. 3.9%, p < 0.0001).
Longitudinal eGFR change
Only 64 donors had multiple serum creatinine measurements available after the diagnosis of diabetes was established. These donors were more likely to be hypertensive (91%), 19% were proteinuric, their BMI exceeded 30 at the time of last follow-up. The annual eGFR change in these donors was −0.80 to 0.9 mL/min/1.73m2 (range −2.99–1.63) while those donors without diabetes after donation was −0.70 to 0.86 mL/min/year.
Seven diabetic donors had multiple serum creatinine measurements pre and post development of diabetes that allowed to compare pre- and post-diabetes eGFR slopes concluding that Prior to development of T2DM, it was −0.88 to 0.67 mL/min/year (range −1.96 to −0.21) while after being DM was −1.10 to 5.6 mL/min/year (range −10.8–7.3),of estimated p = 0.93.
Discussion
The compensatory increase in GFR post donation in the setting of reduced renal mass and diabetes has been strongly linked to the progressive nature of kidney disease. Astonishingly, in case series of diabetic patients presented with either unilateral agenesis or unilateral nephrectomy, none suffered accelerated kidney function in the remaining kidney.
Chang et al. found no difference between the mesangial matrix volume; the hallmark of diabetic nephropathy, in diabetic subjects with one kidney compared to those with two kidneys. Okamoto et al. reviewed the records of 444 kidney donors who donated in the era between 1985 and 2000, seven of 65 survivors with impaired glucose tolerance at the time of donor evaluation became frankly diabetic while no ESRD was reported as well as their survival was similar to the other donors.
A higher prevalence of smoking in the donors who developed diabetes was reported, stating that known smokers were 40% more likely to develop diabetes of 95% CI.
Diabetic donors are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls, however it is also similar to type 2 individuals with two kidneys.
The prevalence of proteinuria is 18 % which is higher than the common rates of albuminuria reported in kidney donors but again it was similar to subjects with diabetes with two kidneys.
According to Garg et al. who quantified the incidence of proteinuria in 42 studies of kidney donors, the estimated incidence was only 12%.
All these data preclude that; the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself, but probably represents the presence of underlying diabetic renal involvement and possibly hypertension.
Limitations of the study, are mainly the lack of sufficient information on retinopathy, renal biopsy or other associated end organ damage from diabetes which would make diabetic renal involvement a more likely reason for this currently increased albuminuria. Also quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls.
It takes many years to develop diabetic renal changes and this study was limited to the first decade after type 2 diabetes development which is also one of the drawbacks. The cause of death was missing in 40% of all donors as well, so true incidence of diabetes could not be precisely determined. The population of the study consisted of mainly white kidney donors, thus it can’t be applied to other ethnicities.
According to the United Kingdom Prospective Diabetes Study (UKPDS); it takes an average of 10 years from the diagnosis of type 2 diabetes for 25% of subjects with diabetes to frankly develop microalbuminuria.
So, longer follow-up is required emphasizing that level of eGFR seen in diabetic and nondiabetic donors as an early sign of progressive renal disease in the diabetic individuals. One would expect that diabetic donors have undergone hyperfiltration and the fact that their eGFR is the same as nondiabetics may be indicative of further decline in their renal function.
Finally, the risk factors for the development of T2DM in kidney donors is similar to the general population, particularly those donors who have albuminuria as it might be suggestive of early diabetic kidney disease.
At last we recommend that larger studies and, more importantly, longer follow-up are needed for all donors especially those with a positive family history for diabetes with advisable strict weight control and healthy lifestyle adoption.
Level of evidence 3
In our practice, proper selection of the living donor with meticulous assessment to avoid the risk of development of diabetic kidney disease is a must. HBA1C is one of the parameters to exclude the evidence of DM in candidate donors as well as the albumin quantification in 24 urinary measurement, it is performed at least twice. Donors with high BMI exceeding 30, or those with significant albuminuria as well as positive family history of DM are excluded from donation.
Introduction:
Material and methods:
Results
Conclusion
Carefully selected donors at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Please reflect on the guidelines provided above and on your practice.
So, donor with family history of DM can be accepted as donor provided the OGT is normal and healthy lifestyle is maintained.
Diabetes after Kidney Donation
Q1- Please summarise this article in your own words.
type 2 diabetes mellitus (T2DM) development risk in donors are similar to general population.
Abstract
The risk factors for developing T2DM are
· Recipient with type 1 DM,
· male gender
· body mass index >30 kg/m2 at time of donation.
Compared to non-diabetic donor controls; diabetic donors have more hypertension , proteinuria, but had a similar serum creatinine.
The available data showed that factors associated with T2DM in kidney donors are similar to that in the general population and these donors has no accelerated diabetic kidney nephropathy .
Introduction
Diabetes mellitus is the leading cause of ESRD.
T2DM is a genetic disease . and 30% of those patient develop kidney damage.
some centers decline kidney donors in the presence of a strong family history of type 2 diabetes, because of the possible additive effect of hyperfiltration of diabetes and reduction in renal mass .
Risk factors for diabetes at the time of donation .
· donating to a family member with type 1 diabetes.
· A BMI greater than 30 .
· male gender .
· over the age of 45 y .
Of the diabetic donors,
· 71% developed hypertension .
· 18.8% develop proteinuria.
This means that patient with T3DM has more chance for developing hypertension and proteinuria than non diabetic .
Silveiro et al . demonstrate that
· Mi-croalbuminuria was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
· Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
The study suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself only , but may be due to the presence of diabetic renaldisease t and hypertension. While the proportion with normoalbuminuria was similar between diabetic and non-diabetic donor controls, only 3.9% of nondiabetic donors reported proteinuria suggesting that diabetes is responsible for the higher prevalence of proteinuria.
the degree of GFR decline is not accelerated when compared to nondiabetic donors, and is similar to patients with two kidneys.
The mean time from donation to development of T2DM is around 21 y .
Based on statisticaldata ,
· the median time till microalbuminuria is 19 years.
· the median till macroalbuminuria is 11 years .
· the median time till nephropathy is 10 years .
In summary,
1. the risk factors for the development of T2DM in kidney donors is similar to the general population and
2. donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease.
3. when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
4. declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified .
5. All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
Q2- what is the level of evidence provided by this article?
Level of evidence is 3 – retrospective – case control study.
Q3- Please reflect on the guidelines provided above and on your practice.
The donor is assessed by FBS, HB AIC , if needed OGT , if high sugar level in these study , the will declined .
Diabetes after Kidney Donation
Introduction
Some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass.
This study reported the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI).
Results:
This study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation. The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at
time of donation.
Compared to age, gender, duration after donation and body mass index (BMI)-
matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine.
eGFR change after T2DM development was -0.80 ± 0.94 mL/min/year, -0.70 ± 0.86 in nondiabetic donors with similar duration after donation and -0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls.
Limitations of the study:
1. The finding needs to be confirmed in a larger group of individuals.
2. No information on retinopathy, kidney biopsy or other end organ damage from diabetes which would make diabetic renal involvement a more
likely reason for this increased albuminuria.
3. Quantitative proteinuria data was only available in 20/154 diabetic donors and 14/154 matched controls.
4. The cause of death was missing in 40% of all donors.
5. The true incidence of diabetes could not be precisely determined.
6. Survival and response bias
7. The study population consisted of mainly white kidney donors and therefore they could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation.
8. Information on family history of type 2 DM in nondiabetic donors was not captured.
9. Reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria.
Conclusion:
Factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease
When compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease. So, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
All kidney donors, particularly those with a positive family history for
diabetes, should be strongly advised to maintain weight control.
# Please summarise this article in your own words
# The objectives:
*Report on the donors’ risk of developing T2DM.
*Compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched non diabetic donors.
*To assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to non diabetic donors.
# Introduction
*DM is the leading cause of ESRD. Its prevalence will more than likely increase as the prevalence of (T2DM) increases in parallel with the rise of obesity in the general population.
*T2DM has a strong genetic component and 30% of those afflicted with it develop kidney damage. So, some transplant centers decline kidney donors with a strong family history of T2DM.
#Method:
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota. They attempted to contact all donors to ascertain their health status. In the last 7 years, they have begun a comprehensive multistep approach to locate all kidney donors. Those known to be alive and with available contact information were sent a survey regarding development of T2DM after donation. The survey included several questions.
#Result
*They surveyed 3777 kidney donors regarding the development of T2DM.
* Of the 2954 who responded, 154 developed T2DM 17.7 +/- 9.0 years after donation.
*The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
* Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine.
