Objectives: Diabetes knowledge among kidney trans-plant recipients with posttransplant diabetes has not been exhaustively assessed. We evaluated levels of diabetes knowledge among our kidney transplant patients using a 35-item diabetes self-care manage-ment questionnaire.

Materials and Methods: The study comprised renal transplant patients with posttransplant diabetes mellitus who were referred from Hamed Al-Essa Organ Transplant Center of Kuwait to the Dasman Diabetes Institute. Patient data were collected through patient identification forms, metabolic control parameters forms, and diabetes self-care scale questionnaires (with score from 0-7).

Results: Of 356 (25.6%) kidney transplant recipients with posttransplant diabetes, 210 patients were enrolled in this study. Most were Kuwaiti (60%), men (48.8%), and with high school education level (43.8%). Some were smokers (11.9%), and the original kidney disease was glomerulonephritis in 37.6% of patients. Most patients (71.9%) received hemodialysis pre-transplant. Most patients (> 88%) reported low mean score of healthy diet (0-3), with > 93% reporting low mean score of practicing exercise (0-3), > 62% not checking blood sugar at home, 85% not following the recommended frequency, and > 72% not caring for their feet (except washing in 86.7%). Moreover, most patients lacked information about sharp disposal, diet regimen, using logbooks, hypoglycemia and hyper-glycemia, sick day management, and the importance of hemoglobin A1c and regular fundus examination. Mean score of practicing exercise was significantly higher in men (especially non-Kuwaiti; P < .05); otherwise, other mean scores were comparable between sexes and different nationalities (P > .05).

Conclusions: Diabetes knowledge is deficient in patients with posttransplant diabetes. Seminars, counseling sessions, and workshops should be arranged period-ically for renal transplant recipients to improve their low level of diabetes knowledge. This is a preliminary report of our randomized controlled study evaluating the impact of structured diabetes education on self-care activities and metabolic control variables.

Key words : Education, Kidney allograft, Lifestyle, Questionnaire, Self-care

Introduction

Diabetes is a chronic irreversible disease, directly concerns individuals of all ages and their relatives, and brings heavy economic burden, affects self-care activities, and shortens life expectancy due to its chronic complications.¹

It is estimated that diabetes incidence will reach to 3% to 6% and the number of patients with diabetes will be more than 300 million by the year 2025. Approximately 20% of people who are 65 years of age or older are diabetic. Diabetes incidence is expected to increase by 165% in the next 50 years.² It is estimated that there are 17 million people with diabetes in the United States alone and that approximately 14.5 million of this population have type 2 diabetes mellitus. Diabetes prevalence in-creases with age, with prevalence of 9% in those in their 20s but exceeding 20% in those age 70 years and older.³

The successful treatment of chronic diseases is closely associated with the education of both patients and their relatives.⁴ Patient education is one of the most important responsibilities of nurses. In the management of diabetes, helping patients improve their health and quality of life is considered an important aspect of diabetes self-care education.⁵

The aim of self-care, which is a universal concept for maintaining and improving health, is to enable individuals to take full responsibility regarding their health. Self-care constitutes 98% of diabetes care. To control their disease, patients with diabetes need to adopt self-care activities such as adopting an appropriate diet, regular exercise, control of blood glucose, appropriate use of oral antidiabetic agents, awareness of the effects and possible adverse effects of insulin treatment, avoiding alcohol use and smoking, preventing complications of diabetes, and compliance to life-long medication.⁶

Diabetes can be prevented or delayed, with 44% to 58% risk reduction, just by adopting a healthy way of life.⁷ In a meta-analysis study on diabetes, education on exercise was reported to decrease glycated hemoglobin (HbA1c) levels of patients with type 2 diabetes mellitus.⁸

According to the World Health Organization, “education” is the key to diabetes treatment and has a vital role in the integration of diabetes with society. Patient diabetes education includes all studies conducted to increase knowledge and experience to enable patients with diabetes to feel better, to protect patients from possible adverse effects by better disease control, to reduce treatment costs, to minimize treatment errors, and to provide patients with skills to use new technology.⁹ Blood glucose monitoring is also key to diabetes management, and self-monitoring of blood glucose can significantly change diabetes care.¹⁰

