肾移植后肺部感染治疗中免疫抑制剂的应用

背景：肾移植后肺部感染病情进展快,重症肺炎死亡率高,对其进行早期诊断及治疗具有重要意义,但部分患者因免疫抑制剂的调整,出现移植肾功能受损。 目的：探讨肾移植后肺部感染治疗过程中免疫抑制剂的应用方案。 方法：回顾分析85例肺部感染的肾移植患者的临床资料。肺部感染发生于肾移植后1-6个月43例(其中2-4个月39例),6-12个月7例,12-24个月7例,24-36个月6例,大于36个月22例。根据患者病情,予以调整免疫抑制剂,联合应用小剂量激素抗炎保护移植肾功能,针对病原学抗感染,呼吸衰竭者给予呼吸机辅助呼吸,同时予以降温及营养支持等对症治疗。肺部感染早期减少或停用免疫抑制44例,进展期减少或调整免疫制剂19例,重症肺炎期停用免疫抑制剂5例,肺炎早期及进展期逐步调整免疫抑制15例,肺炎早期减量至重症肺炎停用免疫抑制剂2例。减少或停用免疫抑制剂3-51 d,平均10.7 d。 结果与结论：85例患者中治愈81例,死亡4例。4例死亡病例中,2例死于急性呼吸衰竭,2例死于多器官功能衰竭。治愈的81例中出现急性排异反应3例,移植肾功能受损6例。结果提示,肾移植后肺部感染短时间减少或停用免疫抑制剂,有利于提高治愈率,减少死亡率,及时恢复免疫制剂的应用,能有效保护移植肾功能,尤其是移植肾功能不全患者,肺部炎症进展控制住,及时恢复免疫抑制,在保护移植肾功能的意义更大。 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程全文链接：     

肾移植患者应用免疫抑制剂后的感染

30 cases of autopsies of patients who died after human renal allografts were studied. The incidence of infection was 60% and the lethal infectious complications amounted to 43%. The most common infectious agents were bacteria, including mycobacterium tuberculosis. In addition, some opportunistic agents, such as Cryptococcus, Aspergillus, mucormycosis, Pneumocystis carinii and cytomegalovirus were also found. All these patients had a history of receiving large dosage of immunosuppressive drugs such as cyclophosphamide, azathioprine, prednisone and dexamethasone after renal allografts. Pathological changes showed marked atrophy of lymphoid tissue and it was compatible with the histologic appearance of immunodeficiency. It is concluded that overuse of immunosuppressive drugs impairs the function of the immune system causing acquired immunodeficiency. Pathological features of lesions caused by the aforementioned infectious agents are also described in this paper.     

分期治疗肾移植后的重症肺部感染

背景：肾移植后肺部感染8%-16%发展为重症肺炎,是目前预防与治疗的难点,发生急性呼吸窘迫综合征概率高,死亡率高。 目的：回顾性分析肾移植后重症肺部感染的原因、临床特点及治疗经验。 方法：总结2007年7月至2010年3月解放军第四军医大学西京医院泌尿外科收治30例肾移植后肺部重症感染患者的临床资料,肾移植后肺部重症感染多发生于肾移植后6个月,在减少或停用免疫抑制剂用量同时,联合抗感染治疗。 结果与结论：30例患者中,10例死亡,发生上消化道出血6例、心功能衰竭5例、肾功能衰竭2例,3例放弃治疗。1例患者最长使用呼吸机辅助呼吸14 d后痊愈出院。肾移植后的肺部重症感染多为混合感染,作者针对其临床特点创新性地将病程分为3期,病情进展迅速,死亡率高。定期随访和规律复查,以及培养患者自我保护意识,早发现、早治疗能有效预防。及时调整免疫抑制剂用量、用法,根据临床检查经验性选用抗生素、抗真菌、抗病毒、抗结核类药物是治愈关键,根据病情早期使用呼吸机辅助呼吸能有效改善症状。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

肾移植术后肺部感染23例临床分析

目的分析肾移植术后肺部感染的临床特点和诊治措施。方法对23例肾移植术后并发肺部感染患者的临床资料进行回顾性分析。结果23例患者中巨细胞病毒感染9例,其中合并细菌感染2例。细菌感染7例,其中复合细菌感染1例,细菌合并真菌感染2例;肺部真菌感染4例。发生细菌败血症1例,真菌败血症1例。另3例未检出病原体。经综合治疗本组中22例治愈,1例死亡,为细菌合并真菌感染的重症肺部感染者,死亡原因为急性呼吸窘迫综合征。结论肾移植术后合并肺部感染病情复杂,死亡率较高;可靠的病原学诊断、及时而有效的综合治疗可提高其治愈率。     

