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中国移植后糖尿病诊疗技术规范(2019版)

中华医学会器官移植学分会

中华医学会器官移植学分会. 中国移植后糖尿病诊疗技术规范(2019版)[J]. 器官移植, 2019, 10(1): 1-9. doi: 10.3969/j.issn.1674-7445.2019.01.001
引用本文: 中华医学会器官移植学分会. 中国移植后糖尿病诊疗技术规范(2019版)[J]. 器官移植, 2019, 10(1): 1-9. doi: 10.3969/j.issn.1674-7445.2019.01.001
Branch of Organ Transplantation of Chinese Medical Association. Technical specifcation for diagnosis and treatment of post transplantation diabetes mellitus in China (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(1): 1-9. doi: 10.3969/j.issn.1674-7445.2019.01.001
Citation: Branch of Organ Transplantation of Chinese Medical Association. Technical specifcation for diagnosis and treatment of post transplantation diabetes mellitus in China (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(1): 1-9. doi: 10.3969/j.issn.1674-7445.2019.01.001

中国移植后糖尿病诊疗技术规范(2019版)

doi: 10.3969/j.issn.1674-7445.2019.01.001
基金项目: 

国家自然科学基金 81570680

详细信息
    通讯作者:

    石炳毅, 男, 1953 年生, 博士, 主任医师, 博士研究生导师, 研究方向为器官移植, Email:shibingyi666@126.com; 李宁, Email:SXTYLining666@126.com

  • 中图分类号: R617, R587.1

Technical specifcation for diagnosis and treatment of post transplantation diabetes mellitus in China (2019 edition)

  • 摘要: 为了进一步规范中国移植后糖尿病(PTDM)的诊断和治疗, 中华医学会器官移植学分会组织器官移植专家和糖尿病专家, 总结器官移植后血糖异常的国内外最新进展, 在《中国器官移植术后糖尿病诊疗指南(2016版)》的基础上, 结合临床实践, 从PTDM的定义和诊断标准、流行病学、危险因素和发病机制、对移植受者和移植物预后的影响、预防及治疗策略等方面, 制定PTDM诊疗技术规范(2019版)。

     

