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中国器官移植术后糖尿病诊疗指南(2016版)

中华医学会器官移植学分会 中国医师协会器官移植医师分会

中华医学会器官移植学分会, 中国医师协会器官移植医师分会. 中国器官移植术后糖尿病诊疗指南(2016版)[J]. 器官移植, 2016, 7(6): 407-416. doi: 10.3969/j.issn.1674-7445.2016.06.001
引用本文: 中华医学会器官移植学分会, 中国医师协会器官移植医师分会. 中国器官移植术后糖尿病诊疗指南(2016版)[J]. 器官移植, 2016, 7(6): 407-416. doi: 10.3969/j.issn.1674-7445.2016.06.001
Guideline on diagnosis and treatment of recipients with diabetes after organ transplantation in China (2016 edition)[J]. ORGAN TRANSPLANTATION, 2016, 7(6): 407-416. doi: 10.3969/j.issn.1674-7445.2016.06.001
Citation: Guideline on diagnosis and treatment of recipients with diabetes after organ transplantation in China (2016 edition)[J]. ORGAN TRANSPLANTATION, 2016, 7(6): 407-416. doi: 10.3969/j.issn.1674-7445.2016.06.001

中国器官移植术后糖尿病诊疗指南(2016版)

doi: 10.3969/j.issn.1674-7445.2016.06.001
基金项目: 

国家自然科学基金 81370578、81570680

本指南的发布不存在与任何公司、机构或个人之间的利益冲突
审稿会:2016年5月20日上海
审稿专家(按汉语拼音字母排序):
敖建华 解放军总医院
蔡 明 解放军第309医院
丰贵文 郑州大学附属第一医院
黄赤兵 第三军医大学附属新桥医院
贾晓伟 解放军第309医院内分泌科
林 涛 四川大学华西医院内分泌科
刘 龙 沈阳军区总医院
彭龙开 湘雅大学附属第二医院
石炳毅 解放军第309医院
孙煦勇 解放军第303医院
谭建明 福州军区总医院
王祥慧 上海交通大学附属瑞金医院
薛武军 西安交通大学附属第一医院
袁建林 第四军医大学西京医院
张小东 首都医科大学附属朝阳医院
赵 明 南方大学附属珠江医院
周江桥 武汉大学人民医院
执笔作者:石炳毅 解放军第309医院
    贾晓伟 解放军第309医院内分泌科
详细信息
  • 中图分类号: R617,R587.1

Guideline on diagnosis and treatment of recipients with diabetes after organ transplantation in China (2016 edition)

  • 摘要:

    实体器官移植后新发糖尿病(NODAT)增加移植物相关并发症的风险,如排斥反应、移植物功能减退或丧失以及感染,最终影响受者的长期生存。此外,NODAT也是导致移植后心血管并发症的主要原因。本指南组织国内器官移植和糖尿病专家在总结器官移植术后血糖异常国内外最新进展的基础上,参考《器官移植术后糖尿病临床诊疗指南(2010版)》并结合我国的临床实践,提出相关的诊疗建议。内容包括NODAT的流行病学、危险因素和发病机制、移植术前筛查和预防措施、术后筛查和治疗策略等。本指南提出早期保护胰腺分泌功能是重要的防治理念,有利于提高NODAT的预防和治疗质量,改善器官移植受者的预后。

     

  • 图  1  NODAT发病的时间特点

    注:DM为糖尿病,T2DM为2型糖尿病,约66%术前无DM的患者出院时存在血糖升高或需要胰岛素治疗。本图引自Chakkera HA,Weil EJ,Pham PT,et al. Can new-onset diabetes after kidney transplant be prevented?[J]. Diabetes Care,2013,36(5): 1406-1412

    Figure  1.  Time characteristics of the occurrence of NODAT

    图  2  NODAT发病机制示意图

    注:HCV为丙型肝炎病毒;CMV为巨细胞病毒;CNI为钙神经蛋白抑制剂。本图引自Chakkera HA,Weil EJ,Pham PT,et al. Can new-onset diabetes after kidney transplant be prevented?[J]. Diabetes Care,2013,36(5): 1406-1412

    Figure  2.  The schematic diagram of pathogenesis of NDDAT

    表  1  美国糖尿病协会(ADA)2014年提出的移植后糖尿病和糖尿病前期诊断标准

    Table  1.   Diagnostic criteria of diabetes after transplantation and prediabetes by American Diabetes Association (ADA)in 2014

