Patients deemed at high risk have 60% chance of post-op diabetes

A diabetes scoring index, using routine endocrine evaluation and preoperative data of diabetes, can predict the development of prediabetes in patients undergoing major pancreatectomy, according to researchers.

Use of this index, called the Post-pancreatectomy Diabetes Index (PDI), shows that patients determined to be at moderate risk by the PDI have 2 times the odds of developing postoperative diabetes, while those determined to be at high risk have 4 times the odds of developing diabetes.

The study, led by Juan M. Sarmiento, MD, FACS, Emory University Hospital, was published in the Journal of the American College of Surgery.

The incidence of Type 2 diabetes mellitus is continuing to increase in the United States and threatens to get worse. According to this 2017 report from the CDC, as of 2015, 9.4% of the U.S. population had diabetes, while another 84.1 million had prediabetes. The objective of this study was to identify risk factors leading to the development of diabetes, and to create a scoring index predicting development of diabetes, after major pancreatectomy.

The prospective study included 1,083 patients who underwent pancreaticoduodenectomy and distal pancreatectomy by the senior author, Sarmiento, from 2007 to 2018.

Of those 1,083 patients, 23.4% had preoperative normoglycemia, 33.4% prediabetes, and 43.2% diabetes. The development and validation groups included 1,023 and 60 patients, respectively.

For each of these patients perioperative fasting and postprandial (OGTT, oral glucose tolerance test) plasma glucose, glycated hemoglobin A1c (HbA1c), insulin, and c-peptide were measured. The primary outcome was those factors that correlated highly with the development of postoperative diabetes in patients after major pancreatectomy.

The authors analyzed 89 patient, pathologic, and surgical-level factors for the development of the PDI. After multivariate analysis, hemoglobin A1c percent at evaluation, BMI > 30 kg/m2 , age 65 years or older, and type of pancreatectomy, were selected as factors predicting diabetes development. Of those 4, age and BMI were moderately associated with the development of diabetes, while hemoglobin A1c had the strongest association.

For purposes of the PDI model, point values were assigned to each of these factors, with a total possible score of 8 points:

  • Hemoglobin A1c or eA1c: < 5.4%, 0 points; 5.5-5.9%, 1 point; 6.0-6.4%, 2 points, 6.5-6.9%,3 points, >7.0%, 4 points.
  • BMI ≥ 30 kg/m2, 1 point.
  • Age ≥ 65 years, 1 point.
  • Distal pancreatectomy procedure, 2 points.

Total scores ≤ 1 are considered to be low-risk with a 22.2% rate of diabetes; scores = 2, moderate-risk with a 32.8% rate of diabetes; and ≥ 3, high-risk with a 58.8 rate of diabetes.

The PDI independently predicted diabetes in development (odds ratio [OR] 4.298, relative risk [RR] 2.486, CI 1.238 to 5.704) and validation (OR 6.970, RR 2.768, CI 2.182 to 22.261) groups, as well as prediabetes in development (OR 1.961, RR 1.325, CI 1.202 to 2.564) and validation (OR 4.255, RR 1.798, CI 1.247 to 14.492) groups.

“Patients determined to be at moderate or high risk have 2 times and 4 times the risk, respectively, with approximately 60% of high-risk patients developing postoperative diabetes,” the authors concluded.

The authors suggested that the PDI could be used in preoperative counseling, especially managing expectations in patients determined to be at moderate or high risk. “All patients undergoing pancreatectomy must understand the risk of postoperative diabetes as a life-altering diagnosis that requires constant patient attention, regardless of the [glycemic control medication] required,” they wrote.

In a discussion section accompanying the study, Sarmiento was asked how he is using the study to drive decision making, particularly in the case of low-risk lesions.

Hypothesizing a patient with a neuroendocrine tumor that is 1.8 cm, has a PDI score of more than 3, and who is determined to undergo a pancreaticoduodenectomy, Sarmiento said he would tell that patient that if he had the procedure he would have a “very high chance of becoming diabetic.” But, with continued follow-up the patient would be normoglycemic, “and probably will be safe,” Sarmiento said.

“On the other hand, if the patient has a very low risk score, and has an inflammatory mass in the head of the pancreas creating pancreatic ductal obstruction, most likely I will tell the patient I will do the resection, you will get better, and possibly, the chance of you not becoming diabetic is pretty good,” Sarmiento added. “I entirely agree that [PDI] is going to help me in my decision making.”

  1. A diabetes scoring index called the Post-pancreatectomy Diabetes Index (PDI) can predict the development of diabetes in patients undergoing pancreatectomy.

  2. A prospective study found that patients shown to be at moderate or high risk by the PDI have 2 and 4 times the odds, respectively, of developing postoperative diabetes.

Michael Bassett, Contributing Writer, BreakingMED™

The authors had no relationships to disclose.

Cat ID: 159

Topic ID: 97,159,730,12,192,918,925,159