Post-transplant metabolic dysregulation: Insights and implications for kidney graft survival

Table 1 Risk factors for post-transplant diabetes mellitus

Category	Risk factor	Implications
Pre-transplant (modifiable)	Obesity (BMI ≥ 30 kg/m2)	Strong association with PTDM
	HCV infection	4 × higher risk; mechanisms include islet dysfunction and insulin resistance; treatable pre-transplant
Pre-transplant (non-modifiable)	Age ≥ 40-45 years	Increased risk
	History of gestational diabetes/family history of T2DM	Genetic predisposition
	Genetic factors	Inconclusive; not recommended for routine testing
Peri-/early post-transplant	Perioperative hyperglycemia	Strong predictor; 29% incidence within 1 year if present
	Other peri-/early factors	HLA mismatching, male sex, deceased donor, CMV infection
	Potential contributors	Polycystic kidney disease, hypomagnesemia (should be corrected if present)
Post-transplant (immunosuppressive therapy)	Glucocorticoids	Dose-dependent risk; withdrawal not clearly protective; high-dose pulses increase the risk
	CNIs (tacrolimus > cyclosporine)	Tacrolimus is more diabetogenic; reversible islet toxicity
	mTOR inhibitors (sirolimus, everolimus)	Worsens insulin resistance; diabetogenic
	Other agents (AZA, MMF, belatacept)	No independent diabetogenic effect; may lower PTDM risk

BMI: Body mass index; PTDM: Post-transplant diabetes mellitus; HCV: Hepatitis C virus; T2DM: Type 2 diabetes; HLA: Human leukocyte antigen; CMV: Cytomegalovirus; CNIs: Calcineurin inhibitors; mTOR: Mammalian target of rapamycin; AZA: Azathioprine; MMF: Mycophenolate mofetil.