优先治疗和普遍预防两种方案在肾移植术后巨细胞病毒感染中的疗效比较

目的 对比分析优先治疗和普遍预防两种方案在预防和治疗肾移植术后巨细胞病毒(CMV)感染中的疗效.方法 将64例肾移植受者随机分为优先治疗组(31例)和普遍预防组(33例).两组受者肾移植术后均接受14 d预防CMV感染的基础治疗(静脉滴注更昔洛韦250 mg/d).随后,普遍预防组受者继续口服更昔洛韦至术后90 d.优先治疗组中的高危受者继续口服更昔洛韦,直至术后90d;中危受者中仅CMV pp65抗原阳性受者静脉滴注更昔洛韦,至CMV pp65抗原转阴后停药,低危受者在基础治疗后不再使用更昔洛韦.研究期为6个月,此期间监测两组受者血清CMV pp65抗原和CMV DNA,以及血常规、尿常规、肝功能、肾功能和排斥反应发生情况.结果 普遍预防组15例(45.5%)出现CMV抗原血症,有5例(15.2%)的CMV DNA负荷量持续升高,其中3例(9.1%)发展成为CMV病.优先治疗组13例(41.9%)出现CMV抗原血症,有4例(12.9%)的CMV DNA负荷量持续升高,其中2例(6.5%)发展为CMV病.普遍预防组和优先治疗组急性排斥反应发生率分别为9.1%(3/33)和9.7%(3/31);其他感染总的发生率分别为15.2%(5/33)和19.4%(6/31),差异均无统计学意义(P>0.05).两组受者移植6个月时的存活率分别为97%和100%,其血肌酐的差异也无统计学意义(P>0.05).结论 根据受者CMV感染的风险状态采取优先治疗方案能有效预防和治疗肾移植术后CMV感染,其效果与普遍预防方案相当.

Efficacy of pre-emptive therapy vs universal prophylaxis to prevent and treat CMV infection alter kidney transplantation

Objective To analyze the effectiveness and safety of two clinical protocols of preemptive therapy and universal prophylaxis in preventing and treating cytomegalovirus (CMV) infection after kidney transplantation. Methods 64 recipients were divided into two groups randomly:universal prophylaxis group (group A, 33 cases) and pre-emptive group (group B, 31 cases). Patients in two groups were primitively treated by intravenous ganciclovir (250 mg/d) for 14 days after operation. Patients in group A were prophylactically treated by ganciclovir for 90 days after transplantation. Patients in group B were divided into high-risk subgroup (D~+ R~- or after ATG or OKT3 therapy), medium-risk subgroup (D~+ R~+/D~- R~+) and low-risk subgroup (D~- R~-), according to donors/recipients CMV serum condition before operation and ATG or OKT3 therapy condition.Patients in high-risk subgroup accepted ganciclovir universally until 90 days after operation. In lowrisk subgroup anti-virus prophylaxis was not used. In medium-risk subgroup the patients accepted ganciclovir only when CMV was positive in serum. PP65 and virus DNA loading were monitored in all patients up to 6 months posttransplant. CMV infection, acute rejection and complications were compared among all groups. Results There were 28 cases of CMV viremia (group A: 15 cases,45.5%; group B: 13 cases, 41.9%). CMV-DNA load was continuously increased in 9 cases (group A: 5 cases, 15.2%; group B: 4 cases, 12.9%), There were 5 cases of CMV infection (3 in group A and 2 in group B). The rate of acute rejection in groups A and B was 9.1% (3/33) and 9.7% (3/31) respectively. The rate of other infections in groups A and B was 15.2% (5/33) and 19.4% (6/31) respectively. Survival rate in groups A and B was 97% and 100% at the 6 th month. Other advert affairs included abnormal liver function, marrow suppression, diarrhea, etc. There was no statistically significant difference between groups A and B. Conclusion Pre-emptive therapy strategy based on the recipients' risk-factors can prevent CMV infection posttransplantation effectively.