Perioperative Glycemic Control in Solid-Organ Transplant PatientsFrances Lee1, Sulay Shah2, India Gaines3, Stephanie Preston4 Jaskirat Dhanoa1, Tina Thethi2, Anil Paramesh3

1Tulane University School of Medicine, 2Department of Endocrinology, Tulane University School of Medicine, 3Department of Surgery, Tulane University School of Medicine, 4Department of Surgery, U.T. Southwestern

Background

Methods

Results Adjusted Glycemic Control Algorithm

Conclusions & Future Directions

AcknowledgementsThis project could not be possible without the coordination and cooperation of the surgical staff, endocrinologists,pharmacists, and nurses at Tulane University.

To date, there is no consensus or the standard of care for transplant dysglycemiathroughout the surgical continuum, especially as hyperglycemic medications cancomplicate their hospital course. Transplant dysglycemia impacts post-operativerecovery through increasing rates of complications, graft function abnormalities, graftrejection, and prolonging length of hospital stay. Current literature for the transplantpopulation dysglycemia is remarkably limited at the face of these challenges. Due tothe short- and long-term consequences of peri-operative dysglycemia, it is imperativeto examine the current epidemiology & management of postoperative hyperglycemia.We further designed adjusted glycemic control algorithms as part of our qualityimprovement project to address our findings.

Results Discussion

Pt with previously

diagnosed DM

Pt is on home insulin, but not

on 70/30

BASAL INSULIN

LANTUS/GLARGINE: 50% of

home dose, One time

NPH: 2/3 of home dose, One

time

LEVEMIR/DETEMIR: 50% of

home dose, One time

CORRECTIONAL SCALE INSULIN

HUMALOG (lispro): Low, Medium, High

dose

Pt is on home insulin AND on

70/30

BASAL INSULIN

GLARGINE (LANTUS): 25%

* TDI

CORRECTIONAL SCALE INSULIN

HUMALOG (lispro): Low, Medium, High

dose

Pt is not on insulin or on

70/30

CORRECTIONAL SCALE INSULIN

HUMALOG (lispro), Low

dose

Post

-Ope

rativ

e B

lood

Glu

cose

If BG 140-220

On Home Insulin

BASAL, Full dose of Home Insulin

LANTUS (Glargine)

NPH

LEVEMIR

Correction Insulin HUMALOG, Low dose, medium dose, high dose

Not on Home insulin Correctional Insulin, Adjust in 24 hours

HUMALOG (lispro), Low dose

If BG > 220 x 2

1) Start Insulin drip

If on Home Insulin: Algorithm 3

If not on Home Insulin: algorithm 2

2) Lantus 0.25 units/kg of Body Weight

3) Discontinue Home or Other Insulin Regimen

(automatic)

4) Consult Endocrine

Figure 5. Pre-operative Glycemic Control Algorithm is based on patient history and home medication regiment

Figure 6. Post-operative Glycemic Control Algorithm is based on immediate post-operative blood glucose readings

Transplant dysglycemia remains a challenge throughout the surgical continuum withimplications on complication rates and length of hospital stay. We proposeinterventions that optimize insulin regiments pre- and post-operatively and define theparameters that would initiate Endocrinology consults. We will prospectively collectand analyze our data to identify degree of post-operative hyperglycemia, rate ofcomplications, and length of stay to understand the impact of our protocol.

Figure 4. Rate of infections, rejection, and endocrine consults for OLT and KT patients. Of note, over 20% of our patients had an infection during their hospital stay.

Figure 3. Percent of patients receiving insulin through various modes for the first post-operative week. Lowest percent of patients on insulin therapy occurred on POD7; highest percent of patients on insulin therapy occurred on POD2.

0102030405060708090

1 2 3 4 5 6 7 8Basal 2.2 3.65 8.3 10.58 12.94 9.4 10.5 5.8IV Insulin 11.2 8.5 8.3 4.7 4.7 3.5 1.1 1.1Correction Scale 6.7 20.7 21.42 22.35 17.6 17.6 16.4 11.7No Insulin 79.77 67.07 61.9 62.35 64.7 69.4 71.7 81.1

Perc

ent o

f cas

es

0 1 2 3 4 5 6 7

Figure 2. Percent of patients with blood glucose (BG) greater than 180 for the first post-operative week. With no reported incidences of hypoglycemia in our data set, the highest rates of hyperglycemia, defined by the ADA as blood glucose >180, occurred on post-operative day 0 and 1, 54% and 60%, respectively.

Figure 1. Types of solid-organ transplants conducted by percentage. KT = Kidney Transplant; OLT = Orthotopic Liver Transplant; KP = Kidney Pancreas Transplant; SLK = Simultaneous Liver Kidney Transplant. Of note, about 30% of all patients had pre-existing DM.

KT76%

OLT19%

KP2%

SLK3%

Other5%

16.47

5.88

2.35

18.82

02468

101214161820

Wound infection

Other Infection

Acute Graft Rejection

consult

Perc

ent o

f cas

es

We conducted a retrospective analysis of 94 transplant recipients over a 6-monthperiod (2015-2016). Data collected include demographic information; pre-operativeA1C; post-operative blood glucose minimum, maximum, and median (day 0-7); modeof insulin delivery; post-operative infection; endocrine consultation during hospitalcourse; and length of stay.

• Given that the highest rates of hyperglycemia occurred on POD0 and POD1 whileinsulin therapy was utilized most on POD2, we observed how clinical inertia canlead to delayed use of insulin therapy. Moreover, over a fifth of our patientsacquired an infection, which may be associated with post-operative dysglycemia.Endocrinology, which could mitigate dysglycemic events, was consulted in lessthan 20% of all cases.

• With our new algorithms, we project that 28%, as opposed to 13.4%, of post-operative transplant recipients will be treated with an insulin drip. We hope thatour pre-operative dysglycemia protocol will prevent post-operative glycemicdeviation. Through stepwise improvements, initially with a blood glucose goal ofless than 220, we hope to achieve a target blood glucose of less than 180 in orderto abide by the ADA guidelines for glycemic control.

54.560.2

50.9

38.9 36.630.8

35.540.5

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9 10

Perc

ent o

f cas

es w

ith B

G >1

80

Post-Operative Day0 1 2 3 4 5 6 7

Pre-Operative Transplant Dysglycemia Post-Operative Transplant Dysglycemia

• Neuroendocrine response• History of insulin resistance• Inadequate pre-transplant management of hyperglycemia

• Hyperglycemic medications, such as steroids and certain immunosuppressants• Para-phenomenon• Clinical inertia that fails to adjust or intensify insulin regiments• Knowledge gaps• Non-ADA diets.

Table 1. Factors that influence dysglycemia peri-operatively. Our quality improvement project aims to adjust both pre-transplant management of hyperglycemia and correct post-transplant clinical inertia (bolded).