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.     

Prevalence and manifestations of tuberculosis in renal transplant recipients: a single-center experience in Thailand

This retrospective review presented the prevalence and manifestations of tuberculosis among renal transplant recipients in our center between 1987 and mid 2007. The prevalence of tuberculosis was 5/151 (3.3%) recipients with a median age of 49 years (range = 38-55). The median time of diagnosis after transplantation was 23 months (range = 1-47). All five patients had pulmonary tuberculosis. None developed extrapulmonary infection. Presenting symptoms were fever (60%), productive cough (80%), weight loss (40%), and hemoptysis (20%). One patient had non-parathyroid-related hypercalcemia. Cyclosporine dosage needed to be increased in all patients. Two subjects who experienced side effects of hepatitis and/or jaundice from rifampicin were switched to second-line drugs. Infection with Mycobacterial tuberculosis is a not uncommon problem in renal transplant recipients especially in endemic areas. Tuberculosis must be excluded for immunosuppressed patients with clinical or radiological suspicion.     

Mycobacterium tuberculosis infection in renal transplant recipients

Mycobacterium tuberculosis (TB) infection is more common among renal allograft recipients compared with the general population due to immunosuppression. The epidemiological risk in a country is an important determinant of transplant TB after transplantation. We retrospectively analyzed 283 renal transplant recipients who underwent renal transplantation between 1990 and 2004. We evaluated the incidence, patient and disease characteristics, prognosis, and outcome of TB infection. Tuberculosis developed in 10 (seven men and three women of mean age of 41+/-9 years) among 283 patients (3.1%). All patients were culture-positive for M tuberculosis. Although pulmonary TB was the most common presentation in the general population, 50% of patients in the study group developed extrapulmonary TB. The mean elapsed time from renal transplantation was 38 months. Three patients (1%) developed TB in the first year after transplantation. All patients were treated with a quartet of anti-TB therapy. One patient developed isoniazid-related reversible hepatotoxicity. No acute allograft rejection occurred during the anti-TB therapy. Two patients (20%) with pulmonary TB died due to dissemination of the disease. In conclusion, extrapulmonary presentations of TB are more common among renal transplant recipients with the increased risk of mortality.     

Tuberculosis in renal transplant recipients

BACKGROUND: Tuberculosis is an important cause of morbidity and mortality in renal transplant recipients, but there are insufficient data regarding the efficacy and complications of therapy and of INH prophylaxis. METHODS: This study is a retrospective review of the records of 880 renal transplant recipients in two centers in Turkey. RESULTS: Tuberculosis developed in 36 patients (4.1%) at posttransplant 3-111 months, of which 28 were successfully treated. Eight patients (22.2%) died of tuberculosis or complications of anti-tuberculosis therapy. Use of rifampin necessitated a mean of 2-fold increase in the cyclosporine dose, but no allograft rejection occurred due to inadequate cyclosporine levels. Hepatotoxicity developed in eight patients during treatment, two of whom died due to hepatic failure. No risk factor, including age, gender, renal dysfunction, hepatitis C, or past hepatitis B infection, was found to be associated with development of hepatic toxicity. A subgroup of 36 patients with a past history of or radiographic findings suggesting inactive tuberculosis, was considered to be at high risk for developing active disease, of whom 23 were given isoniazid (INH) prophylaxis. None versus 1 of 13 (7.7%) of cases with and without INH prophylaxis, respectively, developed active disease (P>0.05). None of the patients receiving INH had hepatic toxicity or needed modification of cyclosporine dose. CONCLUSIONS: These data show that tuberculosis has a high prevalence in transplant recipients, that it can effectively be treated using rifampin-containing antituberculosis drugs with a close follow-up of serum cyclosporine levels, and that INH prophylaxis is safe but more experience is needed to define the target population.     

