甘精胰岛素联合阿卡波糖治疗肝移植术后糖尿病的临床观察

目的观察甘精胰岛素联合阿卡波糖治疗肝移植术后糖尿病（PTDM）的疗效及安全性。方法肝移植术后糖尿病患者60例,随机分为A组（32例）和BN（28例）。A组给予甘精胰岛素皮下注射联合口服阿卡波糖,B组给予预混胰岛素（诺和灵30R）多次皮下注射,疗程均为3个月,治疗目标为FBG≤7．0mmol／L、2hBG≤10mmol／l。结果50例患者完成治疗。治疗后两组患者血糖均达标,免疫抑制剂剂量均较治疗前降低（P〈0．05）。A组治疗后胰岛素用量及低血糖发生率低于B组（P〈0．05）,两组急性排斥及其他不良事件比较,差异无统计学意义（P〉0．05）。结论甘精胰岛素联合阿卡波糖应用于肝移植术后糖尿病患者可达到良好的血糖控制,且依从性较好。     

胰岛素泵在糖尿病治疗过程中体会

搜集23例糖尿病患者住院期间应用胰岛素泵强化治疗与皮下多次注射胰岛素治疗疗效观察，分别监测治疗前后空腹血糖，餐后血糖，低血糖的发生情况。结果：胰岛素泵是目前糖尿病强化治疗的最佳手段，它能模拟人生理胰岛素分泌．更快．更有效地降低血糖，减少低血糖的发生，同时促进胰岛B细胞功能的恢复。     

与肝移植有关的糖尿病

肝移植术后的糖尿病受到广泛重视，发病率约为4％－20％。其发病机理与多种因素有关，如移植肝功能、胰岛素抵抗、免疫抑制剂、病毒感染等。糖尿病对肝移植术后1a、5a的生存率影响，宜使用胰岛素控制血糖，并建议肝移植后使用无激素免疫控制方案。     

短期胰岛素泵强化治疗2型糖尿病疗效观察

选取2型糖尿病患者70例,随机分为两组,每组各35例,分别采用CSII和MSII两种方法,观察两组治疗前后血糖、达标时间、胰岛素用量及低血糖发生次数。结果CSII组强化治疗后患者可在相对短的时间内控制好空腹血糖、餐后血糖,平均胰岛素用量更少,低血糖发生次数更少。结论短期胰岛素泵强化治疗效果优于多次皮下注射胰岛素治疗。     

老年糖尿病胰岛素强化治疗方案的选择及安全性比较

强化胰岛素治疗是临床常用的控制血糖的方法,但老年糖尿病血糖波动大,低血糖发生率高.而强化降糖会导致低血糖.国内外研究表明~([1,2]),胰岛素类似物与普通人胰岛素比较,可减少发生低血糖的风险,但对于老年糖尿病的应用报道较少.本实验比较四种胰岛素强化降糖的方法,并应用动态血糖监测系统(CGMS)技术,观察老年糖尿病患者强化胰岛素治疗后24 h血糖谱变化和低血糖情况.     

胰岛素强化治疗新诊断糖尿病64例临床分析

目的探讨新诊断2型糖尿病胰岛素强化治疗效果。方法应用胰岛素强化治疗32例新诊断2型糖尿病患者并与口服磺脲类或双胍类等药物治疗32例新诊断2型糖尿病患者做比较，观察两组治疗前后空腹血糖、餐后血糖、糖化血红蛋白（HbA1c）、空腹胰岛素（Fins）、C-肽（C-P）水平及胰岛素抵抗指数（HOMA．IR）、胰岛素敏感指数（IAI）比较。结果与口服磺脲类或双胍类等药物治疗组相比，胰岛素治疗组血糖达标率高，HbA1c明显下降，Fins、C-P（rig／ml）水平及IAI明显升高，HOMA-IR明显下降。结论胰岛素治疗新诊断2型糖尿病显著改善血糖和胰岛功能。     

原位肝移植术后胆道并发症的内镜治疗

原位肝移植术后胆道并发症是肝移植后常见的并发症，胆道并发症临床上处理较棘手，再次手术创伤大，并发症多、死亡率高、重复性差。近几年，随着内镜技术的使用，使肝移植术后胆道并发症的治疗倾向于简单。我院共行9例同种异体原位肝移植术，3例术后发生胆道并发症，通过内镜治疗，取得近期满意疗效，结合文献复习，以探讨内镜治疗的价值，为临床提供参考。     

