Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012 Diagnosis, treatment and management of glucometabolic disorders emerging after kidney transplantation A consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group Edited by Mads Hornum and Bo Feldt-Rasmussen, Denmark Jørn Petter Lindahl and Trond Jenssen, Norway Bengt von Zür-Mühlen, Sweden Members of the Expert Group (in alphabetical order):
William Bennet, Lars Bäckman, Jan Carstens, Anders Christensson, Martin Egfjord, Bo
Feldt-Rasmussen, Egil Hagen, Mads Hornum, Trond Jenssen, Kaj Anker Jørgensen, Lena
Mared, Elisabeth R Mathiesen, Søren Schwartz Sørensen, Björn Öqvist, Bengt von Zür
Corresponding author:
Mads Hornum MD PhD, Department of Nephrology
Copenhagen University Hospital, Rigshospitalet
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012 Recommendation 1 It is well documented that many patients on the waiting list for transplantation have undiagnosed diabetes. They should be characterized annually according to absence or
Fasting plasma glucose (FPG) should be measured annually
An OGGT should be performed once before transplantation in all patients on the
Diabetes is diagnosed when FPG ≥ 7 mmol/l and/ or 2-hr plasma glucose ≥ 11.1
mmol/l after a 75-g OGTT measured on at least two occasions.
Recommendation 2 Before transplantation risk factors for development of NODAT are well documented, and should be identified and treated:
Besides age, ethnicity and family history of diabetes, some risk factors are
modifiable such as obesity, the metabolic syndrome and glucose intolerance. An
appropriate screening should be performed before transplantation to identify
patients with higher risk for NODAT. Risk factor intervention should be started
already in the period before transplantation directed towards:
Extreme overweight; consider bariatric surgery
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012 Recommendation 3 Patients with diabetes and poor glycemic control have an increased morbidity and
Plasma glucose should be monitored at least 4 times daily in diabetic and non-diabetic
patients during primary hospitalization after transplantation to diagnose NODAT and
provide an overall optimal immunosuppressive and metabolic treatment of known diabetes
and NODAT after transplantation. Patients with diabetes, cystic fibrosis or NODAT should
be started out with insulin and not oral agents during the first days. If the insulin dose
required per 24-h is modest (below 20 IE per day) they could be changed to oral anti-
During hospitalization (as in general) the treatment targets should be:
Fasting morning plasma glucose 4-7 mmol/l
Pre-prandial plasma glucose 4-10 mmol/l
Plasma glucose at night time 4-10 mmol/l
The treatment targets should not be too low and the treatment not too aggressive. The risk
of hyperglycemia should be weighed against the risk of hypoglycemia.
Consider to use a progressive strategy in the supplementation of insulin where the use of
steroid is increased, remembering that the usual insulin demand is increased by
approximately 40% when treating with a prednisolone dose of 50 mg
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012 Recommendation 4 Use of steroids, calcineurin inhibitors and mTor inhibitors are known modifiable risk factors
In patients with diabetes or NODAT, or high risk of NODAT before transplantation, the
immunosuppressive treatment should be tailored to prevent evolution of diabetes, but not
on the expence of rejection episodes. If possible, it should be considered to aim at low
dose steroids, low trough levels of CNI inhibitors and withholding use of mTOR inhibitors.
Recommendation 5 Patients with NODAT are at risk of diabetic complications and have a high risk of cardiovascular morbidity and mortality. They should be treated according to current guidelines on treatment of patients with diabetes to the extent these do not have a negative impact on the function and survival of the transplanted organ. Such guidelines
Measure FPG annually for a minimum of 5 years, and longer in patients at
higher risk of diabetes i.e. cystic fibrosis, to diagnose NODAT
Measure FPG when significant changes in immunosuppressive changes are
Lifestyle advise (weight, smoking habits, exercise)
Antihypertensive treatment to target < 130/80 mmHg, including RAS
blockade if possible. Blood pressure must also be measured in the standing
position to disclose orthostatic hypotension.
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012
Treating dyslipidemia to target LDL-cholesterol< 3.0 mmol/l
Treating glycemic control to target HbA1c< 7 % ( 51 IFCC units)
Close collaboration with endocrinologists, ophtalmologists
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Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012
Recommendation 1 
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012
Recommendation 3 
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012
Recommendation 4 
Consensus statement by the Scandinavian Post-Transplant Diabetes Expert Group January 2012
Treating dyslipidemia to target LDL-cholesterol< 3.0 mmol/l
Treating glycemic control to target HbA1c< 7 % ( 51 IFCC units)
Close collaboration with endocrinologists, ophtalmologists