Rapamycin in lung transplantation

INTRODUCTION: Rapamycin (RAPA) is a powerful immunosuppressant that also acts as an antiproliferative, which, therefore, could be useful in the treatment and prevention of bronchiolitis obliterans (BOS) in lung transplant recipients. We sought to report our experiences with RAPA in lung transplant patients with BOS that has not responded to the administration of other drugs. MATERIALS AND METHODS: We performed a retrospective analysis of the clinical characteristics, pulmonary function, and complications among patients with BOS who received RAPA. RESULTS: RAPA was administered to 11 patients, three single-lung transplant and eight bilateral lung transplant recipients, of whom five were women and six men, of mean age 48 years (26 to 65). The median posttransplant time to the initiation of RAPA for progressive BOS was 32 months (4 to 69) with a posttreatment follow-up of 15 months (3 to 34). RAPA was administered to all patients in association with a calcineurin inhibitor (tacrolimus in seven cases, and cyclosporine in four and steroids. Eight of the 11 patients (72%) with progressive deterioration of pulmonary function showed improved and/or stabilized FEV1 figures after introduction of RAPA. Eight patients developed adverse effects, which were possibly related to RAPA, leading to treatment withdrawal in two cases. The most frequent adverse effects were infections among 6 of the 12 cases, and myelosuppression in three. CONCLUSIONS: RAPA may be useful to stabilize or improve pulmonary function in patients with BOS. Nevertheless, it was necessary for patients to be closely monitored so that possible adverse effects, and especially infections, may be detected early.     

Mycobacterium tuberculosis infection in solid organ transplant recipients: experience from a single center in China

OBJECTIVE: We sought to explore the prevalence, clinical manifestations, diagnostic procedures, and treatment of tuberculosis (TB) after solid organ transplantation. PATIENTS AND METHODS: In this study, we retrospectively analyzed data of 1947 renal transplant recipients and 85 liver transplant recipients. RESULTS: TB developed in 28 organ transplant recipients with a prevalence of 1.38% (28/2032). The median interval between transplantation and development of TB was 32 months (range, 1-142 months). Mycobacterium tuberculosis isolation, histologic signs of caseating granulomas, and TB-DNA detection directly supported the diagnosis in 10 (35.71%), 7 (25.00%), and 5 (17.86%) patients, respectively. In addition, 6 patients (21.43%) highly suspected of TB infection received tentative antituberculosis treatment with favorable responses. Most renal transplant recipients (22/25; 78.57%) received isoniazid, rifampicin (or rifabutin), and ethambutal (or pyrazinamide) for a mean duration of 10 months (range, 6-14 months). Three liver transplant recipients received a different protocol: isoniazid, rifabutin, ethambutal, and ofloxacin for 3 months; then isoniazid and rifabutin for 6 months. Upon follow-up, 8 subjects (28.57%) died; 5 of the deaths were related to TB. During the antituberculosis therapy, toxic hepatitis was seen in 12 patients (42.86%); cyclosporine levels decreased in 15 patients (53.57%); and allograft rejection developed in 6 of them. CONCLUSIONS: The peak incidences of TB in liver and kidney transplantations are in the first year and after the first year posttransplantation, respectively. Response to antituberculosis treatment should be considered to make a diagnosis among patients highly suspected of TB infections. Except in special circumstances, antituberculosis treatment protocols including isoniazid and rifampicin for about 10 months seem significantly effective and tolerable for non-liver transplant patients. Fluoroquinolones should be emphasized in posttransplantation TB treatment.     

Tuberculosis after heart transplantation: twenty years of experience in a single center in Taiwan

The incidence of tuberculosis is slightly higher among heart transplantation cases than in the general population in Taiwan. Tuberculosis shows a high mortality rate ranging from 22% to 31% in transplant recipients. From October 1987 to October 2007, we performed 315 heart transplantations. Clinical records were reviewed for demographic data, clinical presentation, treatment, and outcome. Tuberculosis was diagnosed by cultures of any body sample in association with compatible symptoms and signs. Mortality was related to tuberculosis if there was evidence of active tuberculosis at the time of death and no other etiology accounted for death. Ten patients who had received heart transplants were diagnosed as tuberculosis. There were seven pulmonary lesions and seven extrapulmonary lesions. Treatment consisted of isoniazid, rifampin, ethambutol, pyrazinamide, streptomycin, ciprofloxacin, and levofloxacin. Seven patients completed the antituberculosis treatment: the median treatment duration was 1 year. Three patients developed hepatitis. There was no tuberculosis-related mortality. Ten out of a total of 315 patients (3.17%) represented a tuberculosis rate higher than that reported for the general Taiwan population (67/100,000). This high mortality of infection may be completely treated by a combination of at least three drugs except pyrzinamide because of side effects and tolerance.     

