探讨糖尿病对不同分级慢加急性肝衰竭(ACLF)肝移植受者术后生存率的影响。

回顾性分析美国移植受者科学登记处2017年1月1日至2017年12月31日因ACLF接受肝移植的1 144例受者临床资料。根据术前是否患有糖尿病，将其分为非糖尿病组(n＝927)和糖尿病组(n＝217)。采用Kaplan-Meier法评估生存率并绘制生存曲线，log-rank法用于比较组间差异。使用Cox比例风险模型分析预后因素。P<0.05为差异具有统计学意义。

糖尿病组与非糖尿病组受者年龄、体质指数(BMI)、基础肝脏疾病、终末期肝病模型评分、ACLF分级和术后住院时间差异均有统计学意义(U/χ²＝-6.290、-3.592、76.451、-2.959、8.150和-2.542，P均<0.05)。两组供者ABO血型差异有统计学意义(χ²＝8.463，P<0.05)。非糖尿病组受者肝移植术后死于多器官功能衰竭的比例(1.54%)低于糖尿病组受者(5.16%)，差异有统计学意义(χ²＝8.863，P<0.05)。两组受者死于移植物功能衰竭、心脑血管疾病、出血、感染、恶性肿瘤和其他疾病的比例差异均无统计学意义(P均>0.05)。截至2021年9月1日，非糖尿病组ACLF 1级肝移植受者术后1、2和3年生存率分别为93.1%、90.5%和88.7%，糖尿病组分别为93.8%、92.2%和92.2%，差异无统计学意义(χ²＝1.021，P>0.05)。非糖尿病组ACLF 2级肝移植受者术后1、2和3年生存率分别为93.6%、89.8%和88.4%，糖尿病组分别为96.8%、95.7%和90.3%，差异无统计学意义(χ²＝0.850，P>0.05)。非糖尿病组ACLF 3级肝移植受者术后1、2和3年生存率分别为91.5%、89.2%和87.5%，糖尿病组分别为80.0%、71.7%和71.7%，差异有统计学意义(χ²＝11.444，P<0.05)。Cox比例风险模型多因素分析结果显示，受者术前糖尿病、族裔(非裔)和BMI是影响ACLF 3级肝移植受者术后生存的独立预测因子(HR＝2.31、2.13和1.04，P均<0.05)。

糖尿病显著降低ACLF 3级肝移植受者术后生存率，但对于ACLF 1、2级受者无明显影响。因此在进行肝移植受者术前评估时，应该重视ACLF 3级受者是否合并糖尿病，以获得更好的预后。

To investigate the effect of diabetes mellitus on the survival rate of liver transplant recipients with different grades of acute-on-chronic liver failure (ACLF) after liver transplantation.

A retrospective study was carried out to investigate 1, 144 recipients with ACLF who underwent liver transplantation from January 1, 2017 to December 31, 2017 in the Scientific Registry of Transplant Recipients of American. According to whether they had diabetes before transplantation, the recipients were divided into two groups: non-diabetic group (n=927) and diabetic group (n=217). The survival rate was calculated by the Kaplan-Meier method and the survival curve was drawn, and then the log-rank test was used to compare the differences between two groups. The Cox proportional-hazards model was used to analyze the independent prognostic factors. A two-tailed P value <0.05 was considered statistically significant.

There were statistically significant differences in recipients′ age, body mass index (BMI), underlying liver disease, model for end-stage liver disease score, ACLF grade and postoperative hospital stay between diabetic and non-diabetic group (U/χ²=-6.290, -3.592, 76.451, -2.959, 8.150 and-2.542, all P <0.05). In terms of the donor characteristics, there was significant statistical difference in ABO blood type between the two groups (χ²=8.463, P<0.05). The proportion of recipients died from multiple organ failure after liver transplantation in the non-diabetic group (1.54%) was significantly lower than that in the diabetic group (5.16%) (χ²=8.863, P<0.05). There were no significant differences in terms of graft failure, cardio-cerebrovascular disease, hemorrhage, infection, malignant tumor and other diseases between the two groups (all P>0.05). The 1-, 2- and 3-year survival rates of ACLF1 recipients in the non-diabetic group were 93.1%, 90.5% and 88.7% by September 1, 2021, while those in the diabetic group were 93.8%, 92.2% and 92.2%, which had no statistically significance (χ²=1.021, P>0.05). The corresponding survival rates of ACLF2 recipients in non-diabetic group were 93.6%, 89.8% and 88.4% respectively, while those in diabetic group were 96.8%, 95.7% and 90.3%, which had no statistically significance (χ²=0.850, P>0.05). The corresponding survival rates of ACLF3 recipients in non-diabetic group were 91.5%, 89.2% and 87.5%, significantly better than those in diabetic group, which were 80.0%, 71.7% and 71.7% respectively (χ²=11.444, P<0.05). Multivariate analysis showed that recipient diabetes, ethnicity (African) and BMI were independent predictors of survival after liver transplantation in ACLF3 recipients (HR=2.31, 2.13 and 1.04, all P<0.05).

Diabetes can significantly reduce the survival rates of ACLF3 recipients after liver transplantation, but it has no significant effect on ACLF1 and ACLF2 recipients. It is important to assess the diabetes status in ACLF3 recipients in the recipient selection process, in order to achieve better post-transplant survival.