title: Post-transplant diabetic ketoacidosis--a possible consequence of immunosuppression with calcineurin inhibiting agents: a case series.
abstract: Post-transplant diabetes mellitus, a complication due to corticosteroids and the calcineurin inhibitors, cyclosporine and tacrolimus (FK506), is commonly regarded as a form of type-2 (adult-onset) diabetes mellitus. Diabetic ketoacidosis, which requires relative insulin deficiency to impair fatty acid metabolism, is a complication of type-1 diabetes mellitus. We report three patients who presented with diabetic ketoacidosis post-transplant. All three patients presented with severe hyperglycemia, significant ketosis and metabolic acidosis of variable severity. One patient was a renal transplant recipient on a cyclosporine-based regimen. The other two patients were liver transplant recipients receiving either cyclosporine or tacrolimus-based immunosuppression. Both of the liver transplant recipients were found to have moderate to high serum levels of calcineurin inhibitors on presentation. The liver recipient on cyclosporine (Neoral) had a 4 hour post-dose level of 388 ng/ml and the patient on tacrolimus was found to have a trough level of 21.2 ng/ml. Our experience suggests that post-transplant diabetes mellitus, in association with calcineurin inhibition, may result in ketoacidosis either secondary to relative beta cell dysfunction, peripheral insulin resistance, or a combination of the two effects. Post-transplant diabetes mellitus can be an atypical form of adult-onset diabetes with features of both type I and type II diabetes mellitus.
authors.affiliation: Vancouver Hospital and Health Sciences Centre, BC, Canada.
authors.forename: E M
authors.initials: EM
authors.lastname: Yoshida
authors.forename: A K
authors.initials: AK
authors.lastname: Buczkowski
authors.forename: S M
authors.initials: SM
authors.lastname: Sirrs
authors.forename: T G
authors.initials: TG
authors.lastname: Elliott
authors.forename: C H
authors.initials: CH
authors.lastname: Scudamore
authors.forename: A
authors.initials: A
authors.lastname: Levin
authors.forename: H D
authors.initials: HD
authors.lastname: Tildesley
authors.forename: D N
authors.initials: DN
authors.lastname: Landsberg
mesh_terms: D000328:Adult; D019703:Calcineurin / Q000009:adverse effects*; D016572:Cyclosporine / Q000009:adverse effects*; D016883:Diabetic Ketoacidosis / Q000139:chemically induced / Q000209:etiology*; D005260:Female; D006801:Humans; D006943:Hyperglycemia; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D016030:Kidney Transplantation / Q000276:immunology*; D016031:Liver Transplantation / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016559:Tacrolimus / Q000009:adverse effects*
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine; D019703:Calcineurin; D016559:Tacrolimus