* e-GFR change after T2DM development was −0.80 + /- 0.94 mL/min/year, −0.70 +/- 0.86 in non diabetic donors with similar duration after donation and −0.61 + /- 0.76 mL/min/year in age, gender, BMI and duration after donation matched non diabetic donor controls.
*These preliminary and short term data demonstrate that factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
# The limitation:
*The cause of death was missing in 40% of all donors therefore, true incidence of diabetes could not be precisely determined.
*Survival bias (do not have information on type 2 diabetes in the majority of donors who have passed away).
*Response bias as responders are certainly different and in this analysis were more likely to have ever smoked and were heavier at donation.
# Concolution:
*The risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than non diabetic donors, which may be suggestive of early diabetic kidney disease.
*When compared to non diabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
*Declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
* All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
# What is the level of evidence provided by this article?
*Level of evidence is 3
# Please reflect on the guidelines provided above and on your practice.
*In our practice for donors that have family history of DM, we do full evaluation with GTT, FBS HbA1c, abnormal BMI and proteinuria, if there any possibility for DM we exclude the donor.
Summary:
Kidney donors are similar to the general population regarding the risk of development of type 2 diabetes mellitus (T2DM).
This study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation.
The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in non diabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched non diabetic donor controls.
These preliminary and short term data demonstrate that factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Level of evidence: 3
Summary
This study is about kidney donors developing diabetes mellitus type 2. There are many centers that take donors who have a family history of diabetes. This study reports that the incidence of diabetes mellitus and the course it takes is similar in both kidney donors and the general population. The lifetime risk in kidney donors in terms of diabetes type 2 remains the same as general population, irrespective of donation.
Some of the characteristics common between diabetic donors were found to be :
Following kidney donation, the following changes take place within 1 week of donation :
DIabetic donors can have significant hypertension and albuminuria in comparison with diabetics in the general population. In addition, diabetic donors have twice the risk of hypertension compared to the general population.
Diabetes in kidney donors can develop anywhere between the first 2 decades following kidney donation. There did not appear to be an increased risk for accelerated kidney disease in diabetic donors in comparison with non-diabetic donors.
Limitations of study include the following :
The study concludes with a recommendation not to reject kidney donors based on positive family history of diabetes type 2, and to maintain longer follow up post donation. Counseling patient for weight management and smoking abstinence in crucial.
Level of evidence
Case control study – level of evidence 3.
This is a single-center retrospective case-control study between 1963 and 2009 with 3825 living donors evaluating the correlation of diabetes mellitus after kidney donation and its consequences, being considered an evidence study 3b.
Potential donors are discouraged when they have both diabetic parents, multiple siblings, or obese (BMI greater than 35), especially when they are Hispanic or African American. In this study, all patients were Caucasian, assessing the prevalence of systemic arterial hypertension, eGFR, proteinuria, age, gender, and age at donation.
Of the 3825 patients, 48 underwent kidney-pancreas, 293 died and 555 did not receive feedback through the voice questionnaire, leaving 2929 patients. In 40% of patients, the cause of death was unknown and only two donors had a death related to diabetes complications.
When calculating risk factors for diabetes, the Hazard Ratio found was:
Family members with DM1 – 2.97
Future risk of developing DM 2 – 3.07
BMI > 30 – 2.97
Male gender – 1.76
> 45 years old at the time of donation – 1.46
Serum creatinine and smoking status at the time of donation were not predictive of T2DM. Donors who developed DM2 had a high prevalence of systemic arterial hypertension, proteinuria, and BMI around 31.
This study suggests that risk factors for the development of T2DM are not different between donors and the general population. Smoking appears to be an important factor, but the study number was not sufficient to generate statistically significant data. On the other hand, the lack of data related to retinopathy, renal biopsy, or end-organ damage findings from diabetes.
This study was exclusively aimed at a Caucasian population, outside the reality of Brazil, where we have an extremely mixed population with very different genetic characteristics. Obesity, smoking, and physical inactivity must be proactively reversed to improve the donor’s quality of life.
DM is the leading cause of ESKD, T2DM has a strong genetic component and 30% its patients mostly develop kidney disease. Transplant centers exclude kidney donors with a strong family history of type 2 diabetes.
This study was done to compare kidney function in diabetic donors to that of age, gender, duration after donation and BMI-matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR when compared to nondiabetic donors.
2929 responders were included, 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM
Donors with diabetes
154 donors (majority were white and 47% donated to a sibling or other family member) who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation.
20% had a positive family history for T2DM. Current HbA1c was available in 51 donors, and it was 8.0 ± 7.8% and a third were receiving oral hypoglycaemic agents
71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; at the same time they were told have diabetes
Serum creatinine was available in 126 of the diabetic donors and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes
29 donors (18.8%) were told they have proteinuria
donors who developed T2DM had an increased prevalence of hypertension and were also more likely to have proteinuria
risk factors for the development of T2DM in kidney donors similar to general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early DKD
eGFR change
The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2
The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year
matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI, and duration after donation and found rate of eGFR change to be almost indistinguishable: 0.61 mL/min/ year.
For diabetic donors pre- diabetes was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and post diabetes eGFR slopes −1.10 ± 5.6 mL/min/year (range −10.8–7.3)
Silveiro et al found that microalbumiuria -higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
Chang et al.found no difference between the mesangial matrix volume; in subjects with one kidney type 1 diabetes who received renal transplants compared to those with two kidneys. Data suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
Diabetic donors are twice more likely to be hypertensive but this frequency of hypertension is, similar to type 2 individuals with two kidneys.
Observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself.
The study is case control level of evidence III, case-control study
In our practise we usually will not take pre diabetic and diabetic patients for living kidney donation.
Aim of the study:
To report on the donors’ risk of developing T2DM
To compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index-matched non-diabetic donors.
To assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to non-diabetic donors.
Methods:
Survey-based study including questions about diabetes, hypertension and proteinuria.
Results:
3777 kidney donors were survyed regarding the development of T2DM.
Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation.
The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at the time of donation. Compared to age, gender, duration after donation and body mass index-matched non-diabetic donor controls; diabetic donors were more likely to have hypertension and proteinuria but had a similar serum creatinine.
eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched non-diabetic donor controls.
Conclusion:
factors associated with T2DM in kidney donors are similar to those in the general population and donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Level 3 ( case-control study ).
Please summarize this article in your own words
DM in one of the leading causes of Kidney Damage and affects 30% of those affected. It has a strong genetic association with prevalence rising due to increase in obesity in general population.
This study assesses
a) Donor’s risk of developing T2DM
b) Compare Kidney function in diabetic Donors to matched Non-Diabetic Donors (age, gender, duration after donation and BMI matched)
c) Vulnerability of faster Decay of GFR in diabetic versus non-diabetic donor
Risk factor for development of diabetes found in this study:
1. Donation to family member with T1DM (HR 2.97)
2. BMI >30(HR 2.97)
3. Male gender (HR 1.76)
4. Donor>45 years, slightly more likely to develop DM(HR 1.46),not statistically significant
Donor with Diabetes:
As compared to matched nondiabetic donor controls, donors who developed T2DM had an
a)increased prevalence of HTN (71% versus 36.3%), in second decade after donation
b)more likely to be proteinuric (18% versus 2.9%), in second decade after donation
Annual eGFR change:
Rate of annual eFGR decline in donors with or without Diabetes when compared longitudinally doesn’t show an accelerated pattern
Prevalence and risk factors for T2DM in kidney donors
Same as general population
United Kingdom Prospective Diabetes Study (UKPDS) suggests:
Avoid :
· Potential Donors with both Diabetic parents
· Potential Donor who has multiple siblings with T2DM with one parent diabetic
· Potential Donor who has multiple siblings with T2DM with one immediate family member with diabetes, especially African American or Hispanic
What is the level of evidence provided by this article?
Retrospective case control study, Level of evidence 3
Please reflect on the guidelines provided above and on your practice.
In my practice,
FBS, PPBS, HbA1c done twice.
If impaired FBS/PPBS, will proceed for OGTT.
If found diabetic, will look for end organ damage like albuminuria, Diabetic retinopathy/Neuropathy.
If no evidence of end organ damage and not significant family history of Diabetes/Diabetic Nephropathy and age at the time of assessment more than 40years, we select such diabetic as prospective Donor with well informed consent
Level 3
DM is the most common cause of ESRD , so its very important to study the risk of developing DM post donation , and to compare the effect of diabetes between donor and non donor population .
