短程小剂量伐昔洛韦预防肾移植术后巨细胞病毒肺炎

目的评价短程小剂量伐昔洛韦预防肾移植术后巨细胞病毒(CMV)肺炎的有效性和安全性。方法2002年12月-2005年12月在我中心进行的首次同种异体尸体肾移植的患者中,接受CMV-IgG血清阳性供体的患者共157例。将入选患者随机分为3组,A组予短程小剂量伐昔洛韦(0.6 g,po,bid×2 mo,此后0.3 g,po,bid×1 mo)预防性治疗;B组予长程伐昔洛韦(0.6 g,po,bid×6 mo)预防性治疗;C组为空白对照组,即不进行预防性治疗。前瞻性观察肾移植术后1 a内各组中CMV肺炎的发病情况,包括发病率、发病潜伏期、发病时间及人/肾存活率。结果CMV肺炎发病率A组为13.46%,B组为14.81%,C组为35.30%,A、B组均低于C组,差异有统计学意义(P<0.05),但A、B组间差异无统计学意义(P>0.05)。结论短程小剂量伐昔洛韦可以有效降低肾移植术后CMV肺炎的发病率,与长程伐昔洛韦预防性治疗相比具有相同预防效果,且同样安全。     

肾移植术后巨细胞病毒肺炎的影像学诊断

目的 探讨肾移植术后巨细胞病毒(CMV)肺炎的影像学诊断.方法 搜集15例肾移植术后CMV肺炎患者的临床、实验室以及胸片和CT检查资料,对其胸片和CT表现进行回顾性分析.结果 X线胸片早期表现基本正常5例,表现两肺纹理增多模糊4例,磨玻璃影和大片状实变影6例.CT表现有两肺弥漫分布的磨玻璃影15例,小结节影10例,斑片...     

肾移植术后巨细胞病毒肺炎的护理体会

肾移植术后长期应用免疫抑制剂使患者机体抵抗力下降,肺部感染机会增加。巨细胞病毒（CMV）感染是器官移植术后主要的严重并发症,也是造成肾移植患者死亡的主要原因,尤其是致命的间质性肺炎,会直接影响人、肾的存活。CMV肺炎起病急,发展快,治疗效果差,病死率极高。     

肾移植术后巨细胞病毒肺炎的诊断与治疗进展

巨细胞病毒(CMV)肺炎是肾移植术后常见及凶险的并发症,是由巨细胞病毒(CMV)引起的肺部感染,由于其早期症状隐匿,进展快,严重影响肾移植术后人/肾存活率。近年来,关于肾移植术后巨细胞病毒性肺炎肺炎的诊断及治疗方面出现大量研究,该文就巨细胞病毒(CMV)肺炎的诊断及治疗阐述如下。     

51例肾移植患者应用免疫抑制疗法并发肺炎的回顾性分析

目的:分析肾移植术后患者应用免疫抑制疗法并发肺炎的病因及临床特点。方法:收集1999年1月至2004年12月,北京4所医院收治的51例肾移植术后应用免疫抑制疗法并发肺炎患者的临床资料。肾移植术后患者均口服环孢素90～400mg/d,吗替麦考酚酯500～1500mg/d,泼尼松5～30mg/d,治疗3个月后逐渐减至维持剂量(环孢素血浓度100～200ng/ml)。分析肾移植术后并发肺炎患者的临床表现、病原学特点以及脏器功能不全的发生率和病死率。结果:51例患者以间质性肺炎为主要临床特征,表现为发热、干咳、胸部X线平片示片状模糊阴影。致病的病原体中细菌感染17例(33.33%),病毒感染7例(13.73%),卡氏肺孢子虫感染4例(7.84%),真菌感染1例(1.96%),病因不明8例(15.69%),混合感染14例(27.45%)。细菌培养显示以革兰阴性菌为多,占总菌株数的60%,革兰阳性菌占40%。并发成人型呼吸窘迫综合征11例(21.57%),弥散性血管内凝血4例(7.84%)。11例死亡(21.57!),治愈40例(78.43!)。结论:肺炎是肾移植患者应用免疫抑制疗法的严重并发症,早期诊断,予以抗感染治疗,并及时调整免疫抑制剂治疗方案,有利于减少肺炎的发生和提高治愈率。     

