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The American Journal of Managed Care April 2020
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Solid-Organ Transplant Recipients With Hyperglycemia on Admission Face Worse Outcomes
Amit Akirov, MD; Tzipora Shochat, MSc; and Ilan Shimon, MD
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Solid-Organ Transplant Recipients With Hyperglycemia on Admission Face Worse Outcomes

Amit Akirov, MD; Tzipora Shochat, MSc; and Ilan Shimon, MD
Elevated glucose levels are common in solid-organ transplant recipients and associated with short- and long-term mortality risks in hospitalized transplant recipients. This increased mortality risk was independent of age, gender, smoking, alcohol, or comorbidities.
ABSTRACT

Objectives:
To evaluate the association between admission blood glucose (ABG) and mortality following hospitalization of solid-organ transplant recipients with and without diabetes.

Study Design: Descriptive, retrospective observational data extracted from electronic health records.

Methods: Observational data derived from the electronic health records of solid-organ transplant recipients who were hospitalized patients 18 years and older, admitted for any cause between January 2011 and December 2013. ABG levels were classified into categories: 70 to 110 mg/dL (normal), 111 to 140 mg/dL (mildly elevated), 141 to 180 mg/dL (moderately elevated), and greater than 180 mg/dL (markedly elevated). The main outcome was all-cause mortality.

Results: Our study included 832 patients (median [SD] age = 59 [14] years; 62% male; 68% kidney transplant recipients), 503 (61%) of whom did not have diabetes. Just over half of patients without diabetes had normal ABG (54%), whereas most of those with diabetes had moderately or markedly increased ABG (58%). In patients without diabetes, markedly elevated ABG was associated with increased 30-day mortality risk compared with normal ABG (adjusted odds ratio [aOR], 6.6; 95% CI, 1.9-22.1). The same pattern was evident with investigation of the mortality risk after 1 year (aOR, 5.9; 95% CI, 2.4-14.7) and 3 years (aOR, 10.2; 95% CI, 4.3-24.0). Among patients with diabetes, there was no difference in mortality risk with different ABG. With a competing risk model for 90-day readmission and mortality, there was no association between ABG and risk for readmissions in patients with or without diabetes.

Conclusions: In organ transplant recipients admitted for any cause to a general ward, markedly elevated ABG in patients without diabetes was found to be independently associated with higher mortality risk compared with normal ABG levels. In patients with diabetes, there was no association between ABG level and mortality.

Am J Manag Care. 2020;26(4):163-168. https://doi.org/10.37765/ajmc.2020.42833
Takeaway Points
  • Patients’ blood glucose levels are readily available in medical wards.
  • Admission blood glucose levels may serve as a surrogate marker for general well-being and are an important prognostic factor in organ transplant recipients.
  • This is the first study to associate elevated glucose levels with short- and long-term mortality risks in hospitalized solid-organ transplant recipients.
  • This study adds further evidence for the importance of routine testing of blood glucose on admission, as it can predict short- and long-term prognosis.
Solid-organ transplantation is associated with glucose abnormalities, which may result from pretransplant diabetes or de novo diabetes after transplantation.1 Diabetes that is first diagnosed after transplant, also called new-onset diabetes after transplantation or posttransplant diabetes, may represent previously undiagnosed diabetes or new-onset diabetes secondary to chronic immunosuppressive medications.1,2

Studies of patients following renal transplantations reported changes in insulin requirements with severe shifts in renal function. In patients following heart transplantation, hyperglycemia was common even in patients without diabetes, with no difference between patients with and without diabetes.3 Although many lung transplant recipients have low body mass index (BMI), hyperglycemia is still common in this population.2 This might be secondary to cystic fibrosis, a common indication for lung transplant, which may be associated with low weight and diabetes secondary to pancreatic insufficiency.4

Previous reports have associated elevated admission blood glucose (ABG) levels with increased morbidity and mortality in patients with and without diabetes following hospitalization for cardiovascular,5-11 cerebrovascular,12 or infectious13,14 diseases.

Glucose levels on admission are frequently a part of the routine blood work for hospitalized patients, and these might assist in predicting the outcomes of transplant recipients hospitalized for any cause.

Our goal was to evaluate the association between ABG levels in transplant recipients with and without diabetes and short- (30 and 90 days) and long-term (≥1 year) mortality.

METHODS

Retrospective observational data were extracted from the electronic health records of transplant recipients who were admitted between January 1, 2011, and December 31, 2013, to the medical wards of Rabin Medical Center in Israel. Inclusion criteria were being 18 years and older and having a history of solid-organ transplantation, according to the records. The first hospital stay was analyzed, and we collected data regarding readmissions. We excluded patients without documented ABG levels.

Rabin Medical Center is a tertiary care facility with more than 1300 beds. Most of the admissions to the 10 medical wards are through the emergency department, and all patients’ data are recorded in electronic medical charts. Mortality data until June 1, 2015, were obtained from the hospital’s mortality database, updated from the Ministry of the Interior Population Registry.

The patients were classified as having preexisting diabetes when 1 of the following was present before the hospitalization: (1) diagnosis of diabetes in the medical record or (2) use of any oral hypoglycemic agent, glucagon-like peptide agonist, or insulin, based on the available medications list on admission.

ABG levels, defined as the blood glucose level closest to the patient arrival time within the first 24 hours of the admission date, were classified as follows: (1) normal range (70-110 mg/dL), (2) mildly elevated (111-140 mg/dL), (3) moderately elevated (141-180 mg/dL), or (4) markedly elevated (≥181 mg/dL). Due to the small number of patients with ABG levels less than 70 mg/dL, these patients were not included in the study. We included glucose measurements based on point-of-care blood glucose measurements using bedside glucometers or serum glucose levels derived from venous blood samples.

We used the International Classification of Diseases, Tenth Revision for classification of the common causes for admission: infectious diseases (ie, bacterial, viral, and other infectious diseases), diseases of the gastrointestinal tract (ie, noninfective enteritis and colitis; disorders of the gallbladder, biliary tract, and pancreas; hernia) and the genitourinary tract (ie, renal failure, urolithiasis, disorders of the genital tract), diseases of the circulatory system (ie, diseases of the arteries, arterioles, and capillaries; diseases of the veins, lymphatic vessels, and lymph nodes; ischemic heart disease; pulmonary heart disease), diseases of the blood and blood-forming organs (ie, anemia, coagulation defect, agranulocytosis), and neoplasms (ie, benign and malignant neoplasms).

Data collected in this analysis included diagnosis of hypertension, ischemic heart disease, chronic heart failure, chronic renal failure, cerebrovascular disease, and chronic obstructive pulmonary disease.

The main outcomes were short-term mortality risk, including 30-day and 90-day mortality, and mortality at the end of follow-up, based on ABG levels and diabetes status. We also investigated the association between cause of hospitalization and mortality risk, as well as the risk for 90-day readmission, according to ABG levels.

The study was approved by the Institutional Review Board of Rabin Medical Center.


 
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