第1和第2型糖尿病患的同步腎臟-胰臟移植結果相似
作者：Jim Kling
出處：WebMD醫學新聞
May 12, 2010 (加州聖地牙哥) — 根據發表於2010年美國移植研討會的研究結果，第2型糖尿病與易變性糖尿症和末期腎臟病患者，接受同步腎臟及胰臟移植(simultaneous kidney and pancreas transplants，SKP)之後的存活率與第1型糖尿病患者相似。
根據「Organ Procurement and Transplantation Network/United Organ Sharing Network (UNOS)」資料庫，研究者檢視在2000至2007年間接受SKP移植的成人病患，他們根據引起末期腎病或末期胰臟疾病的糖尿病類型(第1或第2型)將病患分類，排除其他原因的SKP移植患者。
研究者共辨識6,650名SKP移植接受者，其中5,891人為第1型糖尿病，722人(11%)為第2型糖尿病，對於第1和第2型糖尿病，移植前平均透析期間分別是602天和706天；平均年紀分別是40和46歲；非裔美國人分別是13%和1.4%；男性分別有60.7%和68.6%；血漿腎素分析值高於20 ng/mL者分別有10.5%和15.7%；平均身體質量指數分別是24 kg/m2和25 kg/m2；冠狀動脈疾病者分別有10.2%和11.6%；有週邊血管疾病者分別為7.0%和6.5%。
在這兩個世代中，移植後併發症、腎臟與胰臟異體移植失敗、移植後4年病患死亡等結果相當，研究者校正了各種干擾因素。
對於第1和第2型糖尿病，追蹤中位數分別是1,326天和1,368天。接受移植的第2型糖尿病患比第1型糖尿病患者有較多的胰臟膀胱吻合(14 vs 17；P< .001)。對於第1和第2型糖尿病，移植物功能遲緩比率分別有7.8%和10.8%(P< .001)，1年時腎臟和胰臟同時排斥比率分別是11.6%和11.0%。
巴西Rio de Janeiro州立大學研究員Marcelo Sampaio醫師向Medscape Transplantation表示，第1型糖尿病患比較適合SPK移植，結果相當好，但是對於第2型糖尿病的結果有些爭論。
根據研究者指出，整體而言，第2型病患在SKP移植後傾向比第1型病患差，這是因為一些干擾因素，Sampaio醫師指出，第2型病患傾向較年長且有較多共病症，如血管疾病。
Sampaio醫師報告指出，因為病患數很少，難以將這些因素全部都校正，我們研究的是UNOS資料庫，所以我們可以納入較多的病患，如果我們描述全部的因素，發現結果並無差異。
根據Sampaio醫師表示，這是篇重要的研究，儘管第2型糖尿病患只佔約10%的SKP接受者，有末期腎病的第2型糖尿病患多於第1型糖尿病患者。
他表示，這個病患負擔隨著時間增加，有更多肥胖者，所以有更多糖尿病和腎衰竭合併第2型糖尿病者，最後，他們須依賴胰島素，如果開始使用胰島素，就可以考慮胰臟移植。
Sampaio醫師表示，如果你有一名第2型糖尿病患合併有末期腎病，且適合腎臟移植，你可以提供同步腎臟-胰臟移植給他，但是你必須注意病患的相關狀況，如果是年長、肥胖病患，風險就較高。病患屬於第1或第2型糖尿病並不重要—你必須注意相關狀況來幫助決定。
根據會議共同主持人、加州大學舊金山分校移植外科醫師Peter Stock博士表示，此篇研究的可能缺點之一是，使用UNOS資料來準確分辨第1和第2型接受者可能有些問題。Stock博士向Medscape Transplantation表示，那個資料庫有一些明顯的瑕疵。
該研究並未接受商業補助，Sampaio與 Stock皆宣告沒有相關財務關係。
2010年美國移植研討會：摘要242。發表於2010年5月3日。
Simultaneous Kidney-Pancreas Transplant Outcomes Similar for Type 1 and Type 2 Diabetics
By Jim Kling
Medscape Medical News
May 12, 2010 (San Diego, California) — Type?2 diabetics with brittle diabetes and end-stage renal disease have similar survival rates to type?1 diabetics after receiving simultaneous kidney and pancreas transplants (SKP), according to a study presented here at the American Transplant Congress 2010.