甲基强的松龙对肾移植术后巨细胞病毒肺炎机械通气呼吸力学影响

目的:探讨甲基强的松龙(MP)对肾移植术后巨细胞病毒(CMV)童癌肺炎机械通气怠者呼吸力学的影响.方法:分析我院收治的33例肾移植术后CMV重症肺炎机械通气患者临床实验资料,其中12例加用了MP治疗(MP组),15例未加用MP治疗(对照组),观察2组患者机械通气呼吸力学参数及氧合情况.结果:MP组吸气阻力(Ri)、气道峰压(PIP)、平台压(Pplat)、平均气道压(Pm)、肺内分流量(Qs/Qt)分别显著低于对照组(P<0.05,P<0.01),肺顺应性(Cs,Cd)及氧合指数(PaO2/FiO2)显著高于对照组(P<0.05,P<0.01).结论:MP治疗显著提高CMV重症肺炎患者肺顺应性,改善机械通气过程中呼吸力学特征及氧合情况,减少患者机械通气相关性肺损伤发生的可能性.     

机械通气治疗肾移植术后巨细胞病毒性肺炎合并急性呼吸窘迫综合征的疗效分析

目的探讨机械通气在治疗肾移植术后巨细胞病毒肺炎合并急性呼吸窘迫综合征中的价值。方法14例肾移植术后CMV肺炎合并ARDS患者,在早期抗病毒治疗、调整免疫抑制方案等综合治疗措施的基础上,全部给予机械通气治疗,观察其疗效。结果14例患者中9例有效,有效率为64.2%,5例死亡,死亡率为35.8%。14例患者治疗后2小时、12小时、24小时、48小时及72小时的动脉血氧分压、氧合指数及呼吸频率较治疗前均有改善(均为P<0.01)。结论机械通气可在短时间内纠正缺氧保证氧合,为治疗原发病赢得时间,在治疗肾移植后CMV合并ARDS患者的治疗中具有重要的意义。     

肾移植术后巨细胞病毒性肺炎的诊断与治疗

目的 探讨肾移植术后并发巨细胞病毒(CMV)肺炎的诊断与治疗。方法 对56例肾移植患中，术后并发巨细胞病毒性肺炎的临床资料进行回顾性分析。结果 56例中并发巨细胞病毒性肺炎7例(12．5％)，平均发生时间在术后99．1天。均以发热、咳嗽起病，胸部X线检查均为间质性肺炎改变。7例中CMV-IgM阳性3例，CMV DNA阳性7例，pp65抗原阳性5例。病情进展迅速，3例合并急性呼吸窘迫综合征。3例痊愈，3例死亡，1例放弃治疗。结论 肾移植术后并发CMV肺炎病情凶险，应加强CMV监测。联合应用CMVpp65抗原血症检测及CMV DNA检测有利于早期诊断和治疗。早期使用以更昔洛韦抗病毒为主的综合治疗，调整免疫抑制剂用量、吸氧、无创辅助呼吸、加强全身支持治疗可提高治愈率。     

骨髓移植术后巨细胞病毒肺炎患者体内CD11b的表达及临床意义

目的探讨骨髓移植术后巨细胞病毒(Human cytomegalovirus,CMV)肺炎患者体内中性粒细胞表面黏附分子CD11b的表达及诊断价值。方法收集我院2000年11月至2016年10月收治的骨髓移植术后患者60例,依据CMV-pp65抗原检测结果分组,同时选择我院门诊体检健康者33例为对照组。采用流式细胞仪分别检测上述各组的CD11b表达情况,并计算CD11b在诊断骨髓移植术后CMV肺炎过程中的受试者工作曲线(ROC曲线)。结果本研究高活动性CMV感染组17例(28.33%),CMV活动性感染组29例(48.33%),阴性对照组(未感染CMV)14例(23.34%)。高活动性CMV感染组CD11b表达率为39.11%±4.98%,与CMV活动性感染组、阴性对照组和健康对照组比较,差异均有统计学意义(P<0.05)。CD11b在诊断骨髓移植术后高活动性CMV感染的最佳临界值表达率为43.47%,敏感度为100%,特异度为59.47%,ROC曲线下面积为0.631;CD11b诊断骨髓移植术后CMV肺炎活动性感染者的最佳临界值表达率为69.34%,敏感度为86.92%,特异度为98.81%,ROC曲线下面积为0.987。结论骨髓移植术后CMV肺炎患者体内CD11b表达下调,可作为鉴别诊断骨髓移植术后CMV肺炎活动性感染的实验室依据。     

