髋部骨折合并糖尿病患者的围手术期血糖控制

目的探讨老年糖尿病患者髋部骨折围手术期胰岛素的应用。方法对43例老年髋部骨折合并糖尿病患者随机分为2组，分别采用诺和锐或普通胰岛素治疗，行围手术期监测、控制血糖，并进行总结。结果43例患者于术前或术后使用胰岛素。两组患者术前、术后血糖控制满意，无心脑血管并发症发生；伤口无感染，愈合良好。普通胰岛素治疗组相对于诺和锐组低血糖发生率高（P〈0.05）。结论老年糖尿病患者合并髋部骨折在手术前后应合理使用胰岛素治疗，使血糖得到有效控制，减少并发症。诺和锐能够最大限度地模拟人体生理状态下的胰岛素分泌，更有利于控制高血糖，避免低血糖的发生。     

糖尿病对胆道手术的影响及治疗对策

目的探讨糖尿病对胆道手术的影响及控制血糖的有效方法。方法通过设立严格的病例对照，比较40例糖尿病患者与非糖尿病患者、胰岛素强化治疗与非强化治疗胆道术后并发症的发生率。结果糖尿病显著增加胆道术后并发症的发生率，围手术期胰岛素强化治疗，可减少并发症的发生。结论高血糖是胆道病患者术后并发症高发生率的主要原因，严密监测血糖、尿糖，规范围手术期胰岛素强化治疗是预防术后并发症的关键。     

两剂激素联合两剂达利珠单抗及他克莫司的免疫抑制方案在肝移植中的应用

目的 探讨两剂激素联合两剂达利珠单抗及他克莫司(FK506)的免疫抑制方案在肝移植中应用的安全性及有效性.方法 中山大学附属第一医院器官移植中心2006年9月至2008年3月共实施成人肝移植74例,排除3例血型不合、4例围手术期死亡外,余67例纳人本研究,其中男性54例,女性13例,年龄28～66岁,平均(46.9±8.7)岁.将67例成人肝移植患者随机分为两组:传统免疫抑制方案(激素3个月撤离)组(n=35)和两剂激素免疫抑制方案组(n=32),比较两组术后代谢并发症、感染(含细菌、真菌及巨细胞病毒感染)及排斥反应的发生率的差异.结果 两组患者的术后早期高血糖发生率,高血糖患者使用胰岛素的平均剂量,随访期内糖尿病、高血压及感染的发生率的差异有统计学意义(P<0.05);术后早期高血压发生率及随访期内排斥反应的发生率和高脂血症发生率无明显差异(P0.05).结论 两剂激素的免疫抑制方案是安全有效的,其不增加急性排斥反应的发生率,并可显著减少长期使用激素引起的各种不良反应及并发症的发生.     

老年糖尿病患者髋部骨折围手术期胰岛素的应用

[目的]探讨老年糖尿病患者髋部骨折围手术期胰岛素的应用。[方法]对37例老年髋部骨折合并糖尿病患者围手术期监测、控制血糖，在手术前后使用胰岛素，进行总结。[结果]本组37例患者，25例术前或术后使用胰岛素，使用胰岛素患者术前、术后血糖控制满意，无心脑血管并发症发生；伤口无感染，愈合良好。[结论]老年糖尿病患者合并髋部骨折在手术前后应采用胰岛素治疗，将血糖控制基本正常水平以利于手术，减少并发症，降低死亡率。     

肝移植术后激素24小时撤离的安全性

目的探讨肝移植术后激素24小时撤离的安全性及可行性.方法 76例成人肝移植患者随机分为激素3个月（3 m）撤离组（40例）和24 h撤离组（36例）,所有患者随访至2009年12月,前瞻性比较两组患者术后生存、感染、急性排斥反应、切口愈合不良、肝炎和肝癌复发、新发糖尿病、高脂血症及高血压的发生情况.结果两组间患者术后生存、急性排斥反应、高脂血症、乙肝复发及肝癌复发无明显区别,24 h撤离组的术后切口愈合不良、高血压、感染及新发糖尿病发生率明显低于3 m撤离组.结论肝移植术后采用IL-2单克隆抗体诱导下的以FK506为基础的免疫抑制方案时,激素24 h撤离是安全的,而且可以明显减少激素相关的副作用.     