胰岛素泵治疗对胃癌合并糖尿病患者术后结局的影响

目的探讨胰岛素泵对糖尿病合并胃癌患者术后结局的影响。方法将86例胃癌合并2型糖尿病患者随机分为A组(常规治疗组)46例和B组(胰岛素强化治疗组)40例,比较两组血糖达标时间、胰岛素用量、低血糖发生例数;术后恢复情况、术后并发症发生情况及住院时间、住院费用等。结果与A组比较,B组血糖达标时间、低血糖发生例数均降低(P均<0.05);并发症例数、住院时间、住院费用均降低(P均<0.05);排空障碍发生率降低(P<0.05)。结论胰岛素泵治疗可以改善糖尿病合并胃癌患者的术后结局。     

胰岛素泵治疗2型糖尿病的临床观察

30例胰岛素治疗的住院2型糖尿病患使用两种方法进行胰岛素强化治疗；胰岛素皮下泵（CSⅡ）组12例；多次胰岛素皮下注射组（MSⅡ）18例，结果：两种治疗在血糖控制时间，胰岛素用量，血糖中位数有显性差异，而CSⅡ组低血糖发生率低于MSⅡ组，结论：CSⅡ治疗更符合生理胰岛素分泌，并可更快更有效的控制高血糖。     

新诊断2型糖尿病患者的短期胰岛素强化治疗意义

研究背景:2型糖尿病的发生与胰岛素分泌不足及胰岛素抵抗密切相关。本文研究新诊断2型糖尿病患者接受初期的胰岛素强化治疗后,对患者长期血糖控制的影响。研究方法:该研究共入选16例新诊断2型糖尿病患者,其治疗前的基本资料包括:年龄(52±2)岁,体重指数(30.8±1.9)kg/m2,空腹血糖(13.3±0.7)mmol/L等。所有患者在接受2～3周的初期胰岛素强化治疗使血糖控制基本达标后停用胰岛素,依据血糖控制状况分别接受饮食、运动治疗(7例)、口服降糖药物(8例)或胰岛素治疗(1例),共随访1年。结果:全部患者在胰岛素强化治疗结束及随访1年后空腹血糖较治疗…     

Mechanisms of postprandial hyperglycemia in liver transplant recipients: comparison of liver transplant patients with kidney transplant patients and healthy controls

Impaired glucose tolerance or diabetes mellitus are frequent complications after organ transplantation, and are usually attributed to glucocorticoid and immunosuppressive treatments. Liver transplantation results in total hepatic denervation which may also affect glucoregulation. We therefore evaluated postprandial glucose metabolism in a group of patients with liver cirrhosis before and after orthotopic liver transplantation. Seven patients with liver cirrhosis of various etiologies, 6 patients having received a kidney transplant, and 6 healthy subjects were studied. Their glucose metabolism was evaluated in the basal state and over 4 hours after ingestion of a glucose load with 6.6 (2) H glucose dilution analysis. The patients with liver cirrhosis were studied before, and again 4 weeks (range 2-6) and 38 weeks (range 20-76, n=6) after orthotopic liver transplantation. Basal glucose metabolism was similar in liver and kidney transplant recipients. Impaired glucose tolerance was present in both groups, but postprandial hyperglycemia was exaggerated and lasted longer in liver transplant patients. Postprandial insulinemia was lower in liver transplant recipients, while C-peptide concentrations were comparable to those of kidney transplant recipients, indicating increased insulin clearance. Glucose turnover was not altered in both groups of patients during the initial 3 hours after glucose ingestion, but was higher in liver transplant early after transplantation during the fourth hour. Postprandial hyperglycemia remained unchanged in liver transplant recipients 38 weeks after liver transplantation, despite substantial reduction of immunosuppressive and glucocorticoid doses. We conclude that liver transplant recipients have severe postprandial hyperglycemia which can be attributed to insulinopenia (secondary, at least in part, to increased insulin clearance) and a late increased glucose turnover. These changes may be secondary to hepatic denervation.     

