肾移植术后侵袭性肺曲霉菌病16例诊治分析

目的 探讨肾移植术后侵袭性肺曲霉菌病(IPA)的早期诊断与治疗.方法 回顾性分析16例肾移植术后IPA患者的临床资料.同期接受肾移植手术患者723例,IPA发生率为2.21%.16例患者中男7例,女9例,平均年龄42.9岁.12例应用免疫诱导治疗,其中5例为CD25单克隆抗体,7例为抗胸腺细胞球蛋白(ATG).6例感染出现前发生急性排斥反应,给予甲泼尼龙或ATG对症治疗.结果 IPA感染主要发生在肾移植术后3个月之内.发热是早期的主要症状.胸部高分辨率CT和支气管肺泡灌洗液培养是临床确诊的主要依据.二性霉素B(0.15～0.5 mg·kg~(-1)·d~(-1))可以作为治疗的首选药物,对早期病例疗效满意.7例患者死亡,病死率为43.75%.9例痊愈患者中8例在培养结果之前给予相应治疗.结论 肾移植术后IPA早期临床表现不典型,后期病死率较高.危险因素包括ATG、CD25单克隆抗体和大剂量皮质激素的应用,长期使用广谱抗生素以及环境因素等.早期诊断和治疗是决定预后的关键.

Early diagnosis and treatment of invasive pulmonary aspergiliosis following kidney transplantation

Objective To investigate the early diagnosis and treatment of invasive pulmonary aspergillosis (IPA) infection following kidney transplantation. Methods A retrospective analysis was carried out in 16 IPA patients after kidney transplantation from January 2002 to March 2008. There were 7 males and 9 females with a mean age of 42. 9 years old. The prevalence of IPA was 2. 21%. The induction therapy was given to 12 patients, 5 with CD25 monoclonal antibody and 7 with anti-thymocyte globulin (ATG). All 6 with acute pre-infection rejection were given the methylprednisolone sodium or ATG therapy. Results The intervals between transplantation and diagnosis were largely within 3 months.Persistent or intermittent fever was the main pest-operative symptom High resolution computed tomography (HRCT) of thorax and bronchoalveolar lavage fluid (BALF) for culture were the main evidence of clinical diagnosis. Amphotericin B(0. 15 -0. 5 mg· kg~(-1)· ~ d(-1) )might be the major treatment for IPA because of its satisfactory initial therapeutic effect. The mortality rate was 7/16 (43.75%). Of the 9 surviving patients,8 were treated before the test results were available. Conclusions The clinical symptoms of IPA following kidney transplantation are atypical in the early stage so that it is easy to misdiagnose and a high mortality rate ensues. Major risk factors for IPA include administration of ATG, CD25 monoclonal antibody and steroid boluses for prevention or treatment of allograft rejection; prolonged broad-spectrum antibiotic use after transplantation and environmental factors. Early diagnosis and empirical use of antifungal agents while waiting for a definitive diagnosis are imperative in achieving a favorable outcome.