持续高容量血液滤过在肾移植术后重症肺部感染中的应用

目的探讨应用持续高容量血液滤过（CHVHF）对肾移植术后重症肺部感染患者临床疗效的影响。方法 2003年5月至2011年4月在我院行肾移植术后并发重症肺部感染的51例患者分为A、B两组,A组采用综合治疗结合持续高容量血液滤过（CHVHF）措施,B组采用常规的综合救治措施,未进行过持续高容量血液滤过治疗;比较两组患者在治疗前后同一时段的体温、心率、平均动脉压、血气变化以及两组患者病死率的情况。结果与B组常规治疗后比较,A组患者在体温、平均动脉压、血氧分压以及酸碱平衡有更明显的改善（P〈0.05）。A组24例患者经治疗后22例痊愈出院2,例死亡,死亡率为8.33%;其中8例并发ARDS,有2例发展为MODS后死亡;B组27例患者经治疗后18例治愈出院,死亡9例,死亡率为33.3%;其中13例并发ARDS,有8例出现MODS,两组病死率差异有显著性（P〈0.05）。结论持续高容量血液滤过是能有效地缓解症状,清除炎症介质,有助于重建机体免疫内稳状态,并提供稳定的血流动力学及水电解质平衡,帮助患者渡过危险期,从而为重症感染的救治创造条件。     

甲泼尼龙治疗肾移植后的重症肺部感染

背景：肺部感染是肾移植后的主要感染并发症,其发病时间和发病率可能与肾移植后常规口服预防感染药物有关。目的：分析应用静脉甲泼尼龙替代口服醋酸泼尼松治疗肾移植后重症肺部感染效果。方法：回顾分析58例肾移植后重症肺部感染患者的临床资料。首先根据患者发病特点及肺部CT表现,应用广谱抗生素及抗真菌治疗,随后在得到病原学及真菌、病毒检测结果后进行针对性治疗,停用或调整免疫抑制剂用量和组合方案。58例患者中30例延续口服醋酸泼尼松,28例应用注射用甲泼尼龙琥珀酸钠替代口服醋酸泼尼松治疗。积极纠正低氧血症,并予支持治疗、免疫替代治疗。结果与结论：58例患者病原体检测阳性39例(67.2%),其中单纯细菌性肺炎7例,单纯真菌性肺炎4例,单纯巨细胞病毒感染3例,混合感染25例(多重细菌感染5例,真菌和细菌混合感染17例,真菌、细菌和巨细胞病毒混合感染3例)。甲泼尼龙组患者体温恢复正常时间、患者体温恢复正常时间均短于醋酸泼尼松组     (P均< 0.05),肌酐波动范围值小于醋酸泼尼松组(P < 0.05)。结果表明应用静脉甲泼尼龙可加快肺部炎症渗出吸收,缩短治疗时间。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

四联疗法治疗肾移植术后肺部感染15例治疗体会

目的 探讨肾移植术后肺部感染的治疗方法。方法 回顾性分析了15例尸体肾移植患者肺部感染的治疗经过。结果 结核2例行抗痨治疗，非结核性13例有9例采用四联治疗，全部治愈。另4例只选用了三联治疗，治愈1例。结论 四联疗法对于肾移植术后肺部感染的治疗有效且可以提高治愈率。     

肾移植术后并发肺部感染抢救成功1例

1　资料患者 ,女性 ,5 0岁 ,内蒙古阿拉善左旗人。肾移植术后3月余 ,发热 ,咳嗽 ,咳痰 ,气短半月 ,于 2 0 0 2 .0 8.0 2入院。3月前以“慢性肾小球肾炎 ,肾功不全 (尿毒症期 )”之诊断于 2 0 0 2 .0 4.2 5在西安交通大学第一附属医院行同种异体肾移植术 ,术中顺利 ,术后恢复良好 ,服用环孢素 +骁悉 +强的松三联免疫抑制剂 ,2 4h尿量 40 0 0 m l左右 ,多次复查肾功正常。 2 0 0 2 .0 7中旬无明确原因发热 ,体温波动于 37.2℃ -40℃ ,在当地按“上呼吸道感染”治疗 ,效果不佳。发热时间无规律 ,咳嗽咳痰 ,痰呈白色泡沫样 ,有时亦有脓性痰 ,量…     

菌苗对肺部感染抗感染免疫的疗效观察

菌苗对肺部感染抗感染免疫的疗效观察邱华，郑文辉，王福华，卢莱曾徐州市鼓楼医院变态反应科徐州矿务局职业病防治院关键词菌苗，抗感染免疫，肺部感染肺部感染的诊治目前仍是一个难题，尽管抗生素的研制日新月异，但对一些肺部感染的疗效却很有限，因此，应积极探索更有...     