Impact of banff borderline acute rejection among renal allograft recipients

OBJECTIVE: This study was performed to determine the incidence, treatment, and outcomes of Banff borderline acute rejection (AR) among renal transplant recipients. PATIENTS AND METHODS: We reviewed the courses of adult kidney transplant recipients with borderline AR on clinically indicated biopsies performed at our center from January 2003 to July 2006. Patients with complete transplant records and serum creatinine values at 6 and 12 months were included in this study. The primary outcome measures were serum creatinine values at 1 to 2 weeks after treatment, and at 6 and 12 months after graft biopsy. RESULTS: Among 428 renal graft biopsies, borderline AR was observed in 100 cases (23%). Patients were maintained on the same immunosuppression. The 86 who had complete data were included in the study. Seventy-eight percent of the patients received treatment with 3 days of methylprednisolone, while 22% were untreated. Mean serum creatinine values in the treated group were 2.9 +/- 1.0, 2.6 +/- 2.5, and 3.0 +/- 2.9 mg/dL at the time of biopsy, and at 6 and 12 months thereafter, respectively. In the untreated group, mean serum creatinine values were 2.2 +/- 1.0, 1.9 +/- 0.8, and 2.3 +/- 1.2 mg/dL during biopsy, and at 6 and 12 months thereafter, respectively. There was no significant difference in the serum creatinine at any of the measured time points between the 2 groups. Twelve patients had repeat renal graft biopsies which showed AR (6%), chronic allograft nephropathy (2.4%), and borderline changes (3.8%). Nine of the patients in the treated group eventually developed graft loss. CONCLUSIONS: Patients with borderline AR showed a progressive increase in serum creatinine over time. They should be followed closely; immunosuppression may need to be intensified.     

Tuberculosis in Thai renal transplant recipients: a 15-year experience

OBJECTIVE: Tuberculosis (TB) is a leading cause of morbidity and mortality in renal transplant recipients, especially in developing countries. Its incidence and characteristics remain unknown in Thai recipients. This study sought to determine the incidence, characteristics, risk factors, and outcome of TB in Thailand. METHODS: We retrospectively reviewed case records of all renal transplant recipients from 1992 to 2007 to record demographic information, transplant characteristics, median time to diagnosis of TB, and outcomes. RESULTS: Among 270 recipients, 9 (3.84%, 95% confidence interval [CI] 1.18%-5.49%) developed TB. Their median age was 40 years (range = 23-62 years) and median time from transplantation to diagnosis was 36 months (range = 4-115 months). Although pulmonary TB was the most common form (56%), 2 patients (22%) developed extrapulmonary disease. Disseminated TB occurred in 2 patients (22%). The diagnosis was made on respiratory specimen cultures in 3 cases (33.3%) and body fluid cultures in 3 (33.3%). Five patients (55.6%) were successfully treated with four-drug combination therapy. Two of the other subjects (22.2%) who received triple therapy were noncompliant, succumbing to graft failure and sepsis. Blood group AB (odds ratio [OR] 10.95, 95% CI 1.57-76.60) and use of tacrolimus rescue therapy (OR 9.68, 95% CI 2.13-43.94) were associated with an elevated risk of TB. CONCLUSION: TB is common among Thai renal transplant recipients with an incidence 27 times higher than that of the general Thai population. The extrapulmonary form in particular occurs more frequently with an increased risk of mortality.     