Patient education, in which patients with diabetes are informed about their disease and their awareness is raised, is of vital importance.¹¹ Disease-oriented education given to patients with type 2 diabetes had a positive effect on their self-care activities.¹² Indeed, in different parts of the world and in our country, decreased lipids and arterial blood pressure values were demonstrated in patients who were given education by diabetes nurse educators and who were monitored for approximately 3 months to 1 year.13 Furthermore, decreased HbA1c values were shown in patients with education, with changes observed in body mass index.¹⁴

Transplant recipients are at high risk for devel-oping prediabetes and overt diabetes mellitus due to a number of factors, including immunosup-pressive therapies. Posttransplant diabetes mellitus (PTDM) has emerged as an increasingly important determinant of outcomes and survival in transplant recipients.¹⁵ Nampoory and associates indicated poor survival in patients with pretransplant diabetes mellitus due to coronary artery disease and infections, whereas long-term graft survival was equally good in pretransplant diabetes mellitus and transplant recipients without diabetes.¹⁶

In addition to type 1 and type 2 diabetes, PTDM is now a well-recognized consequence of organ transplant, especially after solid-organ and bone marrow and hematopoietic stem cell transplant. Varying incidences of PTDM have been reported over different posttransplant intervals. At 12 months or greater, rates of PTDM are approximately 20% to 50% for kidney transplant recipients.¹⁷ Patients with PTDM tend to develop microvascular complications more rapidly than patients with nontransplant-related diabetes.¹⁸

Diabetes education and its impact on post-transplant morbidity and mortality have become crucial areas of research in organ transplant popu-lations. Here, we evaluated levels of diabetes knowledge among our kidney transplant patients with PTDM using a 35-item diabetes self-care management questionnaire in addition to assessment of diabetic microvascular complications.

Materials and Methods

The research population included organ transplant recipients with PTDM who were followed at the Hamed AL-Essa Organ Transplant Center of Kuwait and who met the eligibility criteria. This preliminary report of a prospective randomized controlled study included 210 renal transplant recipients with posttransplant diabetes. Patients were planned to receive the structured diabetes education program for 2 years (comparing one-to-one education methods, group education methods, and conventional education methods). Patients who fulfilled the following criteria were included: (1) transplant duration of > 6 months, (2) outpatient status, (3) no psychiatric history of illness, (4) written consent to participate in the research, and (5) age of > 21 years. We excluded younger patients (< 21 years old) and patients with mental abnorm-alities.

Ethical principles of the research
Written permission was received from the insti-tutions where the research was carried out. Aim and scope of the research were submitted and approved by the Ethical Committees of both the Ministry of Health and the Dasman Diabetes Institute of Kuwait.

Patient identification form
This form included information about the patient’s identifying characteristics, including age, sex, education status, and disease-related information (duration of disease and treatments received).

Metabolic control parameters form
This form included information on the patient’s metabolic control variables, including HbA1c, lipids (total cholesterol, triglyceride, high-density lipo-proteins, low-density lipoproteins), and renal and liver function tests. Metabolic control parameters were measured at the Hamed Al-Essa Organ Transplant Center outpatient clinic and were sent with each patient to the Dasman Diabetes Institute within 1 week of patient evaluation.

Blood pressure, height, weight, body mass index, and waist circumference were measured and recorded by the researcher by using the same measurement device and method each time. Waist circumferences were measured midway between the costal margin and iliac crests using a measuring tape in standing position, over underwear and after slight expiration.

Diabetes self-care scale
The Arabic-translated 24-item scale, developed in English by Lee and Fisher19 and which measures the self-care of patients with diabetes, was applied to patients.

Data collection method
In the pretest phase of the research, patients were given a patient identification form, metabolic control parameter form, and the diabetes self-care scale. The forms were completed within 15 to 25 minutes by patients in the presence of the researcher. Telephone numbers and addresses of patients were taken for proper communication if needed.

Diabetic microangiopathies (retinopathy, neuro-pathy and nephropathy ) were assessed by fundus evaluation (performed at Dasman Diabetes institute), electromyography/nerve conduction velocity (done in the Ibn Sina Hospital, Sabah area) and regular urine analysis/graft biopsy when indicated (conducted at Hamed Al-Essa organ transplant center) respectively.

