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中国实体器官移植受者血脂管理规范(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. 中国实体器官移植受者血脂管理规范(2019版)[J]. 器官移植, 2019, 10(2): 101-111. doi: 10.3969/j.issn.1674-7445.2019.02.001
引用本文: 中华医学会器官移植学分会. 中国实体器官移植受者血脂管理规范(2019版)[J]. 器官移植, 2019, 10(2): 101-111. doi: 10.3969/j.issn.1674-7445.2019.02.001
Branch of Organ Transplantation of Chinese Medical Association. Management specification for blood lipid on recipients with solid organ transplantation in China (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(2): 101-111. doi: 10.3969/j.issn.1674-7445.2019.02.001
Citation: Branch of Organ Transplantation of Chinese Medical Association. Management specification for blood lipid on recipients with solid organ transplantation in China (2019 edition)[J]. ORGAN TRANSPLANTATION, 2019, 10(2): 101-111. doi: 10.3969/j.issn.1674-7445.2019.02.001

中国实体器官移植受者血脂管理规范(2019版)

doi: 10.3969/j.issn.1674-7445.2019.02.001
基金项目: 

国家自然科学基金 81570680

国家自然科学基金 81372737

详细信息
    通讯作者:

    石炳毅,中国人民解放军总医院第八医学中心,Email:shibingyi666@126.com;马麟麟,Email:malinlin1009@126.com

  • 中图分类号: R617, R589.2

Management specification for blood lipid on recipients with solid organ transplantation in China (2019 edition)

  • 摘要: 为了进一步规范中国实体器官移植受者的血脂管理,中华医学会器官移植学分会组织器官移植专家和心血管内科专家,总结国内外有关器官移植术后血脂代谢异常研究最新进展,并以我国《器官移植术后高脂血症临床诊疗指南(2015版)》,结合我国《中国成人血脂异常防治指南》为基础,结合临床实践,从实体器官移植后受者血脂异常相关心血管疾病的发病因素、移植后血脂代谢异常的诊断和危险分层、移植术后血脂代谢异常的预防和治疗、器官移植受者的血脂管理等方面,制定中国实体器官移植受者血脂管理规范(2019版)。

     

  • 表  1  免疫抑制剂对高血压、血脂及新发糖尿病的影响

    Table  1.   Effect of immunosuppressants on hypertension, blood lipids and new onset diabetes mellitus

    药 物 高血压 血脂水平 NODAT
    糖皮质激素 ↑↑ ↑↑ ↑↑
    环孢素 ↑↑↑ ↑↑
    他克莫司 ↑↑ ↑↑
    mTORi (SRL/EVL) - ↑↑↑ -
    MMF/MPA - - -
    硫唑嘌呤 - - -
    贝拉西普 - -
    单抗类药物 - -
      GFR为肾小球滤过率; NODAT为移植后新发糖尿病; mTORi为哺乳动物雷帕霉素靶蛋白抑制剂; SRL为西罗莫司; EVL为依维莫司; MMF为吗替麦考酚酯; MPA为霉酚酸。↓代表降低风险; ↑代表增加风险; 箭头数量代表影响的大小; -代表无影响
    下载: 导出CSV

    表  2  临床常用的免疫抑制剂对血脂的影响

    Table  2.   Effect of immunosuppressants on blood lipids commonly used in clinic

    药 物 对血脂的影响 主要机制
    糖皮质激素 升高VLDL、TC、TG; 降低HDL 加速脂肪分解、抑制脂肪合成, 升高血糖、促进糖代谢转向脂肪代谢, 诱导胰岛素抵抗, 产生代谢综合征, 长期使用有累积效应
    环孢素 升高LDL、TC 降低胆汁酸合成, 下调LDL受体功能, 抑制胆固醇清除, 诱导胆固醇合成, 促进VLDL转变为LDL, 与糖皮质激素合用时具有额外的升高血脂作用
    他克莫司 轻度升高LDL、TC 与环孢素同类, 但升血脂效果较弱
    西罗莫司、依维莫司 升高TC、TG 增加肝脏脂质合成, 降低脂质清除, 抑制胰岛素和胰岛素样生长因子通路
      HDL为高密度脂蛋白; LDL为低密度脂蛋白; TC为总胆固醇; TG为甘油三酯; VLDL为极低密度脂蛋白
    下载: 导出CSV

    表  3  移植受者血脂代谢参考标准及分层方案

    Table  3.   Reference standard and layered solutions of lipid metabolism in transplant recipients[mmol/L (mg/dL)]