136例婴幼儿巨细胞病毒感染临床分析

目的探讨由巨细胞病毒(CMV)感染所致婴幼儿的临床特征。方法回顾136例婴幼儿巨细胞病毒感染的临床资料进行分析。结果本院136例婴幼儿CMV感染,肺炎86例占63.2%,肝炎22例占16.2%。结论婴幼儿CMV感染以肺炎、肝炎为主,早期检测有利于诊断和治疗。     

更昔洛韦预防肾移植术后巨细胞病毒感染

目的:观察国产更昔洛韦预防肾移植术后巨细胞病毒(CMV)感染的效果,并与伐昔洛韦比较。方法:60例肾移植病人,男性38例,女性22例,年龄(38±s12)a,随机分为2组。均于术后d7～10抗病毒治疗,更昔洛韦组予更昔洛韦250mg加入100mL氯化钠注射液,iv,gtt,bid;伐昔洛韦组予伐昔洛韦300mg,po,bid,疗程均为2wk。观察术后6mo内的CMV感染情况,检测CMV血清学指标。结果:术后3mo的CMV抗原阳性率和抗CMVIgM抗体阳性率,更昔洛韦组均低于伐昔洛韦组(P<0.05),而抗CMVIgG抗体阳性率,2组间无显著差异(P>0.05)。发生CMV上呼吸道感染10例,更昔洛韦组2例(7%),伐昔洛韦组8例(27%),P<0.05;发生CMV肺炎4例,更昔洛韦组1例(3%),伐昔洛韦组3例(10%),P>0.05。呼吸系统感染发生率更昔洛韦组低于伐昔洛韦组(10%vs37%,P<0.05),且发生时间延迟。结论:术后静脉注射更昔洛韦较口服伐昔洛韦能更好地预防肾移植术后CMV感染的发生。     

Oral valganciclovir: a new option for treatment of cytomegalovirus infection and disease in immunocompromised hosts

Immunocompromised hosts are at increased risk of cytomegalovirus (CMV) infection and serious CMV disease. CMV infection is an important cause of morbidity among patients infected with HIV and after solid organ transplantation (SOT) and may cause life-threatening disease in allogeneic stem cell transplant (SCT) recipients. The introduction into clinical use of potent antiviral compounds and of rapid detection assays for CMV during the past two decades has allowed development of strategies for the prevention and treatment of disease caused by CMV in these groups of immunocompromised patients. At present, the antiviral drugs ganciclovir, foscarnet and cidofovir are commonly used in the treatment of CMV infection and disease. However, these agents have a poor oral bioavailability and, for systemic use, require iv. administration for most indications. Valganciclovir is an oral prodrug of ganciclovir, with a 10-fold greater bioavailability than oral ganciclovir. Studies of the pharmacokinetics of valganciclovir among HIV-infected CMV-seropositive patients and liver transplant recipients suggest that this oral compound has the potential to replace both oral and iv. ganciclovir in many situations if it is shown to be as efficacious and safe as those ganciclovir formulations in immunodeficient patients. In the first part of this review, currently established approaches to the management of CMV infection and disease in SCT and SOT recipients and HIV-infected patients are discussed to highlight possible indications for future valganciclovir use; in the second part, data from human studies of valganciclovir are presented.     

