Glucose Metabolism After Renal Transplantation

OBJECTIVE

We determined prevalence, risk factors, phenotype, and pathophysiological mechanism of new-onset diabetes after transplantation (NODAT) to generate strategies for optimal pharmacological management of hyperglycemia in NODAT patients.

RESEARCH DESIGN AND METHODS

Retrospective cohort study comparing demographics, laboratory data, and oral glucose tolerance test (OGTT)-derived metabolic parameters from kidney transplant recipients versus subjects not receiving transplants.

RESULTS

Among 1,064 stable kidney transplant recipients (≥6 months posttransplantation), 113 (11%) had a history of NODAT and 132 (12%) had pretransplant diabetes. In the remaining patients, randomly assigned OGTTs showed a high prevalence of abnormal glucose metabolism (11% diabetes; 32% impaired fasting glucose, impaired glucose tolerance, or both), predominantly in older patients who received tacrolimus as the primary immunosuppressant. Compared with 1,357 nontransplant subjects, stable kidney transplant recipients had lower basal glucose, higher glycated hemoglobin, lower insulin secretion, and greater insulin sensitivity in each of the three subgroups, defined by OGTT 2-h glucose (<140, 140–199, ≥200 mg/dL). These findings were reinforced in linear spline interpolation models of insulin secretion and sensitivity (all P < 0.001) and in another regression model in which the estimated oral glucose insulin sensitivity index was substantially higher (by 79–112 mL/min m²) for transplant versus nontransplant subjects despite adjustments for age, sex, and BMI (all P < 0.001).

CONCLUSIONS

Glucose metabolism differs substantially between kidney transplant recipients and nontransplant controls. Because impaired insulin secretion appears to be the predominant pathophysiological feature after renal transplantation, early therapeutic interventions that preserve, maintain, or improve β-cell function are potentially beneficial in this population.More than 15,000 adults in the United States receive kidney transplants from deceased and living donors every year, and the majority will have improved quality of life and stable allograft function over the longer-term (1). By the end of the third posttransplant year, however, >40% of previously nondiabetic kidney transplant recipients develop new-onset diabetes after transplantation (NODAT) (2), which portends elevated risks for cardiovascular disease (3). NODAT is not mentioned in the American Diabetes Association position statement, but the American Diabetes Association experts emphasize that it is less important to label the particular type of diabetes than to understand the pathogenesis of hyperglycemia to treat it effectively (4). The pathophysiology underlying NODAT, however, is at present only poorly understood.Type 2 diabetes mellitus (DM) in the general population ranges from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance (4). In kidney transplant recipients with overt NODAT versus normal glucose tolerance (NGT), insulin resistance is increased and β-cell function is diminished (5), but the relative importance of either one component has been controversially reported (6–11). Calcineurin inhibitors, albeit standard initial maintenance immunosuppressive agents in the United States (1), are diabetogenic and inhibit a signaling pathway that is crucial for β-cell growth and function (12). Glucocorticoids are often used simultaneously and are well-known to decrease insulin sensitivity (13) but also might diminish insulin secretion (14).In the current study, we aimed at assessing mechanisms of NODAT development in kidney transplant recipients. Our first goal was to determine prevalence, risk factors, and phenotype of a disturbed posttransplant glucose metabolism. Because previous treatment strategies for NODAT were suggested to follow type 2 DM (15), our second goal was to compare insulin secretion and insulin sensitivity between kidney transplant recipients and nontransplant individuals. In addition, we sought to validate results from stable kidney transplant recipients (≥6 months) against recent findings from patients studied as early as 3 months posttransplantation (16). We hypothesized that these pathomechanistic details, together, would help generate strategies for optimal management of hyperglycemia in NODAT patients.     

肾移植术后并发类固醇性白内障3例分析

肾移植术后并发类固醇性白内障３例分析ＴｈｒｅｅＣａｓｅｓｏｆＳｔｅｒｏｉｄＣａｔａｒａｃｔＡｆｔｅｒＲｅｎａｌＴｒａｎｓｐｌａｎｔａｔｉｏｎ杨淑玲宣蓓ＹａｎｇＳｈｕｌｉｎｇ，ＸｕａｎＢｅｉ（ＮａｎｆａｎｇＨｏｓｐｉｔａｌｏｆＦｉｒｓｔＭｉｌｉｔａｒ...     