This study aims to determine the risk of development of T2DM in kidney donors and to compare rate of kidney function decline in diabetic donors and matched non diabetic donors.
It included 3825 kidney donors who had nephrectomy between 1963 and 2009.
Potential donors with family history of T2DM were accepted if their age at time of assessment was 10 years beyond the age at which parent developed T2DM, those with >1 immediate family member with DKD are discouraged from donation.
Potential donors with BMI >35 are advised to lose weight and to donate when BMI <30.
They found no increased risk of having diabetes in donors, whom experienced diabetes were smokers , having a BMI >30, and the serum creatinine at the time of donation was higher than non diabetic donors.
risk factors for diabetes according to study was:
Conclusion:
Exclusion of potential donors due to presence of positive family history of T2DM and negative oral glucose tolerance test is not justified but further studies with longer follow up are still needed
All kidney donors especially with positive family history for DM should be advised to keep weight control.
in our trasnplantation center we ordered FBS two times with HbA1c if normal we accept the patient if one of them is abnormal we refer him to endocrinologist and do OGTT
thanks
– Diabetes mellitus is the leading cause of end-stage renal disease .
– some transplant centers decline kidney donors with a strong family history of type 2 diabetes, due to theoretical concerns regarding the possible additive effect of hyperfiltration that is instigated by diabetes and reduction in renal mass . Yet it is unknown whether development of T2DM after donating a kidney leads to a higher risk of experiencing acceleration in glomerular filtration rate (GFR) decay when compared to nondiabetic donors or diabetics with two kidneys.
– This study repots on the donors’ risk of developing T2DM, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decay in GFR when compared to nondiabetic donors
– this study surveyed 3777 kidney donors regarding the development of T2DM. Of the 2954 who responded, 154 developed T2DM 17.7 ± 9.0 years after donation. The multivariable risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Results :
Compared to age, gender, duration after donation and body mass index (BMI) , matched non-diabetic donor controls;
– diabetic donors were more likely to have hypertension (70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls.
Conclusions:
– the risk factors for the development of T2DM in kidney donors is similar to the general population
– donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease.
– Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
– Therefore, declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
– All kidney donors, particularly those with a positive family history for diabetes, should be strongly advised to maintain weight control.
– level of evidence>>>III ( case controls study )
– in our practice , we are doing Fasting & post prandial plasma glucose & HBA1C for screening for DM
– if DM>>exclude from donation
-if impaired FPG >>so will do OGTT >>if impaired also>>will be excluded
– if normal OGTT & after reduction of weight & life style modification >> can be accepted with counselling regarding the risk .
. Diabetes after Kidney Donation
1.
The study was about DM and that it is the most frequent cause of kidney failure worldwide. The major risk factors are obesity and a strong family history of DM especially type 2. Due to the major risk that are frequent with DM should it be a liable or viable candidate for kidney transplantation especially when it comes to rapid decrease in kidney functions and that itself will have a great impact on the donor kidney.
The study was conducted at the university of Minnesota of about 3777 kidney donors as it relates to DM type 2. They were looked into closely to see if there was DM, proteinuria, HTN, the number of medications taken and etc.
Based on the study the results showed that the risk of developing DMT2 was related with DMT 1 in the recipient, male patients, and a BMI of greater than 30 kg/m2.
Micro albuminuria was grater single DM kidney than non DM kidneys and the prevalence of albuminuria and HTN was similar in DM donors and DM patients with 2 kidneys, however the HTN risk was greater when compared with the non DM donors.
It was found that patients who are DM donors were more likely to have HTN, proteinuria, but their serum creatinine was similar but the GFR changed after developing DMT2 as it relates to non-DM donors.
It was found that smoking was not a risk factor for DMT2.
The study had some imitations and they are: the follow-up was too short, the cause of death of 40 % of donors were missing, and the self-support urine test assessments.
2. What is the level of evidence provided by this article?
I think the level of evidence is level 3
3. Please reflect on the guidelines provided above and on your practice.
Well currently there is not kidney transplantation in my country but I would like to ensure that the patients are properly screen and studied to ensure all pathologies are diagnosed and treated base on the international guidelines.
◇Summary of the article
This article discusses the incidence of DM post kidney donation
Diabetes mellitus is the leading cause of end-stage renal disease, T2DM has a strong genetic component and 30% iv its patients mostly develop kidney disease.
some transplant centers decline kidney donors with a strong family history of type 2 diabetes.
This study was done to compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI)-matched nondiabetic donors and assess whether diabetic donors are vulnerable to a faster decline in GFR when compared to nondiabetic donors.
2929 responders were included , 154 donors reported developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM,
Donors with diabetes
-For the 154 donors who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation.
-the majority were white and 47% donated to a sibling or other family member
-20% had a positive family history for T2DM. Current HbA1c was available in 51 donors and it was 8.0 ± 7.8% and a third were receiving oral hypoglycemic agents.
-Of the 154 diabetic donors, 71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; almost at the same time they were told they have diabetes.
-Serum creatinine was available in 126 of the diabetic donors and it was 1.26 ± 0.40 mg/ dL with an eGFR of 58.8 ± 16.7 mL/min/1.73m2; 7.7 ± 7.0 years after the development of diabetes.
-29 donors (18.8%) were told they have proteinuria.
-it was found that donors who developed T2DM had an increased prevalence of hypertension and were also more likely to be proteinuric .
-the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease
▪︎Longitudinal eGFR change
Of the 154 donors who developed diabetes
The annual eGFR change in these donors was −0.80 ± 0.9 mL/min/ 1.73m2 .
The annual change of eGFR in 522 donors without diabetes and ≥15 years after donation was −0.70 ± 0.86 mL/min/year .
To strengthen this analysis, we matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year.
-For diabetic donors pre- and postdiabetes eGFR slopes. Prior to development of T2DM, it was −0.88 ± 0.67 mL/min/year (range −1.96 to −0.21) and after developing the condition it was −1.10 ± 5.6 mL/min/year (range −10.8–7.3).
-Silveiro et al found that microalbumiuria
was noted in a higher proportion of single-kidney diabetics (40%) than single-kidney nondiabetics (18%) or two-kidney diabetics (20%).
-Macroalbuminuria was noted in a higher proportion of single-kidney diabetics (30%) than single-kidney nondiabetics, but there was no difference between single-kidney diabetics (30%) and two-kidney diabetics (23%).
-Chang et al.found no difference between the mesangial matrix volume; in subjects with one kidney type 1 diabetes who received renal transplants compared to those with two kidneys
data suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
-Diabetic donors, however, are twice more likely to be hypertensive than age, gender, duration of follow-up and BMI-matched nondiabetic donor controls but this frequency of hypertension is, similar to type 2 individuals with two kidneys.
observations suggest that the higher prevalence of proteinuria in the diabetic donors is unrelated to donation itself.
*Limitations of the study
-longer follow-up is needed as it takes an average of 10 years from the diagnosis of type 2 diabetes for 25% of subjects with diabetes to develop microalbuminuri amedian time before progressing to macroalbuminuria is 11 years and the median time before progressing to nephropathy is 10 years.
-The cause of death was missing in 40% of all donors.
-true incidence of diabetes could not be precisely determined.
-limited by survival bias and by response bias.
-could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation.
The study is case contol level of evidence III
In my practice we ask for fasting, 2 hours post prandual blood Glucose and HBA1C diabetic donors are declined ,
Prediabetics are asked to controll weight ,smoking and other risk factors and counseled about the potential risk after donation
Please summarise this article in your own words
Kidney donors are at risk of developing Type 2 diabetes as general population. The course of donors who develop diabetes has not been studied. In this study 3777 donors were surveyed regarding development of diabetes. 2954 responded.
In this study following variables were assessed.
Frequency of development of diabetes
Risk factors of developing diabetes
Comparing those who develop diabetes with matched non donors (Regarding proteinuria, hypertension and creatinine)
Evaluate consensus of excluding donors with strong family history of diabetes mellitus.
Results-
154 Developed type 2 diabetes 17.7+-9.0 years post donation
Risk of development of Diabetes included male gender, time duration post donation, BMI>30. smoking, Type 1 diabetes in recipient.
Risk of development of hypertension was almost twice than non diabetics (70.8% vs. 36.2%)
Proteinuria -18.8% vs. 3.9%, but had similar serum creatinine
Conclusion
Factors associated with T2DM in kidney donors are similar to those in the general population
Donors screened carefully at the time of donation do not appear to have an acceleration of diabetic kidney disease.
Albuminuria is more in those who develop diabetes as compared to non diabetic donors
Kidney donors with strong family history should be advised for strict weight control
Kidney donation does not contribute to added risk of development of diabetes.
