他克莫司与肝移植术后新发糖尿病的相关性及其作用机制研究

发布时间：2018-06-16 12:18

  本文选题：他克莫司 + 肝移植　； 参考：《浙江大学》2015年博士论文

【摘要】：背景： 新发糖尿病(new-onset diabetes mellitus, NODM)是肝移植术后最为常见的并发症之一,世界各大移植中心报道的器官移植术后NODM发病率为15%-38%。NODM与一些严重并发症密切相关,如感染、肾功能衰竭、移植物失功、心血管并发症等,影响器官移植受者的生活质量和长期生存率。近10年来,器官移植领域的发展突飞猛进,随着受者的存活率稳步提高,术后NODM这一问题显得尤为突出。 NODM的发病机制复杂,到目前为止还未完全阐明。据文献报道,免疫抑制剂的使用、丙型肝炎病毒感染、体重超重、以及TCF7L2基因单核苷酸多态性均可能与NODM相关。临床研究显示,高剂量他克莫司导致的机体血糖升高和胰岛素抵抗可由药物浓度下调而好转,因此,低剂量浓度他克莫司方案被广泛接受。但是尽管如此,NODM的发生率仍高居不下,部分服用低剂量他克莫司的患者,胰岛素合成及分泌功能正常,却仍然发生NODM,其中的具体机制仍未完全阐明。而且目前绝大多数NODM的临床分析和基础研究来自于肾移植受者,肝移植方面的研究相对较少,且考虑的混杂因素有限,缺少更具说服力的大宗病例和长期随访的多中心临床研究。 近年来,葡萄糖转运蛋白与糖尿病之间的关系逐渐引起学者们的关注。研究报道显示,糖尿病患者肠道葡萄糖转运蛋白的表达水平是没有糖尿病患者的3.3倍；糖尿病小鼠行胃肠短路手术后,质子示踪试验表明肠道吸收葡萄糖减少,血糖控制,提示肠道葡萄糖转运蛋白在糖尿病发生和治疗中的可能作用。综合以上国内外研究现状,我们有理由怀疑他克莫司与肝移植术后NODM的发生相关,而且葡萄糖转运蛋白(尤其是SGLT1)可能参与了他克莫司相关肝移植术后NODM发生的作用机制。 第一部分肝移植术前糖尿病对受者预后的影响研究 目的： 评估糖尿病(diabetes mellitus, DM)对肝移植受者长期生存率的影响。方法：、 我们从美国移植受者科学注册系统(Scientific Registry of Transplant Recipients,SRTR)中选取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,按照术前是否有DM分为：DM组和非DM组,比较两组间的移植物存活率和总体生存率。结果： DM组肝移植受者术后1年、3年、5年的移植物存活率分别为86%、74%、62%,显著低于非DM组肝移植受者的87%、77%、67%(Log rank：P0.001),纳入患者年龄、MELD评分、门静脉血栓、急性排斥反应、腹部手术史、丙肝病毒感染和供体风险指数等混杂因素后,多因素cox回归分析结果显示,DM是肝移植受者移植物衰竭的独立危险因素(风险比,1.124；95%置信区间,1.052-1.201,P0.001)。进一步cox回归衍生的依时协变量统计分析发现,受体患有糖尿病的移植物衰竭风险比随着肝移植术后患者生存时间的延长而显著升高。 结论： 术前DM是肝移植患者术后长期生存和移植物存活的独立预测因子,并且术前DM对于患者预后的影响,随着时间的推移,危险程度呈指数级别升高。 第二部分他克莫司与肝移植术后新发糖尿病的相关性研究 目的： 器官移植术后NODM的发生与许多因素相关,目前普遍认为免疫抑制剂起了主导作用,但目前绝大多数NODM的临床分析和基础研究来自于肾移植受者,本研究拟在肝移植患者中,研究免疫抑制剂(尤其是他克莫司)与NODM之间的相关性。 方法： 从SRTR数据库中,选取2008年1月1日至2012年12月31日术前无DM病史的18741例初次接受单纯肝移植的成人患者进行研究,Logist回归分析NODM发生的危险因素,分层比较无DM生存率。再根据免疫抑制剂分层分析其与NODM发生的关联程度。 