Voriconazole in the treatment of invasive aspergillosis in kidney transplant recipients

BACKGROUND: Aspergillosis and other invasive mold infections are severe complications in immunosuppressed patients, and in renal transplant patients it is the most common cause of systemic fungal disease with an incidence ranging from 0.4% to 2.4% with a high mortality of 56% to 100%. We present our experience with voriconazole in a population of kidney transplant recipients with invasive aspergillosis. PATIENTS AND METHODS: From January 2002 to December 2005, 245 kidney transplantations were performed. RESULTS: Four patients (1.6%) presented with clinical and laboratory findings of invasive aspergillosis. Three patients presented with pulmonary aspergillosis, while one patient presented with pulmonary and ocular aspergillosis. All patients underwent a therapy with voriconazole 200 mg twice a day, in combination with caspofungin in one patient. All patients are alive, with no clinical recurrence of aspergillosis at a median follow-up of 13 months. One patient lost her graft due to discontinuation of immunosuppression. CONCLUSIONS: Voriconazole is a potent and well-tolerated antifungal drug that is extremely efficacious in the treatment of invasive aspergillosis in kidney transplant recipients. A careful monitoring of immunosuppressive drugs should be considered to avoid nephrotoxicity.     

Prevalence of anemia in renal transplant patients: results from MOST, an observational trial

INTRODUCTION: Anemia is one of the most common complications of chronic renal disease. However, the incidence or prevalence of anemia in kidney transplant recipients has not been well studied. The aim of this study was to assess the prevalence of anemia in renal transplant in early and late posttransplant period and the influence of drugs (immunosuppressive and antihypertensive). METHODS: MOST is an observational, prospective trial of renal transplant receiving cyclosporine-based immunosuppressive regimen under condition of normal practice in de novo or maintenance recipients. We analyzed the Spanish data from 397 de novo recipients and 2102 maintenance recipients. RESULTS: In maintenance recipients mean hemoglobin levels were 12.8 +/- 1.6 g/dL (13.2 +/- 1.7 in men and 12 +/- 1.4 in women); 22.73% of men and 20.19% of women were found to be anemic. There was a significant correlation between hemoglobin and graft function (r = .14, P < .0001). The percentage of patients with anemia increased with the severity of chronic renal disease according to the KDOQI classification. Therapy with mycophenolate mofetil was also associated with a higher likehood of anemia as compared with other immunosuppressive therapies (azathioprine or sirolimus). There were no differences with angiotensin-converting enzyme inhibitors or ARB II. In de novo patients postransplant anemia was a frequent complication during the first 3 to 6 months. In patients with delayed graft function the recovery of anemia was slower. CONCLUSION: The prevalence of anemia in transplant recipients was remarkably high, especially in the early postransplant period, and appeared associated with impaired renal function and with immunosuppressive treatment.     

Tuberculosis in renal transplant recipients on various immunosuppressive regimens.

BACKGROUND: Mycophenolate mofetil (MMF) and tacrolimus (TAC) are more potent than conventional immunosuppressive drugs, i.e. azathioprine, cyclosporin and prednisolone, and may be associated with an increase in the incidence of infections in the post-transplantation (post-tx) period. The aim of this study was to determine if the use of either or both of MMF and TAC for immunosuppression in renal transplant recipients increases the prevalence or modifies the clinical presentation of tuberculosis (TB), when compared with conventional therapy. METHODS: The medical records of 443 adult patients who received a kidney transplant between 1994 and 2002 were reviewed retrospectively. Comparisons were made between patients who had conventional immunosuppressive treatments (cyclosporin, azathioprine and prednisolone) or an alternative regimen (including MMF, TAC or both). RESULTS: We found 20 patients (4.5%) to have post-tx TB. There were 13 cases of TB (age 38.9+/-10.6 years) among 328 patients who received conventional immunosuppressants (group I) (4.0%) and seven cases (age 24.2+/-7.4 years) among 115 (6.1%) who received an alternative immunosuppressive regimen (group II) (P>0.05). The patients in group II were younger than the patients in group I (P = 0.002). A significantly higher number of patients in group II developed TB within the first 6 months post-tx (P = 0.042). However, there was no significant difference between the two groups regarding clinical and radiographic presentations or outcomes. CONCLUSIONS: Immunosuppression with TAC or MMF is associated with the development of TB earlier in the post-tx period and in younger patients.     

