肝移植后2型糖尿病患者葡萄糖激酶基因突变研究

为探讨肝移植后2型糖尿病患者葡萄糖激酶(glucokinase,GCK)基因的突变情况。应用多聚酶链反应-单链构像多态性（PCR-SSCP)的分析方法，对湖南,湖北30例肝移植后2型糖尿病患者GCK基因12个外显子进行突变检测，在30例肝移植后2型糖尿病患者GCK基因的12个外显子中均没有发现突变。葡萄糖激酶基因可能不是中国湖南，湖北汉族人肝移植后2型糖尿病患者的发病原因可能与GCK突变无关。     

肝移植围手术期糖尿病防治的初步研究

目的研究肝移植围手术期糖尿病对患者的影响及防治措施。方法回顾性分析131例肝移植患者临床资料，观察患者围手术期糖尿病的发生及对术后并发症的影响，探讨移植术后新发糖尿病与原发疾病、术后免疫抑制药物等因素的关系。结果移植术后新发糖尿病发生率为19．3％（21／109），与糖尿病家族史和术后使用大剂量激素有关，与非糖尿病患者相比，围手术期糖尿病患者急性排斥反应、细菌感染、高血压等并发症的发生率显著升高（P〈0．05），术前及术后早期（2周内）将血糖降至正常可减少感染的发生。结论围手术期出现糖尿病会增加肝移植患者术后并发症的发生率，应该有效控制血糖以减少感染并发症的发生，同时肝移植术后早期应避免使用大剂量激素.     

Clinical outcome of preemptive kidney transplantation in patients with diabetes mellitus

End-stage renal disease (ESRD) caused by diabetic nephropathy is increasing throughout the world. The survival of diabetic patients treated by transplantation has improved nowadays. Although recent studies have demonstrated preemptive kidney transplantation to be associated with better graft survival in CKD patients, the effect of pre-transplantation dialysis on graft outcomes among diabetic ESRD patients is unclear. This analysis summarized our experience with preemptive kidney transplantation in diabetic ESRD patients by retrospectively comparing 70 such patients transplanted between 1995 and 2009. These 70 patients were divided into two groups: 30 patients underwent preemptive and the other 40 transplantation after maintenance hemodialysis or peritoneal dialysis. We compared graft survivals, acute rejection episodes, postoperative complications, and delayed graft function rates. The 10-year patient survival of 100% in the preemptive group was similar to that of the nonpreemptive group (85%, P = .11). But the 10 year graft survival was higher among the preemptive than the nonpreemptive group (100% vs 75%, P = .02). Pre-transplantation modality did not affect graft survival. Therefore, preemptive kidney transplantation should be applied to eligible patients with diabetic ESRD.     

Outcome of patients with new-onset diabetes mellitus after liver transplantation compared with those without diabetes mellitus

In liver transplant recipients, new onset of diabetes mellitus (posttransplant diabetes mellitus or PTDM) is estimated to occur in 9% to 21% of recipients. The limited published data on survival and posttransplant complications in liver transplant recipients who develop PTDM show conflicting results. The objective of our study was to compare the morbidity and mortality of 46 patients who developed PTDM with 92 age- and sex-matched patients without pretransplant or posttransplant diabetes mellitus (DM). The demographics of both groups were similar except that there were more blacks with PTDM. The incidence of following complications was higher in the PTDM group compared with the control group: cardiac (48% v 24%; P = .005), major infections (41% v 25%; P = .07), minor infections (28% v 5%; P = .001), neurologic (22% v 9%; P = .05), and neuropsychiatric (22% v 6%; P = .009). Acute rejection was seen more commonly in the PTDM group (50% v 30%; P = .03). The duration of hospital stay, cost of hospitalization, retransplantation rate, and graft survival were similar in both groups. Patient survival also was similar in the PTDM and control groups at 1 year (93.5% v 83.5%), two years (88.1% v 77.9%), and 5 years (75% v 77.2%); Kaplan-Meier survival analysis also did not show survival difference. In conclusion, PTDM was associated with significant morbidity, and our findings suggest that patients with PTDM should be monitored very closely to improve long-term outcome. (Liver Transpl 2002;8:708-713.)     