What is the level of evidence provided by this article?
Cross sectional study Level 1V
Please reflect on the guidelines provided above and on your practice.
In my practice we use fasting and post prandial sugars and HbA1C.
Pre diabetics are advised lifestyle changes and reassessed later
Diabetic donors to be excluded
The study assessed risk of developing type 2 diabetes mellitus in donors, the comparison of renal function, proteinuria, and blood pressure in such donors with age-, denger-, BMI- and duration after donation-matched donors who did not develop diabetes post-donation and whether such donors have increased risk of faster decline in GFR.
The study was done by conducting a survey of the donors asking them regarding diabetes mellitus, hypertension and proteinuria.
154 out of 2954 (5%) developed type 2 diabetes mellitus with a mean of 17.7 years after donation, which was like the incidence in general population. Risk factors for developing DM included donating to a family member with type 1 DM, males, age more than 45 years, and BMI more than 30. There was no relation with smoking or serum creatinine at donation.
71% of the donors who developed diabetes had hypertension (2 times of the non-diabetics, but similar to diabetics with 2 kidneys) and 18.8% developed proteinuria (4.5 times more than the non-diabetics, but similar to diabetic patients with 2 kidneys) while the serum creatinine was similar to non-diabetics. 20% of the diabetic donors had family history of DM. The rate of eGFR change in the diabetic donors and matched non-diabetic donors was similar. The difference in the pre- and post-diabetic eGFR slopes in the diabetic donors was not significant.
The limitations of the study include: non-availability of cause of death of 40% of the donors; survival bias and response bias; the donors were screened at time of donation, hence they are a selected subgroup of the population; role of ethnicity not assessed as the population mainly consisted of whites; family history of diabetes was not captured; Proteinuria was self-reported.
So, risk factors for development of diabetes in renal donors are similar to those in general population. Diabetic donors have increased hypertension and proteinuria than non-diabetic donors, but the frequencies are similar to diabetics with 2 kidneys. It implies that these higher prevalences are unrelated to the act of donation and are more due to the diabetes itself.
Level of evidence: Level 3 – Case-control study.
We perform an HbA1C and Fasting blood sugar with post-prandial blood sugar in all our prospective living donors. In cases with abnormal readings, we perform OGTT before going any further in donor evaluation
As diabetes mellitus DM is a prevalent disease in the community, this study tried to assess the impact of DM on the renal function in kidney donors, as the potential hyperfiltration inflict of DM is theoretically fortified by reduced nephron mass and compensatory nephronal hyperfiltration. Based on this assumption, most of the transplant centers strongly advocate against kidney donation from relatives of DM, especially 2 parents, or more than one sibling.
To verify whether Diabetic kidney donors are increasingly prone to complication of DM that they attracted post donation, in particular, proteinuria. renal failure and hypertension. all diabetic donors were surveyed in comparison to non donor diabetics and non diabetic donors.
Between 1963 and 2009, more than 3000 nephrectomies where done.
154 donors reported to have type 2 DM. The result showcased seemingly common risk factors for developing T2DM with the non-donor’s population with matched risk factors of age, BMI. Nevertheless, the rate of albuminuria was earlier in donor diabetic DD, however GFR changes were comparable between DD and non-DD, concluding that, the donation dose not negatively impact the incidence or course of T2DM in DD. Henceforth, loosening the stringent criteria to involve Donors with family history of DD is advocated.
This study was case control study with level of evidence 3.
In our practice donors with normal blood sugar, fasting, post prandial and HbA1c are considered suitable even if he is of a strong family history of diabetes Mellitus.
Diabetes after Kidney Donation
Am J Transplant. 2010 February
This is a cross-sectional (prevalence) study (level of evidence III) in which 3825(2954 responded) renal donations are done in the University of Minnesota between Jan 1, 1963- March 31 2009 screened regarding the prevalence of type 2 DM, evaluation of its risk factors and comparing diabetic donors after donation to matched non-diabetic donor as controls regarding creatinine, proteinuria, and hypertension.
Results:
Conclusion
Please reflect on the guidelines provided above and on your practice.
Diabetes after Kidney Donation .
Introduction:
Type I and II DM is considered one of the most common cause of ESRD worldwide, risk of developing DM post kidney donation will be reported here, compare kidney function in diabetic donors to that of age, gender, duration after donation and body mass index (BMI) matched nondiabetic donors and assess whether diabetic donors are liable to a faster decay in GFR when compared to nondiabetic donors.
Materials and Methods.
The University of Minnesota surveyed 3777 kidney donors regarding the development of T2DM by contact them and asked if there have DM, duration of diagnosis, on medications or diet control, proteinuria development, HTN developed or not, with medications or not.
Results
2929 have responded to the survey, 154 donors reported developing T2DM 17.7 ± 9.0 years after donation,129 from the 2929 currently alive donors, 17 of 293 deceased donors, only two donors were listed to have died of diabetes-related complications and11 donors have developed ESRD requiring dialysis or transplantation and none was due to diabetic kidney disease.
The risk of development of T2DM was associated with type 1 DM in the recipient, male gender and body mass index >30 kg/m2 at time of donation.
Diabetic donors were more likely to have hypertension, proteinuria but had a similar serum creatinine. eGFR change after T2DM development comparing to non-diabetics donors with similar duration after donation.
Donors with diabetes.
For the 154 donors who developed diabetes, mean age at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation, 154 diabetic donors, 71% developed hypertension requiring treatment 17.6 ± 8.9 years after donation; almost at the same time they were told they have diabetes.
Compared to age, gender, duration after donation and body mass index (BMI)- matched non-diabetic donor controls; diabetic donors were more likely to have proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine. eGFR change after T2DM development was −0.80 ± 0.94 mL/min/year, −0.70 ± 0.86 in nondiabetic donors with similar duration after donation and −0.61 ± 0.76 mL/min/year in age.
Summary:
The risk for the development of T2DM in kidney donors is similar to the general population.
Donors who develop DM have rates of albuminuria that are higher than nondiabetic donors.
Risk factors for developing type II DM
1.Donating to a family member with type 1 diabetes
2.BMI greater than 30.
3.Male gender
4.Donors over the age 45 years old.
Diabetics and nondiabetics donors had a similar serum creatinine.
What is the level of evidence provided by this article?
Level 3 B (retrospective cohort study).
Please reflect on the guidelines provided above and on your practice.
We should be more caution in selection our kidney donors with strong family history of DM, old age, obesity with BMI>30.
We should keep our patients with these criteria to be strictly observation.
More large studies with long term follow up are needed to more clarification of this point.
Introduction
Diabetes mellitus is number one cause of ESRD worldwide. Its prevalence increases with the increase of obesity. T2DM had a genetic predisposition, and since it could cause ESRD, potential kidney donors with strong family history of DM could be excluded from donation.
Aim of the study:
To assess whether post donation development of DM is associated with increased risk of acceleration of eGFR decline when compared to non-diabetic donors or not.
Materials & methods:
Between Jan 1st 1963- March 31st 2009, 3825 renal donation done in the University of Minnesota. Attempts to contact the donor in the last 3 decades to confirm health status, & in last 7 years comprehensive multistep approach used to locate all donors, those who were a life with available contact information were sent survey regarding T2DM development.
The survey included the following questions:
1. Were you ever told you have diabetes? If you answered yes, please answer the following questions:
a. How old were you when you were diagnosed with diabetes?
b. Are you currently taking insulin, a pill to lower your blood sugar (glucose) or both?
c. Are you controlling your blood sugars by diet only?
2. Do you have hypertension (high blood pressure)? If yes, are you taking medications
to lower your blood pressure and when did you start taking them?
3. Were you ever told you have protein in the urine? When?
Donors with 2 diabetic parents, multiple siblings with T2DM in addition to 1 parent with T2DM or >1 immediate family member with type 2 diabetic kidney disease are excluded from donation especially if they are of African American or Hispanic descend.
eGFR (MDRD) done for all donor with comparison to the matched nondiabetic donor (age, BMI, gender & years from donation).
Results & discussion:
Of the 3777 who responded to the survey, 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys In total, 154 donors reported
developing T2DM; 129 from the 2929 currently alive donors, 17 of 293 deceased donors
with available information prior to death and 8 of the 555 donors with no recent health
updates reported having T2DM, as well.
