Recent advances in new-onset diabetes mellitus after kidney transplantation

Table 1 Newer antihyperglycemic agents and chronic kidney disease

CKD stage	1	2	3a	3b	4	5
eGFR (mL/min per 1.73 m2)	≥ 90	60-89	45-59	30-44	15-29	≤ 15
SGLT2 inhibitors
Canagliflozin (Invokana)	300 mg OD	Dose adjustment not required	Reduce dose to 100 mg OD if < 60 mL/min	Reduce dose to 100 mg OD in previously treated patients with albuminuria > 33.9 mg/mol. Do not initiate if < 30 mL/min
Dapagliflozin (Forxiga)	10 mg OD	Dose adjustment not required		Not recommended	Contraindicated
Empagliflozin (Jardiance)	25 mg OD	Dose adjustment not required			Contraindicated
Ertugliflozin (Steglatro)	15 mg OD	Dose adjustment not required	Not recommended for initiation of therapy. Discontinue if persistently < 45 mL/min		Contraindicated
Sotogliflozin (Zynquista)	400 mg OD	Dose adjustment not required	Not recommended for initiation of therapy. Discontinue if persistently < 45 mL/min		Contraindicated; safety not established
GLP-1R agonists
Dulaglutide (Trulicity)	1.5 mg weekly	Dose adjustment not required				Caution as safety not established
Exenatide (Byetta)	10 μg BID	Dose adjustment not required	Caution if 30-50 ml/min		Not recommended due to risk of accumulation
Liraglutide (Victoza)	1.8 mg OD	Dose adjustment not required				Safety not established
Lixisenatide (Adlyxine)	20 μg OD	Dose adjustment not required			Safety not established
Semaglutide (Ozempic)	1 mg weekly	Dose adjustment not required			Limited experience	Not recommended
Semaglutide (Rybelsus)	14 mg OD	Dose adjustment not required			Limited experience	Not recommended
DPP4 inhibitors
Alogliptin (Nesina)	25 mg OD	Dose adjustment not required	Reduce dose to 12.5 mg		Reduce dose to 6.25 mg
Linagliptin (Trajenta)	5 mg OD	Dose adjustment not required				Limited experience
Saxagliptin (Onglyza)	5 mg OD	Dose adjustment not required	Reduce dose to 2.5 mg if < 50 mL/min			Not recommended
Sitagliptin (Januvia)	100 mg OD	Dose adjustment not required	Reduce dose to 50 mg if < 50 mL/min		Reduce dose to 25 mg
Vildaglitin (Galvus)	50 mg BID	Dose adjustment not required	Reduce dose to 50 mg OD if < 50 mL/min

CKD: Chronic kidney disease; eGFR: Estimated glomerular filtration rate; SGLT2: Sodium glucose co-transporter 2; GLP-1R: Glucagon-like peptide-1 receptor; DPP4: Dipeptidyl peptidase 4.

Table 2 Special considerations in prescribing newer antihyperglycemic agents to kidney transplant recipients

Clinical evidence	Largely observational
Kidney function	Reduced glomerular filtration rate
	Fluctuating glomerular filtration rate
	Post-transplant diuresis
Surgically altered urinary tract	Urinary tract infections
Graft arterial anastomosis	Peripheral vascular disease
Immunosuppression	Fluctuating glucose control
	Interaction with calcineurin inhibitors
	Urinary tract infections
Gastrointestinal upset	Intravascular volume depletion
	Dehydration
Others	Post-transplant erythrocytosis