肾移植术后结核的发病特点及诊断和治疗经验

目的 探讨肾移植受者术后结核的发病特点及诊断和治疗经验.方法 1991年1月至2007年4月间的2333例肾移植受者中有37例术后发生结核病,回顾性分析术后发生结核病受者的临床资料,总结肾移植术后结核的发病特点及其诊断和治疗经验.结果 肾移植受者术后结核的发病率为1.59%,发病时间为术后1～91个月,中位时间为术后7个月,22例集中在肾移植术后1年内;29例为肺部结核或肺部结核合并有肺外病灶,其他为肺外结核.肾移植受者术后结核病的表现以发热、咳嗽和咳痰为主;所有受者结核菌素纯化蛋白衍生物(PPD)皮试均为阴性;29例受者X线胸片检查有典型的结核表现;6例痰涂片查抗酸杆菌阳性,16例经病原学和/或病理学确诊.7例确诊合并有其它感染.抗结核治疗采用一线抗结核药物并调整或停用免疫抑制剂和激素,28例受者经治疗后好转,9例因治疗无效死亡.结论 肾移植受者术后早期结核的发病风险较高;X线胸片结合病原学和/或病理学检查是主要的确诊手段;抗结核治疗时,应加强对免疫抑制剂的监测,及时调整抗结核药和采取免疫抑制剂的个体化治疗方案.

Characteristics of post-operational tuberculosis in renal transplant recipients and experiences in diagnosis and treatment

Objective To investigate the characteristics of post-operational tuberculosis in renal transplant recipients and related experiences in diagnosis and management. Methods 2333 cases of re-nal transplantation in our center between Jan. 1991 and Apr. 2007 were retrospectively studied, and the 37 cases with definite diagnosis of post-operational tuberculosis were analyzed. The characteristics of the disease and experiences in diagnosis and management were summarized. Results The incidence of post-operational tuberculosis in renal transplant recipients was 1.59%. The median time of onset was 7 months post-transplant (1～91 months), with 22 cases suffering from tuberculosis within 1 year. Twenty-nine cases had pulmonary tuberculosis with or without extra-pulmonary loci, and 8 ca-ses had only extra-pulmonary foci. Fever, cough and expectoration were main clinical manifestations. Results of purified protein derivative of tuberculin skin test were all negative. Characteristic features were identified in chest films of 29 patients. Acid-fast bacilli were found in sputum smears from 6 pa-tients, and 16 other cases also got pathogenic or pathologic diagnosis. Seven patients were diagnosed having co-infections. First-line anti-tuberculosis drugs were used when immunosuppressants were ceased or modified. Twenty-eight patients recovered while 9 died. Conclusions Renal transplant re-cipients face a high risk of post-operational tuberculosis. Monitoring the serum concentration of immu-nosuppressant(s), personalizing anti-tuberculosis and immunosuppressive therapies are important.