Risk factors for diabetes development were:
1. Donating to a family member with type 1 diabetes; HR 2.97.
2. BMI greater than 30; HR 2.97.
3. Male gender; HR 1.76.
4. Donors over the age of 45 were slightly more likely to develop diabetes; HR 1.46
• Micro-albuminuria was higher in single diabetic kidney (40%) than single non diabetic kidney(18%) & 2 diabetic kidney(20%).
• Macro-albuminuria was higher in single diabetic kidney (30%) than single non diabetic kidney but comparable to 2 diabetic kidneys.
• No difference in prevalence risk factors of T2DM in kidney donor than general population.
• Smoker is not a strong risk factor for T2DM which may be due to clustering of other habits in smokers.
• Prevalence of albuminuria & hypertension was similar in diabetic donor & diabetic patient with 2 kidneys, but hypertension risk was more when compared to matched non diabetic donors.
• eGFR decline was not faster in diabetic donor when compared to non diabetic donor & 2 kidney with diabetes.
Limitations:
· Follow-up done just for first decade after development of diabetes.
· Missing of death cause in 40% of donors.
· Survival bias.
· Inability to assess the role of ethnicity in diabetes development( most donors were white).
· Self-report & dipstick protein assessment
1. What is the level of evidence provided by this article?
Level 3, case control study.
2. Please reflect on the guidelines provided above and on your practice.
In our centre we screen all potential donors with FBS, HB A1c. Donors with family history of DM or obese we do OGTT.
Introduction
Diabetes mellitus is the common cause of ESRD worldwide and its prevalence increases with the increased rate of obesity, around 30% of patients with Type2DM have a genetic susceptibility to CKD and in some centers, they don’t accept a donation from those with a strong family history of DM due to the additional risk of hyperfiltration with nephrectomy. Kidney donors are at risk of DM like the general population, however, still, we don’t know if the diabetic donor compared to non-diabetic donors’ aim of this study is to address the long-term consequences of the donation including the risk of DM.
Material and setting
A single-center study reviews the donors from 1963-2009 from the University of Minnesota, they included > 3825 donors whose nephrectomies, they don’t exclude donors with Positive FH of T2DM, and all donors were contacted and assessed their health status and FU them over 7 years by full multistep style included reviewing their medical records, phone call, and internets connection or through the recipients, also send them to survey about the type2 DM development after kidney donation of three questionnaires ( if you have been told that you have DM at which age after donation are you on treatment ( insulin, pills, or both are under control with diet, any associated hypertension if yes are you under control with medications and when did you start? And Proteinuria.
for determination of e GFR by MDRD formula, and annual change in was calculated and compared between the two groups, proteinuria screen, and blood pressure all matched by 1-1 between the two groups to age and sex. Time form donation by years, BMI at time of donation
all donor and nondiabetic control groups are white populations
Results
In this study, they top diabetes information on 2945out of 3777 donors (2929 + 17 deceased + 8 with no recent contact)
IN 40% of the donors the cause of death was unknown, CVD in 19%, and cancer in 20%, while from diabetic patients only two only
11% progress to ESRD and none have DM
154 donors developed DM with an average age of 39 + The mean time for donation till the development of DM is 17+/-9 years
71% OF diabetic donors were found to be hypertensive, while only 18.8 % reported having proteinuria
Donors with DM are smokers with BMI > 30s and they have higher baseline creatinine, more than 80% of nondiabetic donors, donate prior to 2002 when the high-risk donor should be tested with OGTT.
Risk factors for DM
1. donation to a family member with a T1DM with HR2.9(95%CI 1.9-4.5) and in lower range donation to a Family member with T2DM.
2. BMI>30
3. Male gender
4. donor aged above 45 years
The diabetic donors tend to be more hypertensive 71% vs 34% compared to non-diabetic control and more proteinuria 18.8 vs 3.4 % after adjustment to the age, sex, BMI, and duration of the donation
Longitudinal change in GFR over the FU period is more in DM however did not reach statistical significance.
Discussion
After donor nephrectomy, the GFR will increase due to increased renal plasma flow, up to 70% after the first-week post-donation, so both reduced renal mass and occurrence of DM will have an additive hyperfiltration effect and increased GFR but on long-term fU, this can contribute to progressive CKD
This study suggests that the prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population. smoking did not show statistical significance as risk factor for DM post-donation (small sample size)
Limitation of the study
They include only the white population, exclusion of another ethnicity may affect the results, especially for black ethnicity
Missing data about the FH of DM in nondiabetic donor
Cause of death missing in 40% of the donors
Proteinuria records by self-reporting and by UDS analysis can be misleading and few patients have quantitative urine a/c ratio
Survival bias (Missing data about the DM in the majority of donors who died)
Response bias
Underestimation of the presence of DM, and HTN in the general population
Short follow up
retrospective cohort with the control group, level 3B
Being practicing in the gulf area with a higher rate of DM and DKD which is the leading cause of ESRD in Oman around 66% of patients on dialysis due to DKD so excluding donor with DM and those with impaired fasting will do OGTT IF impaired GTT also we exclude them, metabolic syndrome with high HBAIC , fatty live hyperuricemia and BMI> 30 we decline them for donation.
The kidney donor have the same risk as general population of having diabetes , the risk factors ; as obesity , male gender, age, and body mass index >30 .
In survey done in Menissota university by medicine and surgery department , they found that among 2954 donor , 154 develop t2 DM after 17.7 +-9 yrs after donation.
Diabetic donor have more incidence rate of developing HTN (70.8 vs 36.2) P<0.005, and proteinurea (18.8 vs 3.9%) P <0.0001. with similar s.cr. eGFR change was -0.80+-0.94 in diabetic vs -0.70+-0.86 in non-diabetic donors, so this short term survey noted that factor associated with T2DM in kidney donors, is same as for general population .
Survey done have no exclusion criteria, from 3777 , 2929 share in the survey .
The rsult of the survey was; 293 died, 555 no feed back during the last 4 yrs, 154 develop T2 DM.
T2 DM donors post transplant have previuos risk factor thann non diabetic ( smoking, BMI> 30 , and their s.cr was slightly higher pre donation ., also notced that 80% of donors undewent donation before 2002, when GTT is moadatory for high risk donors.
Charecteristic of diabetic, non-diabetic, and non-responder;-
Risk factors for development of T2 DM;
variables at donation HR;
Unadjusted group;
MBI >30 T1 DM in rcipient 3.07
T2 DM in recipient 2.46
Men 1.35
Donor age > 45 yrs 1.53
S.Cr 0.95
Smoking 1.22
Adjusted group;
BMI; 2.9
T1 DM 2.27
T2Dm 3.07
Men 1.76
Donor age >45 1.46
S.Cr 0.79
Smoking 1.22
Level of eidence ((3)).
Reflection of guidelines on local practice;
Diabetic patient with risk factor such as uncontrolled, obses, with microvascular complication e.g micro albuminurea , are always excluded from donation .
DM is one of the commonest causes of ESKD, 30% of patients with T2DM may develop renal impairment, so potential donors with strong family history of T2DM may be excluded for fear of GFR decline after donation as donor nephrectomy induce hyperfiltration leading to increased GFR, the compensatory increase in GFR in presence of reduced renal mass and DM may accelerate the deterioration of diabetic kidney disease.
The concern is raised about adverse effect of hyperfiltration after donation and hyperfiltration due to DM.
This study aims to determine the risk of development of T2DM in kidney donors and to compare rate of kidney function decline in diabetic donors and matched non diabetic donors.
It included 3825 kidney donors who had nephrectomy between 1963 and 2009.
Potential donors with family history of T2DM were accepted if their age at time of assessment was 10 years beyond the age at which parent developed T2DM, those with >1 immediate family member with DKD are discouraged from donation.
Potential donors with BMI >35 are advised to lose weight and to donate when BMI <30.
The study showed that:
Limitations:
Short term follow up of diabetic donors
The cause of death was missing in 40% of donors, missing information may lead to survival bias.
Presence of response bias about DM and HTN as patients with DM or HTN may be unaware of their presence.
Only included white donors.
Small proportion of donors had quantified method for assessment of proteinuria, majority was assessed.
Conclusion:
Exclusion of potential donors due to presence of positive family history of T2DM and negative oral glucose tolerance test is not justified but further studies with longer follow up are still needed
All kidney donors especially with positive family history for DM should be advised to keep weight control.
Level of evidence: 3 Case control study
In our practice, potential donors with impaired oral glucose tolerance test are excluded.
Please summarise this article in your own words
The study try to figure out the risk for diabetes occurrence among donors, conducted by University of Minnesota, from January,1, 1963 -nMarch 31, 2009, cohort case control study, using a questionnaire.
