DIABETES MELLITUS IN

LUNG TRANSPLANTATION

By Ramsey Hachem, MD

Washington University School of Medicine

Division of Pulmonary & Critical Care

In recent years, complications other than rejection after organ transplantation have received increasing attention because of their effects on morbidity and mortality.  This is especially true in kidney and heart transplantation, where the incidence of rejection has been minimized and metabolic complications such as diabetes and high blood pressure affect graft function over time.  Similarly, although rejection remains the primary obstacle to better long-term outcomes after lung transplantation, diabetes has a significant impact on morbidity and quality of life.  Complications of diabetes include stroke, heart attack, kidney failure, vision loss, peripheral vascular disease and infections.  The prevalence of diabetes in the general population in the United States varies from 5 to 15%, and this has been increasing as the incidence of obesity has been increasing. Approximately 25% of lung transplant recipients develop diabetes within one year of transplantation, and the incidence increases to 35% to 40% within five years of transplantation.

Diabetes is a metabolic disorder characterized by abnormally high blood sugar.  It develops as a result of either a lack of production of sufficient amounts of insulin or a resistance to the effects of insulin.  Insulin, a hormone produced by the pancreas, plays a central role in carbohydrate and fat metabolism.  It stimulates the uptake of glucose by various tissues including the liver, fat, and muscle.  In type-1 diabetes, pancreatic beta cells do not secrete insulin as a result of autoimmune inflammation.  This results in chronically elevated blood sugar, which is spilled in the urine causing frequent urination, increased thirst, and weight loss.  Type-1 diabetics are insulin-dependent and cannot be treated with oral medicines.  In type-2 diabetes, the pancreas secretes insulin, but the cells that normally take up glucose are resistant to the effects of insulin.  The result is similar to type-1 diabetes with high blood sugar resulting in the same symptoms.  However, type-2 diabetics can be managed with exercise, weight loss, dietary modifications, and oral medicines if necessary, although treatment with insulin is also sometimes necessary.

The medical regimen after transplantation increases the risk of diabetes.  Prednisone can cause insulin resistance, and this is true for all steroids.  The effect is most pronounced on blood sugar measurements after meals while the early morning fasting measurements often remain in the normal range.  The effect of prednisone on blood sugar is dose-dependent, but doses as low as 10 mg a day or less increase the risk of diabetes almost two fold.  In addition, weight gain is another side effect of prednisone and this exacerbates the insulin resistance.  Furthermore, tacrolimus is also diabetogenic and this effect is directly associated with blood levels.  In general, it is thought that the risk of diabetes is higher with tacrolimus than cyclosporine.  However, tacrolimus is more effective in preventing and treating rejection, and it has supplanted cyclosporine as the calcineurin inhibitor of choice at most lung transplant centers.  Lastly, sirolimus, which is structurally similar to tacrolimus, is also diabetogenic, and its effects on insulin resistance may be more pronounced than tacrolimus or cyclosporine.  In contrast, azathioprine and mycophenolate mofetil are not known to cause or exacerbate diabetes independently.

All patients are screened for diabetes after transplantation with fasting blood sugar measurements.  Additionally, patients routinely have their blood sugar measured before meals in the immediate period after transplantation because the steroid doses are typically highest in the first few weeks.  At this stage, diabetes is usually managed with sliding scale insulin, and the dose requirement often predicts the need for ongoing treatment as the prednisone dose is reduced.  In some cases, prednisone is tapered to lower doses more rapidly than usual to improve glycemic control, but this approach needs to be balanced with the risk of rejection.  Furthermore, while some patients require insulin in the first few months after transplantation, this may be withdrawn as the prednisone dose is tapered and the targeted tacrolimus levels are reduced.  In addition to insulin, a number of oral agents are available and can be tried.  Lifestyle modifications are also critical to managing diabetes.  Exercise and weight loss ameliorate the insulin resistance associated with obesity, and dietary modifications are important.  Formal diabetic education is usually necessary to instruct patients how to check their blood sugar, inject insulin if necessary, and the symptoms of hypoglycemia.  Finally, regular screening for the complications of diabetes including annual eye exams and urine tests is necessary. 
 

                       We Remember

                        Michael Poole

November 20, 1947 - April 17, 2011 

Michael Poole, 63, Normal, Illinois died at 1:16 p.m. Sunday, April 17, 2011 at Barnes-Jewish Hospital, St. Louis, Missouri. 