Statistical analyses
Statistical analyses were done using SPSS software (version 20; SPSS Inc., Chicago, IL, USA). To analyze the identifying and disease-related characteristics of patients, matched t tests were used to compare means and standard deviations of numerical variables of analyzed groups. Categorical data were compared using the chi-square test. P < .05 was considered significant.

Results

Most patients were middle aged, with mean age of 43.6 ± 12.4 years in men and 45.05 ± 13.1 years in women (P = .44). Most received grafts from living donors (86.5% in men and 82.5% in women) during their 4th decade of life (P > .05; Table 1).

In our cohort, we observed that most women with PTDM were Kuwaiti (63 cases, 77.8%), whereas non-Kuwaiti patients were mostly men (51.1%), with 47 non-Kuwaiti Arabs (36.4%) and 19 non-Kuwaiti non-Arabs (14.7%) (Table 1).
We noticed no significant differences between the 2 study groups (men and women) regarding their original kidney disease, dialysis type, and level of education, with most having secondary level of education (P > .05).

Pretransplant comorbidities were comparable between men and women, especially hypertension, history of treatment of tuberculosis, ischemic heart disease, bone disease, and anemia (P > .05). Moreover, most patients had comparable rates of cytomegalovirus (CMV) immunoglobulin G, and CMV immunoglobulin M (P > .05) but the rate of chronic hepatitis C was significantly more in PTDM group (P = .037).

Immediate posttransplant graft function was assessed, and we found no significant differences between the 2 groups regarding graft function, as represented by immediate and slow graft function (P = .172).

Both men and women were equivalent regarding mean number of HLA mismatches, with no sig-nificant differences in type of immunosuppression therapy (both induction and maintenance) (P > .05; Table 1).

At the time of PTDM diagnosis, we found that most patients were hypertensive (94.7% in men vs 93.2% in women). However, despite comparable mean systolic blood pressure levels in men and women, mean diastolic blood pressure was signi-ficantly higher in men (P = .036). We found no significant difference between men and women regarding the mean number of antihypertensive agents (P = .31; Table 2). Most patients in our study used oral agents for diabetes control (73.4% in men vs 77.2% in women), and some patients developed microangiopathies as represented by retinopathy (13.2% in men vs 9.8% in women) and neuropathy (28.1% in men vs 25.85 in women), with no significant differences between groups (P > .05).

Regarding obesity at the time of PTDM diagnosis, we observed that body mass index and waist circumference were comparable between men and women (P > .05; Table 2). It is worth noting that metabolic parameters at the time of PTDM diagnosis were significantly higher among men (higher serum creatinine, bilirubin, albumin, alanine aminot-ransferase, and hemoglobin levels; P < .05); however, all levels were within normal limits (Table 2). Higher fasting blood sugar and HbA1c were observed in men, although this was not significant (P > .05).

As shown in Table 3, men and women showed equal incidences of BK viremia or BK viral-associated nephropathy, as well as CMV infection (P > .05). Regarding posttransplant immunologic complications, we found no significant difference between groups regarding mean number of acute rejection episodes (P = .38). Moreover, we found no significant differences between groups regarding graft and patient outcomes (P > .05).

As shown in Table 4, concerning level of diabetes education among kidney transplant recipients with PTDM, we found that most patients had low levels of knowledge about healthy food (89.2% of men vs 87.3% of women), low levels of knowledge about exercise (92.4% in men vs 96.2% in women), and low levels of knowledge about healthy foot care (92.4% in men vs 71.8% in women), with all levels of knowledge being comparable between groups (P > .05). Mean exercise knowledge score was significantly higher among men (P = .042).

We also observed that scores regarding healthy diet, healthy exercise, and sharp disposal knowledge did not exceed 23.2%, with no significant difference between men and women. However, mean score of transplant-related advice was around 40%, with comparable results between men and women (P > .05; Table 4). Smoking prevalence was signi-ficantly higher among men (19.3% vs 8.6% in women), with only 18.5% of men versus 3.7% of women counseled about smoking (P < .05; Table 4).

Few patients used logbooks to monitor blood sugar (5% in men vs 3.8% in women); moreover, few patients received advice on hyper- and hypoglycemia (9.2% in men vs 5.1% in women) and sick day management (2.5% in men vs 1.3% in women) (P > .05; Table 4).

