Transplant, steroids, and diabetes: Inpatient and outpatient management

Transplant, steroids, and diabetes: Inpatient and outpatient management
Transplant, steroids, and diabetes: Inpatient and outpatient management

Mr. B, aged 60 years, presented with a history of type 2 diabetes for 15 years. He was admitted to the hospital to undergo renal transplant surgery. He weighed 88 kg.

The patient's pre-admission diabetes therapy consisted of glipizide 5mg by mouth once daily in the morning. Mr. B's hemoglobin A1c value, taken just prior to surgery, was 7.4%. Upon admission, the patient's blood glucose value was 140 mg/dL.

Throughout the surgery, Mr. B's blood glucose values ranged from 140 to 300 mg/dL. During the surgery, the patient received a total of 16 units of insulin aspart (NovaLog) in correction doses for noted hyperglycemia prior to an intravenous (IV) insulin infusion.

Mr. B. was told nothing by mouth on the day of surgery. On post-operative day 1, the patient would be able to resume a clear liquid diet, which he could advance as tolerated.

Steroids were initiated on the day of surgery as part of the anti-rejection medication regimen. Methylprednisolone 500 mg IV was given in the operating room. Mr. B's transplant team planned to decrease to methylprednisolone 250 mg IV on post-operative day 1.

The morning after surgery, the patient's blood glucose was 220 mg/dL, and it was desired for the patient to transition off the IV insulin infusion. Mr. B was planning on eating small amounts of clear liquids in the morning, but advanced his diet later in the day.

Read the answer and explanation for Question 1.

On post-operative day 1, blood glucose values ranged 220 mg/dL in the morning to 233 mg/dL at noon to 220 mg/dL in the evening, and 190 mg/dL at bedtime.

On post-operative day 2, blood glucose value was 185 mg/dL. Also on post-operative day 2, Mr. B's steroid dose decreased from methylprednisolone 250 mg IV to methylprednisolone 125 mg IV.

Read the answer and explanation for Question 2.

Mr. B was approved to dismiss from the hospital on post-operative day 5 on a maintenance dose of prednisone 5 mg once daily and had no plans to taper off steroids. He also discharged on sirolimus (Rapamune), which was started during hospital stay following transplant, as part of his anti-rejection medication regimen. Glucose values were ranging from 115 to 168 mg/dL in the 24 hours preceding hospital discharge.

After discharge, the patient was recommended to take NPH insulin twice daily --  20 units in the morning and 10 units in the evening. Mr. B was told to check glucose values twice daily in the morning and in the evening . The patient was asked to follow-up with the transplant endocrinology nurse practitioner and diabetes educator.

Read the answer and explanation for Question 3.

Question 1: What would be the most appropriate way to transition this patient from intravenous to subcutaneous insulin on post-operative day 1?

Answer: B. Prescribe neutral protamine hagedorn (NPH) insulin, 20 units in the morning; discontinue insulin infusion 2 hours after NPH insulin is given; continue insulin aspart per correction of hyperglycemia after insulin infusion is discontinued.

NPH insulin was started along with correction doses of insulin aspart. A weight based formula was used to determine a safe starting dose. NPH insulin was chosen as because it has a greater tendency to peak than insulin glargine and has a shorter du­ration of action, which is desirable when managing steroid-related hyperglycemia.

Hyperglycemia persisted throughout the day, and it was determined that Mr. B required an evening dose of NPH insulin, 15 units. As he began to eat better, a set dose of insulin aspart, 6 units, was also added at mealtimes to cover oral intake.

Question 2: On post-operative day 2, what would be the most appropriate way to manage blood glucose values?

Answer: B. Consider the half-life of the steroid; continue with same doses of NPH insulin; cautiously adjust insulin aspart meal doses.

NPH insulin 20 units was continued in the morning along with prandial and correction doses of insulin aspart. The patient advanced his diet. Prandial insulin doses were increased due to noted hyperglycemia.  

Throughout post-operative day 2, blood glucose values ranged from 185 mg/dL in the morning, 176 mg/dL at noon, 155 mg/dL in the evening, and 160 mg/dL at bedtime. NPH insulin 10 units was prescribed in the evening.

Throughout hospital stay, as steroid doses decreased, the patient discontinued meal doses of insulin aspart and used NPH insulin twice daily.

Question 3: What are some common transplant-related endocrinology issues that are important to assess for in this patient who is going to be maintained on long term immunosuppression therapy?

Answer: D. All of the above.

With long term immunosuppression therapy, osteoporosis, hyperlipidemia, and malignancy are often seen.  Both female and male kidney recipients lose up to 8% of bone mass during the first 18 months after transplantation.

The incidence of hyperlipidemia peaks within the first year after transplantation, but remains a long-term complication in a significant proportion of patients on immunosuppression therapy, especially in patients who are prescribed sirolimus.

Studies suggest that sirolimus alters the insulin signaling pathway so as to increase adipose tissue lipase activity and/or decrease lipoprotein lipase activity, resulting in increased hepatic synthesis of triglyceride, increased secretion of very low-density lipoprotein (VLDL), and increased hypertriglyceridemia. 

The 10-year prevalence of post-transplantation malignancy in the United States is reported to be as high as 30%, with a noted increase in lung, colon, stomach, esophagus, pancreas, prostate, breast, ovary, melanoma, leukemia, hepatobiliary, renal, cervical, vulvovaginal cancers, Kaposi sarcoma, non-Hodgkin lymphoma, and nonmelanoma skin cancers.

One year following transplant, the patient followed-up with his outpatient transplant endocrinology nurse practitioner. His weight was stable over the past year. He continued on prednisone 5 mg once daily, along with sirolimus for his immunosuppression regimen.

The patient continued on statin therapy for previous history of hyperlipidemia. Low-density lipoprotein (LDL) values remained within normal limits with sirolimus therapy. His blood glucose values consistently ranged 100 to 130 mg/dL on twice daily NPH insulin therapy. Mr. B's hemoglobin A1c indicated controlled diabetes at 6.8%.

A dual x-ray absorptiometry (DEXA) scan was performed, which revealed a T score of -2.6. Mr. B had no history of fractures. Along with calcium and vitamin D supplementation, bisphosphonate therapy was initiated. The patient was recommended for yearly DEXA scans.

Jennifer A. Grenell, APRN, CNP, practices at the Mayo Clinic department of Endocrinology, specializing in diabetes management.

Tricia Veglahn, CNP, practices at the Mayo Clinic department of Endocrinology, specializing in diabetes and transplant endocrinology management.

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