發(fā)布時間：2018-06-16 12:18

  本文選題：他克莫司 + 肝移植��； 參考：《浙江大學(xué)》2015年博士論文

【摘要】：背景： 新發(fā)糖尿病(new-onset diabetes mellitus, NODM)是肝移植術(shù)后最為常見的并發(fā)癥之一,世界各大移植中心報道的器官移植術(shù)后NODM發(fā)病率為15%-38%。NODM與一些嚴重并發(fā)癥密切相關(guān),如感染、腎功能衰竭、移植物失功、心血管并發(fā)癥等,影響器官移植受者的生活質(zhì)量和長期生存率。近10年來,器官移植領(lǐng)域的發(fā)展突飛猛進,隨著受者的存活率穩(wěn)步提高,術(shù)后NODM這一問題顯得尤為突出。 NODM的發(fā)病機制復(fù)雜,到目前為止還未完全闡明。據(jù)文獻報道,免疫抑制劑的使用、丙型肝炎病毒感染、體重超重、以及TCF7L2基因單核苷酸多態(tài)性均可能與NODM相關(guān)。臨床研究顯示,高劑量他克莫司導(dǎo)致的機體血糖升高和胰島素抵抗可由藥物濃度下調(diào)而好轉(zhuǎn),因此,低劑量濃度他克莫司方案被廣泛接受。但是盡管如此,NODM的發(fā)生率仍高居不下,部分服用低劑量他克莫司的患者,胰島素合成及分泌功能正常,卻仍然發(fā)生NODM,其中的具體機制仍未完全闡明。而且目前絕大多數(shù)NODM的臨床分析和基礎(chǔ)研究來自于腎移植受者,肝移植方面的研究相對較少,且考慮的混雜因素有限,缺少更具說服力的大宗病例和長期隨訪的多中心臨床研究。 近年來,葡萄糖轉(zhuǎn)運蛋白與糖尿病之間的關(guān)系逐漸引起學(xué)者們的關(guān)注。研究報道顯示,糖尿病患者腸道葡萄糖轉(zhuǎn)運蛋白的表達水平是沒有糖尿病患者的3.3倍；糖尿病小鼠行胃腸短路手術(shù)后,質(zhì)子示蹤試驗表明腸道吸收葡萄糖減少,血糖控制,提示腸道葡萄糖轉(zhuǎn)運蛋白在糖尿病發(fā)生和治療中的可能作用。綜合以上國內(nèi)外研究現(xiàn)狀,我們有理由懷疑他克莫司與肝移植術(shù)后NODM的發(fā)生相關(guān),而且葡萄糖轉(zhuǎn)運蛋白(尤其是SGLT1)可能參與了他克莫司相關(guān)肝移植術(shù)后NODM發(fā)生的作用機制。 第一部分肝移植術(shù)前糖尿病對受者預(yù)后的影響研究 目的： 評估糖尿病(diabetes mellitus, DM)對肝移植受者長期生存率的影響。方法：、 我們從美國移植受者科學(xué)注冊系統(tǒng)(Scientific Registry of Transplant Recipients,SRTR)中選取2008年1月1日至2012年12月31日的23240例第一次接受肝移植的成人患者,按照術(shù)前是否有DM分為：DM組和非DM組,比較兩組間的移植物存活率和總體生存率。結(jié)果： DM組肝移植受者術(shù)后1年、3年、5年的移植物存活率分別為86%、74%、62%,顯著低于非DM組肝移植受者的87%、77%、67%(Log rank：P0.001),納入患者年齡、MELD評分、門靜脈血栓、急性排斥反應(yīng)、腹部手術(shù)史、丙肝病毒感染和供體風(fēng)險指數(shù)等混雜因素后,多因素cox回歸分析結(jié)果顯示,DM是肝移植受者移植物衰竭的獨立危險因素(風(fēng)險比,1.124；95%置信區(qū)間,1.052-1.201,P0.001)。進一步cox回歸衍生的依時協(xié)變量統(tǒng)計分析發(fā)現(xiàn),受體患有糖尿病的移植物衰竭風(fēng)險比隨著肝移植術(shù)后患者生存時間的延長而顯著升高。 結(jié)論： 術(shù)前DM是肝移植患者術(shù)后長期生存和移植物存活的獨立預(yù)測因子,并且術(shù)前DM對于患者預(yù)后的影響,隨著時間的推移,危險程度呈指數(shù)級別升高。 第二部分他克莫司與肝移植術(shù)后新發(fā)糖尿病的相關(guān)性研究 目的： 器官移植術(shù)后NODM的發(fā)生與許多因素相關(guān),目前普遍認為免疫抑制劑起了主導(dǎo)作用,但目前絕大多數(shù)NODM的臨床分析和基礎(chǔ)研究來自于腎移植受者,本研究擬在肝移植患者中,研究免疫抑制劑(尤其是他克莫司)與NODM之間的相關(guān)性。 方法： 從SRTR數(shù)據(jù)庫中,選取2008年1月1日至2012年12月31日術(shù)前無DM病史的18741例初次接受單純肝移植的成人患者進行研究,Logist回歸分析NODM發(fā)生的危險因素,分層比較無DM生存率。再根據(jù)免疫抑制劑分層分析其與NODM發(fā)生的關(guān)聯(lián)程度。 結(jié)果： 肝移植術(shù)后NODM的總體發(fā)生率為16.3%,并且60%以上的NODM發(fā)生在肝移植術(shù)后第一年。通過Kaplan-Meier生存分析法,我們發(fā)現(xiàn)活體供肝肝移植(living donor liver transplantation, LDLT)組患者的1年、3年、5年無糖尿病生存率顯著高于尸體供肝肝移植(deceased donor liver transplantation, DDLT)組患者(91%、85%和79%vs.87%、80%和71%,P0.001)。