肾移植受者耶氏肺孢子菌肺炎的临床及流行病学特征分析

目的 探讨肾移植受者耶氏肺孢子菌肺炎（PJP）的临床及流行病学特征。 方法 收集2021年7月至2021年12月68例肾移植受者的临床资料，根据肺部感染情况分为PJP组（11例）、普通肺部感染组（24例）、非肺炎组（33例）。分析肾移植术后PJP的发生及治疗情况，比较各组受者的基本特征及实验室指标，分析PJP患者的基因分型及传播图谱。 结果 64例肾移植受者中，11例明确诊断PJP，最常见的临床表现为体温升高、干咳伴进行性呼吸困难。所有患者胸部CT表现为双肺弥漫性间质炎症，磨玻璃样改变。确诊后，均口服复方磺胺甲唑3~4周。2例患者由于严重肺部感染和呼吸困难，使用无创呼吸机辅助呼吸，其余受者均使用鼻导管吸氧。1例患者出院时血清肌酐升高，发生移植肾失功，其余10例PJP受者移植肾功能正常，无受者死亡。与非肺炎组比较，PJP组排斥反应发生率较高，住院时间较长，淋巴细胞计数较少，淋巴细胞比例较低，C-反应蛋白、血清肌酐、乳酸脱氢酶水平较高，血清白蛋白水平较低，CD4+T细胞计数较少（均为P < 0.05）。与普通肺部感染组比较，PJP组淋巴细胞计数较少，淋巴细胞比例较低，CD4+T细胞计数较少，1, 3-β-D-葡聚糖（BDG）水平较高（均为P < 0.05）。在检测的12例样本中，10例样本未发现新的基因分型。考虑PJP主要存在2条传播链，以及2例独立传播个体。 结论 由于细胞免疫功能受损，肾移植受者更易感染耶式肺孢子菌（PJ），最常见的临床表现为体温升高、干咳伴进行性呼吸困难，部分同时出现头痛，乏力，胸部CT表现为双肺弥漫性间质炎症、磨玻璃样改变。PJ可通过呼吸道传播，在肾移植随访门诊存在小规模的PJP爆发可能，应及时做好预防工作。

Clinical and epidemiological features analysis of pneumocystis jirovecii pneumonia in kidney transplant recipients

Objective To investigate clinical and epidemiological features of pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients. Methods Clinical data of 68 kidney transplant recipients admitted from July, 2021 to December, 2021 were collected. All patients were divided into the PJP group (n=11), common pulmonary infection group (n=24) and non-pneumonia group (n=33) according to the status of pulmonary infection. The incidence and treatment of PJP after kidney transplantation were analyzed. Basic characteristics and laboratory parameters of the recipients were compared among all groups. The genotyping and transmission map of PJP patients were evaluated. Results Among 64 kidney transplant recipients, 11 cases were definitely diagnosed with PJP. The most common clinical manifestations included elevated body temperature, and dry cough complicated with progressive dyspnea. Chest CT scan showed diffuse interstitial inflammation and ground glass-like lesions of bilateral lungs in all patients. After diagnosis, all patients were orally given with compound sulfamethoxazole for 3-4 weeks. Two patients received non-invasive ventilator-assisted ventilation due to severe lung infection and dyspnea, and the remaining patients were given with nasal cannula oxygenation. One patient experienced elevated serum creatinine level upon discharge, and developed renal allograft failure. The remaining 10 recipients with PJP obtained normal renal allograft function, and no recipient died. Compared with the non-pneumonia group, the rejection rate was higher, the length of hospital stay was longer, the lymphocyte count was less, the lymphocyte proportion was lower, the levels of C-reactive protein, serum creatinine and lactate dehydrogenase were higher, and the levels of serum albumin was lower and CD4+T cell count was less in the PJP group (all P < 0.05). Compared with common pulmonary infection group, the lymphocyte count was less, the lymphocyte proportion was lower, the CD4+T cell count was less and 1, 3-β-D- glucan (BDG) level was higher in the PJP group (all P < 0.05). No new genotype was detected in 10 of the 12 testing samples. It was considered that PJP mainly depended on two transmission chains and two independent transmission individuals. Conclusions Kidney transplant recipients are prone to pneumocystis jirovecii (PJ) infection due to impaired cellular immune function. The most common clinical manifestations consist of elevated body temperature and dry cough complicated with progressive dyspnea, accompanied by headache and fatigue in partial patients. Chest CT scan shows diffuse interstitial inflammation and ground glass-like lesion of bilateral lungs. PJ may be transmitted through respiratory tract. Small-scale PJP might occur in the follow-up outpatient of kidney transplant recipients. Preventive measures should be delivered in a timely manner.