肝移植术后两种极端糖尿病性昏迷的临床分析

doi:10.3877/cma.j.issn.1674-0793.2015.03.008

中华普通外科学文献(电子版) ›› 2015, Vol. 09 ›› Issue (03) : 211 -215. doi: 10.3877/cma.j.issn.1674-0793.2015.03.008

所属专题：文献；

论著

肝移植术后两种极端糖尿病性昏迷的临床分析

周健¹, 鞠卫强¹, 袁小鹏¹, 陈传宝¹, 焦兴元¹, 朱晓峰¹, 王东平¹, 何晓顺¹^,^†(

)

^1. 510080　广州，中山大学附属第一医院器官移植中心

收稿日期:2014-11-04 出版日期:2015-06-01
通信作者: 何晓顺
基金资助:
国家自然科学基金资助项目(81170448); 高等学校博士学科点专项科研基金新教师类资助课题(20130171120076); 国家科技支撑计划资助项目(2008BAI60B02); 教育部博士点-博导类资助项目(20100171110063)

Clinical analysis of two extreme diabetic comas after liver transplantation

Jian Zhou¹, Weiqiang Ju¹, Xiaopeng Yuan¹, Chuanbao Chen¹, Xingyuan Jiao¹, Xiaofeng Zhu¹, Dongping Wang¹, Xiaoshun He¹^,^†()

^1. Organ Transplantation Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China

Received:2014-11-04 Published:2015-06-01
Corresponding author: Xiaoshun He
About author:
Corresponding author: He Xiaoshun, Email: gdtrc@163.Com

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目的

探讨肝移植术后基于移植后糖尿病(PTDM)的高渗性非酮症高血糖昏迷(HNKHC)和酮症酸中毒(DKA)的诊治。

方法

回顾性分析本院2005年1月至2013年12月完成的805例肝移植患者资料,总结2例HNKHC和DKA患者的诊治经过。2例术前均无糖尿病史,肝移植术后均服用他克莫司和雷帕鸣抗排斥,1例女性患者曾给予甲强龙冲击治疗急性排斥反应,另1例男性患者入院后将他克莫司改为环孢素。

结果

例1诊断为HNKHC,例2诊断为DKA。2例经给予快速大量补液、小剂量胰岛素持续静脉滴注、纠正电解质及酸碱平衡紊乱等综合治疗,患者临床症状和体征消失,最终病愈出院。随访半年均未再发HNKHC、DKA和PTDM。

结论

肝移植术后HNKHC和DKA的发病率极低,但病情凶险,预后取决于准确的诊断和及时有效的综合治疗措施。无糖尿病史的肝移植患者术后昏迷应警惕HNKHC和DKA的发生。

关键词: 肝移植, 移植后糖尿病, 高渗性非酮症高血糖昏迷, 酮症酸中毒, 并发症, 诊治, 预后

Objective

To summarize the diagnosis and treatment of hyperosmolar non-ketotic hyperglycemic coma (HNKHC) and diabetic ketoacidosis (DKA) based on post-transplant diabetes mellitus (PTDM) after liver transplantation.

Methods

The data of 805 patients with liver transplantation in our hospital from January 2005 to December 2013 was reviewed retrospectively. Only 2 cases with HNKHC and DKA were found out. Both cases had no history of diabetes, and used tacrolimus and sirolimus for immunosuppression. After admission, the female had been given methylprednisolone impulse therapy for acute rejection, and tacrolimus was transformed into sirolimus for the male patient.

Results

The female patient was diagnosed as HNKHC, and the male patient suffered from DKA. After comprehensive treatment, such as rapid rehydration, small doses of insulin continuously intravenous dripping, correcting electrolyte and acid-base balance disorders, the symptoms and signs disappeared, and the patients is eventually discharged from the hospital. There was no recurrence on HNKHC, DKA and PTDM after 6 months follow-up.

Conclusions

The morbidity of post-liver transplantation HNKHC and DKA is extremely low, but they are extremely dangerous. The prognosis depends on accurate diagnosis and effective comprehensive treatment in a timely manner.

Key words: Liver transplantation, Post-transplant diabetes mellitus, Hyperosmolar non-ketotic hyperglycemic coma, Diabetic ketoacidosis, Complications, Diagnosis and treatment, Prognosis

表1 2例肝移植患者HNKHC和DKA实验室检查结果

项目	例1	例2	参考值
血糖（mmol／L）	33	23.6	2.9～6.0
尿糖	阳性（＋＋＋＋）	阳性（＋＋＋＋）	阴性
尿酮体	阴性	阳性（＋＋＋＋）	阴性
钾离子（mmol／L）	4.43	5.01	3.5～5.3
钠离子（mmol／L）	146	127	135～145
氯离子（mmol／L）	115	102	96～110
尿素氮（mmol／L）	14.5	8.1	2.9～8.6
肌酐（μmol／L）	109	98	53～115
渗透压（mOsm／L）	339	283	275～295
pH	7.35	7.12	7.35～7.45
HCO₃^－（mmol／L）	21	6.2	22～27

表1 2例肝移植患者HNKHC和DKA实验室检查结果

项目	例1	例2	参考值
血糖（mmol／L）	33	23.6	2.9～6.0
尿糖	阳性（＋＋＋＋）	阳性（＋＋＋＋）	阴性
尿酮体	阴性	阳性（＋＋＋＋）	阴性
钾离子（mmol／L）	4.43	5.01	3.5～5.3
钠离子（mmol／L）	146	127	135～145
氯离子（mmol／L）	115	102	96～110
尿素氮（mmol／L）	14.5	8.1	2.9～8.6
肌酐（μmol／L）	109	98	53～115
渗透压（mOsm／L）	339	283	275～295
pH	7.35	7.12	7.35～7.45
HCO₃^－（mmol／L）	21	6.2	22～27

图1 例1肝脏穿刺活组织病理学检查(HE染色,×10倍)

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Clinical analysis of two extreme diabetic comas after liver transplantation

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