High blood sugars after a transplant

The medication you have been prescribed to prevent your body rejecting your new organ (immunosuppressants) can make it harder for your body to control your blood sugar (glucose) levels. This can lead to your blood sugar levels being higher than normal (normal range 4 to 8 mmol/L). This is often a temporary effect but there is a small possibility it may become long term. It would then be called diabetes.

Which medications can increase my blood sugar levels?

• Steroids (Prednisolone)
• Tacrolimus (Prograf®, Adoport® or Advagraf®)
• Ciclosporin (Neoral®)
• Sirolimus (Rapamune®)

What symptoms can high blood sugar levels cause?

High blood sugar levels (called hyperglycaemia) can cause symptoms such as; tiredness, thirst, passing a lot of urine (especially at night), blurred vision and weight loss.

It is important to maintain sugar levels within an acceptable range. This will prevent the unpleasant symptoms of high sugars and minimise the risk of developing long term complications which can affect your eyes, heart, kidneys and nerves.

Why do these medications increase blood sugar levels?

Blood sugar levels are normally regulated by a hormone called insulin which is naturally produced by your pancreas. The above medications can cause your liver to produce more sugar and less insulin than usual. It can also cause your body to become more resistant to the insulin your pancreas produces. This causes your blood sugar levels to rise above the normal range.

Treating high blood sugar levels

For some people, changing their anti-rejection medications can be enough to control blood sugar levels. Other people will need to alter their eating habits to do so. More details of this are outlined below.

You may need to take tablets (e.g. metformin, gliclazide) to help your body be less resistant to the insulin your pancreas is producing or to stimulate your pancreas to produce more insulin when the supply is inadequate.

Sometimes daily insulin injections are required if your body is not producing enough insulin. If the medical team decide this is the best treatment option for you, you will be given further information and support.

Dietary recommendations

The dietary advice for people who are struggling to control their blood sugar levels after a transplant is very similar to the advice given to other people after a transplant.

As you have recently had a major operation, initially you will need more energy and protein in your diet than the general population. This is to help your wounds heal, prevent infections and avoid long stays in hospital.

You may be advised to moderate the type and amount of carbohydrate you eat as these foods have the greatest effect on your blood sugar levels. The main sources of carbohydrate in the diet are bread, pasta, rice, potatoes, breakfast cereals, cakes, biscuits, fizzy drinks, fruit, milk, yogurts and sugar.

Eat carbohydrate at each meal

• Carbohydrate foods are digested and absorbed into the bloodstream as sugar (glucose). Eating these foods regularly at each meal, in balance with activity and medication (if taken) will help control your blood sugar levels.
• Different carbohydrates affect blood sugars in different ways. This is known as the Glycaemic Index (GI).
• Carbohydrates that have a low GI are digested slowly and cause a slow rise in blood sugar levels after they are eaten.
• Slowly digested carbohydrates include wholegrain bread, potatoes, rice, pasta, high fibre breakfast cereals, beans, lentils, crispbreads, fruit, milk and milk products (for example, yoghurt). These are good food choices.

Reduced sugar

Your diet does not need to be sugar free, however, it is advisable to avoid having large quantities of sugar at one time.

You can reduce sugar in the diet by:

• Using artificial sweeteners such as Canderel, Nutrasweet, Hermesetas, Sweetex in place of sugar.
• Choose tinned fruit in natural juice, fresh fruit, and stewed/baked fruit (sweetened with artificial sweetener) rather than tinned fruit in syrup.
• Try sugar free squash and diet fizzy drinks instead of sugar containing squash and normal fizzy drinks.
• Try non-sugar coated breakfast cereals, for example Weetabix, Branflakes, Shredded Wheat and porridge, rather than cereals such as Sugar Puffs, Frosties and Coco Pops.
• Try puddings made with sweeteners rather than sugar, for example, milk pudding, custard, sugar free jelly or sugar free Angel Delight.
• Replace sweets and mints with sugar free sweets / mints. These should be eaten in moderation as sorbitol (the sweetener) may cause diarrhoea if eaten in large quantities.

Eating regularly

Spreading food evenly over the day and eating small amounts regularly helps to stabilise and control blood sugars more easily.

Avoid missing meals and going for long periods of time without food.

A suggested meal plan

• Breakfast: baked beans or egg on wholemeal toast with spread or wholewheat cereal with full fat milk.
• Lunch: meat, chicken, fish or meat alternative with vegetables or salad and potato, rice, pasta or noodles. Followed by a small piece of cake, yogurt or a few biscuits.
• Evening meal: wholemeal bread sandwich with meat, cheese or tinned fish and salad with a yoghurt, fruit or piece of cake.