The effect of insulin-dependent diabetes mellitus on outcome of liver transplantation

BACKGROUND: It is not known whether there was a difference in outcome between insulin-dependent diabetes mellitus (type 1) and non-insulin dependent diabetes mellitus (type 2) after liver transplantation. METHODS: The outcome of liver transplantation in adult patients with type 1 (n=1,629) and type 2 (n=1,618) was compared to those without diabetes mellitus (DM) (nondiabetics, n=17,974) using the United Network for Organ Sharing database from 1994 to 2001, after excluding patients who had living donor or multiple organs or who underwent retransplantation, and those with incomplete data. RESULTS: Cryptogenic cirrhosis, hypertension, and coronary artery disease (CAD) were two to three times more common in types 1 and 2 compared with nondiabetics. Five-year patient and graft survivals by Kaplan-Meier analysis were significantly lower for type 1 (P <0.0001) compared with type 2 or nondiabetics; only patient survival was lower for type 2 ( P=0.04). Cox regression survival analysis, after adjusting for confounding variables, showed a lower 1-year, 2-year, and 5-year patient and graft survival in patients with type 1 compared with nondiabetics; however, type 2 was not an independent predictor of survival. Preexisting CAD, and not hypertension, was also an independent predictor of poor 5-year survival. Patients who had both DM and CAD had a lower survival compared with those with either DM or CAD. CONCLUSIONS: Type 1 and CAD are both independent predictors of poor outcome after liver transplantation. Liver transplant recipients with type 1 or CAD have approximately 40% lower 5-year survival compared with patients without DM or CAD.     

Myosteatosis to predict inferior perioperative outcome in patients undergoing orthotopic liver transplantation

Muscle wasting and alterations of body composition are linked to clinical outcomes in numerous medical conditions. The role of myosteatosis in posttransplant outcomes remains to be determined. Here we investigated skeletal muscle mass and myosteatosis as prognostic factors in patients undergoing orthotopic liver transplantation (OLT). The data of 225 consecutive OLT recipients from a prospective database were retrospectively analyzed (May 2010‐December 2017). Computed tomography–based skeletal‐muscle‐index (muscle mass), visceral‐fat‐area (visceral adiposity), and mean skeletal‐muscle‐radiation‐attenuation (myosteatosis) were calculated using a segmentation tool. Cut‐off values of myosteatosis resulted in a good stratification of patients into low‐ and high‐risk groups in terms of morbidity (Clavien‐Dindo ≥3b). Patients with myosteatosis had significantly higher complication rates (90‐day Comprehensive Complication Index 68 ± 32 vs 44 ± 30, P < .001) and also displayed significantly longer intensive care (18 ± 25 vs 11 ± 21 days, P < .001) and hospital stay (56 ± 55 vs 33 ± 24 days, P < .001). Estimated costs were 44% higher compared to patients without myosteatosis. Multivariable analysis identified myosteatosis as an independent prognostic factor for major morbidity (odds ratio: 2.772, confidence interval: 1.516‐5.066, P = .001). Adding myosteatosis to the well‐established Balance‐of‐Risk‐(BAR) score resulted in an increased prognostic value compared to the original BAR score. Myosteatosis may be a useful parameter to predict perioperative outcome in patients undergoing OLT, supporting the role of muscle quality (myosteatosis) over quantity (muscle mass) in this setting.     

