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RESEARCH PRODUCT

Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients.

subject

description

Diabetes is common in patients wait-listed for liver transplantation due to end-stage liver disease or to hepatocellular cancer as well as in post-transplant phase (post-transplantation diabetes mellitus-PTDM). In both conditions the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use - including the most recent drug classes available - and to the inclusion of bariatric surgery in the treatment cascade. In wait-listed patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the post-transplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent de-listing and to improve long-term outcomes.