Schiel Ralf, Heinrich Sebastian, Steiner Thomas, Ott Undine, Stein Günter
Department of Internal Medicine III, University of Jena Medical School, Jena, Germany.
Nephrol Dial Transplant. 2005 Mar;20(3):611-7. doi: 10.1093/ndt/gfh657. Epub 2005 Feb 2.
Compared with non-diabetic subjects, patients with type 2 diabetes and end-stage renal disease (ESRD) have seldom been selected for renal transplantation. It was the aim of this study to compare the long-term prognoses of the two groups of patients after transplantation and to identify factors associated with allograft rejection.
In a retrospective analysis, we studied all 333 consecutive patients who received a kidney transplant at our centre since 1992. Mean follow-up in 302 out of 333 patients (91%) was 3.3+/-1.5 (0.1-11.7) years. At the time of transplantation, diabetes mellitus (type 1, n=3; type 2, n=46) was known in 49 patients.
Patients with diabetes mellitus were older [patients without diabetes (n=253) vs patients with diabetes (n=49), 52.2+/-12.6 vs 58.8+/-13.1 years, respectively; P=0.002], but they had very good diabetes control [haemoglobin A1c (HbA1c) of patients with diabetes 6.3+/-0.9% vs those without diabetes 5.2+/-1.0%, P=0.03]. Even during their follow-up, patients with diabetes showed a tendency to further improvement (HbA1c for patients with diabetes 5.7+/-0.9% vs those without diabetes 5.5+/-0.9%, P=0.30). At the end of follow-up also, there were no differences between the groups with respect to blood pressure control (patients with diabetes 135.3+/-28.2/79.6+/-17.2 mmHg vs patients without diabetes 130.9+/-28.7/78.8+/-17.1 mmHg, P=0.33/0.78) and renal function (creatinine, 142.9+/-61.6 vs 151.8+/-68.2 micromol/l, P=0.38; glomerular filtration rate, 63.1+/-23.3 vs 59.1+/-24.0 ml/min/1.73 m(2), respectively, P=0.30). In total, 26 patients had acute transplant rejections [eight patients with diabetes (prevalence 16.3%) vs 18 patients without diabeteses (prevalence 7.1%), P=0.11]. In multivariate analysis, the most important parameter associated with the incidence of transplant rejections was the preceding fasting blood glucose (R2=0.044, beta=0.21, P=0.009). All other parameters included in the model (body mass index, time since transplantation, diabetes duration, immunosuppressive therapy, HbA1c and HLA mismatch) revealed no associations.
Following kidney transplantation, the prevalence of rejections in patients with diabetes mellitus is slightly but not significantly higher than in non-diabetic subjects. One of the most important risk factors seems to be fasting blood glucose. Hence, following renal transplantation, treatment strategies should focus not only on optimal immunosuppressive therapy and HLA matching, good HbA1c and blood pressure control, but also on maintaining near-normal fasting blood glucose levels.
与非糖尿病患者相比，2型糖尿病合并终末期肾病（ESRD）患者很少被选作肾移植对象。本研究旨在比较两组患者移植后的长期预后，并确定与移植肾排斥相关的因素。
在一项回顾性分析中，我们研究了自1992年以来在本中心接受肾移植的333例连续患者。333例患者中的302例（91%）平均随访时间为3.3±1.5（0.1 - 11.7）年。移植时，49例患者已知患有糖尿病（1型糖尿病3例，2型糖尿病46例）。
糖尿病患者年龄较大（非糖尿病患者253例与糖尿病患者49例，分别为52.2±12.6岁和58.8±13.1岁；P = 0.002），但他们的血糖控制良好（糖尿病患者糖化血红蛋白[HbA1c]为6.3±0.9%，非糖尿病患者为5.2±1.0%，P = 0.03）。即使在随访期间，糖尿病患者也有进一步改善的趋势（糖尿病患者HbA1c为5.7±0.9%，非糖尿病患者为5.5±0.9%，P = 0.30）。随访结束时，两组在血压控制（糖尿病患者135.3±28.2/79.6±17.2 mmHg，非糖尿病患者130.9±28.7/78.8±17.1 mmHg，P = 0.33/0.78）和肾功能（肌酐，分别为142.9±61.6与151.8±68.2 μmol/L，P = 0.38；肾小球滤过率，分别为63.1±23.3与59.1±24.0 ml/min/1.73 m²，P = 0.30）方面也无差异。共有26例患者发生急性移植排斥反应[8例糖尿病患者（发生率16.3%）与18例非糖尿病患者（发生率7.1%），P = 0.11]。多因素分析中，与移植排斥发生率相关的最重要参数是术前空腹血糖（R² = 0.044，β = 0.21，P = 0.009）。模型中纳入的所有其他参数（体重指数、移植后时间、糖尿病病程、免疫抑制治疗、HbA1c和HLA错配）均未显示相关性。
肾移植后，糖尿病患者的排斥发生率略高于非糖尿病患者，但差异无统计学意义。最重要的危险因素之一似乎是空腹血糖。因此，肾移植后，治疗策略不仅应注重优化免疫抑制治疗和HLA配型、良好的HbA1c和血压控制，还应注重维持空腹血糖水平接近正常。
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