Post-transplant diabetes mellitus (PTDM) is associated with infection, cardiovascular morbidity, and mortality. A retrospective cohort study involving patients who underwent renal transplantation in a transplantation center in Taiwan from January 2000 to December 2018 was conducted to investigate the incidence and risk factors of PTDM and long-term patient and graft survival rates. High age (45–65 vs. <45 years, adjusted odds ratio (aOR) = 2.90, 95% confidence interval (CI) = 1.64–5.13, p < 0.001), high body mass index (>27 vs. <24 kg/m², aOR = 5.35, 95% CI = 2.75–10.42, p < 0.001), and deceased organ donor (cadaveric vs. living, aOR = 2.01, 95% CI = 1.03–3.93, p = 0.04) were the three most important risk factors for the development of PTDM. The cumulative survival rate of patients and allografts was higher in patients without PTDM than in those with PTDM (p = 0.007 and 0.041, respectively). Concurrent use of calcineurin inhibitors and mammalian target of rapamycin inhibitors (mTORis) decreased the risk of PTDM (tacrolimus vs. tacrolimus with mTORi, aOR = 0.28, 95% CI = 0.14–0.55, p < 0.001). Investigating PTDM risk factors before and modifying immunosuppressant regimens after transplantation may effectively prevent PTDM development.

Ching-Yao Cheng, Yu-Tung Feng, Hue-Yu Wang. Korean J Transplant 2020;34:231-7. https://doi.org/10.4285/kjt.20.0026

Background: Acute kidney injury (AKI) is a syndrome with heterogeneous causes and mechanisms. An early warning system (EWS) for AKI was created to reduce the incidence and improve outcomes. However, the benefits of AKI-EWS remain debatable. Methods: We launched a project to design and create AKI-EWS for inpatients in our institute. Incidence of AKI and its outcome before and after the implementation of AKI-EWS were collected for analysis. Results: We enlisted a stakeholder map before creating AKI-EWS. We then started an action plan for this initiative. The diagnosis was automatic and based on the definition of Kidney Disease: Improving Global Outcomes (KDIGO). The differential diagnosis of causes of AKI was also automatic. Users are to adjust the threshold of detection. After the implementation of this AKI-EWS, the incidence of AKI fell. The proportion of AKI > 4% was reduced significantly (47.7% and 41.6%, p = 0.010) in patients with serum creatinine measured. The proportion of AKI > 0.9% also dropped significantly (51.67% and 35.94%, p = 0.024) in all inpatients. Trends of AKI outcomes also showed improvement. The loading of consultation of nephrologists decreased by 15.5%. Conclusions: Through well-designed AKI-EWS, the incidence of AKI dropped, showing improved outcomes. The factors affecting benefits from AKI-EWS included high-risk identification (individual threshold detection), timely and automatic diagnosis, real-time alerting on electronic health information systems, fast self-diagnosing of the cause of AKI, and coverage of all inpatients.

Tacrolimus is a cornerstone immunosuppressive agent in solid organ transplantation due to its efficacy in preventing rejection. Achieving optimal tacrolimus levels remains challenging and limited studies have explored quality improvement (QI) initiatives aimed at optimizing tacrolimus trough levels. We conducted a QI initiative at Taichung Veterans General Hospital targeting tacrolimus level optimization in renal transplant recipients between January 2015 and January 2019. This multifaceted intervention included: physician reminders integrated into the Electronic Health Information System (EHIS) to monitor trough levels and variability, patient engagement through a mobile application displaying immunosuppressant levels, and automated tacrolimus concentration measurement to reduce ordering errors. Outcomes were descriptively evaluated before and after the interventions, including measurement accuracy, biopsy-proven acute rejection (BPAR) rates, and intrapatient variability (IPV), without formal statistical comparison. The implementation of automated tacrolimus measurement eliminated ordering errors, leading to an estimated cost saving of $78,911.3 over 2 years. A numerical decrease in BPAR incidence was observed, from 9% pre-intervention to 0% post-intervention. Tacrolimus intrapatient variability (IPV) also showed a decreasing trend, from 26.45% in 2019 to 18.7% in 2022. Physician reminders and patient engagement interventions contributed to improved monitoring but had a less pronounced impact on acute rejection rates. This study describes a structured QI initiative, including the automation of tacrolimus concentration measurements, and its association with improvements in therapeutic drug monitoring processes in renal transplant recipients. These findings suggest a potential role for mistake-proofing mechanisms in enhancing measurement accuracy and contributing to cost savings. Observed changes in rejection rates were descriptive and should be interpreted with caution given the small number of events.

Background: Direct real-world comparisons of empagliflozin and canagliflozin regarding renal outcomes in patients with type 2 diabetes mellitus (T2DM) remain limited. This study compared longitudinal changes in the estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR). Methods : This retrospective observational cohort study included 215 adults with type 2 diabetes mellitus who received either empagliflozin (n = 115) or canagliflozin (n = 100) at a tertiary medical center. Renal outcomes, including estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR), were evaluated over 18 months. Between-group differences in renal outcomes were assessed using multivariable regression models adjusted for relevant baseline clinical characteristics. Linear mixed-effects models were additionally employed to account for repeated measurements and evaluate differences in longitudinal trajectories between treatment groups. A reduction in UACR of ≥30% from baseline was evaluated as a clinically meaningful albuminuria response using multivariable logistic regression. Subgroup analyses were performed according to age and baseline UACR. Results: In multivariable linear regression analysis, the 18-month change in eGFR did not differ significantly between canagliflozin and empagliflozin (adjusted β, −0.43 mL/min/1.73 m²; 95% confidence interval [CI], −4.12 to 3.26; p = 0.819). Consistently, linear mixed-effects models showed no significant treatment-by-time interaction for eGFR (p for interaction = 0.356) or log-transformed UACR (p for interaction = 0.104). In the adjusted logistic regression analysis, canagliflozin was associated with lower odds of achieving a ≥30% reduction in UACR at 12 months compared with empagliflozin (adjusted odds ratio [OR], 0.40; 95% CI, 0.20–0.79; p = 0.008). However, this association was not statistically significant at 18 months (adjusted OR, 0.62; 95% CI, 0.32–1.18; p = 0.147). Subgroup interaction analyses did not demonstrate significant effect modification by age or baseline UACR (p for interaction = 0.859 and 0.626, respectively). Conclusions: In this real-world cohort of patients with type 2 diabetes mellitus, empagliflozin and canagliflozin showed comparable longitudinal eGFR and UACR trajectories over 18 months. Although a difference in the likelihood of achieving a ≥30% reduction in UACR was observed at 12 months, this finding was not sustained at 18 months and should be interpreted cautiously. Overall, our findings do not establish the superiority of either SGLT2 inhibitor in terms of renal outcomes. Further studies with larger populations and prospective designs are warranted.