They found no increased risk of having diabetes in donors, whom experienced diabetes were smokers , having a BMI >30, and the serum creatinine at the time of donation was higher than non diabetic donors.
risk factors for diabetes according to study was:
The mean time to have diabetes after donation was 17.7 -/+9 years, 71% of diabetic patients found to have HTN requiring treatment.
The eGFR decline was comparable in diabetic and non diabetic donors.
Microalbuminuria was higher single kidney diabetic(40%), than single kidney no diabetic(18%), or two kidney diabetic(20%), it takes 19 years to occur.
Macroalbuminuria was the same in single kidney diabetic and non diabetic(30%), and lesser in two kidney diabetic(23%). it takes 11 years to occur and 10 years to progrees to nephropathy.
There was higher prevalence of smoking among diabetic donors, but not of clinical significance.
Measurement of OGTT in donors, with family history of diabetes is justified to refuse donation!.
Conclusion:
The incidence of diabetes post kidney donation was not different among donors and non donors.
Diabetic donor is not at higher risk to progress to nephropathy and end stage renal disease.
Kidney donors with strong family history for diabetes, should not smoke and maintain a normal weight.
What is the level of evidence provided by this article?
Level of evidence is III b case control cohort study.
Please reflect on the guidelines provided above and on your practice.
In our practice we perform twice FBS and Hba1c in the evaluation of patients and ask about the clinical signs of diabetes.
If FBS >126 mg/dl in two occasions, or HbA1c > 5.8% we consider OGTT.
usually we decline the donor if he has an impaired glucose tolerence.
Please summarise this article in your own words :
1- 293 of donors were died. the cause of death was unknown in 40% of them, cardio-vascular causes accounted to 19% and cancer causes accounted to 20% of their mortality. diabetic complications accounted to only 2 % of mortality.
2- 555 of donors were not responding to the survey questionnaire.
3- there were remaining 2929 who responded to the questionnaire.
4- 154 donors developed T2DM over a post-donation period of 17.7+/-9 years. 129 of them were out of the 2929 donors,17 of them were out of the 293 dead donors and 8 of them were out of the 555 non-responding donors with no recent contact.
5- hypertension was developed in 70.8% of donors versus 36.2% of non-donors.
6- proteinuria was developed in 18.8 % of donors versus 3.9 of non-donors.
7- serum creatinine was not changed between donors and non-donors.
1- the risk and associated factors of T2DM development in kidney donors are similar to these of the general population.
2- living kidney donors who were screened carefully at the time of donation have no acceleration of diabetic kidney disease in the first decade post-donation. therefore, declining donors with +ve family history of T2DM may not be fully justified. however, all donors should be advised to maintain their ideal body weight.
3- larger and longer studies are still needed for more evaluation.
What is the level of evidence provided by this article?
Please reflect on the guidelines provided above and on your practice.
Diabetes after Kidney Donation
Summary
This retrospective study analyzed KT donors with perspective to T2DM in the period from 1963 to 2007 at the university of Minnesota.
1. No policy that excludes donors with family history of T2DM.
2. Potential donors with multiple siblings having T2DM in addition to diabetic parent or one immediate family member are strongly discouraged from donation.
3. All potential donors have a normal GTT which was performed in the followings:
i. more than one immediate family member with T2DM.
ii. women with history of gestational diabetes.
iii. those with fasting blood sugar ≥99 mg/dL.
4. Accepted BMI is less than 30 kg/m2.
Risk factors for diabetes in LKDT:
1. Family member with type 1 diabetes.
2. Family member with type T2DM (to a lesser extent, but not statistically significant).
3. A BMI greater than 30.
4. Male gender.
5. Donor age > 45 y.
6. Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM.
Study Conclusion:
1. The risk factors for the development of T2DM in kidney donors is similar to the general population.
2. Donors who develop it have rates of albuminuria that are higher than nondiabetic donors.
3. Diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
Suggestions by the study’s group:
1. Declining donors with positive family history of type 2 diabetes, if screened with oral glucose tolerance, may not be fully justified but larger studies and, more importantly, longer follow-up are needed.
2. Potential donors with FH of DM should be strongly advised to maintain weight control.
The level of evidence provided by this article: level III
Please reflect on the guidelines provided above and on your practice.
We don’t exclude potential donor with positive FH od DM unless having impaired an abnormal blood sugar level( fasting blood sugar or GTT).
Observational study aimed to address possible risk factors of diabetes in kidney donors, and thereafter check the influence of diabetes in development of other complications (hypertension, proteinuria, the rate of eGFR change/decline in renal function) compared to matched non diabetic donors.
Single centre study was conducted Between January 1963 and March 2009, at the University of Minnesota. 3825 donor nephrectomies were performed * exclude patients also donated a partial pancreas: remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded. In total, 154 donors reported developing T2DM.
Risk factors for diabetes include:
1. BMI>30; HR2.97 (95% CI 1.93–4.56), p<0.001
2. male gender; HR 1.76 (95% CI 1.12–2.76),
3. family member with type 1 diabetes; HR 2.97 (95% CI 1.93–4.56), p < 0.001, and to a lesser extent, but not statistically significant T2DM; HR 3.07 (95% CI 0.92–10.23), p = 0.07, were associated with the future risk of developing T2DM
4. Donors who were over the age of 45 were slightly more likely to develop diabetes; HR 1.46 (95% CI 0.97–2.19), p = 0.07
* serum creatinine and smoking status at donation not predictive of the future risk of T2DM.
For the 154 donors who developed diabetes, mean age (±SD) at time of donation was 39.8 ± 11.4 years and the diagnosis of diabetes occurred 17.7 ± 9.0 years after donation. the majority were white and 47% donated to a sibling or other family member. The cause of ESRD in the recipient was type 1 diabetes in 33%, hypertension in 35%, T2DM in 10%, polycystic kidney disease in 5% and other in 15%. Of the 154, 20% had a positive family history for T2DM.
Then for the determination of the prevalence of hypertension, eGFR and proteinuria, diabetic donors were matched (1:1) on age, gender, years from donation and BMI at donation to donors who did not develop diabetes. All diabetic and nondiabetic controls were white. diabetic donors were more likely to have hypertension
(70.8% vs. 36.2%, p = 0.005), proteinuria (18.8% vs. 3.9%, p < 0.0001) but had a similar serum creatinine.
In a matched 56 donors out of the above 522 nondiabetic donors to the 64 diabetic donors on age, gender, BMI and duration after donation and found their rate of eGFR change to be almost indistinguishable; 0.61 mL/min/ year (eGFR change after T2DM development was -0.80 ± 0.94 mL/min/year, -0.70 ± 0.86 in nondiabetic donors with similar duration after donation and -0.61 ± 0.76 mL/min/year in age, gender, BMI and duration after donation matched nondiabetic donor controls)
What is the level of evidence provided by this article?
Observational, Case control study (retrospective controlled), level 3
Please reflect on the guidelines provided above and on your practice.
Practice: All potential donor assessed in details clinically (history, examination, lab) for diabetes
impact: carefully address possible risk factors: BMI, family history of diabetes specially in older male
may retrieve data of previous donors already at risk: follow up more frequent for possibility of diabetes
The aim o the study ;
The prevalence and risk factors for T2DM in kidney donors.
The type of the study;
Case control study .
The study area ;
The University of Minnesota.
Ethical approval ;
approval by the University of Minnesota Institutional Review Board.
Population;
The study surveyed 3777 kidney donors regarding the development of T2DM.
Inclusion criteria ;
Alive donors and with available contact information.
The method ;
A comprehensive multi step approach to locate all kidney donors (including review of medical records, utilizing phone and internet directories and also the help of the recipients). The included donors were sent a survey regarding development of T2DM after donation.
Statistical method;
1-Categorical variables were compared using the chi-square or Fisher’s exact test. Continuous variables were compared utilizing the unpaired t-test.
2-A Cox proportional hazard model was used to study the predictors for the development of type 2 diabetes, utilizing variables ascertained at the time of donation.
3-All other results are expressed as mean ± SD, unless otherwise specified. p < 0.05 was considered significant. SAS 9.1 (SAS Institute Inc., Cary, NC) was used for all analyses.
Results;
The prevalence and risk factors for T2DM in kidney donors are not different than what is observed in the general population.
There study limitations ;
1-The cause of death was missing in 40% of all donors.
2 -The population of the study consisted of mainly white kidney donors and therefore we could not assess whether ethnicity plays a factor in the development of type 2 diabetes after donation.
3- The information on family history of type 2 DM in non diabetic donors was not captured.