Incidence and prevalence of diabetes mellitus in patients with cystic fibrosis undergoing lung transplantation before and after lung transplantation

Cystic fibrosis (CF) related diabetes mellitus (DM) occurs in 15% of adult pancreatic insufficient CF patients. Lung transplantation is a treatment option for end-stage CF. We hypothesized that the prevalence of DM increases after lung transplantation. The study population included adult patients undergoing lung transplantation from March 1988 to March 2002 for end-stage CF at the University of Toronto. Demographic data, exocrine pancreatic function, presence of DM before and after transplant, as well as timing of its development after transplant were collected. Eighty-six patients met the study criteria; 77 of 86 (89.5%) of patients were pancreatic insufficient and were further analyzed. Median follow-up post-transplant was 3.3 yr (interquartile range: 1.2-7.2). Their mean age was 29.7 +/- 8.1 yr and 46 of 77 (59.7%) were male. The prevalence of DM increased from 22 of 77 (28.6%) before transplant to 38 of 77 (49.4%) after transplant (p = 0.008). The median time of DM development after transplant was 80 d (range: 13-4352). Sixteen of 55 (29.1%) of pancreatic insufficient patients who were non-diabetic prior to transplant, developed DM after transplant. DM is common in CF patients undergoing lung transplantation and the prevalence increases after transplant.     

Heart transplantation in patients with diabetes mellitus in the current era.

BACKGROUND: In this study, we used a single-institution database to examine the risks of heart transplantation in patients with diabetes mellitus (DM). METHODS: Recipients 18 years and older who underwent cardiac transplantation from July 1994 to December 2000 were reviewed; 101 consecutive patients with insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus were compared with 244 patients who did not have DM and who received standard donor hearts. Survival, renal function (serum creatinine concentration), development of transplant coronary artery disease (TCAD), severe rejection, and infection (requiring hospitalization) were analyzed. RESULTS: Patients with DM were older (mean age, 57.1 years vs 51.4 years), had greater body mass index (mean, 26.7 vs 24.1 kg/m(2), p < 0.02), and more commonly had ischemic cardiomyopathy (58% vs 43%, p = 0.02). We found a trend toward decreased survival for those with DM at 1 year (85.1% vs 90.9%; p = 0.12). Five-year survival was 81.6% for both groups. Mean follow-up time was 4.1 years. Infection rate within 3 months was greater among those with DM (14% vs 3%, odds ration = 5.09; 95% confidence interval, 1.59-16.23). Freedom from infection at 4 years was 71.0% for patients with DM and 85.0% for those without DM (p = 0.02). Freedom from rejection at 4 years was similar (70.6% vs 73.6%, p = 0.69). At 4 years, transplant coronary artery disease (TCAD)-free survival was 69.5% for those with DM and 81.6% for those without (p = 0.23). Mean serum creatinine concentration at 4 years after transplant was 1.5 mg/dl in patients with DM (vs 1.4, p = 0.28). Multivariate analysis showed increased baseline creatinine level as a significant risk factor for survival and showed pre-transplant ischemic cardiomyopathy as a risk factor for TCAD in both groups. Body mass index >30 was a significant risk factor for survival among patients with DM. CONCLUSION: We found an increased risk of serious infections in patients with DM, particularly in the early post-operative period. Careful consideration of obesity and renal function during evaluation of candidacy is indicated.     

Outcomes in patients with hepatopulmonary syndrome undergoing liver transplantation

Hepatopulmonary syndrome (HPS) is a condition of significant hypoxia due to intrapulmonary shunting (IPS) in patients with advanced liver disease. Reversibility of HPS after liver transplantation (LT) has been suggested, but the results of LT for HPS remain poorly defined. We studied 78 patients with decompensated liver disease who underwent LT after a preoperative evaluation including contrast echocardiography. We compared the baseline characteristics and outcomes after LT in patients with HPS (n = 13) with those of patients without HPS (n = 65, controls). Before LT, prolongation of prothrombin time was more severe and an advanced Child-Pugh class were more frequent among HPS, patients compared with controls (INR 2.5 +/- 0.8 vs 1.9 +/- 0.7, P = .01; Child-Pugh class A:B:C = 0%:31%:69% vs 14%:65%:21%, P < .01). After LT, no significant differences were observed between the two groups in: clinical outcomes, duration of endotracheal intubation (4.5 +/- 7.7 vs 4.4 +/- 15.0 days), duration of intensive care unit stay (12.0 +/- 8.7 vs 14.4 +/- 19.4 days), duration of total hospital stay (40.0 +/- 33.5 vs 39.8 +/- 23.0), rate of pulmonary complications (7.7% vs 9.2%), or 3-month survival rates (92.3% vs 86.1%). These findings suggest that the presence of HPS does not significantly affect LT outcomes in patients with decompensated liver disease.     

