Posttransplant diabetes is a common complication of solid-organ transplantation. We present the possible role of diabetes education in improvement of post-transplant diabetes in a 36-year-old bodybuilder who was a kidney transplant recipient. The patient had been abusing some medications to help in bodybuilding. He underwent living unrelated-donor renal transplant with thymoglobulin induction and was maintained on steroids, tacrolimus, and mycophenolate mofetil. Posttransplant diabetes was confirmed by blood tests. His blood sugar was partially controlled by 3 oral agents. The patient participated in our structured diabetes education program. This program was created to cover different items related to diabetes control, including diet, proper exercise, blood sugar monitoring, sick day management, and pathophysiologic roles of diabetes medications. Within 4 months of participation in this program, the patient’s blood sugar became well controlled and his diabetes medications started to be minimized. He presently has stable graft function with hemoglobin A1c level around 5.6% on only diet management. Bodybuilders are at risk of deterioration of their kidney function. A proper diabetes education program is recommended to help renal transplant recipients with early posttransplant diabetes mellitus to control their disease. Success requires close evaluation and a multidisciplinary approach.
Key words : Diet, Kidney transplant outcome, New-onset diabetes after transplant
Posttransplant diabetes mellitus (PTDM) is a com-mon complication of solid-organ transplantation and is likely to become even more common with the current epidemic of obesity in some countries.
Many risk factors have been identified, including hepatitis C infection, immunosuppression, and genetics. Nearly 50% of transplant patients with PTDM have shown improvements in glucose tolerance after reduction of immunosuppressive agents. Complete remission of PTDM is difficult to predict; however, some patients with PTDM within the first year posttransplant may show partial remission.1,2
Bodybuilders often prefer a high‐protein and creatine‐supplemented diets to achieve maximum skeletal muscle hypertrophy and training adap-tations during intense exercise. Their lifestyle, which leads to chronic hypovolemia, may magnify renal damage processes, and are often exacerbated by an on‐the‐spot use of diuretics.3
Anabolic steroids provide a scenario that may increase the risk of renal failure, especially in those with preexisting kidney diseases. Bodybuilders, who are usually exposed to forced muscle gain and hyper-tensive situations, should be considered a high‐risk group in particular.4 Growth hormone excess is characterized by insulin resistance at the hepatic and muscular levels,5 resulting in a counterregulatory effect of insulin. Exogenous administration of suprap-hysiologic doses of such hormones could lead to hyperglycemia.
Here, we present the role of diabetes education in improvement of PTDM in a kidney transplant bodybuilder.
A 36-year-old bodybuilder had been abusing some medications, including anabolic steroids, subcu-taneous short-acting insulin, and even growth hormone to help in bodybuilding. He was not diabetic, not hypertensive, and had no family history of diabetes. During travel for an international competition, he developed some fatigue. Clinical investigations found that he had reached end-stage kidney disease, which had been triggered by excessive exercise-induced myoglobinuria. Renal biopsy was performed, which showed focal seg-mental glomerulosclerosis.
The patient received hemodialysis until he underwent unrelated living-donor renal transplant with thymoglobulin induction. He was maintained on steroids, tacrolimus, and mycophenolate mofetil. Several weeks after transplant, he developed poly-dipsia, polyuria, nausea, headache, blurry vision, and an inability to complete his training course. He was evaluated, and PTDM was confirmed by blood tests. His blood sugar was partially controlled by 3 oral agents.
The intensive insulin therapy was tailored to control his blood sugar. His C-peptide level was acceptable, and the anti-glutamic acid decarboxylase antibody test was negative. However, his blood sugar was not tightly controlled. In view of his high hemoglobin A1C level (around 9%), he was enrolled in our structured diabetes education program. This program was created to cover different items related to diabetes control, including diet, proper exercise, blood sugar monitoring, sick day management, and pathophysiology of diabetes and diabetes medications. Within 4 months of completion of this education program, his blood sugar became well controlled and his diabetes medications started to be minimized. He presently has stable graft function with hemoglobin A1c level around 5.6% on only diet management.
Many bodybuilders using performance‐enhancing drugs do not consider these drugs a form of abuse. Rather, they consider these drugs as tools that help them to build their bodies in addition to self-realization and self‐expression factors. The prevalence of multi-drug abuse among professional and amateur athletes and bodybuilders has increased all over the world.1 Our patient abused insulin, anabolic steroids, and even growth hormone as performance‐enhancing agents. Insulin increases the synthesis of glycogen and proteins and thereby inhibits catabolism in muscle and liver.3 With concomitant hyperamino-acidemia, its use has been demonstrated to be anabolic.4 Therefore, insulin is prohibited in those without diabetes.5
Our patient possibly had chronic kidney disease that was triggered by excessive exercise-induced myoglobinuria and drug abuse to reach end-stage kidney disease.6 Growth hormone and insulin are presently freely available over the internet, with costs ranging from £60 to £300 for a typical month’s supply. However, the question of whether growth hormone really enhances performance is highly debatable, and no consensus exists in the medical community.7
Despite his frequent use of subcutaneous insulin, he did not develop any hypoglycemic episodes, as reported previously.8 This might be explained by the professional way of insulin use by our patient.
Anabolic steroid users are more likely than nonusers to meet criteria for substance dependence disorder. Ip and associates7 reported that anxiety disorder, cocaine use, and sexual abuse are more frequent among such populations. However, all of these issues were not reported in our patient, possibly due to religious factors.
Present assays do not differentiate between synthetic and natural growth hormones. Consequently, these have become common substances of misuse over the past decade.9 There have been no studies to monitor the chronic effects of growth hormone misuse. Most studies have focused on the acute effects that it has on muscle mass and physical performance.10,11 Therefore, it is not known whether growth hormone misuse simply unmasks latent type 2 diabetes mellitus at an early stage or whether it actually induces diabetes in an individual otherwise without diabetes.
Excess growth hormone has been shown to cause symptoms of acromegaly, which predisposes up to 40% of patients to diabetes. Geraci and associates12 reported a case of a young bodybuilder without significant past medical history who was diagnosed with new-onset type 2 diabetes mellitus associated with growth hormone and anabolic steroid abuse. Both of these agents can induce diabetes. This was matched by our patient who had been abusing both in addition to insulin. We investigated our patient for autoimmune-induced diabetes mellitus by anti-insulin and anti-glutamic acid decarboxylase tests, and both were negative.
Boregowda and associates13 reported a patient with primary gonadal failure due to chronic abuse of anabolic steroids used for bodybuilding. Our patient also had a transient period of erectile dysfunction despite a normal hormonal assay.
To our knowledge, this is the first kidney transplant bodybuilder with PTDM who responded well to a structured intensive diabetes education program, with maintenance on lifestyle changes to control his disease.
Bodybuilders are at risk of deterioration of their kidney function. A proper diabetes education program is recommended to help renal transplant recipients with early PTDM in controlling their disease. Success requires close evaluation and a multidisciplinary approach.
Volume : 17
Issue : 1
Pages : 169 - 171
DOI : 10.6002/ect.MESOT2018.P46
From the 1Dasman Diabetes Institute, Kuwait; the 2Kuwait Ministry of Health,
Al-Essa Organ Transplant Center, Sabah Area, Kuwait; the 3Faculty of Nursing,
Mansoura University, Egypt; and the 4Urology and Nephrology Center, Mansoura
University, Mansoura, Egypt
Acknowledgements: The authors want to acknowledge Mr. Essam Salem for his cooperation and efforts; the authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Osama Ashry Gheith, Hamed Al-Essa Organ Transplant Center, Kuwait