  • 表  1  ADA制定的糖尿病和糖尿病前期诊断标准

    Table  1.   Diagnostic criteria of diabetes and prediabetes by ADA

    诊断 ADA标准a
    糖尿病 糖尿病症状且RPG≥11.1 mmol/L(200 mg/dL)或FPG≥7.0 mmol/L(126 mg/L)或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(100~124 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(100 mg/dL)且2HPG & #60;7.8 mmol/L(140 mg/dL)且HbA1c < 5.7%
    RPG为随机血糖,指1日中不论上次进餐时间的任意时刻血糖;FPG为空腹血糖,指至少8 h无热量摄入;OGTT为口服葡萄糖耐量试验,使用75 g无水葡萄糖水溶液后口服进行;2HPG为OGTT 2 h血糖;HbA1c为糖化血红蛋白;糖尿病症状包括多尿、多饮和不明原因的体质量降低。a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
    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 available hypoglycemic 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T2DM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
    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 30~50 mL/min
    禁用3:eGFR < 30 mL/min
    禁用4:eGFR < 60 mL/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(西格列汀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 < 50 mL/min
    无需调整6
    减量7
    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
    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
  • [1] VALDERHAUG TG, HJELMESÆTH J, JENSSEN T, et al.Early posttransplantation hyperglycemia in kidney transplant recipients is associated with overall long-term graft losses[J].Transplantation, 2012, 94(7):714-720.DOI: 10.1097/TP.0b013e31825f4434.
    [2] SIRAJ ES, ABACAN C, CHINNAPPA P, et al.Risk factors and outcomes associated with posttransplant diabetes mellitus in kidney transplant recipients[J].Transplant Proc, 2010, 42(5):1685-1689.DOI:10.1016/ j.transproceed.2009.12.062.
    [3] COLE EH, JOHNSTON O, ROSE CL, et al.Impact of acute rejection and new-onset diabetes on longterm transplant graft and patient survival[J].Clin J Am Soc Nephrol, 2008, 3(3):814-821.DOI:10.2215/ CJN.04681107.
    [4] WAUTERS RP, COSIO FG, SUAREZ FERNANDEZ ML, et al.Cardiovascular consequences of new-onset hyperglycemia after kidney transplantation[J].Transplantation, 2012, 94(4):377-382. doi: 10.1097/TP.0b013e3182584831
    [5] DAVIDSON J, WILKINSON A, DANTAL J, et al.Newonset diabetes after transplantation:2003 international consensus guidelines.proceedings of an international expert panel meeting.Barcelona, Spain, 19 February 2003[J].Transplantation, 2003, 75(10 Suppl):SS3-SS24. http://www.ncbi.nlm.nih.gov/pubmed/12775942
    [6] SHARIF A, HECKING M, DE VRIES AP, et al.Proceedings from an international consensus meeting on posttransplantation diabetes mellitus:recommendations and future directions[J].Am J Transplant, 2014, 14(9):1992-2000.DOI: 10.1111/ajt.12850.
    [7] CHAKKERA HA, WEIL EJ, CASTRO J, et al.Hyperglycemia during the immediate period after kidney transplantation[J].Clin J Am Soc Nephrol, 2009, 4(4):853-859.DOI: 10.2215/CJN.05471008.
    [8] COTOVIO P, NEVES M, RODRIGUES L, et al.Newonset diabetes after transplantation:assessment of risk factors and clinical outcomes[J].Transplant Proc, 2013, 45(3):1079-1083.DOI: 10.1016/j.transproceed.2013.03.009.
    [9] BAYER ND, COCHETTI PT, ANIL KUMAR MS, et al.Association of metabolic syndrome with development of new-onset diabetes after transplantation[J].Transplantation, 2010, 90(8):861-866.DOI: 10.1097/TP.0b013e3181f1543c.
    [10] U.S.Renal Data System.USRDS 2013 Annual Data Report:atlas of chronic kidney disease and end-stage renal disease in the United States[M].Bethesda:National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2013.