From the Organ Procurement and Transplantation Network/United Organ Sharing Network (UNOS) database, the researchers identified adult patients receiving SKP transplants between 2000 and 2007. They stratified patients on the basis of diabetes type (1 or 2) coded as causing end-stage renal disease or end-stage pancreatic disease. They excluded SKP recipients with other known causes.
The researchers identified 6650 SKP transplant recipients, of whom 5891 had type?1 and 722 (11%) had type?2 diabetes. For type?1 and type?2 diabetes, respectively, mean pretransplant dialysis dudation was 602 days and 706 days; mean age was 40 and 46 years; 13% and 1.4% were African American; 60.7% and 68.6% were male; 10.5% and 15.7% had a plasma renin assay level above 20?ng/mL; mean body mass index was 24?kg/m2 and 25 ?kg/m2; 10.2% and 11.6% ahd coronary artery disease; and 7.0% and 6.5% had peripheral vascular disease.
Between the 2 cohorts, the team compared posttransplant complications, kidney and pancreas allograft failure, and patient death in the 4 years after transplantation. The researchers adjusted for various confounders.
Median follow-up time was 1326 days for type?1 and 1368 days for type?2 diabetes. Recipients with type?2 diabetes experienced more pancreas anastomosis to the bladder than recipients with type?1 diabetes (14 vs 17; P?< .001). For type?1 and type?2 diabetes recipients, respectively, 7.8% and 10.8% had delayed graft function (P?< .001), and 1-year combined rejection of the kidney and pancreas was 11.6% and 11.0%.
SPK transplants have been perfected in type 1 diabetics, and the outcomes are very good, but there is some controversy about the outcomes for type 2 diabetics, Marcelo Sampaio, MD, research fellow at the State University of Rio de Janeiro in Brazil, who presented the research, told Medscape Transplantation.
Overall, type?2 patients tend to do worse after SKP transplants than type?1 recipients, but this is due to confounding factors, according to the researchers. Type?2 recipients tend to be older and have more comorbidities such, as vascular disease, Dr. Sampaio pointed out.
"Since the number of patients is very small, it's difficult to adjust for all these factors. We looked at the UNOS [database] so that we could include a larger number of patients. If we address all these factors, we find no difference in outcomes," Dr. Sampaio reported.
The research is important because although type 2 diabetics comprised only about 10% of SKD recipients, there were a lot more type?2 than type 1 diabetics with end-stage renal disease, according to Dr. Sampaio.
"This burden of patients is increasing with time," he said. "You have more obesity, so more diabetes and more people with kidney failure with [type?2] diabetes. Eventually they may be dependent on insulin, and if they're dependent on insulin you can [consider] a pancreas transplant."
"If you have a patient with type?2 diabetes that has end-stage renal disease and a kidney transplant is indicated, you can offer the patient a simultaneous kidney–pancreas transplant. But you have to look at the associated conditions with this patient. If it's a very old patient, or obese patient, the patient has more risk. It doesn't matter much if [the patient has] type 1 or type 2 [diabetes] — you have to look at associated conditions to help you decide," said Dr. Sampaio.
One potential drawback of the study is that there might be some issues with using the UNOS data to accurately define type?1 and type?2 recipients, according to Peter Stock, MD, PhD, a transplant surgeon at the University of California at San Francisco, who comoderated the session. "There are significant flaws in the database," Dr. Stock told Medscape Transplantation.
The study did not receive commercial support. Dr. Sampaio and Dr. Stock have disclosed no relevant financial relationships.
American Transplant Congress (ATC) 2010: Abstract?242. Presented May?3, 2010.