    诊 断ADA标准*
    糖尿病(DM)糖尿病症状且
    RPG ≥ 11.1 mmol/L(200 mg/dl) 或FPG ≥ 7.0 mmol/L(126 mg/dl) 或OGTT 2HPG ≥ 11.1 mmol/L(200 mg/dl) 或HbA1c ≥ 6.5%
    糖尿病前期病变(prediabetes)
    空腹血糖受损(IFG)FPG 5.6~6.9 mmol/L(100~126 mg/dl)
    糖耐量减低(IGT)FPG 6.1~7.0 mmol/L 且 2HPG 7.8~11.0 mmol/L
    高危患者HbA1c 5.7% ~ 6.4%
    正常糖耐量FPG<5.6 mmol/L(110 mg/dl) 且 2HPG<7.8 mmol/L(140 mg/dl) 且HbA1c<5.7%
    注:RPG为随机血糖;FPG 为空腹血糖;OGTT为口服葡萄糖耐量试验; 2HPG 为OGTT 2 h血糖;HbA1c为糖化血红蛋白。*血糖异常次日必须复查静脉血糖以确认诊断,任何情况下都必须排除明确的急性代谢异常导致的高血糖。糖尿病症状包括多尿、多饮和不明原因的体质量降低。RPG定义为日间任何时间的血糖,不考虑与进食的关系。空腹定义为至少8 h内无热量摄入。OGTT使用75 g无水葡萄糖水溶液后口服进行
    下载: 导出CSV

    表  2  现有降糖药物的临床使用小结

    Table  2.   Summary of the clinical use of oral glucose-lowering drugs

    制 剂作用机制优点缺点肾功能不全时的剂量
    双胍类(二甲双胍)减少肝糖输出;改善胰岛素抵抗减轻体质量,不增加低血糖风险;降低肥胖2型糖尿病患者心血管事件和死亡风险;价廉胃肠道反应; 肾功能不全时乳酸酸中毒减量:CKD 3a期 停用:GFR<45 ml/ (min·1.73 m2)
    磺脲类(格列吡嗪、格列齐特等)促进胰岛β细胞释放胰岛素可降低HbA1c 1%~2%低血糖、体质量增加、肾功能不全时蓄积 减量:CKD 3期 禁用:CKD 4~5期
    噻唑烷二酮类(罗格列酮、吡格列酮)增加胰岛素敏感性经肝脏代谢并不增加血糖风险液体潴留、增加心力衰竭风险;增加骨质疏松、 骨折、膀胱癌风险无需调整:CKD 1~3a期 慎用:CKD 3b~5期
    格列奈类(瑞格列奈1、那格列奈2)促进早时相胰岛素分泌吸收快、起效快、作用时间短、降低餐后血糖、不加速肾衰竭1 低血糖、体质量增加、肾衰竭时剂量调整2 无需调整1:CKD 1~5期 无需调整2:CKD 1~3a期 减量2:CKD 3b~4期 慎用2:CKD 5期
    GLP-1受体激动剂(依克那肽3、利拉鲁肽4)促进胰岛素分泌、减少胰高血糖素产生、增加饱腹感不增加体质量(可能降低)、低血糖风险小、降血压胃肠道反应、胰腺炎影响药物吸收、价格昂贵、肾功能损害、产生抗体慎用3:eGFR30~50ml/min 禁用3:eGFR<30ml/min 禁用4:eGFR<60ml/min
    α糖苷酶抑制剂(阿卡波糖)延缓胃肠道碳水化合物吸收低血糖事件少、不增加体质量且有减轻趋势胃肠道反应禁用:CKD 4~5期
    DDP-4抑制剂(西他列汀5、维格列汀6、利格列汀6、沙格列汀7)减慢肠促胰岛素失活不增加体质量价格昂贵、胰腺炎风险、可能致癌禁用5:eGFR<50ml/min 6无需调整剂量 7减量
    胰岛素外源性降糖激素有效减少微血管和大血管并发症,无“封顶效应”,剂型丰富方便个体化治疗体质量增加、皮下给药、低血糖、可能致癌常常需要减量
    注:GLP-1为胰高血糖素样肽-1;DDP-4为二肽基肽酶-4;eGFR为估算肾小球滤过率;GFR为肾小球滤过率;CKD为慢性肾脏疾病;相同的上标数字为同一药物
    下载: 导出CSV
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出版历程
  • 收稿日期:  2016-07-10
  • 网络出版日期:  2021-03-19
  • 刊出日期:  2016-11-15

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