Gut perforation after orthotopic liver transplantation in adults

AIM： To describe cases of gut perforation after orthotopic liver transplantation.
METHODS： Data were colleted from our center database and medical records. Six of 187 patients （3.2%）who underwent orthotopic liver transplantation from January to December 2005 developed gut perforation.All patients were male with an average age of 46 years.Modified piggyback liver transplantation was performed at the Organ Transplantation Center, First Affiliated Hospital, Sun Yat-Sen University.RESULTS： Previous operation, steroid therapy, and prolonged portal venous cross clamp time, poor nutritional status and iatrogenic injury were found to be its ecological factors. The patients with gut perforation were found to have fever, increased leukocytes, mild abdominal pain and tenderness. The median portal venous clamp time was 63 min （range 45-72 min）,median cold ischaemia time was 11.3 h （range 7-15 h）.Median intraoperative blood loss was 500 mL （range 100-1200 mL） and median operation time was 8.8 h （range 6-12 h）. None of the six patients developed acute cellular rejection. White cell count was above 18 × 10^9/L in five patients （neutrophilic leukocytes were above 90%） and 1.5 × 10^9/L in one patient. Bacterial culture in drainage liquid revealed enterococci in five patients. Of the 6 patients undergoing orthotopic liver transplantation, 3 survived and 3 died after modified piggyback liver transplantation.
CONCLUSION： Gut perforation occurs after orthotopic liver transplantation in adults. A careful and minimal dissection during OLT, longer retention of the stomach tube, and reducing the portal clamp time and steroid dose should be taken into consideration. If gut perforation is not prevented, then early diagnosis,preferably through detection of enterococci may ensure better survival.     

Hepatic venous outflow obstruction after piggyback liver transplantation by an unusual mechanism： Report of a case

INTRODUCTIONHepatic venous outflow obstruction after piggybackorthotopic liver transplantation is a rare complication[1,2]. However, failure of early recognition and treatment of this complication can result in graft failure and even death of patients. We…     

Prevention of hyperglycemia improves the long-term result of islet transplantation in streptozotocin-diabetic rats.

We examined the hypothesis that prevention of hyperglycemia during the critical period immediately following islet transplantation will improve the outcome of the transplantation in streptozotocin-diabetic rats. Two days after intravenous injection of streptozotocin (70 mg/kg), 400 or 1,000 islets were transplanted into the left kidney subcapsular space. A group of rats transplanted with 400 islets was treated with insulin from 1 day before transplantation and for 7 days. Intravenous glucose infusion was performed at 10 days and 3 months after transplantation. In addition, at 3 months, the grafts were examined by light and electron microscopy. We found that rats transplanted with 400 islets without any concomitant insulin administration remained diabetic throughout the 3-month period and no plasma insulin response was induced by glucose infusion in these rats. In contrast, diabetic rats transplanted with 400 islets and treated with insulin for 7 days remained normoglycemic throughout the 3-month period, as did rats transplanted with 1,000 islets. Furthermore, these rats had normal glucose-stimulated insulin secretion both at 10 days and at 3 months after transplantation. Moreover, islet grafts from rats transplanted with 400 islets and administered insulin as well as from rats transplanted with 1,000 islets were morphologically normal, and following removal of the graft, hyperglycemia developed rapidly. In contrast, the islet grafts from rats transplanted with 400 islets without concomitant insulin administration had only few insulin cells. Thus, by preventing hyperglycemia at the time of islet transplantation, the long-term result of islet transplantation was improved. Therefore, the ambient glucose level initially following islet transplantation is critical for the long-term result.     

肝脏移植概述

肝脏移植是治疗终末期肝病的根本方法,其适应证包括良性终末期肝病、肿瘤性疾病和先天性、代谢性肝病。肝脏移植术式包括经典原位肝移植、背驮式肝移植和腔静脉成形式肝移植等。术后要防治并发症,控制排异反应,乙型肝炎患者要控制乙型肝炎,肝癌患者要防止肿瘤复发。     

Remission of active diabetic hepatitis after correction of hyperglycemia

²Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands ABSTRACT— A 60-year-old obese woman with type II diabetes mellitus and hepatomegaly exhibited progression of steatosis to hepatitis and cirrhosis. The patient was treated with large amounts of insulin combined with sulfonylurea, resulting in correction of the hyperglycemia. In the subsequent 9 months, weight loss did not occur, whereas insulin therapy could be discontinued. The liver decreased in size, and liver tests normalized. We suggest that intensive treatment of hyperglycemia may result in reversal of insulin resistance in patients with diabetic liver disease, while correction of hyperglycemia can lead to resolution of the hepatic abnormalities associated with diabetes mellitus.     