As shown in Table 5, most Kuwaiti patients had significantly lower levels of knowledge about exercise versus non-Arabs (97.5% vs 86.4%; P = .004). Moreover, we observed no significant differences between patients regardless of their nationalities concerning knowledge on logbook use to monitor blood sugar, receiving advice for hyper- and hypoglycemia and sick day management, and knowledge about HbA1c (P > .05; Table 5).

Discussion

The value of patient knowledge about diabetes has been raised in a number of reports, which have shown that diabetes education can be cost-effective by reducing hospital admissions and readmissions.^20-22 Studies from both developed and developing countries have reported that diabetes knowledge is generally poor among patients with diabetes.^23-25 Compliance with management of diabetes was better in patients with good knowledge.²⁶

Despite the importance of PTDM as a cause of morbidity, mortality, increased cost, and patient anxiety, few randomized controlled trials have explored interventions that can diminish the development of diabetes in kidney allograft recipients.²⁷

Patients at risk of new-onset diabetes after transplant (NODAT) should be counselled on the importance of lifestyle modification, including weight control, diet, exercise, and smoking cessation.28 Overweight patients should achieve a weight reduction of at least 7% of the initial body weight.29 Dietician referral may be needed to enhance treatment of diabetes.³⁰

A low saturated fat and cholesterol and high complex carbohydrate and fiber diet is encouraged, especially in patients with diabetic dyslipidemia. Physical activity of at least 150 minutes per week is recommended as a prevention strategy for NODAT. Treatment of hepatitis C with interferon and a sustained virologic response before transplant may reduce the risk of NODAT.³¹ Lifestyle modifications can delay the onset of diabetes in nontransplant populations with abnormal glucose metabolism.³²

In our cross-sectional study to evaluate diabetes knowledge among our kidney transplant patients with PTDM using a 35-item diabetes self-care management questionnaire and assessment of diabetic microvascular complications, most patients were middle-aged. This finding was matched with that reported by Gomes and associates33 and Yu and colleagues,34 who reported similar mean ages in both male (46.9 ± 12.9 y) and female patients (49.6 ± 10.8 y) with PTDM.

Nejhad and associates³⁵ found that patients with lower level of education had lower diabetes-specific and generic health-related quality of life. In our study, we noticed no significant difference between men and women regarding level of education, with most having secondary level of education (P > .05).

Nejhad and associates35 also found that hepatitis C virus (2.9%) and CMV infections (97%) were associated with NODAT. Hepatitis C virus causes insulin resistance, abnormalities in glucose meta-bolism, and pancreatic β-cell dysfunction.³⁵ In our cohort, there was a higher prevalence of hepatitis C (7%), and the prevalence was higher in men (9%) versus women (3%), although not significantly (P > .0378). Moreover, both groups were comparable regarding CMV immunoglobulin G and immuno-globulin M (P > .05). The higher prevalence of hepatitis C virus among our patients might explain the higher prevalence of NODAT (25.6%)36 in our renal transplant recipients in the Middle East.

In their study of deceased-donor recipients, Gomes and associates33 found higher frequencies of hepatitis C infection (2.9%), CMV infection (97%), and acute rejection (14.6%) in their NODAT group; however, differences did not reach statistical significance. We observed similar prevalence among our cohort, but with higher prevalence of hepatitis C virus infection.

The 2014 international consensus guidelines on PTDM recommended a stepwise approach for the management of PTDM that consists of lifestyle modification followed by oral antidiabetic therapy and then insulin therapy.³⁷ According to the latest guidelines, diabetes in most of our patients was controlled by oral agents (73.4% in men and 77.2% in women). This was in agreement with that reported by Gomes and associates,33 in which most patients with PTDM responded to oral hypoglycemic agents, followed by insulin, and few requiring combined therapy.