Tuberculosis in Chronic Renal Failure in Jeddah

The incidence of tuberculosis is still high in many developing countries and immunocompromised patients with chronic renal failure requiring haemodialysis have been reported to be at increased risk of developing tuberculosis. In this study 80 patients with chronic renal failure were followed up for a period of three years and were carefully monitored for the development of tuberculosis. Mantoux test, chest radiograph and sputum were performed at the beginning of the study and every six months thereafter. At the end of the study period, 8 (10%) of the patients had developed tuberculosis, confirming the high incidence of tuberculosis in this group of patients. No particular underlying renal disease was associated with the development of tuberculosis. Four patients developed pulmonary tuberculosis, 2 renal tuberculosis and one each with cervical tuberculous lymphadenitis and tuberculous meningitis. All patients responded satisfactorily to anti-tuberculosis therapy as diagnosis was established early. The delayed recognition of tuberculosis and therefore a delay in the initiation of effective treatment is not only detrimental to the patient but also results in a potentially profound impact on public health. We recommend routine screening for tuberculosis in patients with chronic renal failure presenting at Renal Units and tuberculosis chemoprophylaxis for those undergoing haemodialysis, particularly in countries with high incidence of tuberculosis.     

Adjuvant treatment of refractory lung transplant rejection with extracorporeal photopheresis.

BACKGROUND: Extracorporeal photopheresis is an immunomodulatory technique in which a patient's leukocytes are exposed to ultraviolet-A light after pretreatment with 8-methoxypsoralen (methoxsalen). There have been few reports describing the use of extracorporeal photopheresis in lung transplant recipients. METHODS: We reviewed our experience using extracorporeal photopheresis in 8 lung transplant recipients since 1992. All 8 patients had progressively decreasing graft function and 7 were in bronchiolitis obliterans syndrome grade 3 before the initiation of photopheresis. One patient had undergone a second transplant operation for obliterative bronchiolitis. Two patients had a pretransplantation diagnosis of chronic obstructive pulmonary disease, 1 alpha1-antitrypsin deficiency, 1 cystic fibrosis, 1 bronchiectasis, 1 idiopathic pulmonary fibrosis, and 2 primary pulmonary hypertension. Before refractory rejection developed, all patients had been treated with 3-drug immunosuppression and anti-T-cell therapy. The median time from transplantation to the start of extracorporeal photopheresis was 16.5 months and the median number of treatments was 6. RESULTS: The condition of 5 of 8 patients subjectively improved after extracorporeal photopheresis therapy. In these 5 patients photopheresis was associated with stabilization of the forced expiratory volume in 1 second. In 2 patients there was histologic reversal of rejection after photopheresis. With a median follow-up of 36 months, 7 patients are alive and well. Three patients required retransplantation at a median of 21 months after completion of the treatments. Four patients have remained in stable condition after photopheresis. There were no complications related to extracorporeal photopheresis. CONCLUSION: We believe that this treatment is a safe option for patients with refractory lung allograft rejection when increased immunosuppression is contraindicated or ineffective.     

