Diabetes in Kidney Transplantation.
Diabetes in Kidney Transplantation.
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DOI：
10.1053/j.ackd.2021.10.004
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发表时间：
2021-11
影响因子：
2.9
通讯作者：
Martinez Cantarin MP
中科院分区：
文献类型：
--
作者：
Martinez Cantarin MP
糖尿病（DM）是肾移植后最常见的并发症之一，与包括死亡在内的不良后果相关。移植前可能出现糖尿病，但移植后糖尿病 (PTDM) 是指实体器官移植后诊断出的糖尿病。尽管 PTDM 患病率很高，但预防 PTDM 并发症的最佳治疗方法尚不清楚。由于抗糖尿病药物和免疫抑制剂之间频繁的相互作用，移植后已存在的 DM 或 PTDM 的药物治疗具有挑战性。由于残余肾脏疾病以及接受免疫抑制剂治疗的患者出现药物副作用的风险较高，还经常需要调整药物剂量。葡萄糖钠 2 抑制剂 (SGLT2-i) 在未进行移植的糖尿病患者中表现出良好的心肾功能，因此在该患者群体中具有很大的前景，尽管人们担心尿路感染的风险较高。我们对肾移植后糖尿病的病理生理学、诊断和治疗的理解存在重大差距，亟待解决。一个。移植后糖尿病（包括先前存在的糖尿病和移植后糖尿病）极为常见，并且与发病率和死亡率增加有关。 b.移植后糖尿病的发病机制与其他 2 型糖尿病亚组有相似之处。然而，PTDM 呈现出代谢功能障碍的独特驱动因素，包括钙调神经磷酸酶抑制剂对胰腺 β 细胞的毒性，从而使 PTDM 成为一个单独的实体。 c.空腹血糖和糖化血红蛋白可能无法反映器官移植后代谢的改变，这使得 PTDM 的诊断更具挑战性。口服葡萄糖耐量试验应被视为诊断的金标准。 d. PTDM 的最佳治疗目标尚不清楚。 e. SGLT2-i 已证明在治疗非移植相关糖尿病方面具有有效性和安全性，可改善心血管风险并减少肾脏疾病进展。然而，肾移植后的 SGLT2-i 治疗可能会导致泌尿生殖系统感染和血管舒缩性急性肾损伤的风险显着升高。移植后需要进行研究以确定 SGLT2-i 是否具有临床益处，包括心血管预防和肾保护作用。
Diabetes mellitus (DM) is one of the most common complications after kidney transplantation and is associated with unfavorable outcomes including death. DM can be present before transplant but post-transplant diabetes mellitus (PTDM) refers to diabetes that is diagnosed following solid organ transplantation. Despite its high prevalence, optimal treatment to prevent complications of PTDM are unknown. Medical therapy of pre-existent DM or PTDM after transplant is challenging due to frequent interactions between antidiabetic and immunosuppressive agents. There is also frequent need for medication dose adjustments due to residual kidney disease and a higher risk of medication side effects in patients treated with immunosuppressive agents. Sodium glucose 2 inhibitors (SGLT2-i) have demonstrated a favorable cardio-renal profile in patients with DM without a transplant and hence hold great promise in this patient population although there is concern about the higher risk of urinary tract infections. The significant gaps in our understanding of the pathophysiology, diagnosis and management of diabetes mellitus after kidney transplantation need to be urgently addressed. a. Diabetes mellitus after transplant, which includes pre-existing diabetes and post-transplant diabetes, is extremely common and is associated with increased morbidity and mortality. b. The pathogenesis of post-transplant diabetes shares similarities with other subgroups of type 2 diabetes. However, PTDM presents distinct drivers for metabolic dysfunction including calcineurin inhibitor toxicity to the pancreatic beta cell, thus making PTDM a separate entity. c. Fasting glucose and hemoglobin A1c may not reflect the altered metabolism after an organ transplant making the diagnosis of PTDM more challenging. Oral glucose tolerance test should be considered the gold standard for its diagnosis. d. Optimal treatments goals in PTDM are unknown. e. SGLT2-i have demonstrated efficacy and safety in the treatment of non-transplant related DM with improvement in cardiovascular risk and decrease in kidney disease progression. However, SGLT2-i therapy post-kidney transplant may pose a substantially higher risk of genitourinary infections and vasomotor acute kidney injury. Studies to determine whether SGLT2-i provide clinical benefits including cardiovascular prevention and nephroprotective effects are need post-transplant.
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