8a Liver transplantation: newer surgical approaches

The standard procedure for orthotopic liver transplantation remains transplantation of the whole organ together with resection of the vena cava and the use of venovenous bypass. In cases of severe mismatch of the donor and recipient vena cava, the piggyback technique, if necessary with vena cava plasty, is preferable. Furthermore, in all cases where venovenous bypass cannot be performed, the piggyback or other technique preserving the vena cava should be performed. In paediatric patients, reduced/size liver transplantation may be indicated because of the shortage of small livers. In the hands of experienced surgeons, the results of reduced-size liver transplantation in paediatric patients are similar to those of whole organ transplantation. Further innovative procedures to overcome the problem of organ shortage include split-liver and living related transplantation in children. Distinct advantages of living related transplantation can be seen in a well-functioning graft, lack of preservation injury, elective operation and optimal graft-size matching. The immunological advantage that has been claimed could not be demonstrated so far, and will need to be examined in the long-term follow-up. However, there remains a distinct disadvantage for living related transplantation with regard to the surgical technique. Pre-operative portal venous thrombosis should be carefully assessed, but is not a contraindication to liver transplantation if the confluence of the superior mesenteric vein and splenic vein is patent. Arterial reconstruction at the confluence of two arteries (hepatic and gastroduodenal or splenic artery) seems to be preferable to an end-to-end anastomosis because of improved inflow into the graft and a reduced risk of arterial stenosis and thrombosis. Where the common hepatic arteries are small, with reduced or reversed flow, and in patients with coeliac trunk stenosis, we recommend a direct approach to the suprarenal or infrarenal aorta. Bile duct anastomosis may preferably be performed with a side-to-side technique, to reduce early and late biliary complications.     

Relationship between Inpatient Hyperglycemia and Insulin Treatment after Kidney Transplantation and Future New Onset Diabetes Mellitus

Background and objectives: Approximately two-thirds of kidney transplant recipients with no previous history of diabetes experience inpatient hyperglycemia immediately after kidney transplant surgery; whether inpatient hyperglycemia predicts future new onset diabetes after transplant (NODAT) is not established.Design, setting, participants, & measurements: A retrospective study was conducted to determine the risk conferred by inpatient hyperglycemia on development of NODAT within 1 year posttransplant. All adult nondiabetic kidney transplant recipients between June 1999 and January 2008 were included. Posttransplant inpatient hyperglycemia was defined as any bedside capillary blood glucose ≥ 200 mg/dl or insulin therapy during hospitalization. NODAT was defined as HbA1C ≥ 6.5%, fasting venous serum glucose ≥ 126 mg/dl, or prescribed diet or medical therapy for diabetes mellitus.Results: The study cohort included 377 patients. NODAT developed in 1 (4%) of the 28 patients without inpatient hyperglycemia, 4 (18%) of the 22 patients with inpatient hyperglycemia but not treated with insulin, and in 98 (30%) of the 327 of the patients who were diagnosed with inpatient hyperglycemia and were treated with insulin. In adjusted analyses, requirement of insulin therapy during hospitalization posttransplant was associated with a 4-fold increase in NODAT (relative risk 4.01; confidence interval, 1.49 to 10.7; P = 0.006).Conclusion: Development of inpatient hyperglycemia after kidney transplantation in nondiabetic patients significantly increased the risk of NODAT. Additionally, we observed a significantly increased risk of cardiovascular events in patients who developed NODAT.New onset diabetes mellitus after transplantation (NODAT) is a frequent and serious complication after kidney transplantation (1–3) with negative consequences on long-term graft and patient outcomes, quality of life, and health care costs (1,2,4–6). Rates of NODAT have been reported as high as 50% (7), but more recent studies suggest a 1-year cumulative incidence between 15% and 25% (1–3). Some of the reasons for the wide dispersion in the reported incidence of NODAT include lack of uniformity in diagnostic criteria and variations in immunosuppression protocols and study cohorts.While NODAT traditionally is diagnosed during the outpatient phase of care (i.e., after hospital discharge), hyperglycemia among patients with no previous history of diabetes may become evident as early as in the immediate posttransplant in-patient period. Our recent report is among the first to describe the issues related to inpatient hyperglycemia in the immediate posttransplant period after kidney transplantation (8). In that analysis, 87% of 319 nondiabetic patients admitted for their first kidney transplant had at least one episode of inpatient hyperglycemia following surgery, and 66% were administered insulin on the day of hospital discharge (8). It is not clearly known whether inpatient hyperglycemia identified during the period immediately after kidney transplantation among patients with no history of diabetes is a transient problem that results from stresses associated with surgery, hospitalization, and immunosuppression, or whether it poses a risk for future NODAT. If inpatient hyperglycemia is associated with future NODAT among patients with no history of diabetes before transplant, then based on our previous analyses, a substantial number of patients could be at risk for developing NODAT. Recognition of this risk for NODAT while patients are still in the hospital could allow planning for early outpatient intervention or even prevention. We conducted a retrospective analysis in a cohort of kidney transplant recipients with no known history of diabetes mellitus to explore the prognostic value of inpatient hyperglycemia for development of future NODAT. Additionally, we analyzed selected transplant outcomes among patients who had evidence of posttransplant inpatient hyperglycemia.     

Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia

Context: Transition of diabetic patients from iv insulin infusion to sc insulin frequently results in rebound hyperglycemia. Objectives: We hypothesized that initiation of a long-acting insulin therapy concurrently with iv insulin infusion would decrease the rate of rebound hyperglycemia after discontinuation of the insulin infusion. Design and Intervention: Sixty-one diabetic patients receiving iv insulin therapy participated in this prospective randomized study. Subjects in the intervention group received daily injections of glargine sc (0.25 U/kg body weight) starting within 12 h of initiation of iv insulin infusion. Capillary blood glucose measurements were obtained up to 12 h after discontinuation of insulin infusion. Rebound hyperglycemia was defined as a blood glucose level greater than 180 mg/dl. Setting: The study was conducted at the University of Colorado Hospital. Patients: Sixty-one hospitalized patients with known type 1 or type 2 diabetes receiving iv insulin infusion participated in the study. Main Outcome: The primary outcome of this study was to compare the rates of rebound hyperglycemia between the control and the intervention groups after iv insulin infusion is discontinued. Results: Overall, 29 subjects in the control group (93.5%) had at least one glucose value above 180 mg/dl during the 12-h follow-up period. This was significantly greater than the rate of rebound hyperglycemia in the intervention group (10 subjects or 33.3%, P < 0.001). The effect of the intervention was apparent in subjects who presented with diabetic ketoacidosis, after solid organ transplantation, and in patients with other surgical and medical diagnoses. There were three hypoglycemic measurements in two control subjects (68, 62, and 58 mg/dl) and none in the intervention group. Conclusions: Once-daily sc insulin glargine administered during iv insulin infusion is a safe method for preventing future rebound hyperglycemia, without increased risk of hypoglycemia.     

Glucose homeostasis in a diabetic patient during liver transplantation: a case report

A 66-year-old woman with type C hepatitis had been treated for hepatocellular carcinoma (HCC) with transcatheter arterial embolization and radiofrequency ablation. Liver function worsened gradually to decompensated liver cirrhosis. She had recurrence of HCC and was later admitted to Juntendo University Hospital for living-donor liver transplantation. Although blood glucose was high, she had never been diagnosed with diabetes mellitus. No diabetes-related complications were detected at that time. We started treatment with multiple insulin injections. There is a unique time called the anhepatic phase during liver transplantation during which the liver does not exist in the body. Recent reports show that it is not necessary to administer glucose for patients with normal glucose tolerance during the anhepatic phase since plasma glucose could be maintained at normoglycemia to hyperglycemia (100-150 mg/dl). In our patient, plasma glucose concentration was rather high during the anhepatic phase without glucose administration. We analyzed the levels of blood glucose, insulin and various other hormones during the anhepatic phase. This could be the first report on glucose homeostasis during the anhepatic phase in a diabetic patient.