肝移植术后糖尿病危险因素分析

目的 探讨肝移植术后糖尿病（PTDM）的发生及发展的危险因素。方法 回顾性分析98例肝移植受者的临床资料。根据其肝移植术后是否发生糖尿病，分为糖尿病组（36例）和非糖尿病组（62例）。以术前和术后可能的9个危险因素作为分析指标，进行这些指标的单因素分析和χ^2检验。结果 在对两组患者的年龄、乙型肝炎病毒（HBV）感染情况、有无肝硬化及肝硬化的程度、术前糖耐量情况、免疫抑制剂的选择及其血药浓度、激素的使用时间的比较分析中发现：术前肝硬化患者PTDM的发生率明显高于无肝硬化者；肝硬化失代偿期患者PTDM的发生率高于代偿期。术前糖耐量异常的患者PTDM的发生率明显高于糖耐量正常者。激素半年内撤离的患者PTDM的发生率明显低于半年内未撤离者。而两组患者的年龄、HBV的感染情况、免疫抑制剂的选择及其血药浓度相比较，差异均无统计学差异。结论 肝硬化、尤其是肝硬化失代偿期，糖耐量异常，长期使用激素是PTDM发生的危险因素。     

老年骨折合并糖尿病围手术期的处理

目的探讨老年骨折合并糖尿病患者围手术期的血糖控制方法。方法对56例老年骨折合并糖尿病患者围手术期如何控制血糖,术前准备,选择麻醉以及术后处理进行回顾性分析。结果 56例手术患者血糖控制满意且顺利度过围手术期,术后随访6个月～3 a,无1例发生感染和酮症酸中毒等并发症,骨科疾病均痊愈,日常生活能力恢复至术前水平。结论对老年骨折合并糖尿病患者,积极合适的围手术期治疗尤其是正规使用胰岛素有效调控血糖争取最佳手术时机,术中合理选择麻醉和手术方式,术后早期功能锻炼,这些是患者成功治疗的关键和保证。     

重型肝炎肝移植疗效初步分析

目的 探讨重型肝炎患者肝移植术后的疗效。方法 总结我院2002年9月至2004年10月期间37例重型肝炎行肝移植术患者的临床资料，回顾性分析重型肝炎患者肝移植术后疗效和并发症。结果 全组37例重型肝炎患者术后1年生存率为83．8％，围手术期死亡6例，死亡率为16．2％，死亡原因为多脏器功能衰竭（4例），原发性移植肝功能不良＋急性肾功能衰竭（1例），术后4个月因脑梗塞合并严重肺部感染（1例）。术后并发症：急性肾功能不全12例（32．4％），其中2例行血液滤过治疗，12例患者经有效治疗后肾功能均恢复；肺部感染14例（37．8％），其中细菌感染9例，细菌合并真菌感染5例，气管切开2例，14例患者经治疗后痊愈；术后胆道并发症2例（5．4％），经ERCP介入治疗病情缓解；急性排斥反应2例（5．4％），予激素冲击治疗后排斥反应得到控制。结论 肝移植是治疗重型肝炎的有效方法，应加强围手术期管理，提高重型肝炎患者移植术后的生存率。     

再次肝移植80例临床报告

目的总结再次肝移植的临床经验。方法回顾性分析我中心自1999年1月至2005年7月实施的80例再次肝脏移植的原因、与首次肝移植的时间间隔、选择的术式、1年存活率、围手术期死亡率及死亡的主要病因。结果再次肝移植的主要原因是胆道并发症,占45．0％;距首次移植术后超过1个月再次移植围手术期死亡率（19．6％）明显低于首次移植术后8～30d行再次移植患者（70．0％）;围手术期死亡的主要原因是感染（54．5％）和多脏衰（18．2％）。结论选择合适的手术适应证及手术时间,根据术中情况决定具体术式,制定合理的免疫抑制方案及有效的抗感染治疗是提高再次移植生存率的关键。     

