INSERM U 859, Endocrinology and Metabolism, Endocrine Surgery and Nephrology Department, Lille University Hospital, 59037 Lille cedex, France.
Ann Endocrinol (Paris). 2009 Dec;70(6):443-8. doi: 10.1016/j.ando.2009.08.002. Epub 2009 Sep 9.
Type 1 diabetes are intrinsically unstable conditions because of the loss of both insulin secretion and glucose sensing. Guidelines to treat type 1 diabetes have become stricter since the Diabetes Control and Complications Trial (DCCT) results demonstrated the close relationship between microangiopathy and HbA1c levels, whereas the deleterious role of glucose variability on macroangiopathy has been more recently suspected. Therapeutic strategies first require the treatment of underlying organic causes of the brittleness whenever possible and, secondly, the optimization of insulin therapy using analogues, multiple injections and consideration of continuous subcutaneous insulin infusion. Alternative approaches may still be needed for the most severely affected patients, including islet transplantation. We propose islet after kidney transplantation in diabetic patients with end-stage kidney disease ineligible for double kidney-pancreas transplantation (i.e C peptide negative patients over 45 years of age or with severe macroangiopathy) if creatinine blood levels are stable below 20mg/l at least six months after kidney transplantation and steroid discontinuation. Islet transplantation alone is proposed to (1) C peptide negative diabetic patients, (2) aged 18-65 with a duration of diabetes of at least five years, (3) treated with intensive subcutaneous insulin therapy, but unable to obtain a glycated hemoglobin level below 7% without hypoglycemia and / or with brittleness and unpredictable hyper- and hypoglycemia altering quality of life, (4) with normal body weight (< 80 kg) and / or low daily insulin needs (the lower, the better), (5) with renal function close to normal (creatinine clearance above 60 ml/min with albuminuria lower than 300 mg/24 h), (6) with no desire for pregnancy in women. Currently and until more complete assessment of the 5-year overall benefit-risk ratio, islet transplantation remains a clinical research procedure. As already provided for other types of transplantation, and once recognized as a "routine" procedure, prioritization of enlisted patients for islet transplantation could be aided by the calculation of a score that should be determined by a multidisciplinary team.
1 型糖尿病本质上是不稳定的疾病，因为胰岛素分泌和葡萄糖感应都丧失了。自从糖尿病控制和并发症试验 (DCCT) 的结果表明微血管病变与 HbA1c 水平密切相关以来，治疗 1 型糖尿病的指南已经变得更加严格，而葡萄糖变异性对大血管病变的有害作用最近才被怀疑。治疗策略首先需要尽可能治疗脆性的潜在器质性原因，其次是使用类似物优化胰岛素治疗，多次注射并考虑连续皮下胰岛素输注。对于受影响最严重的患者，包括胰岛移植，可能仍需要替代方法。我们建议在患有终末期肾病且不符合双胰肾移植条件的糖尿病患者（即 C 肽阴性患者年龄大于 45 岁或有严重大血管病变）中，在肾移植后至少六个月且停用类固醇后，如果血肌酐水平稳定在 20mg/l 以下，进行胰岛移植。我们建议单独进行胰岛移植（1）C 肽阴性的糖尿病患者，（2）年龄在 18-65 岁之间，糖尿病病程至少五年，（3）接受强化皮下胰岛素治疗，但无法在不发生低血糖的情况下将糖化血红蛋白水平降至 7%以下，和/或脆性和不可预测的高血糖和低血糖改变生活质量，（4）体重正常（<80kg）和/或每日胰岛素需求量低（越低越好），（5）肾功能接近正常（肌酐清除率大于 60ml/min，白蛋白尿低于 300mg/24h），（6）女性无妊娠愿望。目前，在更全面评估 5 年整体获益风险比之前，胰岛移植仍然是一种临床研究程序。正如已经为其他类型的移植所规定的那样，一旦被认为是一种“常规”程序，就可以通过计算一个评分来帮助优先考虑列入胰岛移植的患者，这个评分应由多学科团队确定。