4- Reporting on proteinuria was by self-report and dipstick protein assessment which are clearly inferior to quantitative methods and only a small fraction of donors had quantitative measurement of proteinuria.
2-What is the level of evidence provided by this article?
Level III.
3-Please reflect on the guidelines provided above and on your practice.
1- All potential donors should be screened for diabetes and categorized according to their risks for developing diabetes in the future .
2-All potential donors should be screened for diabetes or IFG using an OGTT.
3-Those,who have diabetes ,(IFG/IGT and family history of diabetes ) should be excluded from donation .
4- Life style modification before and post donation for donors .
5-Post donation screening for diabetes should be based on the pre donation risk assessment and follow the standard guidelines of general population .
6- This information help in counseling potential donors .
Summary
This is a case control study looking at the incidence of diabetes post kidney donation. It was a retrospective survey that looked at 2 outcomes:
Donors risk of developing T2DM
Compare kidney function in diabetic donors to that of age, gender, duration after donation and BMI – matched non-diabetic donors and whether diabetic donors are vulnerable to a faster decay in in GFR compared to non-diabetic donors. All the records donors who donated a kidney between the period of January 1963 to March 2009 were looked. The donors were traced and those that could be contacted were asked questions regarding the development of diabetes, hypertension and proteinuria. This already introduces a recall bias.
They had data for 3777 kidney donors out of which 2954 responded. 154 donors developed diabetes after donation – 129 were currently alive and 17 had died.
Of the 154 donors who developed diabetes after donation, the mean age at the time of donation was 39.8 years and the diagnosis of diabetes occurred 17.7 years after donation.
Compared to the non-diabetic donors matched for age, gender, duration post-donation and BMI, diabetic donors were more likely to have hypertension (70.8% versus 36.2%, p=0.005), and proteinuria (18.8% vs 3.9%, p< 0.0001) but had similar GFR decay.
The risk factors for the development of T2DM included:
The authors concluded that the risk of developing T2DM post-donation was similar to that of general population and the decline in GFR was similar to the non-diabetic donors,
The limitations of these study:
Level of Evidence
It is level III as this is a case control study
In my practice we take a detailed history of the potential donor. All potential donors are screened for diabetes or IFG using an OGTT. If the potential donor has IFG/IGT and a family h/o diabetes then he /she is excluded from being a donor and counselled on lifestyle and diet and followed up in the diabetic clinic. If there is no family h/o diabetes and the potential donor is obese, he/she is advised on lifestyle and diet and weight loss
Summary of Diabetes after Kidney DonationDM is the major cause of ESRD .
T2DM has strong genetic component and 30% of these affect with it develop kidney damage.
METHOD AND MATERIAL
Between jan/ 1963 to 3/2009 3825 donor nephrectomies done at university of MINNESTRA ,all these donor available for more information.
there are 2 group to evaluate eGFR change in these diabetics donors :
1- 522 non diabetics donors who also had multiple serum creatinine available.
2-56 non DM donors matched an age ,gender,BMI and duration after donation who had multiple creatinine measurement available .
RESULT
In total 154 donors reported developing T2DM
129 from alive donor.
two donors were listed to have died of DM related complication .
11donors develop ESRD requiring dialysis or transplantation.
Risk factors for SM :
BMI >30 .
male Gender .
Age >45 y.
Fmily history of type1DM .
but neither smoking nor serum creatinine were predictive of the future risk of T2DM.
Discussion:
In case series of DM patients with either unilateral agenesis or unilateral nephrectomy,none suffered accelerated kidney function in the remaining kidney .
Microalbuminurea was noted in ahigher proptipon of single kidney DM than non-DM but both have normal kidney function
type1 DM associtted factor for the development of T2dm in the donor and marginal nonstatistical association with type 2 DM in the recipient .
summary:
The risk factors for the T2DM in kideny donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than non diabetics donors,which may be suggestive of early diabetic kidney disease,there is accerlated risk of kidny disease in DM donors.
Donor with impaired GTT and postive family history for DM should be declined.
2- level of evidence 111
3- in our practize donor with postive family history are not excluded
but donor with impaired GTT and DM are excluded from donation.
Diabetes mellitus is the leading cause of ESRD and has a strong genetic component, and some transplant centers preclude donors with a family history of diabetes. The course of donors who develop T2DM has not been studied well.
Aim of the study:
– Report on the donors’ risk of developing T2DM.
– Compare kidney function in diabetic donors to matched nondiabetic donors
– Assess the decline in GFR when comparing diabetic to nondiabetic donors.
Materials and Methods
– Reviewing kidney donation at the University of Minnesota Between January 1, 1963, and March 31, 2009.
– Surveyed 3777 kidney donors regarding the development of T2DM post-donation.
– 293 have died, 555 lost follow-up in the last 4 years, and 2929 have responded to the surveys
– Diabetic donors were matched (1:1) on age, gender, years from donation and BMI at donation to donors who did not develop diabetes.
– All diabetic and nondiabetic controls were white.
Results:
Diabetes information on 2945 donors (2929 + 17 deceased + 8 with no recent contact)
Of 2954 who responded, 154 developed T2DM 17.7 +- 9.0 years after donation
Donors with diabetes were more likely to be smokers, have a BMI greater than 30, and have slightly higher serum creatinine at the time of donation compared to their non-diabetic counterparts.
Risk factors for diabetes development (at time of donation); donating to a family member with T1DM, a lesser extent T2DM, BMI greater than 30, male gender, and age of over 45.
Neither serum creatinine nor smoking status at donation were predictive of the future risk of T2DM, possibly due to the small number of donors studied
The diabetic donors had an increased prevalence of HTN (71% vs. 36.3%) and were also more likely to be proteinuric 18.8%.
Diabetic donors had a comparable degree of albuminuria and hypertension in the first decade of diabetes to what has been generally described in subjects with diabetes and two kidneys
The frequency of hypertension in diabetic donors is twice nondiabetic donors; however, it is similar to type 2 individuals with two kidneys.
The rate of GFR decline is not accelerated when compared to nondiabetic donors ( 0.8ml/min vs 0.7 ml/min) and is similar to the rate observed in two kidney diabetic subjects with hypertension and microalbuminuria. Comparing pre- and post-diabetes eGFR slopes, it was not statistically significant.
Silveiro et al.
Studied T2DM with uni-nephrectomy (single-kidney diabetes), versus nondiabetics who had undergone uni-nephrectomy (single-kidney nondiabetic) and versus T2DM having 2 kidneys with similar renal function at the time of the study.
Microalbuminuria was noted in a higher proportion of single-kidney diabetics, followed by 2 kidneys diabetic compared to single-kidney nondiabetics. Macro-albuminuria was also higher in single-kidney diabetics with similar degrees in two-kidney diabetics.
Chang et al, showed no difference in histological findings in kidney biopsy of T1DM recipients compared with diabetics with 2 functioning kidneys.
Data from UKPDS indicate that it takes;
– the median time with normoalbuminuria before progressing to microalbuminuria is 19 years
– the median time with microalbuminuria before progressing to macroalbuminuria is 11 years.
– and the median time with macroalbuminuria before progressing to nephropathy is 10 years
limitations.
– The cause of death was missing in 40% of all donors.
– The true incidence of diabetes could not be precisely determined.
– Survival bias (missing information about T2DM in most donors who have passed away.
– Response bias to the survey, information self-reported
– Study included only white donors, so generalizability to other ethnicity is difficult.
In conclusion, the risk factors for the development of T2DM in kidney donors is similar to the general population and donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early diabetic kidney disease. Importantly, when compared to nondiabetic donors, diabetic donors in the first decade of diabetes development did not exhibit an increased risk for accelerated kidney disease.
What is the level of evidence provided by this article?
Retrospective case-control study level III.
Please reflect on the guidelines provided above and on your practice.
– Screen with GTT to all potential donors.
– If GTT is impaired and the potential donor has a family history of diabetes, to be excluded.
– If GTT is impaired and no FHx of DM, they need to control their weight and be re-evaluated.
This is a cross sectional study (level of evidence III) evaluating 2954 kidney donors regarding the frequency of development of type 2 DM, with assessment of risk factors associated with the development of this disease, and comparing those who develop DM to matched non-diabetic donor controls regarding creatinine, proteiniuria and hypertension.
Also it evaluates a common consensus of excluding donors with strong family history of DM since the occurrence of 2 cause of hyper filtration (single kidney and DM) may theoretically harm the kidney.