Tuberculosis after renal transplantation: experience of one Turkish centre

Background: In this study, renal transplant recipients with tuberculosis of different organs, were retrospectively analysed with respect to prevalence, outcome and drug toxicity. Patients and methods: In 520 patients, 22 (4.2%) tuberculosis of various organs was diagnosed. The time interval between transplantation and diagnosis of tuberculosis was 44.4±33.5 (range 3-111) months. In 18 (82%) of the patients, tuberculosis was detected after the first year of transplantation. The most common form was pleuro/pulmonary tuberculosis (54%), and other localizations included jejunum, liver, bone, and urogenital tract. Results: Sixteen of the 22 patients responded favourably to the treatment and maintain excellent allograft function, whereas six patients (27.2%) died. Toxic hepatitis was seen in four (18%) patients, and one case was complicated with acute hepatocellular failure due to isoniazide (INH). However, of the 23 patients at risk of tuberculosis who had had INH prophylaxis for 1 year, neither tuberculosis, nor hepatotoxicity was observed. Conclusion: Tuberculosis is a common infection of renal transplant recipients in developing countries. The peak incidence is after the first year of transplantation and mortality is considerable. Hepatoxicity is a considerable risk of treatment, possibly as a result of additive toxic effects of immunosuppressive drugs.     

Successful management of two heart transplant recipients with mycobacterial pulmonary infections

We report two cases of pulmonary tuberculosis in heart transplant recipients: a 46-year-old man with pulmonary tuberculosis due to Mycobacterium tuberculosis and a 64-year-old man with nontuberculous mycobacterial infection with pulmonary infiltrates due to Mycobacterium xenopi. The time intervals from transplantation to diagnosis were 3 and 4 years, respectively. The patient with tuberculosis underwent standard treatment with isoniazid, rifampin, ethambutol, and pyrazinamide. The patient with the nontuberculous mycobacterial infection received treatment with clarithromycin and ciprofloxacin for 18 months in addition to rifampin for the first 3 months. Both patients responded well to treatment. No recurrences were observed during follow-up. The interactions between antibiotic treatment and cyclosporine therapy should be observed closely in organ transplant recipients, requiring frequent level determinations and dosing changes.     

Tuberculosis in southern Chinese renal‐transplant recipients

Abstract: Objectives: To analyze the characteristics of tuberculosis (TB) in Southern Chinese renal transplant recipients, and summarize the corresponding experiences in diagnosis and management. Method: Retrospectively study 41 documented post‐transplant TB cases out of the 2333 patients who received kidney transplantation in the First Affiliated Hospital of Sun Yat‐sen University between Jan. 1991 and Apr. 2007. Results: TB in the post‐renal‐transplant population in Southern China displayed the following characteristics: (i) high incidence within a short time after transplantation, the median interval between renal transplantation and diagnosis of TB was 8 months (range: 1‐156 months) and 56.1% were diagnosed within the first year post‐transplant; (ii) high prevalence (51.2%) of extra‐pulmonary tuberculosis; (iii) high co‐infection rate (19.5%), pathogens included candida albicans, pseudomonas aeruginosa, staphylococcus aureus, Acinetobacter haemolyticus and cytomegalovirus; (iv) fever (82.9%), cough (56.1%) and sputum (39.0%) are the most common clinical manifestations; (v) purified protein derivative of tuberculin (PPD) skin test had little diagnostic value in this group with a negative result in all 41 cases; (vi) acute rejection (29.3%) and liver function damage (17.1%) were the main adverse effects of anti‐tuberculosis chemotherapy; (vii) mortality of patients with post‐transplant tuberculosis reached up to 22.0%. Conclusions: Chinese renal transplant recipients face a high risk of TB because of their immuno‐compromised state and epidemiological prevalence of the disease. Therefore, attention should be given to this differential diagnosis in clinical practice. Balancing the benefits and disadvantages of anti‐tuberculosis chemotherapy is of importance for this specific population.     

Seroprevalence of human herpes virus-8 in renal transplant recipients: a single center study from Iran

