Post-transplant metabolic dysregulation: Insights and implications for kidney graft survival

Kidney transplantation is the preferred treatment for end-stage kidney disease, improving survival and quality of life. Yet, metabolic disorders including post-transplant diabetes mellitus, dyslipidemia, hyperuricemia, secondary hyperparathyroidism, and obesity are common in kidney transplant recipients and threaten graft function and patient outcomes. Post-transplant diabetes mellitus affects up to 30% of recipients within the first year, while transient hyperglycemia occurs in 60% of nondiabetic patients post-surgery. Dyslipidemia, obesity, and hyperuricemia exacerbate cardiovascular and metabolic risks, and secondary hyperparathyroidism impairs bone health and graft longevity. Immunosuppressive agents such as corticosteroids, calcineurin inhibitors, and mammalian target of rapamycin inhibitors contribute significantly to these complications, underscoring the need for tailored regimens. Management strategies should be comprehensive, combining lifestyle modification, pharmacological interventions (sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists), and, in selected cases, bariatric surgery. Close monitoring of post-transplant weight gain, particularly visceral fat, is essential to prevent insulin resistance and metabolic syndrome. Despite these advances, significant gaps persist in evidence-based guidelines, and emerging therapies alongside multidisciplinary collaboration hold promise in addressing these complex metabolic challenges. This review underscores the prevalence, pathophysiology, and clinical implications of post-transplant metabolic dysregulation, emphasizing the need for early detection, personalized management, and integrated care to optimize graft survival and long-term patient outcomes.