Materials and Methods
Between January 1, 1963 and March 31, 2009, 3825 donor nephrectomies were performed at the University of Minnesota. Attempts to contact the donor in the last 3 decade to confirm health status and in last 7 years comprehensive multistep approach used to locate all donors, those who were a life with available contact information were sent survey regarding T2DM development
The survey included the following questions:
1. Were you ever told you have diabetes? If you answered yes, please answer the
following questions:
a. How old were you when you were diagnosed with diabetes?
b. Are you currently taking insulin, a pill to lower your blood sugar (glucose)
or both?
c. Are you controlling your blood sugars by diet only?
2. Do you have hypertension (high blood pressure)? If yes, are you taking medications
to lower your blood pressure, and when did you start taking them?
3. Were you ever told you have protein in the urine? When?
To address whether the rate of eGFR change is accelerated in diabetic donors, they studied diabetic donors who had multiple serum creatinine measurements obtained after T2DM development and that were at least 1 year apart. eGFR change in these diabetic donors was compared to two groups:
1. Five hundred and twenty-two nondiabetic donors who also had multiple serum creatinines available in the same time frame the diabetic donors’ onset of T2DM (i.e. ≥15 years after donation).
2. Fifty-six nondiabetic donors matched on age, gender, BMI and duration after donation who also had multiple creatinine measurements available. This group is a subset of the 522 nondiabetic donors mentioned earlier.
Result:
Of the 3825 who underwent uninephrectomy for kidney donation as of March 31, 2009, 48 also donated a partial pancreas and, therefore, were not included in the analyses. Of the remaining 3777: 293 have died, 555 did not send back any health updates in the last four years and 2929 have responded to our surveys (Figure 1). In total, 154 donors reported developing T2DM; 129 of 2929 currently alive donors, 17 of 293 deceased donors with available information prior to death and 8 of the 555 donors with no recent health updates reported having T2DM, as well.
In our practice we declined donor with diabetes and even the one who is border line
Diabetes mellitus cause ESRD and there’s genetic cause & obesity contribute to develop T2DM. All patients with family history T2DM are declined for donation of kidney because risk of DM after donation and hyper-filtration effects on kidney due to compensatory factor and diabetic kidney lead to reduce renal mass.
This article focus on donor risk to develop T2DM and compare with kidney function in diabetic donor to age/ gender/ BMI and duration of donation.
This study done between January 1963 to March 2009 for all nephrectomy were performed at university of minnesota.
Survey done with detailed history regarding DM / age/ race of patients and duration of DM, medication and controlling of DM.
History of hypertension and medication; history of micro albuminuria.
Family history of T2DM. All donated with family history of DM has normal glucose tolerance test / women with history of gestational DM & blood sugar > 99 mg/dl should underwent GTT. Donor with BMI > 35 kg/m2 should maintain body weight less than 30kg/m2.
Serial S. Cr and protein creatinine ratio and measurement of eGFR by MDRD study equation.
Risk factors of DM:
Age > 45, family history of DM + BMI > 30. smoking history and slightly increase of s. Cr not contribute to develop of T2DM.
This study shows mean age at time of donation 39.8 years and diagnosis of DM occur after 17.7 years post donation. Majority are white donated to siblings or family members.
Cause of ESRD in recipient T1DM 33% / hypertension 35% / T2DM 10% / ADPKD 5% / positive family history of T2DM and HBA1C between 8-7.8.
In this study 71% diabetic donor develops hypertension and requires treatment 17.6 years post donation with target blood pressure 126/75 and S. Cr 1.2, eGFR 58.8 ml/min. 18% has proteinuria and PCR between 68-176 mg/dl. 75% normoalbuminuria and 20% micro albuminuria and 10% macro albuminuria.
Prevalence of hypertension increase with diabetic donor in comparison to non diabetic donor.
Uninephrectomy undergoing to compensatory matching with increase renal blood flow and GFR lead to compensatory hyper filtration with presence of DM and it’s effects on kidney and further hyper filtration lead progress kidney disease and reduce renal mass. So prevalence of micro albuminuria and macro albuminuria more in single diabetic kidney in comparison to single non diabetic kidney.
There’s high prevalence of smoking in donor who develop DM and smoking was not significant factor for T2DM. in this prospective cohort study shows 40% of smoking develop T2DM. but there’s lack of data to show associations between smoking and DM.
The observational study shows higher prevalence of proteinuria in diabetic donor is unrelated to donation itself but it may due to presence of underlying diabetic renal involvement and hypertension.
The mean time for donation to develop T2DM is 17 years.
UKPDS: there’s average 10 years of diabetic donor to develop micro albuminuria. Median time with normoalbuminuria for progress to micro albuminuria is 19%. median time with micro albuminuria to progress macro albuminuria 11%. median time from macro albuminuria to progress to nephropathy needs 10 years. So fallow up is mandatory.
Notice that diabetic donor undergoing to hyper filtration and eGFR increase as same to non diabetic donor may reflect a drop in their renal function.
Limitations of this study is lack cause of death and incidence of DM in donation is missing because lack of fallow up and also because random sample.
Risk factors for developing T2DM in kidney donor similar to general population.
Incidence of micro albuminuria is higher in comparison to non diabetic donor.
Diabetic donor is not exhibit increase accelerated kidney disease in first decade. All kidney donor with positive family history of DM should strongly maintain weight control and decline all donor with positive family history of DM and positive GTT.
What is the level of evidence provided by
this article? Level 3
Please reflect on the guidelines provided above and on your practice.
The criteria to select kidney donor is healthy donor with well control hypertension and tight control of blood sugar Hba1c less than 7% and fasting blood sugar less than 99 mg/dl.
In those of positive family history of DM should be excluded from donation
BMI less than 30 kg/m2.
Normal protein creatinine ratio
Normal level of creatinine level
renal biopsy shows no evidence of diabetic kidney and no sign of hyper filtration.
IV. Diabetes after Kidney Donation
Please summarise this article in your own words
To study the course of donors who develop T2DM, the authors surveyed 3777 kidney donors. Out of 2954 (2929 + 17 deceased + 8 with no recent contact) responders, 154 developed T2DM 17.7 ± 9.0 years post- donation.
The cause of death in donors:
Unknown (40%)
CVD (19%)
Cancer (20%)
Diabetes-related complications (2 donors)
ESRD developed in 11 donors; none was due to DKD.
Risk factors for development of T2DM:
T1DM in the recipient
Male gender
BMI >30 at time of donation.
Donors with diabetes (154 donors)
Mean age at donation: 39.8 ±11.4 years
Diagnosis of T2DM: 17.7 ± 9.0 years after donation.
Prevalence of hypertension: 71% vs. 36.3% (p = 0.005)
Prevalence of proteinuria: 18.8% vs. 3.9% (p < 0.0001).
eGFR: no significant change.
Discussion
In a study by Silveiro et al, macro-albuminuria was seen more among single-kidney diabetics (30%) than single-kidney nondiabetics; however, there was no difference between single-kidney diabetics (30%) & two-kidney diabetics (23%).
Chang et al. found no difference between the mesangial matrix volume in biopsies from subjects with T1DM & those with DM & 2 functioning kidneys.
The current study suggests that the prevalence & risk factors for T2DM in kidney donors are not different than that seen in the general population.
Diabetic donors had a degree of albuminuria & HTN in the 1st decade of diabetes comparable to that seen in subjects with DM & 2 kidneys in the 1stfew years of T1DM.
Diabetic donors are twice more likely to be hypertensive than matched non-diabetic donor controls; however, this frequency of HTN is, also, similar to T2DM with 2 kidneys.
Prevalence of proteinuria in 128 donors was 18.8% by self-report & 25% UACR in 20/154 donors; a prevalence is higher than the usual rates seen in kidney donors but similar to those with DM with 2 kidneys. Garg et al.(42 studies, 4793 donors) reported an incidence of proteinuria of 12% (95% CI 8–16%).
Summary:
Risk factors forT2DM in kidney donors is similar to the general population & donors who develop it have rates of albuminuria that are higher than nondiabetic donors, which may be suggestive of early DKD.
Compared to nondiabetic donors, diabetic donors in the 1stdecade of DM development didn’t show increased risk for accelerated kidney disease; thus, no good reasons to decline donors with positive FH of T2DM, if screened with OGTT.
Kidney donors (especially if FH of diabetes) should be strongly advised to maintain weight control.
=======================
What is the level of evidence provided by this article?
Level III
=======================
Please reflect on the guidelines provided above and on your practice.
In concordance with guidelines stated above, in our center, we will exclude donors with strong FH of diabetes only if there are also other CV risk factors, such as hypertension & obesity.
We send potential donors for OGTT if HbA1c is between 6.1 to 6.9.