肝移植病人围手术期营养支持治疗

目的 总结肝移植病人围手术期营养支持治疗的经验。 方法 回顾性分析并对比广州军区广州总医院肝胆外科2003年8月至2006年12月（A组）和2007年1月至2010年3月（B组）两个阶段共205例肝移植病人临床资料、营养支持方法及有关指标。 结果 B组术前重度营养不良率为28.2%,显著高于A组（18.9%）;B组围手术期注重营养支持并辅以大黄鼻饲、灌肠以及吴茱萸散（自制）外敷脐部,术后肛门排气排便中位时间1.5d、感染并发症发生率32.82%;A组未注重营养支持,术后肛门排气排便中位时间3.5d、感染并发症发生率51.35%。两组差异有统计学意义。 结论 肝移植围手术期加强营养支持,辅以改善胃肠功能的方法可以提高肝移植病人耐受性、促进胃肠蠕动功能恢复、降低术后感染并发症发生率。     

肝移植术后糖尿病的初步研究

目的 探讨肝移植术后糖尿病的发生规律和对病人的影响。方法 收集2000年7月～2003年1月间35例长期存活的肝移植病人的临床资料,观察移植术后糖尿病(Post Transplantation Diabcte Mellitus,PTDM)与病人年龄、免疫抑制剂、皮质激素用量和原发病之间的关系及PTDM对病人的影响。结果 术后新出现11例糖尿病,术前空腹血糖和年龄对PT-DM的发生无明显影响。FK506(普乐可复)组和CSA(环孢霉素)组的PTDM发生率无明显差别。晚期肝硬化和接受大剂量皮质激素冲击治疗的病人术后PTDM的发生率明显升高。PTDM对病人术后巨细胞病毒(CMV)感染率无明显影响。结论肝移植术后糖尿病的发生与晚期肝硬化和大剂量激素冲击治疗相关,与年龄和术前空腹血糖无关。     

Diabetes Mellitus After Living Donor Liver Transplantation: Data From Mainland China

Most reported data on posttransplantation diabetes mellitus (PTDM) are from Western countries with patients who underwent deceased donor liver transplantation. A retrospective study was performed to assess the prevalence and predictive factors of PTDM in the context of living donor liver transplantation (LDLT) in the Chinese population using the definition of PTDM proposed in 2003 by the World Health Organization and the American Diabetes Association. The prevalence of DM after LDLT in our study was 25% (21/84), and the incidence of PTDM was 14.9% (11/74) with 64% of cases diagnosed within 3 months after LDLT; 9.5% were observed to show impaired fasting glucose postoperatively. Multivariate analysis identified body mass index ≥ 25 kg/m² before LDLT as the only independent risk factor for developing PTDM. Only one patient was operated for hepatitis C virus (HCV) infection. Hepatitis B virus (HBV)-related diseases were common in our study population, accounting for 78.6% of all patients. Both HCV and HBV infection status were not independent risk factors for developing PTDM. In addition, a greater tacrolimus trough blood level in the PTDM group versus no-DM group was observed at 3 months post-LDLT (11.03 ng/mL vs 4.87 ng/mL). The mean tacrolimus dose was not significantly different between the two groups. In conclusion, PTDM was prevalent among Chinese LDLT recipients.     

Do anti-CD25 monoclonal antibodies potentiate posttransplant diabetes mellitus?

