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Jagpal et al. Vessel Plus 2018;2:24 I http://dx.doi.org/10.20517/2574-1209.2018.27 Page 11 of 14

Due to the nature of this study, follow-up times were not exactly on time for each patient, but for this study,
flexibility of two weeks was allowed in data collection. All information was readily available and there were
no technical difficulties faced during this study.

Implications
Understanding the risk of hyperglycaemia with different maintenance immunosuppressant regimens
is very important as chronic hyperglycaemia can negatively affect a patient’s quality of life and can
result in high morbidity and mortality. A major modifiable risk factor for the development of PTDM is
immunosuppression, but risk versus benefit analysis is needed to balance the risk of developing PTDM
versus rejection. This study does not support the view of switching patients from tacrolimus to ciclosporin.
Rejection episodes and survival data collection were not included in the study; therefore, this study cannot
comment on the superiority of one drug over the other.

Instead, implications lie in informing clinicians about the possibility of developing diabetes after tacrolimus
use and the complications of this on patients. Therefore, greater attention should be paid to recognising
diabetes through different glycaemic parameters. As a result of the findings of this study, the heart transplant
unit at the Golden Jubilee National Hospital has introduced regular HbA1c testing in all heart transplant
patients. A HbA1c diagnosis of diabetes is already endorsed in the general population and should be used to
recognise PTDM, especially due to its ability to predict diabetic complications.

Hyperglycaemia is extremely common in the early postoperative period. It can also occur because of critical
conditions such as infections or as a consequence of rejection therapy. In this study, there is no data on
patient glucose metabolism before transplantation. This would be helpful when making a formal diagnosis of
PTDM, as the patient’s pre-transplant glucose function can be compared to after transplantation when they
are stable on their maintenance immunosuppression, have stable cardiac allograft function and no acute
infections.

Further studies should consider collaborating and combining data that links fasting glucose and HbA1c with
end points, including microvascular complications, cardiovascular events, patient and graft survival. There
is also a need to facilitate clinical trials into the prevention of PTDM, one way by which this can be done is
to identify patients at risk. A limitation of this study, as mentioned previously, is the lack of data. Patient risk
factors for PTDM are well established and encompass general information such as family history of diabetes.
There is a room for possibly preventing PTDM and its complications when such factors are collected.

The future of pharmacological management in transplant recipients is beyond calcineurin inhibitors. Based
on this research and personal recommendation, more advanced immunological methods could reduce side-
effects produced currently. This could also help reach the ultimate goal of organ transplantation, which
is the development of safe and effective regimens that manipulate host immune system into accepting
transplanting organs in absence of immunosuppressive management or ‘tolerance’. This would prevent
the morbidity of chronic immunosuppression including CVD. Nevertheless, CNIs have dominated
transplantation for decades through targeting T-cells, a key player in rejection. Research surrounding the
function and clinical effects of both tacrolimus and ciclosporin will be valuable for the manipulation of
immune cells in the future.

In conclusion, both tacrolimus and ciclosporin continue to remain at the backbone of pharmacological
management in heart transplant patients. Even though tacrolimus is a newer agent with a greater ability to
prevent allograft rejection, patients are at increased risk of diabetes. Pharmacological development in this
area is required as the gap between the need for cardiac transplantations worldwide and the development of
effective immunosuppressant regimens is growing. A heart transplantation can transform a patient’s life,