Approach to the patient: Early post-renal transplant hyperglycemia.

CONTEXT Though post-transplant diabetes mellitus (PTDM, occurring >45 days after transplantation) and its complications are well-described, early post-renal transplant hyperglycemia (EPTH) (<45 days) similarly puts kidney transplant recipients at risk of infections, re-hospitalizations, graft failure and is not emphasized much in the literature. Proactive screening and management of EPTH is required given these consequences. EVIDENCE ACQUISITION A PubMed search was conducted for "early post-renal transplant hyperglycemia", "immediate post-transplant hyperglycemia", "post-renal transplant diabetes", "renal transplant", "diabetes" and combinations of these terms. EVIDENCE SYNTHESIS EPTH is associated with significant complications including acute graft failure, re-hospitalizations, cardiovascular events, PTDM and infections. CONCLUSION Patients with diabetes experience better glycemic control in end-stage renal disease (ESRD), with resurgence of hyperglycemia after kidney transplant. Both patients with and without known diabetes are at risk of EPTH. Risk factors include elevated pre-transplant fasting glucose, diabetes, glucocorticoids, chronic infections, and post-transplant infections. We find that EPTH increases risk of re-hospitalizations from infections (CMV, possibly COVID-19), acute graft rejections, cardiovascular events and PTDM. It is essential, hence, to provide diabetes education to patients prior to discharge. Insulin remains the standard of care while inpatient. Close follow up after discharge is recommended for insulin adjustment. Some agents like dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists have shown promise. The tenuous kidney function in the early period post-transplant and lack of data limits the use of sodium-glucose co-transporter 2 (SGLT-2) inhibitors. There is a need for studies assessing non-insulin agents for EPTH to decrease risk of hypoglycemia associated with insulin and long-term complications of EPTH.