肾移植受者422例病原菌感染分析

文题释义：肾移植术：将健康者的肾脏移植给有肾脏病变并丧失肾脏功能的患者。人体有左右2个肾脏,通常一个肾脏就可以支持正常的代谢需求,当慢性肾功能不全发展至终末期,可用肾移植方法治疗。肾移植因其供肾来源不同分为自体肾移植、同种异体肾移植和异种肾移植,习惯把同种异体肾移植简称为肾移植。病原菌感染：为了预防肾移植手术后的排斥反应,一般都要常规使用免疫抑制剂。使用免疫抑制剂的过程中会使机体的免疫功能下降,而导致患者容易发生细菌、病毒、真菌、原虫等感染,其中最为常见的是细菌感染性疾病的发生。革兰阴性菌分离率较高的分别为肺炎克雷伯菌、鲍曼不动杆菌和大肠埃希氏菌,革兰阳性菌分离率较高的分别为金黄色葡萄球菌、屎肠球菌和表皮葡萄球菌。肾移植受者感染的致病菌以革兰阴性菌为主,其中大多数病原菌对多种抗生素耐药率偏高。 背景：了解肾移植受者细菌感染的类型和特点,分析肾移植术后医院感染病原菌分布及细菌耐药性变迁趋势,旨在为临床医生提供精准有效的治疗和防控措施,达到对肾移植受者临床合理使用抗菌药物的目的。 目的：探讨肾移植受者术后医院感染流行病学特点。 方法：对2014年8月至2019年8月在郑州人民医院肾移植中心术后发生病原菌感染的422例受者进行调查,包括标本类型、病原菌分布、病原菌耐药率等。该临床研究的实施符合郑州人民医院对研究的相关伦理要求。结果与结论：①肾移植受者发生病原菌感染阳性标本主要来自于痰液、尿液和外周血;②422株病原菌中革兰阴性菌274株(占64.9%),革兰阳性菌75株(占17.8%),真菌73株(占17.3%),其中革兰阴性菌分离率较高的分别为肺炎克雷伯菌、鲍曼不动杆菌和大肠埃希氏菌,革兰阳性菌分离率较高的是金黄色葡萄球菌、屎肠球菌和表皮葡萄球菌;③革兰阴性菌对多数抗菌药物的耐药率均较高,革兰阳性菌除了对万古霉素、替考拉宁和利奈唑胺完全敏感外,对其他抗菌药物有不同程度的耐药率;④结果表明,肾移植受者感染的致病菌以革兰阴性菌为主,其中大多数病原菌对多种抗生素耐药率偏高,有的已产生多重耐药性,应加强对肾移植受者耐药性的监管,合理使用抗菌药物。 ORCID: 0000-0001-6861-6619(郭娟) 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

Single-center experience with tacrolimus-based immunosuppressive regimens in renal transplantation

The efficacy and safety of tacrolimus (FK506; Prograf) were determined in 28 adult kidney transplant patients (20 males and 8 females), aged 18-68 years (mean+/-S.D.: 46.9+/-4.03 years). Induction therapy was ATG-F (n=23), daclizumab (n=3), or none (n=2), and maintenance immunosuppression consisted of tacrolimus, combined with mycophenolate mofetil (MMF; n=26) or azathioprine (AZA; n=2) and prednisone (Pred). In seven patients, cyclosporine A microemulsion (Neoral) was replaced by tacrolimus for acute rejection (AR; three patients), slow graft function (SGF, two patients) and Neoral side effects (two patients). Acute rejection occurred in five patients (17.8%), three of whom were steroid-resistant treated with a second course of ATG-F. Infection occurred in 10 patients (35.7%) with a total of 15 infectious episodes, comprising bacterial (73%) and viral (27%) infections related to CMV. Other side effects related to tacrolimus were hypertension in four patients (14%) and post-transplantation hyperglycemia in nine patients (32%), three of whom required insulin therapy. In addition, hypercholesterolemia and hypertriglyceridemia occurred in six (21%) and eight patients (28.5%), respectively. The patient's hospital stay was 12.7+/-1.3 days (range: 8-24 days), and mean serum creatinine upon discharge, and at 1, 3 and 6 months following transplantation were: 2.1+/-0.5, 1.47+/-0.21, 1.41+/-0.53 and 1.23+/-0.11 mg/dl, respectively. The 6-month actuarial patient and graft survival rates were 100%. While tacrolimus is an effective calcineurin inhibitor for kidney transplantation (KT), severe acute rejection seen is related to highly sensitized patients, and the CMV infections noted were related to the presence of more CMV-negative recipients receiving kidneys from CMV-positive donors. Longer follow-up with a larger patient sample is needed to fully assess both the efficacy and safety of tacrolimus, including its metabolic effects.     