而針對NODM發(fā)生風(fēng)險的多因素Logist回歸分析中,我們發(fā)現(xiàn)DDLT(風(fēng)險比,1.341；95%置信區(qū)間,1.059-1.698,P=0.015)、他克莫司(風(fēng)險比,1.542；95%置信區(qū)間,1.319-1.804,P0.001)和激素(風(fēng)險比,1.531；95%置信區(qū)間,1.374-1.706,P0.001)是NODM發(fā)生的獨立危險因素。再根據(jù)供體來源的不同進行分層分析,我們發(fā)現(xiàn)在DDLT組中,他克莫司和激素與NODM密切相關(guān),尤其使用他克莫司的肝移植受者術(shù)后發(fā)生NODM的風(fēng)險增加66.2%；而在LDLT組中,僅發(fā)現(xiàn)激素的使用與活體肝移植術(shù)后NODM發(fā)生相關(guān)。進一步針對邊緣性供肝的研究,我們發(fā)現(xiàn)乙肝病毒攜帶的供肝肝移植并不降低肝移植患者的生存率；使用他克莫司患者的移植物存活率和總體生存率顯著高于不使用他克莫司的患者；但是同樣地,使用他克莫司患者的無糖尿病生存率顯著低于不使用他克莫司的患者。 結(jié)論： 在肝移植患者中,他克莫司與NODM的發(fā)生密切相關(guān)；使用他克莫司免疫抑制治療方案的患者擁有更高的移植物存活率和患者總體生存率；他克莫司對DDLT患者術(shù)后NODM的影響程度遠甚于LDLT患者；另外,乙肝病毒攜帶的供肝不影響患者的生存率和移植物存活率,使用乙肝免疫球蛋白和他克莫司可以延長患者生存率,但是后者同樣會增加術(shù)后NODM的發(fā)生率。 第三部分基于腸道葡萄糖轉(zhuǎn)運蛋白研究他克莫司致糖尿病的分子機制 目的： 前期研究已經(jīng)證實他克莫司與NODM的發(fā)生密切相關(guān),而且葡萄糖轉(zhuǎn)運蛋白在糖尿病中的作用逐漸受到重視。本研究擬基于腸道葡萄糖轉(zhuǎn)運蛋白研究他克莫司致糖尿病的分子機制。 方法： 選取24只雄性的8周齡C57BL/6小鼠隨機分成4組：control組、low組(他克莫司0.5mg/kg/d)、medium組(他克莫司1mg/kg/d)、high組(他克莫司5mg/kg/d)。每日測量各組小鼠的體重、血糖和進食量；藥物持續(xù)注射2周后進行口服糖耐量試驗；每組的腸道糖吸收功能用Ussing Chamber技術(shù)檢測,用與葡萄糖共轉(zhuǎn)運的鈉離子產(chǎn)生的短路電流(Isc)來定量；用蘇木素和伊紅染色檢測術(shù)后腸道形態(tài)變化；葡萄糖轉(zhuǎn)運蛋白的基因轉(zhuǎn)錄和蛋白表達分別用實時定量聚合酶鏈式反應(yīng)(qRT-PCR)和蛋白印跡技術(shù)(Western blot)來檢測。 結(jié)果： 與control組相比,他克莫司組小鼠在進食量和體重方面無明顯差異；在腸道組織形態(tài)學(xué)方面亦無明顯差異；口服糖耐量試驗顯示腸道糖吸收顯著增加,機體胰島素水平也相應(yīng)地升高。他克莫司組葡萄糖誘導(dǎo)的短路電流顯著增加,表明腸道中SGLT1的活性加強,PCR和Western Blot試驗也相應(yīng)地發(fā)現(xiàn)SGLT1蛋白表達的顯著升高,而腸道中GLUT2和GLUT5在mRNA水平和蛋白表達水平無顯著差異,而上述實驗結(jié)果與他克莫司的劑量無關(guān)。 結(jié)論： 我們首次證實了腸道葡萄糖的吸收功能在他克莫司誘導(dǎo)DM的過程中發(fā)揮著一定的作用；腸道葡萄糖轉(zhuǎn)運蛋白SGLT1與他克莫司相關(guān)性DM的發(fā)生密切相關(guān)；他克莫司可能是通過誘導(dǎo)腸道SGLT1表達和活性的上調(diào),加強腸道對葡萄糖的吸收轉(zhuǎn)運,繼而機體血糖升高,糖耐量異常,甚至導(dǎo)致糖尿病的發(fā)生。
[Abstract]:Background:
New-onset diabetes mellitus (NODM) is one of the most common complications after liver transplantation. The incidence of NODM after organ transplantation in the world's major transplantation centers is closely related to the incidence of 15%-38%.NODM and some serious complications, such as infection, renal failure, graft dysfunction, cardiovascular complications and so on, affecting organ transplantation. The quality of life and the long-term survival rate of the recipient. In the past 10 years, the development of organ transplantation has developed rapidly. With the steady improvement of the survival rate of the recipient, the problem of NODM after the operation is particularly prominent.