Anti-CD25 monoclonal antibodies (MAbs) are directed against the IL-2 (CD-25) receptor, which is associated with the pathogenesis of diabetes mellitus (DM). Measuring CD25 on peripheral blood lymphocytes could be a new immunologic marker to identify patients with prediabetes. OBJECTIVE: The study aimed to analyze whether administration of anti-CD25 MAbs was an independent risk factor for posttransplant diabetes mellitus (PTDM) in kidney transplant (KT) patients at 3 months after transplantation. PATIENTS AND METHODS: Seventy-four stable, nondiabetic KT patients were included in the study. The overall sex distribution was 70% men and mean overall age, 52 +/- 10 years. Thirty-eight subjects where treated with anti-CD25 antibodies (basiliximab). The diagnosis of PTDM was made if patients required insulin or oral antidiabetic drugs and/or had glycemia >200 mg/dL at 120 minutes after an oral glucose tolerance test (75 g glucose). We determined the age, weight, body mass index, acute rejection, chronic hepatitis C virus (HCV) infection, and type of calcineurin inhibitor. RESULTS: Thirty-four percent of patients developed PTDM. Patients treated with anti-CD25 antibodies were older (P = .022) and showed a greater incidence of PTDM (P = .041). The logistic regression analysis (dependent variable: PTDM; independent variables: age, anti-CD25, tacrolimus vs cyclosporine) showed that treatment with anti-CD25 is an independent risk factor for PTDM (P = .041; OR 3.28; CI 95% 1.04-10.31). CONCLUSION: Patients treated with anti-CD25 MAbs showed greater incidence of PTDM.     

Post-Transplant Diabetes Mellitus and HCV Seropositive Status After Renal Transplantation: Meta-Analysis of Clinical Studies

Hepatitis C virus (HCV) infection has a detrimental role on patient and graft survival after renal transplantation (RT). Some studies have also implicated HCV in the development of post-transplant diabetes mellitus (PTDM). We conducted a systematic review of the published medical literature of the relationship between anti-HCV seropositive status and DM after RT. The risk of DM occurrence in anti-HCV-positive and -negative patients after RT was regarded as the most reliable outcome end-point. We used the random effects model of DerSimonian and Laird to generate a summary estimate of the Odds Ratio (OD) of new onset DM in HCV-positive and -negative patients after kidney transplantation. Ten studies involving 2502 unique RT recipients were identified. The incidence of PTDM after RT ranged between 7.9% and 50%. The summary estimate for adjusted OR was 3.97 with a 95% confidence interval (CI) of 1.83-8.61 (p-value for homogeneity <0.0473). Thus, pooling of study results demonstrated the presence of a significant link between anti-HCV seropositive status and DM after RT. This relationship provides one potential explanation for the adverse effects of HCV on patient and graft survival after RT.     

Minimal model analysis in nondiabetic renal transplant recipients with hepatitis C

INTRODUCTION: Epidemiological data suggest that hepatitis C virus (HCV) infection may contribute to the development of posttransplantation diabetes mellitus (PTDM). METHODS: We investigated the glucose metabolism in 19 renal transplant recipients with antiHCV antibodies and without DM according to World Health Organization criteria before or after transplantation. We measured insulin sensitivity (SI), glucose effectiveness (SG), and pancreatic insulin response using the frequently sampled intravenous glucose tolerance test (FSIGTT). SI and SG were estimated using the Bergman minimal model method and pancreatic insulin response was expressed as the area under insulin curve (AUIC) between 0 and 19 minutes. RESULTS: Impaired glucose tolerance was shown in 42% of patients, some (31.5%) in the range of glucose intolerance (KG: 1-1.5) and others (10.5%) in the diabetes range (KG < 1). SI and SG were decreased in 39% and 63% of patients, respectively. Pancreatic insulin response revealed high variation among patients although showing a tendency to be enhanced. CONCLUSIONS: A high number of HCV-positive renal transplant recipients without clinically manifest PTDM have impaired glucose tolerance, which suggests the future development of diabetes in these patients.     

