肾移植术后肺炎48例诊治分析

目的总结肾移植术后肺炎的诊治经验。方法回顾性分析48例肾移植术后肺炎患者的临床资料。结果 48例肾移植术后肺炎患者的发病时间为术后7d～2年3个月,其中术后1～4个月发病占75%(36/48)。重症肺炎12例(25%),4例(8%)在发病后迅速发展为急性呼吸窘迫综合征(ARDS)。肺炎患者早期临床症状不突出,发热是最早或主要表现,有时是唯一的表现,部分病例有干咳、咯黄白色黏液痰,混合细菌或真菌感染时痰量增多。肺部体征多不明显。移植3个月内以巨细胞病毒(CMV)肺炎为主,并常混合其他微生物感染,3个月后以细菌感染为主。影像学检查结果主要表现为间质性肺炎。2007年6月至2008年6月发生感染的患者,只给予麦考酚吗乙酯(MMF)或钙调磷酸酶抑制剂(CNI)减量。2008年6月以后,诊断肺部感染的患者,确诊后完全停用MMF和CNI减量。3例患者使用免疫球蛋白500mg/(kg.d)。酌情使用甲泼尼龙20mg或40mg,每日2次。在无确切临床病原学资料时,给予广谱抗生素、抗病毒联合治疗。病原学明确后,给予针对性抗感染治疗。43例(90%)治疗有效,3例转外院,1例并发脑出血放弃治疗,1例死于急性呼吸衰竭。结论肾移植受者肺炎起病大多隐匿,病程进展快。病原体以CMV和细菌为主,多表现为多重感染及重症肺炎。肾移植术后第1～4个月是肺炎发生和死亡的危险时期。及时调整机体免疫抑制状态,明确肺部感染的病原体,采用针对性抗感染治疗,有助于提高肾移植术后肺炎治愈率和降低病死率。

Analysis on diagnosis and treatment of pneumonia after renal transplantation:48 cases report

Objective To sum up the experiences of diagnosis and treatment of pneumonia after renal transplantation.Methods Clinical data of 48 cases with pneumonia after renal transplantation were retrospectively analyzed.Results The time of onset of pneumonia in 48 patients were ranging from 7 days to 2 years plus 3 months after transplantation.Almost 75% patients(36/48)developed pneumonia within one month to four months.Twelve cases developed severe pneumonia(25%),and 4 cases(8%)rapidly deteriorated into acute respiratory distress syndrome(ARDS)after the onset.The incipient symptoms of patients with pneumonia were not prominent,in which fever was primary manifestation,and sometimes was the only presentation.Some cases had a dry cough or tussiculation with yellow or white mucus phlegm,and the amount of expectoration increased when mixed with bacterial or fungal infections occurred.Signs on lung were often not prominent.The pneumonia was mainly cytomegalovirus(CMV)pneumonia within 3 months after transplantation,which often mixed with other microbial infections,and then bacterial infection was common after three months.Imaging findings were mainly interstitial pneumonia.The patients infected with pneumonia from June 2007 to June 2008 were only given mycophenolate mofetil(MMF)or reduced calcineurin inhibitors(CNI).MMF was withdrawn and CNI was reduced in the patients with pneumonia after June 2008 once the diagnosis was made.Immune globulin was administrated in three patients at a dosage of 500 mg/(kg·d).Methylprednisolone of 20 mg or 40 mg was used twice a day appropriately.The patients were treated with broad-spectrum antibiotics and antiviral combination therapy when there was no exact clinical etiology information.Specific anti-infection treatments were given after pathogens defined.Forty-three patients(90%)were effectively treated,three patients were transferred to other medical centers,one case abandon treatment due to cerebral hemorrhage,and one patient died of acute respiratory failure.Conclusions The onsets of pneumonia in renal transplantation recipients are often insidious and deteriorative rapidly.The patients suffered from CMV and bacterial infection mainly,or multiple infections and severe pneumonia.The first month to the fourth month after transplantation is a risky period of pneumonia onset and death.It is helpful to increase the cure rate of pneumonia and decrease mortality after renal transplantation by the immune-suppressive adjustment timely,pathogens detection and identification,as well as pathogen-directed anti-infective therapy.