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ANNA Transplant Special Interest Group Session: Posttransplant Glucose Management and Donor Exchange Programs

Clara D. Neyhart, BSN, RN, CNN, is Nephrology Nurse Clinician, University of North Carolina at Chapel Hill, Division of Nephrology, Chapel Hill, NC. She is a member of the Cardinal Chapter of ANNA.

The ANNA Transplant Special Interest Group (SIG) session at the 2006 National Symposium in Nashville presented two topics that addressed both pre- and posttransplant clinical issues. “Glucose Management Posttransplant” was presented by Jean Colaneri, and Kim Waugh presented “Paired Donor Exchange: Pros and Cons.” These are significant and timely topics for nurses working with patients undergoing kidney transplant.

Posttransplant Glucose Management

Posttransplant glucose management is a potential problem associated with risk factors that may contribute to developing new onset posttransplant diabetes. These include:

Black or Hispanic ethnicity
Family history of diabetes
Obesity
Glucose intolerance
Hepatitis C viral infection
Metabolic syndrome (high triglycerides, low LDL, hypertension, hyperuricemia)
Use of immunosuppressive therapy
Deceased donor kidney
Recipient over age 40

Three physiologic factors are theorized to contribute to post transplant diabetes: increased insulin resistance, decreased insulin synthesis, and beta-cell damage from immunosuppressive regimens in the transplant recipient. Insulin resistance is a problem specific to obese patients. Obesity is a frequent problem that usually worsens in the posttransplant period. Patients feel better and develop an improved appetite as they progress. Many patients continue to take prednisone posttransplant that stimulates the appetite further.

Weight requirements prior to transplant may facilitate patient understanding of this issue. Body Mass Index is an example of a criterion that may be used for transplant candidacy since obesity is clearly associated with diabetes and a host of posttransplant complications. There is no established standard or consistent approach across the country regarding the impact of weight on patient candidacy for transplant. Many transplant programs have moved away from steroid use in part due to the obesity problem, but obesity is a multi-factorial problem from which many patients free of steroids suffer. Recent studies support obesity as an independent risk factor for chronic kidney disease, independent of diabetes and hypertension. Thus, pretransplant education regarding the dangers of obesity is important. Some programs have a formal educational and screening tool to assess diabetes risk prior to transplant, and much interest was expressed in utilization of such a tool to quantify risk for patients.

There are a number of oral medications currently available to treat hyperglycemia. While these may be useful agents, many patients will still require insulin for adequate glucose control after transplantation. There are a number of concerns surrounding the use of insulin, however, for both the health care provider and the patient. Many providers worry that insulin will not improve glycemic control and that it will promote cardiovascular disease, particularly as patients who are taking insulin often tend to gain weight.

Patient adherence to an insulin regimen and the associated glucose monitoring is an additional concern. There are many different types of insulin available now so that many providers are not comfortable with the varied choices. Hence, referral to an endocrinologist is often required even if there is resistance by primary care providers. Patients tend to have more practical concerns with insulin therapy, such as the fear of hypoglycemia, fear of needles, added complexity to the daily life, and decreased quality of life. A review of the multiple types of insulin regimens, including insulin, delivery systems, glucose monitoring, and insulin pumps that are available to meet the needs of patients who are transplanted, further support the advantage of referral to a multidisciplinary endocrinology program.

Pre-transplant screening and education are essential to decrease the incidence of diabetes in recipients of kidney transplants. Further discussion should occur related to standardizing screening using a tool to assess for risk factors prior to transplantation.
Self-monitoring is an essential part of the plan and should be emphasized beginning in the pre-transplant period.
Lipid levels and Hemoglobin A1C levels should be monitored according to ADA guidelines.
Patients with diabetes should be monitored annually for complications such as retinopathy and neuropathy.
Patients should be referred to a comprehensive, multidisciplinary diabetes center.

Paired Donor Exchange
The Paired Donation Consortium (PDC) is a group of transplant centers in the same region who are working together to make paired donation available to patients with renal failure. The idea is based on the premise that one recipient may have an acceptable live kidney donor who is incompatible with his/her recipient due to blood type or positive cross-match. There may be a donor elsewhere who is in the same situation with his/her recipient, and the PDC creates an avenue by which the donors could be “swapped” if found to be compatible. While paired exchange theoretically increases the donor supply, there are several logistical concerns, the first of which is location.

Paired exchange requires the use of four operating rooms simultaneously. The best scenario is if the two recipient/donor pairs are within the same transplant institution. If the pairs are at different institutions, some of the issues that may arise include where the surgeries will occur, whether insurance will cover a different transplant center and where the out-of-town recipient/donor pair will be housed after discharge. Another issue may be the availability of laproscopic surgery for the donor.

These and several administrative issues may arise in a paired exchange program. There are questions of how billing is carried out involving more than one center and how the recipients are followed as outpatients. Computer software is needed to standardize evaluations and searches for donors. Another extension of the paired donor exchange program is the idea of donor registries as have been used for bone marrow transplantation. Donor registries avoid some of the logistical problems that occur with paired exchange.

Summary
Posttransplant glucose management and paired donor exchange programs are important topics that require additional focus and development. Nurses who work with patients receiving transplants need to become familiar with both in order to make the necessary changes in nursing practice.