Insulin Therapy for the Prevention of New Onset Diabetes After Transplantation Prospective Study in Non-Diabetic De Novo Kidney Transplant Recipients
Insulin Therapy for the Prevention of New Onset Diabetes After Transplantation Prospective Study in Non-Diabetic De Novo Kidney Transplant Recipients
This study aims to assess the effects of early basal insulin therapy in previously
 non-diabetic de novo kidney transplant patients in reducing the incidence of new onset
 diabetes in particular and abnormal glucose metabolism in general during subsequent
 follow-up.The ITP NODAT study should be seen in connection with the Vienna SAPT-NODAT study
 (clinicaltrials.gov record number: NCT01680185), as for the final analysis, the data yielded
 from the three arms in those two studies will be used for an pooled analysis.
New-onset diabetes after transplantation (NODAT) is strongly associated with postoperative
 hyperglycemia, and reduced patient as well as graft survival. In our recent proof-of-concept
 clinical trial (TIP), we have shown that immediate post-transplant basal insulin therapy
 decreases hyperglycemia and reduces the prevalence of NODAT by improving pancreatic β-cell
 function.

 In consequence, this study as an interventional trial comparing aggressive glycemic control
 with early institution of insulin therapy to standard of care (dietary precaution, life-style
 modification, oral hypoglycemic agents and/or insulin as needed) aims to assess the effects
 of early basal insulin therapy in previously non-diabetic de novo kidney transplant patients
 in reducing the incidence of new onset diabetes in particular and abnormal glucose metabolism
 in general during subsequent follow-up.

 Patients will be enrolled through the University of Michigan and the Medical University of
 Vienna, Austria (MUV), who is the official sponsor of the European part of the ITP-NODAT
 study. This record only refers to the European part of the ITP-NODAT study, specifically to
 all study patients from the following study Centers: MUV; Medical University of Graz,
 Austria; Charité Berlin, Germany; Hospital Del Mar, Barcelona, Spain. For the patients
 enrolled through the University of Michigan (i.e., the US-part of the ITP-NODAT study), a
 separate records exists (responsible PI: Dr. Akinlolu Ojo).

 This study will involve previously non-diabetic ESRD patients undergoing kidney
 transplantation with either a deceased or living donor kidney who will receive standard
 triple immunosuppression regimen including a calcineurin inhibitor (once-daily tacrolimus in
 Europe, twice-daily tacrolimus in the U.S.), an anti-metabolite (mycophenolate mofetil) and
 corticosteroids (prednisone) and be followed at each transplant center's outpatient clinic
 for at least 2 years following transplantation according to the established standard center
 protocol.

 Methods: Combining the study presented here (ITP-NODAT) and the SAPT-NODAT study mentioned
 above will yield three study arms, with 28 patients in each arm, namely: [1] the control arm,
 treated by standard-of-care; [2] the basal insulin arm, treated predominantly with
 intermediate acting NPH insulin (human insulin isophane, Humulin N, Eli Lilly); [3] the SAPT
 arm, treated with short acting insulin (Insulin lispro, Humalog, Eli Lilly), applied
 continuously by SAPT technology. Adult patients with absence of diabetes will be randomized
 prior to renal transplantation and stratified by deceased donor or living donor, if they are
 capable of understanding the study and are willing to give informed written consent for all
 three study arms. Patients will receive standard triple immunosuppressive medications
 (twice-daily tacrolimus, mycophenolate mofetil or mycophenolic sodium and steroids) with
 predefined tacrolimus targets and steroid doses. The algorithm for insulin administration is
 designed to account for the prominent evening peak of hyperglycemia observed in our previous
 TIP-study. The primary endpoint is HbA1c (in rel.%), at 3 months, and superiority will be
 assumed if a statistically significant difference between the SAPT-treatment group versus the
 standard-of-care control group can be determined, by two-sided Student's t-test. Secondary
 endpoints will be compared between all three groups and will include hypoglycemic events,
 glycemic variability, 2h glucose ≥200 mg/dL (by oral glucose tolerance test [OGTT] to
 determine prevalence of diabetes, prediabetes and normal glucose tolerance), beta cell
 function and insulin sensitivity derived from OGTT, serum creatinine, quality of life
 measures, patient and graft survival. All secondary endpoint comparisons relying on OGTTs
 will be made at 6, 12 and 24 months after kidney transplantation, respectively. The result of
 the 6-months OGTT will be blinded to patients and investigators to prevent subsequent
 treatment bias.
Inclusion Criteria:

 1. Adult patients with end stage renal disease undergoing kidney transplantation with a
 deceased or living donor kidney.

 2. Absence of diabetes prior to kidney transplantation, defined according to American
 Diabetes Association guideline (not on oral hypoglycemic agents or insulin with
 fasting glucose < 126 mg/dl).

 3. Receiving standard triple immunosuppressive medications that include tacrolimus
 (once-daily in Europe, twice-daily in the U.S.), mycophenolate mofetil or mycophenolic
 sodium and steroids.

 4. Capable of understanding the study and willing to give informed written consent for
 study participation.

 Exclusion Criteria:

 1. Patients with a diagnosis of diabetes mellitus prior to kidney transplantation, or
 receiving anti-diabetic medications, or having pre-transplant fasting glucose level
 equal or greater than 126 mg/dl on two occasions at least three days apart.

 2. Patients receiving an organ transplant other than kidney.

 3. Patients receiving an unlicensed drug or therapy within one month prior to study
 entry.

 4. Patients with history of hypersensitivity to injectable insulin.

 5. Patients with documented HIV infection.