注射用喷昔洛韦在预防肾移植患者病毒感染中的应用

目的:评价注射用喷昔洛韦在预防肾移植患者病毒感染中的疗效与安全性。方法:对25例早期肾移植患者应用注射用喷昔洛韦预防病毒感染的临床资料进行回顾性分析。结果:实验组20例无任何感染的临床表现和实验室阳性结果,1例术后6周口周单纯疱疹感染,病毒感染发病率为4%(1/25);1例术后4周口腔溃疡并明确诊断为白念珠菌感染,1例术后2月肺部细菌感染,1例术后2月肺部曲霉菌感染,1例术后7周有右大腿局部皮肤刺痛,但未见明显水泡,3 d后自愈。对照组25例在术后6周和8周各出现1例带状疱疹,在院外用静脉阿昔洛韦治愈;术后85 d出现1例CMV肺炎,用缬更昔洛韦治愈,病毒感染发病率为12%(3/25);术后75 d和92 d各出现1例洛菲不动杆菌性肺炎和光滑念珠菌性肺炎,收住院后均治愈。用药前后,2组患者的免疫抑制剂浓度,肝肾功能,血常规化验等均平稳,前后比较在统计上相差不显著(P>0.05)。术后5周和3月分别查血CMV-DNA,实验组均为阴性;对照组在3月的复查中发现2例CMV-DNA弱阳性,故两组的病毒感染发生率相差显著,实验组为4%(1/25),对照组实际为20%(5/25),(P<0.05)。结论:注射用喷昔洛韦在预防肾移植患者病毒感染中是有效和安全的。     

Strategies for managing cytomegalovirus in transplant recipients

Importance of the field: Cytomegalovirus (CMV) is the most important pathogen that affects transplant recipients, by directly causing clinical disease and by indirectly reducing patient and allograft survival.

Areas covered in this review: This review provides a brief overview of the direct and indirect effects of CMV disease and the traditional and newly described factors that increase the risk of disease after transplantation. Newly acquired data in the diagnostics, prevention and treatment of CMV infection are discussed, with emphasis on guidelines for management as recently endorsed by the American Society of Transplantation and the Transplantation Society.

What the reader will gain: The reader will gain up-to-date insights into the contemporary management of CMV after solid organ transplantation. Practical aspects of its diagnosis, prevention and treatment are discussed. Emerging concerns of late-onset CMV disease and antiviral resistance are also highlighted to emphasize the need to optimize CMV-prevention strategies.

Take home message: Prevention of CMV disease is an important goal in the management of solid organ transplant recipients. The efficacy of CMV prevention should be measured not only by the significant reduction in CMV incidence but, as importantly, by the improvement in long-term allograft and patient survival.     

Cytomegalovirus infection in solid organ transplantation: economic implications

Cytomegalovirus (CMV) is a pathogen, commonly encountered in the recipients of solid organ transplantation and is an important cause of morbidity and mortality in these patients. CMV infection and disease have been shown to increase the cost of care in transplant recipients and several different strategies of prevention have been shown to be effective in clinical trials. A systematic review of published information on the economic impact of CMV in solid organ transplantation was performed; both clinical- and decision-analysis-based studies were reviewed. Clinical studies have shown that CMV infection and disease is associated with increased length of hospital stay and overall costs. Decision-analysis-based studies suggest that in general, antiviral chemoprophylaxis against CMV in transplant recipients is a cost-effective intervention compared with other established healthcare interventions such as strategies for colorectal cancer screening. Prophylaxis with oral or parenteral ganciclovir is probably the most cost-effective strategy; however, restricting prophylaxis to high-risk groups (such as donor seropositive/recipient seronegative status and the use of an antilymphocyte antibody) or chemoprophylaxis for an extended period does not improve cost effectiveness. Pre-emptive therapy is an evolving strategy for prevention of CMV disease in transplant recipients and is rapidly gaining in popularity. Well-designed trials incorporating prospective cost data and comparing pre-emptive therapy versus conventional antiviral prophylaxis are needed to establish the superiority of one strategy over the other.     

我院2013—2015年肾移植患者术后感染的流行病学研究

目的 了解肾移植患者术后院内感染发病情况、流行病学分布、病原菌种类和预后情况,为制定防控措施提供依据.方法 监测我院2013年1月—2015年12月行肾移植手术共576例,观察术后发生院内感染的情况.结果 2013—2015年肾移植术后院内感染50例(8.68%),感染部位主要为肺部、泌尿系和血液感染,病原体有革兰阴性杆菌、革兰阳性球菌、真菌和巨细胞病毒.感染患者给予相应的抗菌、抗病毒治疗,大部分患者治愈,2例死亡.结论 肾移植术后感染以肺部感染为主,预防肾移植术后肺部感染,尤其是控制真菌性肺炎的发生,是降低肾移植术后感染发生率的关键.