结果： 肝移植术后NODM的总体发生率为16.3%,并且60%以上的NODM发生在肝移植术后第一年。通过Kaplan-Meier生存分析法,我们发现活体供肝肝移植(living donor liver transplantation, LDLT)组患者的1年、3年、5年无糖尿病生存率显著高于尸体供肝肝移植(deceased donor liver transplantation, DDLT)组患者(91%、85%和79%vs.87%、80%和71%,P0.001)。而针对NODM发生风险的多因素Logist回归分析中,我们发现DDLT(风险比,1.341；95%置信区间,1.059-1.698,P=0.015)、他克莫司(风险比,1.542；95%置信区间,1.319-1.804,P0.001)和激素(风险比,1.531；95%置信区间,1.374-1.706,P0.001)是NODM发生的独立危险因素。再根据供体来源的不同进行分层分析,我们发现在DDLT组中,他克莫司和激素与NODM密切相关,尤其使用他克莫司的肝移植受者术后发生NODM的风险增加66.2%；而在LDLT组中,仅发现激素的使用与活体肝移植术后NODM发生相关。进一步针对边缘性供肝的研究,我们发现乙肝病毒携带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总体生存率显著高于不使用他克莫司的患者；但是同样地,使用他克莫司患者的无糖尿病生存率显著低于不使用他克莫司的患者。 结论： 在肝移植患者中,他克莫司与NODM的发生密切相关；使用他克莫司免疫抑制治疗方案的患者拥有更高的移植物存活率和患者总体生存率；他克莫司对DDLT患者术后NODM的影响程度远甚于LDLT患者；另外,乙肝病毒携带的供肝不影响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长患者生存率,但是后者同样会增加术后NODM的发生率。 第三部分基于肠道葡萄糖转运蛋白研究他克莫司致糖尿病的分子机制 目的： 前期研究已经证实他克莫司与NODM的发生密切相关,而且葡萄糖转运蛋白在糖尿病中的作用逐渐受到重视。本研究拟基于肠道葡萄糖转运蛋白研究他克莫司致糖尿病的分子机制。 方法： 选取24只雄性的8周龄C57BL/6小鼠随机分成4组：control组、low组(他克莫司0.5mg/kg/d)、medium组(他克莫司1mg/kg/d)、high组(他克莫司5mg/kg/d)。每日测量各组小鼠的体重、血糖和进食量；药物持续注射2周后进行口服糖耐量试验；每组的肠道糖吸收功能用Ussing Chamber技术检测,用与葡萄糖共转运的钠离子产生的短路电流(Isc)来定量；用苏木素和伊红染色检测术后肠道形态变化；葡萄糖转运蛋白的基因转录和蛋白表达分别用实时定量聚合酶链式反应(qRT-PCR)和蛋白印迹技术(Western blot)来检测。 结果： 与control组相比,他克莫司组小鼠在进食量和体重方面无明显差异；在肠道组织形态学方面亦无明显差异；口服糖耐量试验显示肠道糖吸收显著增加,机体胰岛素水平也相应地升高。他克莫司组葡萄糖诱导的短路电流显著增加,表明肠道中SGLT1的活性加强,PCR和Western Blot试验也相应地发现SGLT1蛋白表达的显著升高,而肠道中GLUT2和GLUT5在mRNA水平和蛋白表达水平无显著差异,而上述实验结果与他克莫司的剂量无关。 结论： 我们首次证实了肠道葡萄糖的吸收功能在他克莫司诱导DM的过程中发挥着一定的作用；肠道葡萄糖转运蛋白SGLT1与他克莫司相关性DM的发生密切相关；他克莫司可能是通过诱导肠道SGLT1表达和活性的上调,加强肠道对葡萄糖的吸收转运,继而机体血糖升高,糖耐量异常,甚至导致糖尿病的发生。
[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锛，

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