    分 层 TC LDL-C HDL-C TG
    最佳值 < 2.59(100)
    合适范围 < 5.18(200) < 3.37(130) ≥1.04(40) < 1.70(150)
    边缘升高 5.18~6.21(200~239) 3.37~4.13(130~159) 1.70~2.25(150~199)
    升高 ≥6.22(240) ≥4.14(160) ≥1.55(60) ≥2.26(200)
    极高 >4.93(190) >5.67(500)
    降低 < 1.04(40)
      HDL-C为高密度脂蛋白胆固醇; LDL-C为低密度脂蛋白胆固醇; TC为总胆固醇; TG为甘油三酯
    下载: 导出CSV

    表  4  移植后血脂异常危险分层

    Table  4.   Risk stratification of dyslipidemia after transplantation

    分 层 TC 5.18~6.21 mmol/L
    LDL-C 3.37~4.13 mmol/L
    TC ≥6.22 mmol/L
    LDL-C≥4.14 mmol/L
      无高血压且其他危险因素a < 3个 低危 低危
      高血压或其他危险因素≥3个 低危 中危
      高血压且其他危险因素≥1个 中危 高危
      冠心病等危险因素b 高危 高危
      a危险因素包括:器官移植; 蛋白尿≥3 g/24 h; 血压≥140/90 mmHg或接受降压治疗; 吸烟; 肥胖(BMI≥28 kg/m2); 低HDL-C (< 1.04 mmol/L); 年龄(男性≥45岁, 女性≥55岁); 早发性ASCVD家族史(男性一级亲属发病时 < 55岁, 女性一级亲属发病时 < 65岁)。b冠心病等危险因素包括:有临床表现的冠状动脉以外的动脉粥样硬化, 包括脑血管和周围动脉疾病; 糖尿病; 有多种发生主要冠状动脉疾病的危险因素, 其风险相当于已确诊冠心病; 代谢综合征。代谢综合征诊断标准包括BMI≥25 kg/m2, TG≥1.70 mmol/L, 血HDL-C男性 < 0.91 mmol/L、女性 < 1.01 mmol/L, 血压≥140/90 mmHg, 空腹血糖≥6.1 mml/L、餐后2 h血糖7.8 mmol/L或有糖尿病史
    下载: 导出CSV

    表  5  血脂异常受者开始调节血脂治疗的检验值及目标值

    Table  5.   Test value and target value of dyslipidemia recipients beginning to lipid adjusting treatment (mmol/L)

    危险等级 TLC开始 药物治疗开始 治疗目标值
    低危:10年危险性 < 5% TC ≥ 6.22
    LDL-C ≥ 4.41
    TC ≥ 6.99
    LDL-C ≥ 4.92
    TC < 6.22
    LDL-C < 4.41
    中危:10年危险性5%~10% TC ≥ 5.18
    LDL-C ≥ 3.37
    TC ≥ 6.22
    LDL-C ≥ 4.41
    TC < 5.18
    LDL-C < 3.37
    高危:冠心病等危险因素, 或10年危险性11%~15% TC ≥ 4.14
    LDL-C ≥ 2.59
    TC ≥ 4.14
    LDL-C ≥ 2.59
    TC < 4.14
    LDL-C < 2.59
    极高危:急性冠状动脉综合征或缺血性心血管病合并糖尿病 TC ≥ 3.11
    LDL-C ≥ 2.07
    TC ≥ 4.14
    LDL-C ≥ 2.07
    TC < 3.11
    LDL-C < 2.07
      TLC为以治疗为目的改变生活方式; TC为总胆固醇; LDL-C为低密度脂蛋白胆固醇
    下载: 导出CSV

    表  6  他汀类药物的作用效度分类

    Table  6.   Classification of statins validity (mg)

    强效a 中效b 弱效c
    阿托伐他汀40~80 阿托伐他汀10~20 辛伐他汀10
    瑞舒伐他汀20~40 瑞舒伐他汀5~10 普伐他汀10~20
    辛伐他汀20~40 洛伐他汀20
    普伐他汀40~80 氟伐他汀20~40
    洛伐他汀40 匹伐他汀1
    氟伐他汀80或40, 每日2次
    匹伐他汀2~4
      强效a为日剂量平均降低LDL-C≥50%;中效b为日剂量平均降低LDL-C 30%~49%;弱效c为日剂量平均降低LDL-C < 30%
    下载: 导出CSV

    表  7  与他汀类药物代谢具有药物相互作用的主要诱导剂和抑制剂

    Table  7.   The main inducers and inhibitors with drug interaction in statins drug metabolism