Kidney and pancreas transplantation in patients with insulin-dependent diabetes mellitus

The article analyses the results of one-stage transplantation of the kidney and pancreas in three patients suffering from insulin-dependent diabetes mellitus with diabetic nephropathy in the stage of terminal renal failure which called for programmed hemodialysis. The specific features of early postoperative management of patients are described, particularly the various routes of drug administration.     

Renal transplantation in diabetes mellitus. Influence of preexisting vascular disease on outcome

We reviewed the recommendations and outcomes for all patients with diabetes mellitus and end-stage renal disease referred to the Medical Center Hospital of Vermont from 1971 through December 1983. During this period, we recommended transplantation in 53 of 73 patients evaluated. Thirty-two transplants were performed in 30 patients. Of the 30 patients, 10 had clinical vascular disease prior to transplantation, i.e., claudication, amputation, active angina, myocardial infarction, or stroke. Seven of the 10 had only claudication or amputation. These 10 patients showed a clear excess in graft failure and mortality. One- and 2-year graft survival was 37 and 13%; patient survival was 48 and 24%. By comparison, the 20 patients without evident vascular disease had 1- and 2-year graft survival rates of 83 and 75% and patient survival rates of 85% at both 1 and 2 years. The incidence of cardiovascular death in the group with vascular disease was 45% at 1 year and 63% at 2 years, as compared with none in the group without vascular disease. The high graft loss and mortality in this group after transplantation should be a major consideration when therapeutic alternatives are considered in diabetics with end-stage renal disease.     

肝移植术后糖尿病的最新进展

糖尿病是肝移植术后最常见的并发症之一,肝移植术后并发糖尿病的受者生存率及移植物长期存活率明显低于无糖尿病的肝移植受者。近年来,随着肝移植在中国迅速发展,肝移植术后糖尿病也引发了高度关注。尽管过去20余年对于移植后糖尿病(PTDM)的研究从未停歇,但仍有许多问题有待进一步研究解决。本文旨在总结肝移植术后糖尿病的最新研究进展,包括PTDM的定义与诊断标准,肝移植术后糖尿病的危险因素、预防及治疗等,以期加深对于肝移植术后糖尿病的认识和理解,并进行有效预防和治疗,从而提高肝移植受者长期存活率及生活质量。     

肝移植术后糖尿病的诊治策略

目的探讨肝移植术后糖尿病(PTDM)的临床特征和诊治措施。方法回顾性分析我院自2003年10月到2008年8月的58例PTDM患者的临床资料。70.7%(41/58)的患者予胰岛素治疗,激素组23例口服激素的PTDM患者中有15例激素减量或停用;FK506组16例使用单药他克莫司(FK506)免疫抑制方案的PTDM患者,转换为霉酚酸酯(MMF)或西罗莫司(RPM)为主的免疫抑制方案,随访3个月,观察改变免疫抑制方案对PTDM的影响。结果 89.7%(52/58)的PTDM患者临床症状不典型,激素组有5例患者空腹血糖正常,出现糖尿病逆转;11例患者胰岛素用量显著降低或停用,无一例发生急性排斥反应。FK506组有2例患者糖尿病逆转,10例患者胰岛素用量显著降低或停用,1例患者发生急性排斥反应,在FK506加量后排斥反应得以控制。结论肝移植术后PTDM的临床症状不典型,胰岛素治疗占主体。减低激素和FK506用量,转换MMF或RPM为主的免疫抑制方案,可能是防治PTDM的有效手段。     