肾移植术后血清微量元素的监测

【目的】监测肾移植患者术前术后铁(Fe)、铜(Cu)、锌(Zn)三种微量元素的变化并探讨其意义。【方法】用亚铁嗪比色法等方法检测50例正常人和51例肾功能衰竭患者肾移植前1d和肾移植后d7、d14、d21的血清Fe、Cu、Zn含量。【结果】患者术后血清Fe水平较术前明显有所提高,但仍显著低于正常人水平(P<0.01)。手术前后血清Zn水平均显著低于正常对照组(P<0.01),而血清Cu水平手术前后与健康体检者无差异(P>0.05)。【结论】肾移植患者术后可能会出现血清微量元素Fe、Zn缺乏,应动态检测,以便及时适量补充。     

肾移植供受者病毒感染的调查与分析

为了解肾移植供受者肝炎等病毒的感染情况，研究其感染后的护理与肾移植术后人肾存活率的关系。对供受者进行乙型肝炎（HBV）、丙型肝炎（HCV）、庚型肝炎（HGV）及巨细胞病毒（CMV）、EB病毒、单纯疱疹病毒（HSV）、艾滋病病例（HIV）的调查。结果：200例供者中感染HBV16例，感染HCV5例，感染HGV1例，CMV－IgM阳性者31例，EB－IgM阳性者24例，HSV－IgM阳性者36例，HIV病毒携带者1例。210例移植者中HBV感染者136例，HCV感染者74例，HBV、HCV双重感染者49例，HGV感染者14例，HGV、HBV双重感染者14例，HGV、HBV、HCV三重感染者7例，HSV－IgM阳性者86例，无HIV携带者。结论：供受者术前病毒感染状态对移植受者术后是否发生病毒感染至关重要，良好的术前术后护理可降低术后并发症的发生率。     

男性肾移植术后性功能调查分析

按照WTO的标准 ,人类健康不单单是没有疾病 ,而应包括躯体、心理和社会文化的总体健康。现代健康新概念使性与生殖健康在总体健康中的地位显得更为重要。随着肾移植技术不断的提高以及各类新型免疫抑制剂在临床上的应用 ,肾移植受者长期存活率得到了很大的提高 ,其对术后生活质量也提出了更高要求 ,其中 ,性功能是这些受者健康状况的重要标志 ,直接影响肾移植受者生活质量。我院自 1978年— 2 0 0 2年 11月共施行同种异体肾移植手术 2 2 0 0多例。为了解男性肾移植受者性功能状态的变化 ,我们随机选择已婚男性肾移植受者 60例 ,对他们病前…     

移植肾功能延迟恢复的原因分析及预防

目的探讨肾移植术后移植肾功能延迟恢复(DGF)的原因及预防措施。方法对32例发生DGF的患者进行回顾性分析。结果术后发生DGF 32例(12.4%),常见原因是:供肾热缺血时间过长(4例)、器官灌注不良(10例),术中低血压(6例)、早期急性排斥反应(10例)、外科并发症(2例)。结论缩短供肾热缺血时间、改善器官灌注量和压力、加强低血压病人的术中处理是预防术后DGF的主要措施。     

Renal Transplantation

Medical and scientific advances have improved the diagnosis and treatment of kidney disorders. Organ transplantation has evolved from an experimental surgery to a medically accepted form of treatment for organ failure. The kidney was the first organ to be successfully replaced by a donor organ, and it is presently the most commonly transplanted organ. Kidney transplantation restores reasonably normal health to patients whose kidneys no longer function, and it frees them from the limitations imposed by dialysis. Improved graft survival rates have further enhanced the desirability of transplantation. AORN J 68 (December 1998) 964-993.     

异基因造血干细胞移植后急性肾衰竭的临床研究

本研究探讨异基因造血干细胞移植（allo—HSCT）后急性肾衰竭（acuterenalfailure,ARF）的发生率、危险因素以及对患者预后的影响。采用回顾性研究方法,对86例allo—HSCT患者的资料进行了分析。采用单因素分析及多因素Logistic回归模型分析,研究了ARF发生的危险因素。使用Cox回归法分析了ARF与allo—HSCT患者生存时间的关系。结果表明：ARF发生率为31．40％,发病中位时间为allo—HSCT后59．5天。单因素及多因素分析发现,移植前肾脏疾病、败血症或感染中毒性休克、高胆红素血症为allo—HSCT后ARF发生的独立危险因素。同时,ARF是影响allo—HSCT患者生存的独立危险因素。结论：Allo—HSCT后ARF发生率高;败血症或感染中毒性休克、高胆红素血症、既往肾脏病史是allo—HSCT后ARF发生的独立危险因素;ARF是影响allo—HSCT患者生存时间的独立危险因素。     