The pathogenesis of NODM is complex and has not yet been fully elucidated. It is reported that the use of immunosuppressive agents, hepatitis C virus infection, overweight, and TCF7L2 gene single nucleotide polymorphisms may be associated with NODM. Clinical studies have shown that high levels of tacrolimus caused by high dose of tacrolimus and insulin resistance can be made by drugs. However, the low dose of tacrolimus scheme is widely accepted. However, the incidence of NODM is still high. In patients with low dose of tacrolimus, the insulin synthesis and secretion function are normal, but the NODM is still occurring, and the body mechanism is still not fully elucidated. And most of the NODM is present. The clinical analysis and basic research are derived from recipients of renal transplantation. There are relatively few studies on liver transplantation, with limited confounding factors, lack of more persuasive large cases and long-term follow-up multicenter clinical studies.
In recent years, the relationship between glucose transporter and diabetes has gradually aroused the attention of scholars. The study shows that the expression of glucose transporter in the intestinal tract of diabetic patients is 3.3 times as high as that of non diabetic patients; after the operation of gastrointestinal short circuit, the proton tracer test shows that the intestinal absorption of glucose is reduced and the blood sugar is reduced. Control, suggesting the possible role of intestinal glucose transporter in the occurrence and treatment of diabetes. Combined with the current status of domestic and foreign research, we have reason to suspect that tacrolimus is associated with the occurrence of NODM after liver transplantation and that the glucose transporter (especially SGLT1) may be involved in the occurrence of NODM after the transplantation of tacrolimus related liver transplantation. Use the mechanism.
Part one the effect of preoperative diabetes on the prognosis of liver transplant recipients
Objective:
Objective: To evaluate the effect of diabetes mellitus (DM) on long-term survival in liver transplant recipients.
From the Scientific Registry of Transplant Recipients (SRTR), we selected 23240 adult patients who received the first liver transplant from January 1, 2008 to December 31, 2012. According to whether there were DM in group DM and non DM before the operation, the graft survival rate and overall survival rate between the two groups were compared. Fruit:
1 years, 3 years, and 5 years of graft survival in group DM were 86%, 74%, 62%, respectively, significantly lower than 87%, 77%, 67% (Log rank:P0.001) of non DM liver transplant recipients, including patient age, MELD score, portal vein thrombosis, acute rejection, abdominal surgery, hepatitis C virus infection and donor risk index. Cox regression analysis showed that DM was an independent risk factor for graft failure in liver transplant recipients (risk ratio, 1.124; 95% confidence interval, 1.052-1.201, P0.001). Further Cox regression derived statistical analysis of the dependent time covariance found that the risk of graft failure in the receptor with diabetes was longer than the prolongation of the survival time of patients after liver transplantation. A significant increase.
Conclusion:
Preoperative DM is an independent predictor of long-term survival and graft survival in patients with liver transplantation, and the effect of preoperative DM on the prognosis of patients increases exponentially with time.
The second part is the correlation between tacrolimus and new onset diabetes after liver transplantation.
Objective:
The occurrence of NODM after organ transplantation is associated with many factors. It is widely believed that immunosuppressive agents play a leading role, but most of the clinical and basic studies of NODM are from renal transplant recipients. This study is intended to study the correlation between immunosuppressive agents (especially tacrolimus) and NODM in patients with liver transplantation.
Method錛，

本文編號：2026632