    [11] CHAKKERA HA, WEIL EJ, PHAM PT, et al.Can newonset diabetes after kidney transplant be prevented?[J].Diabetes Care, 2013, 36(5):1406-1412.DOI:10.2337/ dc12-2067.
    [12] CAILLARD S, EPRINCHARD L, PERRIN P, et al.Incidence and risk factors of glucose metabolism disorders in kidney transplant recipients:role of systematic screening by oral glucose tolerance test[J].Transplantation, 2011, 91(7):757-764.DOI: 10.1097/TP.0b013e31820f0877.
    [13] HORNUM M, JØRGENSEN KA, HANSEN JM, et al.New-onset diabetes mellitus after kidney transplantation in Denmark[J].Clin J Am Soc Nephrol, 2010, 5(4):709- 716.DOI: 10.2215/CJN.05360709.
    [14] HECKING M, WERZOWA J, HAIDINGER M, et al.Novel views on new-onset diabetes after transplantation:development, prevention and treatment[J].Nephrol Dial Transplant, 2013, 28(3):550-566.DOI:10.1093/ndt/ gfs583.
    [15] LUND LH, EDWARDS LB, KUCHERYAVAYA AY, et al.The Registry of the International Society for Heart and Lung Transplantation:Thirty-second Official Adult Heart Transplantation Report--2015; Focus Theme:early graft failure[J].J Heart Lung Transplant, 2015, 34(10):1244- 1254.DOI: 10.1016/j.healun.2015.08.003.
    [16] ABE T, ONOE T, TAHARA H, et al.Risk factors for development of new-onset diabetes mellitus and progressive impairment of glucose metabolism after living-donor liver transplantation[J].Transplant Proc, 2014, 46(3):865-869.DOI: 10.1016/j.transproceed.2013.12.027.
    [17] HACKMAN KL, SNELL GI, BACH LA.Prevalence and predictors of diabetes after lung transplantation:a prospective, longitudinal study[J].Diabetes Care, 2014, 37(11):2919-2925.DOI: 10.2337/dc14-0663.
    [18] BERGREM HA, VALDERHAUG TG, HARTMANN A, et al.Undiagnosed diabetes in kidney transplant candidates:a case-finding strategy[J].Clin J Am Soc Nephrol, 2010, 5(4):616-622.DOI: 10.2215/CJN.07501009.
    [19] TUFTON N, AHMAD S, ROLFE C, et al.New-onset diabetes after renal transplantation[J].Diabet Med, 2014, 31(11):1284-1292.DOI: 10.1111/dme.12534.
    [20] HAGEN M, HJELMESAETH J, JENSSEN T, et al.A 6-year prospective study on new onset diabetes mellitus, insulin release and insulin sensitivity in renal transplant recipients[J].Nephrol Dial Transplant, 2003, 18(10):2154-2159. doi: 10.1093/ndt/gfg338
    [21] NAM JH, MUN JI, KIM SI, et al.beta-Cell dysfunction rather than insulin resistance is the main contributing factor for the development of postrenal transplantation diabetes mellitus[J].Transplantation, 2001, 71(10):1417- 1423. doi: 10.1097/00007890-200105270-00011
    [22] SHIMIZU M, IINO Y, TERASHI A.Improvement of insulin sensitivity after renal transplantation measured by a glucose clamp technique[J].Nihon Ika Daigaku Zasshi, 1998, 65(1):50-54. doi: 10.1272/jnms1923.65.50
    [23] HECKING M, HAIDINGER M, DÖLLER D, et al.Early basal insulin therapy decreases new-onset diabetes after renal transplantation[J].J Am Soc Nephrol, 2012, 23(4):739-749.DOI: 10.1681/ASN.2011080835.
    [24] HEIT JJ, APELQVIST AA, GU X, et al.Calcineurin/ NFAT signalling regulates pancreatic beta-cell growth and function[J].Nature, 2006, 443(7109):345-349. doi: 10.1038/nature05097
    [25] REDMON JB, OLSON LK, ARMSTRONG MB, et al.Effects of tacrolimus (FK506) on human insulin gene expression, insulin mRNA levels, and insulin secretion in HIT-T15 cells[J].J Clin Invest, 1996, 98(12):2786-2793. doi: 10.1172/JCI119105
    [26] HEROLD KC, NAGAMATSU S, BUSE JB, et al.Inhibition of glucose-stimulated insulin release from beta TC3 cells and rodent islets by an analog of FK506[J].Transplantation, 1993, 55(1):186-192. doi: 10.1097/00007890-199301000-00035