In our study, we observed that most of our patients had mild obesity with mean body mass index of 32.4 ± 7.7 in men and 33.7 ± 6.6 kg/m² in women. This observation was in harmony with that reported by Centenaro and associates,³⁸ who reported, in a cross-sectional study, higher body mass index and body fat percentage, higher levels of triglycerides, and higher urinary protein-to-creatinine ratio than shown in a group without NODAT. Kim and associates showed that weight gain after kidney transplant was proportional to the risk of PTDM, independent of the pretransplant body mass index.39 Moreover, a 6-month intensive, structured lifestyle modification program that included referral to a dietitian, exercise program, and weight loss advice induced regression to normoglycemia in up to 44% of patients.⁴⁰

We found that some patients developed reti-nopathy (13.2% in men vs 9.8% in women) and neuropathy (28.1% in men vs 25.85 in women), with no significant difference between groups (P > .05). Our observations matched another study from Egypt by Nagib and associates who reported retinopathy in 8.22% and neuropathy in 24.2% of their NODAT patients.⁴¹

Dietary habits leading to high Mediterranean diet score were associated with lower risk of NODAT. These results suggest that healthy dietary habits are of paramount importance for renal transplant recipients.⁴² A healthy style diet, such as a Medi-terranean diet, has a positive impact on the devel-opment of NODAT and mortality in renal transplant recipients, possibly due to the content of antioxidants, dietary fiber, magnesium, and unsaturated fatty acids.⁴³ A Mediterranean-style diet may have a protective effect on oxidative stress and antioxidant defense, since this diet is characterized by high intake of fruits and vegetables.²⁹ Second, the high intake of dietary fiber may reduce plasma insulin levels, having an advantageous effect on glucose metabolism. Third, magnesium may play an important role in preventing type 2 diabetes mellitus.⁴³

Both men and women in our study had a low knowledge level regarding healthy food, exercise, and healthy foot care. However, we found that men had a significantly higher mean exercise knowledge score (P = .042). In general, this observation was similar to that reported by Murata and associates, in which men with type 2 diabetes mellitus had higher mean knowledge score than women.⁴⁴

It was observed that male sex, higher education, and older age (> 40 years) were associated with knowledge regarding diabetes mellitus.⁴⁵ In a study from Bangladesh, Mumu and associates observed that 68% had average knowledge. They also realized that male sex and higher educated people are likely to have better knowledge regarding diabetes.⁴⁶ The poor diabetes knowledge among our patients (23.2% knowledge on diet, exercise, and sharp disposal) was similar to ideas in other patients that lifestyle modification only included healthy dietary habits.⁴⁷

Cigarette smoking is known to increase cardio-vascular events and decrease patient and graft survival. Although not verified, cigarette smoking may also be associated with rejection. Cigarette smoking has also been associated with increased opportunistic infections and malignancies in kidney transplant recipients.⁴⁸ Despite these adverse effects, we noticed that smoking prevalence was signi-ficantly higher among male patients (22% vs 3% in women) and only 21.2% of men were counseled about smoking (vs 8.9% in females; P < .05; Table 4). This finding could be explained by the standard life style in the Gulf region.

Renal transplant recipients should receive guid-ance on outpatient follow-up, immunosuppressive medication, treatment of rejection, and prevention of complications (heart disease, infection, cancer, bone disease, and blood disorders). Issues regarding contraception and reproduction should also be discussed.⁴⁹

Despite our routine posttransplant education program, the mean score of knowledge about transplant-related guidance was around 40%. The relatively low level of knowledge could be due to lower level of education (most of our patients had a secondary level of education).

In our study, Kuwaiti patients had significantly lower level of knowledge of exercise than non-Arab patients (97.5% vs 86.4%; P = .004). This observation was similar to a recent report from Umeh and Nkombua,⁴⁷ in which only 35% of their South African patients with diabetes participated in exercises, with brisk walking (59%) as the preferred form of exercise.

In our study, few patients were monitoring their blood sugar (5% in men vs 3.8% in women), which could be explained by the few patients who had received advice regarding hyperglycemia and hypoglycemia, HbA1c, and sick day management. In addition, we observed no significant differences between patients regardless of their nationalities concerning their knowledge (P > .05; Table 5). This low level of knowledge may be explained by the fact that most patients with diabetes thought that lifestyle modifications only included healthy eating.⁴⁷ Odili and associates⁵⁰ reported that there were knowledge deficits related to misconceptions in diabetes diet and knowledge of blood glucose monitoring with glycosylated hemoglobin test.

Conclusions

Diabetes knowledge is deficient in patients with PTDM. Seminars, counseling sessions, and workshops should be arranged periodically for renal transplant recipients to improve their low level of diabetes knowledge. This is a preliminary report of our randomized controlled study evaluating the impact of structured diabetes education on self-care activities and metabolic control variables.

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