Michael received a bilateral lung transplant on December 6, 2006 at Barnes-Jewish Hospital. 

Michael was born Nov. 20, 1947, in Owensboro, Ky, the son of Chester and Wilma Rogers Poole. He married Kathleen Bagley on May 27, 1972, in Bloomington, IL. She survives. 

Also surviving are two daughters, Elizabeth Poole, Boston, Mass., and Sarah (Robert) Kucharski, Arnold, Mo.; one grandson, Justin Kucharski; six brothers and sisters, Rachelle Poole, Owensboro, Ky.; Bobby (Alice) Poole, Hebron, Ind.; Chester (Cindy) Poole Jr. and Ivy Ann (Rex) Case, both of Owensboro, Ky.; and twins, Debra Poole, Owensboro, Ky., and David (Wanda) Poole, Evansville, In.

Michael was preceded in death by his parents and an infant brother, Larry Poole.  

Michael received his bachelor's degree in mathematics from Kentucky Wesleyan University and his master's degree in computer science from Bradley University. He was a computer programmer at State Farm Insurance Cos. in Bloomington, retiring in 2003 after 34 years with the company.    

He enjoyed golf, travel and crossword puzzles and was a wonderful cook. Michael will be dearly missed by his family and friends.     

Memorials may be made to St. Louis Second Wind Lung Transplant Association, Inc. and mailed C/O Peter Nicastro, 2169 Willow Ridge Lane, Chesterfield, MO 63017.    

Treasurer's Report

Coming In September!

SAVE THE DATE!

Matt Alber will be playing a benefit Concert for St. Louis Second Wind on September 10, 2011 at Christ Church Episcopal Cathedral in downtown St. Louis. Concert details to follow.

To learn more about Matt and his music visit his web site  www.mattalber.com.    

Anniversaries for May 2011

By Jan Kwasigroh

Wow, what a month it has been.  Fires in Texas, earthquakes and tsunami's overseas, rain and tornados in...,well, just about everywhere.  And we haven't even hit hurricane season yet!  There's a song from a movie (years ago, I might add) that says we just pick ourselves up, dust ourselves off and start all over again.  I believe the song goes on to talk about having high hopes and so we do.  This month we remember those whose high hopes became their "second wind" and are celebrating their transplant anniversary.  Spring is really beautiful!

 

 

  

Summer Picnic 2011

Please join us for a fun-filled Second Wind Family Picnic on Sunday, July 10. 

We'll gather at Tower Grove Park in South St. Louis at 2:00 PM for an afternoon of good food and great fellowship.  We have reserved the Stupp Center* with both indoor and outdoor spaces to accommodate the weather and those who need to be out of the sun. 

Please RSVP no later than Thursday, July 7th to Tom via email tea3440@sbcglobal.net or call (314) 664-6360 and let us know the names of the children and adults in your group. Also, you may mail your picnic donation made payable to Second Wind Picnic to Tom at 3440 Halliday Avenue, St. Louis, MO 63118.  

Hendris Catering will again provide beverages, barbequed burgers and other meat entrées. Each family is asked to bring a dish to share for potluck.  In order to have a variety, we'd like to use the following assignment list as a guide:

Last names beginning -

A - F   Salads/fruits - healthy stuff

G - L   Casseroles - pasta, potatoes, etc. - filling stuff

M - R   Vegetable dishes - the "almost healthy if it weren't covered with cheese" kind

S - Z    Desserts - the most important food group!

These are guidelines only and we want everyone attending to enjoy the meal, so if there is a dish that your family is crazy about, by all means, make it!  We also want this to be affordable for everyone, so if money is tight, a bag of chips will do.  Really tight?  Then just come out and enjoy the efforts of the rest of the crew.  We want as many of our Second Wind family members as possible to be together and have a day to remember.

* The Stupp Center is located just inside Tower Grove Park off of South Grand Blvd. - the East Entrance of the park.  Once in the park, take the first left on Osborne and follow for a short distance to the green copper-clad roof of the Center.

The address for Tower Grove Park is 4256 Magnolia Ave, St Louis, MO 63110 for those who would like to google or Mapquest directions.

We are looking forward to a great picnic!