Snacks

The following snacks are suitable for people who have been getting high blood sugars:

• 1 apple / pear / orange / nectarine / peach / 2 satsumas / 10 grapes / 2 plums / 1 small banana (one handful)
• 1 pot of diet / sugar-free yoghurt
• 1 Weetabix® with 100ml semi-skimmed milk
• 1 small or medium slice of wholemeal toast or bread sticks
• 1/2 pitta bread with salsa or salad
• 1 packet of Twiglets® or crisps
• 2 handfuls of unsweetened popcorn
• 2 crackers or crisp breads (with marmite® or very low fat cheese spread)
• 2 plain biscuits for example rich tea, morning coffee, Hob Nobs®, digestives, fig rolls
• 1 crumpet
• A handful of nuts
• A glass of milk

Artificial sweeteners

You may wish to use artificial sweeteners if you like very sweet foods and are trying to limit the amount of sugar you are having. Be aware that some sweeteners may have a laxative effect, particularly if eaten in large quantities, and may give you loose stools.

Special food products

The use of ‘diabetic’ speciality foods is not recommended, as they are expensive and not necessary.

Illness

If it is possible, continue to eat as normal even if you don’t feel well.

If eating normally is not possible, try a light diet and eat smaller amounts more frequently, for example, every two to three hours.

• Bread or toast with soup / egg
• Breakfast cereal
• Crackers / crispbread / plain biscuits
• Milky puddings
• Yoghurt

This can be supplemented with carbohydrate containing fluids such as milky drinks and fruit juices.

If you cannot eat a light diet, take sugary drinks in small amounts more frequently, for example every one to two hours:

• Normal fizzy drinks (flat)
• Sugared drinks
• Lucozade
• Ordinary jelly

Blood sugar levels generally run higher during times of illness. It is important to still drink plenty of sugar free fluids, such as eight to 10 tall glasses daily to help flush the sugars out.

Medicines

Tablet medications are generally sugar free, while some liquid medications will contain sugar. Although the amount of sugar in a single dose or ordinary mixture is unlikely to make much difference to blood sugar levels, many medicines such as cough mixtures are available in sugar free forms. Discuss the availability of sugar free medicines with your pharmacist.

Hypoglycaemia (hypo)

Hypoglycaemia or low blood sugars are very rarely seen in people with diet or tablet controlled (especially Metformin) blood sugar levels.

Hypoglycaemia occurs when blood glucose falls below 4 mmol/l known as 'four is the floor'.

Symptoms of hypoglycaemia

The first four are early signs:

• Hunger
• Headache
• Anxiety
• Tremor and cold sweat

Blurred vision

Slurred speech

Causes of hypoglycaemia

• Missed or delayed meal or snack
• Increased activity
• Excessive amounts of alcohol
• Too little carbohydrate at meal or snack

If you experience hypos regularly and cannot identify the cause, contact your doctor.

Always carry foods to treat your hypo when away from home or in the car, for example, glucose tablets and a cereal bar.

Treatment

Take some fast acting carbohydrate to raise blood sugar levels quickly, followed by some longer acting carbohydrate to maintain it at the higher level, examples of these are given below. Chocolate is not a good hypo treatment food as the high fat content slows down absorption of the sugar into the body.

15g of fast acting carbohydrate

For example take one of these:

• 4 glucose tablets, for example Dextrosol, Dextro energy, Lucozade tablets
• 4 jelly babies
• 150mls ordinary fizzy drink (about half a can) for example Coke, Lilt, Fanta
• 100mls Lucozade (not Sports Lucozade)
• 200ml Fruit Juice
• Glucojuce bottle (60ml)

Symptoms should start to improve after five minutes. If they do not, repeat the above

Once you start to feel better, take: 10g to 15g of slow acting carbohydrate.If a meal or snack is due, have straight away. Otherwise please eat one of the following:

• one slice of bread
• one glass of milk
• one piece of fruit
• one digestive / Hob Nob or 2 rich tea biscuits.

Night time hypos

The risk of a hypo at night can be greatly reduced by having a high fibre snack such as wholemeal bread, or high fibre breakfast cereal e.g. Weetabix with semi-skimmed milk before going to bed at night. You may wish to have a larger bed time snack if your bed time blood glucose level is less than seven mmol/l or you have had a particularly active day. Keep some hypo treating foods by the bedside.

It is important to share this information on how to treat a hypo with close family and friends so that they can assist you, if necessary, to treat a hypo safely.

Contact dietician

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Telephone: 01223 216655