    他汀类药物 诱导剂(降低血药浓度) 抑制剂(升高血药浓度)
    经CYP3A4途径代谢:
    阿托伐他汀、辛伐他汀、
    洛伐他汀、瑞舒伐他汀
    苯妥英、苯巴比妥、巴比妥类、
    利福平、地塞米松、环磷酰胺、
    金丝桃、卡马西平、曲格列酮
    环孢素、他克莫司、三唑类抗真菌药、大环内酯类、
    三环类抗抑郁药、奈法唑酮、文拉法辛、氟苯氧丙胺、
    氟西汀、硫氮唑酮、维拉帕米、胺碘酮、咪达唑仑、
    糖皮质激素、他莫昔芬、蛋白酶抑制剂、西柚汁
    经CYP2C9途径代谢:
    氟伐他汀、瑞舒伐他汀、
    匹伐他汀(极少部分)
    利福平、苯巴比妥、苯妥英、
    曲格列酮
    三唑类抗真菌药、磺胺苯吡唑
    下载: 导出CSV

    表  8  他汀类药物在肾移植受者中的推荐剂量

    Table  8.   The recommended dose of statins in renal transplant recipients (mg)

    他汀类药物 GFR水平[mL/(min·1.73m2)] 合并使用
    环孢素
    ≥30 < 30或透析
    阿托伐他汀 10~80 10~80 10~40
    氟伐他汀 20~80 10~40 10~40
    洛伐他汀 20~80 10~40 10~40
    普伐他汀 20~40 20~40 20~40
    辛伐他汀 20~80 10~40 10~40
    下载: 导出CSV

    表  9  调节血脂药对肾功能的影响和调整

    Table  9.   Effect and adjustment of lipid-adjusting drugs on renal function

    药 物 根据GFR[mL/(min·1.73m2]调整 注意事项
    60~90 15~59 < 15
    阿托伐他汀 不调整 不调整 不调整 退出
    瑞舒伐他汀 不调整 降低50% 降低50% 退出
    氟伐他汀 未知 未知 未知
    洛伐他汀 不调整 降低50% 降低50%
    普伐他汀 不调整 不调整 不调整
    辛伐他汀 未知 未知 未知
    烟酸 不调整 不调整 降低50% 34%经肾代谢
    考来替泊 不调整 不调整 不调整 不吸收
    考来烯胺 不调整 不调整 不调整 不吸收
    考来维仑 不调整 不调整 不调整 不吸收
    苯扎贝特 降低50% 降低25% 避免使用 可能升高Scr
    氯贝丁酯 降低50% 降低25% 避免使用 可能升高Scr
    环丙贝特 未知 未知 未知 可能升高Scr
    菲诺贝特 降低50% 降低25% 避免使用 可能升高Scr
    吉非贝齐 不调整 不调整 不调整 可能升高Scr
    依折麦布 不调整 不调整 不调整
    下载: 导出CSV

    表  10  心脏移植受者的他汀类药物推荐剂量

    Table  10.   The recommended dose of statins in heart transplant recipients (mg)

    药 物 推荐剂量
    普伐他汀 20~40
    辛伐他汀 5~20
    阿托伐他汀 10~20
    氟伐他汀 40~80
    洛伐他汀 20
    瑞舒伐他汀 5~20
    下载: 导出CSV

    表  11  肺移植受者的他汀类药物推荐剂量

    Table  11.   The recommended dose of statins in lung transplant recipients (mg/d)

    药 物 推荐剂量 备注
    开始剂量 最大量
    阿托伐他汀 10(睡前) 80
    氟伐他汀 20(睡前) 80 首选
    普伐他汀 10(睡前) 40
    下载: 导出CSV

    表  12  肝移植受者术后的他汀类药物推荐剂量

    Table  12.   The recommended dose of statins in liver transplant recipients (mg/d)

    药 物 正常人群推荐剂量 肝移植受体推荐剂量
    阿托伐他汀 10~80 10~40[44, 46, 48-49]
    瑞舒伐他汀 5~40 5~20[50-51, 56]
    洛伐他汀 40~80 20~40[44, 52]
    辛伐他汀 20~40 20~40[48, 53]
    普伐他汀 40~80 20~40[48, 56]
    氟伐他汀 80 40[54-55]
    下载: 导出CSV
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  • 收稿日期:  2018-11-30
  • 网络出版日期:  2021-01-19
  • 刊出日期:  2019-03-15

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