Pancreas islet transplantation in patients with type 1 diabetes mellitus after kidney transplantation

Diabetic patients with end-stage renal disease have a high mortality rate. A combined kidney-pancreas transplant is associated with greater life expectancy. Pancreas islet transplantation is an alternative involving a lower degree of morbidity. We present two patients, of 41 and 37 years of age, with a long history of diabetes mellitus (C-peptide negative), both with a previous kidney transplant, who had been treated with 22 and 28 U of insulin/d, respectively. Both patients had frequent episodes of unawareness hypoglycemia. Pancreatic islets were infused to a total of 7809 and 19,180 IE/kg, respectively. Basal posttransplant C peptide levels were 2.9 and 1.3 ng/mL. After the implant, one patient required occasional doses of insulin, and the other patient more than 50% reduced dose. After the first implant neither patient had any episodes of unawareness hypoglycemia. HbA1c at 4 months were 6.2% and 6.9%. There were no transplant-related complications.     

Review of prevalence and outcome of vascular disease in patients with diabetes mellitus.

OBJECTIVES: Review the literature to determine the prevalence and outcome in patients with diabetes that undergo surgery to correct carotid artery stenosis, lower extremity arterial disease, and abdominal aortic aneurysm (AAA). DESIGN AND MATERIALS: Studies were obtained from searches over the past 15 years on the National Library of Medicine's online search engine. RESULTS: The review demonstrated an equivalent prevalence of carotid artery stenosis requiring surgery in patients with diabetes, it favored no increase risk of post-CEA stroke, and it was split on perioperative morbidity and mortality risk. There was an increase prevalence of lower extremity arterial disease requiring surgery in patients with diabetes, it favored equivalent patency and limb salvage rates, and it was split on the morbidity and mortality risk. The review demonstrated a decrease in AAA prevalence among patients with diabetes, it found an increase in the morbidity risk, and equivalent mortality risk. CONCLUSIONS: Stroke, graft patency, and limb salvage rates in patients with diabetes after surgery are similar to patients without diabetes; however, their risk of complications is increased after surgery and the mortality risk may be higher after CEA.     

Surgical outcome of cervical expansive laminoplasty in patients with diabetes mellitus

STUDY DESIGN: The results from cervical laminoplasty in 18 patients with diabetes mellitus were compared with results from the same procedure in 34 nondiabetic patients matched for age, gender, and disease. OBJECTIVE: To analyze the effects of diabetes mellitus on the surgical outcome after cervical laminoplasty. SUMMARY OF BACKGROUND DATA: There have been no reports on the results of cervical laminoplasty patients with diabetes. METHODS: A retrospective analysis of 18 patients with diabetes mellitus who underwent cervical laminoplasty and 34 nondiabetic patients who underwent the same surgical procedure was undertaken. The postoperative score, intra- and postoperative findings, complications, and radiologic factors were compared between the two groups. In the group with diabetes, the correlation between the recovery rate of the Japanese Orthopedic Association score and the factors indicating the severity of diabetes was assessed. RESULTS: There was no statistical difference between the total Japanese Orthopedic Association scores of the two groups. However, the group with diabetes mellitus showed a poor recovery of sensory function of the lower extremities. Three patients in the group with diabetes had superficial wound complication after surgery. In contrast, none of the patients in the control group had a wound problem. Furthermore, a negative correlation was observed between the recovery rate and the preoperative HbA1 level in the group with diabetes. CONCLUSIONS: Although patients with diabetes mellitus who had cervical myelopathy experienced benefits from cervical laminoplasty similar to those of nondiabetic patients, the patients with diabetes were more likely to have wound complication. Furthermore, the negative correlation between the recovery rate and the preoperative HbA1 value might suggest that long-term diabetes control of more than 2 to 3 months before surgery at least is recommended for a favorable surgical outcome.