The long-term risk of malignancy among renal transplant patients is approximately 100 times that of the general population. Unlike North America and many European countries, Kaposi's sarcoma is the most common cancer after renal transplantation in most series reported from the Middle East. Human herpes virus-8 (HHV-8) has a major role in the pathogenesis of Kaposi's sarcoma. The risk of posttransplantation Kaposi's sarcoma is 23% to 28% among seropositive patients compared with 0.7% among seronegative patients. This study was conducted to investigate the seroprevalence of HHV-8 among our transplant recipients. The sera from 100 renal transplant recipients were examined by indirect immunofluorescence against latent nuclear antigen. Sixty of 100 patients were males. The overall mean age was 41.1 years (range, 17-74 years) with 17 patients older than 55 years. The mean transplantation duration was 41.6 months. Twenty-five percent of patients were seropositive for HHV-8. There was statistically significant seropositivity for HHV-8 among recipients older than 55 years (P=.02). Eight of 17 patients older than 55 years were seropositive (47%), whereas 17/83 patients younger than 55 years were seropositive (20%). There were no significant differences for HHV-8 seropositivity regarding sex, transplantation duration, and immunosuppressive regimen, including dose of immunosuppressive drugs and cyclosporine blood levels. In this study, we showed seropositivity for HHV-8 among a significant percentage of our renal transplant recipients, a finding which may render them at risk to develop Kaposi's sarcoma. Seropositive and seronegative patients were followed for 16 months. One HHV-8 seropositive patient (1/25) developed Kaposi's sarcoma.     

HLA半相合骨髓移植后并发肺结核四例

目的 探讨HLA半相合骨髓移植后并发肺结核的诊断与治疗.方法 4例白血病患者,采用阿糖胞苷、环磷酰胺及直线加速器全身照射进行预处理,然后接受HLA半相合未去T淋巴细胞骨髓移植.移植后采用环孢素A、短程甲氨蝶呤、霉酚酸酯、抗CD25单克隆抗体和抗胸腺细胞球蛋白预防移植物抗宿主病.4例均获造血重建.4例分别于移植后150 d、120 d、47 d和43 d出现高热,伴轻度咳嗽,痰少,或干咳无痰;肺部CT检查,均有异常改变,但无特征性;结核菌素试验及结核菌素抗体试验均呈阴性反应;既往均无结核病史及接触史.例1经开胸肺活检病理诊断为增殖性肺结核,另3例抗结核治疗有效,确立肺结核诊断.采用利福平、链霉素、吡嗪酰胺及异烟肼抗痨治疗9～12个月.结果 4例患者经抗结核治疗,体温下降,肺部病灶明显缩小、吸收,除1例因急性移植物抗宿主病死亡外,其余3例患者均存活.治疗期间,维持原免疫抑制方案,1例血环孢素A浓度一度较低,增加CsA剂量后恢复至正常范围.结论 HLA半相合骨髓移植后并发的结核感染,其临床表现不典型,肺部CT表现无特征性,应注意与其它感染相鉴别,抗结核治疗有效.     

肾移植术后重症肺炎28例报告

目的总结肾移植术后重症肺炎的诊断和治疗体会。方法回顾性分析28例肾移植术后重症肺炎患者的临床资料。结果重症肺炎的发生时间为术后25d至术后10个月,平均3．5个月,其中术后1～6个月发病26例,占总数的93％。临床表现为高热伴进行性呼吸困难。该组经反复检测病原微生物培养、巨细胞病毒（CMV）脱氧核糖核酸（DNA）、CMV免疫球蛋白（Ig）M,24例获得病原学证据（混合性感染20例,单纯细菌感染4例）,4例未获得病原学证据。治疗前25例（90％）患者CD4^＋、CD8^＋T淋巴细胞计数减少。治疗方案：停用免疫抑制剂,应用免疫增强剂,联合抗细菌、抗病毒、抗真菌,机械通气,营养支持等综合治疗。22例（79％）治愈,其中20例移植。肾功能正常,2例血清肌酐轻度升高。6例死于急性呼吸窘迫综合征（ARDS）,均为CD4^＋、CD8^＋ T淋巴细胞计数持续低水平者,其中2例为细菌＋真菌＋CMV感染者,1例为细菌＋CMV感染者,3例为未明确病原菌患者。结论肾移植术后重症肺炎临床表现缺乏特异性,病原学诊断对指导治疗有重要意义,因此需反复进行病原微生物培养、CMVDNA、CMV IgM检测。促进免疫功能恢复、联合应用抗病原微生物药物、对症和支持治疗是成功救治的关键。