心脏移植术后新生糖尿病的危险因素分析

目的 探讨原位心脏移植术后新生糖尿病的发病率、发生的独立危险因素及其对患者长期存活的影响.方法 对术前病史资料详实、无糖尿病、术后存活时间大于6个月的92例原位心脏移植患者进行回顾性研究.患者平均随访31个月.随访期间发生移植后新生糖尿病者(PTDM组)共19例(19/92,20.7%),未发生新生糖尿病者(NPTDM组)73例.记录与移植后新生糖尿病相关的因素,并对可能的危险因素进行单因素分析和多因素回归分析.记录原位心脏移植术后新生糖尿病的发病率.绘制患者的Kaptan-Meier生存曲线.结果 移植后患者整体的空腹血糖水平较移植前明显升高[移植后为(5.52±1.07)mmol/L,移植前为(4.95±0.64)mmol/L,P%0.01].多因素Logistic回归分析显示,移植后新生糖尿病发生的独立危险预测因素是高龄(OR=1.09,P<0.05)、体重指数(OR=1.45,P<0.01)、糖尿病家族史(OR=7.97,P<0.05)和术前空腹血糖(OR=5.83,P<0.01).92例患者术后1、3和5年存活率分别为96.29%、88.80%和80.62%,PTDM组术后1、3和5年存活率分别为87.50%、72.92%和72.92%,NPTDM组术后1、3和5年存活率分别为96.95%、93.44%和81.95%.分层次Log-rank检验显示,PTDM组和NPTDM组的两条生存曲线无明显差异(P>0.05).结论 移植后新生糖尿病的独立危险因素包括年龄、糖尿病家族史、体重指数和术前空腹血糖状态.     

Detection and treatment of post kidney transplant hyperglycemia: a Spanish multicenter cross-sectional study

INTRODUCTION: The prevalence of diabetes mellitus (DM) is greater among patients with solid organ transplants than in the general population, although the factors associated with posttransplant DM (PTDM) are unknown. OBJECTIVES: The objective of this study was to estimate the prevalence of and assess the risk factors for PTDM. PATIENTS AND METHODS: We included outpatients with functioning isolated solid organ allografts (kidney, liver, heart, and lung). We collected demographic and posttransplant clinical data that included DM diagnostic ADA criteria, DM treatment, DM family history, presence of hepatitis C virus (HCV), immunosuppression treatment, hypertension, and dyslipidemia. RESULTS: A total of 2178 patients included, 1410 kidney recipients, 489 liver transplants, 207 heart transplants, and 72 lung recipients. Seventeen and four-tenths percent of the patients who did not have DM prior to transplantation, developed PTDM (median time: 79 days). A greater prevalence was observed among patients with a family history, HCV, and tacrolimus treatment (with or without steroids P < .05). By logistic regression analyses, OR for these factors were 1.51, 1.65, and 1.38, respectively. Of those patients who did not suffer PTDM, 55.2% showed basal blood glucose values under 100 mg/dL; only 68% presented with a hemoglobin Alc under 6. CONCLUSIONS: The prevalence of PTDM among kidney recipients was higher than that in the general population. DM family history, HCV positive, and tacrolimus were risk factors associated with this entity.     

Post–liver transplantation diabetes mellitus: An association with hepatitis C

A retrospective study was performed on all liver transplant recipients from British Columbia from 1989 to March 2000 to determine the prevalence and predictive factors of diabetes mellitus (DM) post-liver transplantation. DM was defined as hyperglycemia requiring treatment with insulin or oral hypoglycemic agents. Patient characteristics, cause of liver disease at transplantation, and immunosuppression regimen were considered. Both univariate and multiple logistic regression analyses were performed. Posttransplantation DM (PTDM) occurred in 43 of 177 transplant recipients (24%). Of these, 13 transplant recipients had DM pretransplantation, whereas 30 patients developed de novo PTDM. The majority of patients were treated with insulin (80%). In univariate analysis, transplantation for hepatitis C virus (HCV) liver disease was associated with a greater incidence of PTDM (odds ratio [OR], 3.01; 95% confidence interval [CI], 1.46 to 6.23) and de novo PTDM (OR, 5.20; 95% CI, 2.25 to 11.99). Patients administered tacrolimus had a greater incidence of PTDM (OR, 2.04; 95% CI, 1.01 to 4.13), and there was a trend toward increased PTDM in older patients (mean age, 49 years). Recipient sex, steroid dosage, and acute rejection were not predictive of PTDM. The incidence of graft loss and death rates were similar between the two groups. On logistic regression, HCV was the only independent predictor of PTDM (OR, 4.12; 95% CI, 1.91 to 8.90) and de novo PTDM (OR, 6.02; 95% CI, 2.55 to 14.20). In conclusion, DM post-liver transplantation is a common occurrence and is associated with HCV. (Liver Transpl 2002;8:356-361.)     

