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

Table 3 Management of post-transplant diabetes mellitus

Clinical context	Risk factors	Drug contributions	Newer/preferred therapies
Unstable graft	High steroid dose, fluctuating renal function	Steroids → insulin resistance; CNIs → β-cell toxicity	Insulin for glycemia well above target (rapid titration). DPP-4 inhibitor (linagliptin preferred vs vildagliptin/sitagliptin) for mild hyperglycemia (safe in renal dysfunction). Meglitinides (repaglinide) for postprandial hyperglycemia
Stable graft	Obesity, pre-existing diabetes	CNIs, steroids	SGLT2 inhibitors (CV/renal protection). GLP-1 receptor agonists (weight loss, CV benefit)
Severe hyperglycemia	HbA1c > 9%, fasting glucose > 250	Steroids, CNIs	Insulin therapy (short-term stabilization)
Comorbidities	ASCVD, HF, obesity	Steroids worsen CV risk	GLP-1 receptor agonists for ASCVD/obesity. SGLT2i for HF/renal protection

CNIs: Calcineurin inhibitors; DPP-4: Dipeptidyl peptidase 4; SGLT2: Sodium-glucose cotransporter 2; CV: Cardiovascular; GLP-1: Glucagon-like peptide-1; HbA1c: Glycated hemoglobin; ASCVD: Atherosclerotic cardiovascular disease; HF: Heart failure.