供肝脂肪变性与肝移植术后糖尿病发病风险的关系

目的探讨肝移植术后糖尿病（PTDM）发病的危险因素以及供肝脂肪变性对PTDM发病风险的影响。方法回顾性分析2001年4月至2008年12月438例接受肝移植患者的术前、术后的临床资料。采用2006年中华医学会肝脏病学分会制定的非酒精性脂肪性肝病（NAFLD）诊疗指南的组织病理评分标准判定供肝脂肪变性程度，肝功能状态判定采用Child—Pugh评分系统。根据术后空腹血糖将患者分为非PTDM组（n=298，男250例，女48例，平均年龄48岁）与PTDM组（n=140，男120例，女20例，平均年龄50岁）。对PTDM可能的危险因素，包括年龄、性别、空腹血糖、体质指数、术前肝功能、供肝脂肪变性、术后抗排异药种类、白细胞介素-2受体拮抗剂（IL-2RA）应用等进行单因素分析。在单因素分析基础上进行logistic多元回归分析。结果非PTDM组供肝脂肪变性者占34．6％（103／298），PTDM组供肝脂肪变性者占44．3％（62／140），2组无显著差别（X^2=3．83，P=0．05）。单因素分析提示术前空腹血糖（F=23．38，P〈0．05）、术前肝功能、IL-2RA、免疫抑制剂类型与PTDM显著相关（X^2值分别为7．69、8．30、0．02，均P〈0．05），而供肝脂肪变性与PTDM相关性处于临界水平（X^2=3．83，P=0．05）。logistic多元回归分析提示术前空腹血糖异常（OR=1．853，P〈0．01）、供肝脂肪变性（OR=1．80，P〈0．05）可提高PTDM患病风险，而使用IL．2RA（OR=0．43，P〈0．01）可降低PTDM患病风险。结论供肝脂肪变性、术前空腹血糖异常为PTDM的危险因素，而IL-2RA应用则可降低PTDM发生风险，术前肝功能异常可能增加PTDM的发生风险，免疫抑制剂与PTDM的关系有待进一步研究。

Relationship between donor liver steatosis and post-transplant diabetes mellitus in patients undergoing liver transplantation

Objective To discuss the risk factors of post-transplant diabetes mellitus (PTDM) in patients undergoing liver transplantation,especially donor liver steatosis.Methods Retrospectively analyze the data of 438 patients who received orthotopic liver transplantation from April,2001 to December,2008.The grade of donor liver steatosis was measured by histopathologic grading of non-alcoholic fatty liver disease in the guideline issued by Chinese Society of Hepatology.The donor liver function was evaluated by ChildPugh grade system.According to the level of fasting plasma glucose after the operation,the patients were divided into non-PTDM group (n =298,250 males and 48 females,mean age 48 years) and PTDM group (n =140,120 males and 20 females,mean age 50 years).Univariate analysis was used to analyze the possible risk factors of PTDM,such as age,gender,fasting plasma glucose,body mass index,liver function before operation,steatosis of donor liver,anti-rejection drug,interleukin-2 receptor antagonist ( IL-2RA )use.Multivariate logistic regression was employed based on the univariate analysis.Results There were 103 cases of donor liver steatosis in 298 non-PTDM patients (34.6％ ),and 62 donor liver steatosis in 140PTDM patients (44.3％ ),no significant differences was found between the two groups(x2 =3.83,P =0.05 ).Univariate analysis showed that fasting plasma glucose before operation( F =23.38,P ＜0.05 ),liver function before operation,the use of IL-2RA and calcineurin inhibitor were significantly related to PTDM (x2values was 7.69,8.30,0.02,respectively; all P＜0.05),but donor liver steatosis was at the critical level in relation to PTDM (x2 =3.83,P =0.05 ).While multivariate logistic regression indicated abnormal fasting plasma glucose before operation and donor liver steatosis had a positive relation with PTDM,the odds ratio (OR) value was 1.853 ( P ＜ 0.01 ) and 1.80 ( P ＜ 0.05 ),respectively.And the use of IL-2RA was negatively related with PTDM with a OR value of 0.43 (P ＜ 0.01 ).Conclusions Abnormal fasting plasma glucose before operation and donor liver steatosis are risk factors of PTDM,and use of IL-2RA can reduce the risk of PTDM; abnormal liver function before operation may increase the risk of PTDM,while the correlation between calcineurin inhibitor and PTDM needs further studv.