影响肝移植术后新发糖尿病逆转的相关因素

目的 探讨影响肝移植术后新发糖尿病(PTDM)逆转的相关因素.方法 回顾分析232例肝移植受者的临床资料,术后共有62例患者发生PTDM,发生率为26.7%.根据PTDM是否发生逆转,将62例患者分为暂时性PTDM组(34例)和持续性PTDM组(28例).对两组患者的性别、年龄、体重指数、糖尿病家族史、乙型肝炎病毒感染情况、术前空腹血糖水平、免疫抑制剂使用及其血药浓度、皮质激素的使用时间等相关因素进行分析.结果 两组间患者的性别、体重指数、糖尿病家族史、术前空腹血糖水平、免疫抑制方案中皮质激素的持续使用时间、术后血他克莫司浓度及使用环孢素A的患者比例等因素的差异均无统计学意义(P＞0.05).与持续性PTDM组相比,暂时性PTDM组患者移植时年龄较轻,分别为(54±8)岁和(42±6)岁(P＜0.05);发生PTDM的术后时间较晚,分别为术后(18±23)d和(35±42)d(P＜0.05);免疫抑制方案中联合运用吗替麦考酚酯(MMF)或西罗莫司(SRL)的患者比例较高,分别为0和8.9%(P＜0.05).经多因素Logistic回归分析显示,只有移植时年龄是PTDM逆转的独立预测因子(比值比为1.312,95%可信区间为1.005～1.743).结论 患者移植时年龄、发生PTDM时的术后时间及免疫抑制方案中使用MMF或SRL的患者比例等因素与肝移植术后PTDM逆转相关,但只有移植时年龄是PTDM逆转的独立预测因子.

Abstract：

Objective To study the related factors associated with the reversal of posttransplant diabetes mellitus (PTDM) following liver transplantation. Methods The clinical data of 62patients with PTDM in 232 patients receiving liver transplantation (26. 7 %) were retrospectively analyzed and the patients were divided into two groups: patients with transient PTDM (34 cases) and those with persistent PTDM (28 cases). Pre-operative and post-operative variables, including sex,age, body mass index, family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose, the immunosuppressant regime, FK506 concentration and duration of steroid usage, were analyzed retrospectively. Results The variables, including sex, age, body mass index,family history of diabetes, hepatitis B virus infection, pretransplantation fasting plasma glucose,FK506 concentration at month 1, 3 and 6 after operation, rate of cyclosporine usage and duration of steroid usage had no significant difference between the two groups (P＞0. 05). Compared with the persistent PTDM patients, the transient PTDM patients were characterized by younger age at the time of transplantation (54 ± 8 vs. 42 ± 6 years, P＜0. 05), longer time before the development of PTDM (18 ± 23 vs. 35 ± 42 days, P＜0. 05), and higher rate of mycophenolate mofetil or sirolimus usage (0vs. 8. 9 %, P＜0. 05). Based on a multivariate analysis, age at the time of transplantation was determined as the single independent predictive factor associated with reversal of PTDM following liver transplantation (odds ratio: 1. 312, 95 % confidence interval: 1. 005 - 1. 743). Conclusion Age at the time of transplantation, duration before the development of PTDM and rate of mycophenolate mofetil or sirolimus usage are associated with reversal of PTDM following liver transplantation. Among these factors, age at the time of transplantation is only the single independent predictive factor.     

肾移植术后糖尿病的临床特性及高危因素

目的 研究肾移植术后糖尿病（ＰＴＤＭ）的临床特性及高危因素。方法 将５１２例肾移植患者分为２组,其中４８例ＰＴＤＭ患者为糖尿病组。其余４６４例患者为非糖尿病组。定期监测患者体重、用药情况、生化指标、病毒抗体,并用血清学方法及聚合酶链反应（ＰＣＲ）方法检测主要组织相容性抗原（ＨＬＡ）。结果 糖尿病组的平均年龄及术后６个月内激素的用量明显高于非糖尿病组。肾移植术后半年内易出现ＰＴＤＭ,且全部ＰＴＤＭ