肾移植术后并发结核感染的观察与护理35例

结核是肾移植术后常见的感染性并发症之一 ,肾移植患者结核的发病率高于普通人群 ,可高达4 .1%～ 11.8% [1～ 3] ,肾移植术后大量免疫抑制剂的使用 ,极大地降低了以T淋巴细胞为主的细胞免疫系统功能 ,为结核菌感染和潜伏性结核杆菌 (休眠结核菌 )的复燃提供了条件和机会[4 ] 。此类患者并发结核病病情复杂 ,诊治困难 ,易于全身播散 ,死亡率高[5] 。 1999年 3月～ 2 0 0 2年 11月我科共收治肾移植术后结核感染 35例 ,加强观察和护理尤为重要 ,现报告如下。1　临床资料1.1　一般资料1999年 3月～ 2 0 0 2年 11月我科共收治肾移植术后结核感染…     

早期应用小剂量ATG预防尸体肾移植术后排斥反应

采用小剂量抗胸腺淋巴细胞球蛋白（ＡＴＧ）对４３６例尸体肾移植术后病人进行排斥反应的预防。结果：发生急性排斥反应７２例（１６．５１％），血肌酐在２ｄ～１０ｄ恢复正常３４８例（７９．８２％），１１ｄ～３２ｄ６２例（１４．２２％），并发感染１８例（４．１３％），摘除移植肾１９例（４．３６％），死亡１２例（２．７５％）。提示：肾移植术后早期应用小剂量ＡＴＧ可预防排斥反应，降低ＣｓＡ肾中毒。     

Infections in a Renal Unit

Five hundred and thirty-three patients in the Oxford renal unitwere reviewed to determine the incidence of infection in onecalender year. There were 310 patients who received dialysis,53 with acute renal failure and 211 with chronic renal disease.Renal transplant patients were not included in the study. Apartfrom infections related to dialysis access, patients on maintenancehaemodialysis or continuous ambulatory peritoneal dialysis developedfew serious infections unless they had another disease causingsuppression of immune function. A total of 97 urinary tractinfections were seen; in patients with chronic renal diseasenot receiving dialysis the incidence of urinary tract infectionwas significantly associated with increasing uraemia, with diabetes,and with treatment with azathioprine or cyclophosph amide. Inpatients with acute renal failure, Gram-negative septicaemiaand fungal infections were important causes of morbidity andmortality, but cardiovascular disease caused 42 per cent ofthe deaths unlike results from other series where sepsis hasbeen by far the commonest cause of death.     

肝移植术后病人的依从性

肝移植已被世界公认为治疗终末期肝病的有效手段,而移植术后病人依从性的好坏将直接影响肝移植效果。因此,肝移植术后应对病人依从性进行评价,明确影响依从性的相关因素,对不依从病人进行干预,从而提高肝移植的效果和病人的生活质量。该文汇总讨论了依从性的概念、评价依从性的方法、影响肝移植术后病人依从性的相关因素、不依从的不良后果,并提出相应的干预措施。     

临床肾移植进展

自从1954首次成功在孪生子问进行肾移植以来，经过半个世纪的不懈努力，肾移植技术已从探索走向成熟。美国器官共享联合网络(The United Network for Organ Sharing，UNOS)的最新统计资料显示：美国2003年进行各种类型的肾移植15121例，其中活体肾移植为8661例，尸体肾移植为6460例；1996～2001年的资料显示：尸体肾移植的移植肾1年存活率为88．4％，5年存活率为65．5％；活体肾移植的移植肾1年存活率为94．5％。     

Infectious Process Complicating Renal Transplantation

Although diagnosis of acute myocardial infarction is usually based on the patient history and electrocardiographic findings, nuclear myocardial perfusion imaging has an important role in assessing myocardial damage and predicting patient prognosis. In this article, Dr Umfrid discusses the unique characteristics of technetium Tc 99m sestamibi that make it especially useful in managing acute myocardial infarction.