Real-Time Continuous Glucose Monitoring Improves Glycemic Control in the Early Postoperative Period Following Liver Transplantation: A Randomized Controlled Trial

Background: Early postoperative glycemic control after orthotopic liver transplantation (OLTx) is challenging because of surgical stress, corticosteroid and calcineurin-inhibitor immunosuppression, and parenteral nutrition. We evaluated whether adding real-time continuous glucose monitoring (rtCGM) to standard care increases time in the target glucose range. Methods: In this single-center randomized controlled trial, OLTx recipients were randomized after surgery to open (Active) or blinded (Control) rtCGM (Dexcom G6); in the Active group, sensor data guided insulin titration. The primary endpoint was time in target range (TIR, 6.0–10.0 mmol/L), analyzed in a modified intention-to-treat population. Secondary endpoints included glycemic metrics, insulin requirements, and predefined clinical outcomes. Results: We randomized 154 patients; 142 with available data were analyzed (82 Active, 60 Control). The Active group spent more time in target range (68.9% vs. 60.8%; median difference 7.2 percentage points [95% CI: 2.7–12.0]; P = 0.003), with less time in Level 1 hyperglycemia ( P = 0.025) and fewer extended hyperglycemic episodes (incidence rate ratio 1.65 [1.03–2.65] for Control vs. Active; P = 0.039). TIR improved similarly in patients with and without pretransplant diabetes; the only significant treatment-by-diabetes interaction was a greater reduction in Level 2 hyperglycemia among patients with diabetes ( P < 0.001). Hypoglycemia was minimal in both groups. Infectious complications were less frequent in the Active group (45.1% vs. 63.3%; P = 0.041). Conclusions: Adding rtCGM to standard postoperative care improved glycemic control after liver transplantation, with consistent benefit regardless of diabetes status and the greatest effect on Level 2 hyperglycemia in patients with diabetes. The lower infection rate is a hypothesis-generating finding warranting a dedicated trial.