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
Guideline on diagnosis and treatment of recipients with diabetes after organ transplantation in China (2016 edition)
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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。
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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 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:eGFR30~50ml/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 -
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