    [27] VINCENTI F, FRIMAN S, SCHEUERMANN E, et al.Results of an international, randomized trial comparing glucose metabolism disorders and outcome with cyclosporine versus tacrolimus[J].Am J Transplant, 2007, 7(6):1506-1514. doi: 10.1111/ajt.2007.7.issue-6
    [28] HUSCHER D, THIELE K, GROMNICA-IHLE E, et al.Dose-related patterns of glucocorticoid-induced side effects[J].Ann Rheum Dis, 2009, 68(7):1119-1124.DOI: 10.1136/ard.2008.092163.
    [29] QI D, RODRIGUES B.Glucocorticoids produce whole body insulin resistance with changes in cardiac metabolism[J].Am J Physiol Endocrinol Metab, 2007, 292(3):E654-E667. doi: 10.1152/ajpendo.00453.2006
    [30] ULLRICH S, BERCHTOLD S, RANTA F, et al.Serumand glucocorticoid-inducible kinase 1 (SGK1) mediates glucocorticoid-induced inhibition of insulin secretion[J].Diabetes, 2005, 54(4):1090-1099. doi: 10.2337/diabetes.54.4.1090
    [31] BECKER B, KRONENBERG F, KIELSTEIN JT, et al.Renal insulin resistance syndrome, adiponectin and cardiovascular events in patients with kidney disease:the mild and moderate kidney disease study[J].J Am Soc Nephrol, 2005, 16(4):1091-1098. doi: 10.1681/ASN.2004090742
    [32] KASISKE BL, SNYDER JJ, GILBERTSON D, et al.Diabetes mellitus after kidney transplantation in the United States[J].Am J Transplant, 2003, 3(2):178-185. doi: 10.1034/j.1600-6143.2003.00010.x
    [33] ORTEGA-CAMARILLO C, GUZMÁN-GRENFELL AM, GARCÍA-MACEDO R, et al.Hyperglycemia induces apoptosis and p53 mobilization to mitochondria in RINm5F cells[J].Mol Cell Biochem, 2006, 281(1/2):163-171. http://www.ncbi.nlm.nih.gov/pubmed/16328969?dopt=Abstract&holding=npg
    [34] SMILEY DD, UMPIERREZ GE.Perioperative glucose control in the diabetic or nondiabetic patient[J].South Med J, 2006, 99(6):580-591. doi: 10.1097/01.smj.0000209366.91803.99
    [35] RABKIN R, RYAN MP, DUCKWORTH WC.The renal metabolism of insulin[J].Diabetologia, 1984, 27(3):351- 357. doi: 10.1007/BF00304849
    [36] CLEMENT S, BRAITHWAITE SS, MAGEE MF, et al.Management of diabetes and hyperglycemia in hospitals[J].Diabetes Care, 2004, 27(2):553-591. doi: 10.2337/diacare.27.2.553
    [37] OPELZ G, DÖHLER B.Cardiovascular death in kidney recipients treated with renin-angiotensin system blockers[J].Transplantation, 2014, 97(3):310-315.DOI: 10.1097/01.TP.0000437672.78716.28.
    [38] HACKMAN KL, BAILEY MJ, SNELL GI, et al.Diabetes is a major risk factor for mortality after lung transplantation[J].Am J Transplant, 2014, 14(2):438- 445.DOI: 10.1111/ajt.12561.
    [39] LANGSFORD D, DWYER K.Dysglycemia after renal transplantation:definition, pathogenesis, outcomes and implications for management[J].World J Diabetes, 2015, 6(10):1132-1151.DOI: 10.4239/wjd.v6.i10.1132.
    [40] YATES CJ, FOURLANOS S, COLMAN PG, et al.Screening for new-onset diabetes after kidney transplantation:limitations of fasting glucose and advantages of afternoon glucose and glycated hemoglobin[J].Transplantation, 2013, 96(8):726-731.DOI: 10.1097/TP.0b013e3182a012f3.
    [41] WILKINSON A, DAVIDSON J, DOTTA F, et al.Guidelines for the treatment and management of newonset diabetes after transplantation[J].Clin Transplant, 2005, 19(3):291-298. doi: 10.1111/ctr.2005.19.issue-3
    [42] PHAM PT, PHAM PM, PHAM SV, et al.New onset diabetes after transplantation (NODAT):an overview[J].Diabetes Metab Syndr Obes, 2011, 4:175-186.DOI: 10.2147/DMSO.S19027.
    [43] JUAN KHONG M, PING CHONG CH.Prevention and management of new-onset diabetes mellitus in kidney transplantation[J].Neth J Med, 2014, 72(3):127-134. http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=a2d09f9a472edf74c11f01afc1246a92
