Purpose: Diabetes mellitus (DM), the most common cause of ESRD, limits access to transplantation and impairs patient and allograft outcome. Prediabetes is an independent risk factor for progression to manifest DM, as well as new onset diabetes after transplantation. We describe the prevalence of DM and prediabetes on kidney transplant waiting list, its underlying pathophysiology and propose an approach for individual risk stratification.

Methods: All patients on the active kidney transplant waiting list of a large European university hospital transplant center were metabolically phenotyped. Determination of HbA1c as well as standard oral glucose tolerance test (OGTT) was performed and indices for insulin sensitivity and -secretion calculated.

Results: Of 138 patients, 30 (22%) had known DM. Using ADA criteria, 4 patients (3%) were newly diagnosed with DM, 42 patients (30%) were detected to have prediabetes. Insulin sensitivity and -secretion indices revealed different underlying pathophysiology according to clinical phenotype. Age was an independent risk factor for impaired insulin secretion resulting in a relative risk (RR) for prediabetes of 2.95 (95% CI 1.38-4.83) with a cut-off at 48 years. BMI independently affected insulin sensitivity as a continuous variable.

Conclusions: The prevalence of DM or prediabetes on kidney transplant waiting list is as high as 55%, with more than 30 % of patients previously undiagnosed. Metabolic phenotyping allows for differentiation of underlying pathophysiology and risk factors. To our knowledge, we report for the first time a CKD V cohort on kidney transplant waiting list that has been fully metabolically characterized. Our approach provides a basis for early individual risk stratification and specific intervention to improve patient and allograft outcome.

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