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