    [44] COSIO FG, KUDVA Y, VAN DER VELDE M, et al.New onset hyperglycemia and diabetes are associated with increased cardiovascular risk after kidney transplantation[J].Kidney Int, 2005, 67(6):2415-2421. doi: 10.1111/j.1523-1755.2005.00349.x
    [45] SHIVASWAMY V, BOERNER B, LARSEN J.Posttransplant diabetes mellitus:causes, treatment, and impact on outcomes[J].Endocr Rev, 2016, 37(1):37-61.DOI: 10.1210/er.2015-1084.
    [46] Kidney Disease:Improving Global Outcomes (KDIGO) Transplant Work Group.KDIGO clinical practice guideline for the care of kidney transplant recipients[J].Am J Transplant, 2009, 9 (Suppl 3):S1-S155.DOI:10.1111/ j.1600-6143.2009.02834.x.
    [47] DAVIDSON JA, WILKINSON A, International Expert Panel on New-Onset Diabetes after Transplantation.NewOnset Diabetes After Transplantation 2003 International Consensus Guidelines:an endocrinologist's view[J].Diabetes Care, 2004, 27(3):805-812. doi: 10.2337/diacare.27.3.805
    [48] YOUNG-HYMAN DL, DAVIS CL.Disordered eating behavior in individuals with diabetes:importance of context, evaluation, and classification[J].Diabetes Care, 2010, 33(3):683-689.DOI: 10.2337/dc08-1077.
    [49] American Diabetes Association.Classification and diagnosis of diabetes:standards of medical care in diabetes-2018[J].Diabetes Care, 2018, 41(Suppl 1):S13-S27.DOI: 10.2337/dc18-S002.
    [50] LI Y, XU W, LIAO Z, et al.Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients is associated with improvement of beta-cell function[J].Diabetes Care, 2004, 27(11):2597-2602. doi: 10.2337/diacare.27.11.2597
    [51] WENG J, LI Y, XU W, et al.Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes:a multicentre randomised parallel-group trial[J].Lancet, 2008, 371(9626):1753-1760. doi: 10.1016/S0140-6736(08)60762-X
    [52] JENSSEN T, HARTMANN A.Prevention and management of transplant-associated diabetes[J].Expert Opin Pharmacother, 2011, 12(17):2641-2655.DOI: 10.1517/14656566.2011.628936.
    [53] MORA S, AMES JM, MANSON JE.Low-dose aspirin in the primary prevention of cardiovascular disease:shared decision making in clinical practice[J].JAMA, 2016, 316(7):709-710.DOI: 10.1001/jama.2016.8362.
    [54] BAX JJ, YOUNG LH, FRYE RL, et al.Screening for coronary artery disease in patients with diabetes[J].Diabetes Care, 2007, 30(10):2729-2736. doi: 10.2337/dc07-9927
    [55] BODEN WE, O'ROURKE RA, TEO KK, et al.Optimal medical therapy with or without PCI for stable coronary disease[J].N Engl J Med, 2007, 356(15):1503-1516. doi: 10.1056/NEJMoa070829
    [56] BHATT DL, BONACA MP, BANSILAL S, et al.Reduction in ischemic events with ticagrelor in diabetic patients with prior myocardial infarction in PEGASUSTIMI 54[J].J Am Coll Cardiol, 2016, 67(23):2732-2740.DOI: 10.1016/j.jacc.2016.03.529.
    [57] BARI 2D Study Group, FRYE RL, AUGUST P, et al.A randomized trial of therapies for type 2 diabetes and coronary artery disease[J].N Engl J Med, 2009, 360(24):2503-2515.DOI: 10.1056/NEJMoa0805796.
    [58] WACKERS FJ, CHYUN DA, YOUNG LH, et al.Resolution of asymptomatic myocardial ischemia in patients with type 2 diabetes in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study[J].Diabetes Care, 2007, 30(11):2892-2898. doi: 10.2337/dc07-1250
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  • 收稿日期:  2018-11-01
  • 网络出版日期:  2021-01-19
  • 刊出日期:  2019-01-15

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