Cytomegalovirus infection after bone marrow transplantation: relation of pneumonia to postgrafting immunosuppressive treatment

Five fatal cases of CMV associated interstitial pneumonia occurred among 20 patients who had received allogenic bone marrow transplantation for acute leukemia or aplastic anaemia. This outcome was analysed in relation to prospectively obtained data on complement fixing (CF) and IgM anti-CMV titres and excretion of CMV in urine or pharynx. Altogether 16 patients had primary or reactivated CMV infection. Five of these patients receiving corticosteroids at the time of infection, at a dose of more than 1 mg/kg/day, failed to mount a significant CF antibody response, excreted large amounts of virus, and died from pneumonia, while the remaining 11 infected patients obtained high CF antibody titres and showed no severe symptoms related to CMV infection. IgM antibodies occurred simultaneously with CF antibodies in most cases of primary and reactivated infection. The results of the study suggest a protective role of the humoral immune response to CMV infection in BMT recipients, and passive immunisation with CMV hyperimmune globulin should be attempted especially in patients given additional immunosuppression with high dose corticosteroids.     

肾移植受者中CMV感染的检测

目的探讨巨细胞病毒(Cytomegalovirus,CMV)在肾移植受者中的感染状况.方法应用酶联免疫吸附试验(ELISA)、免疫组化方法及聚合酶链反应技术测定167例肾移植受者的CMV抗体、抗原和CMVDNA.结果肾移植受者的抗CMVIgG和抗CMVIgM阳性率分别为98.8%和1.8%;CMV抗原阳性细胞数平均为(3.2±3.1)/5×104WBC,阳性率为47.3%;CMVDNA的阳性率为50.9%.结论肾移植受者术后存在不同程度的CMV感染.临床上开展CMV抗体、抗原及核酸的检测对早期诊断肾移植受者术后CMV感染具有重要意义.     

Renal glycosuria in renal homograft recipients

Summary Transient renal glycosuria was observed in eight renal transplant patients during the recovery phase from initial tubular necrosis or acute rejection. In these subjects and three homograft recipients without glycosuria we performed glucose titration experiments. Three patients were found to have type A glycosuria, two had type B and three type C. The titration curve was normal in the three patients without glycosuria. In addition, most subjects presented with hypophosphataemia and hyperphosphaturia. Apart from a direct correlation between the point of splay of the glucose titration curves and the fractional clearance of phosphate, there was no clear-cut relationship between the handling of glucose and phosphorus. Mild hyperchloraemic acidosis was observed in six subjects, but this was unrelated to the type and grade of glycosuria. It is concluded that in homograft recipients the tubular alterations have a patchy and unpredictable distribution and may cause a variety of symptoms which do not necessarily occur in close association.Abbreviations GFR Glomerular filtration rate - C_PAH Sodium p-aminohippurate clearance - FF Filtration fraction - T_G Rate of glucose reabsorption - Tm_G Maximal rate of glucose reabsorption - C_Na Sodium clearance - P_Ca Serum calcium - P_{PO 4} Serum phosphate - C_{PO 4} Phosphate clearance - FE_{PO 4} Fractional phosphate excretion - PEI Phosphate excretion index - P_G Plasma glucose     

肾移植后并发肺结核感染的诊断与治疗

背景：肾移植后患者肺结核感染率较高,临床表现缺乏典型性,给诊断和治疗带来不便。 目的：总结同种异体肾移植后肺结核感染的诊断和治疗方法。 方法：回顾性分析2010年1月至2013年10月期间在南方医科大学珠江医院器官移植科诊断为肾移植后肺结核感染的13例患者相关临床诊断和治疗方法。 结果与结论：肾移植后并发肺结核感染的患者发病时间为肾移植后4-120个月,62%(8/13)患者于移植后18个月内发病。患者多以长时间发热为主要的临床表现,常以低热为首发表现。4例根据病史、影像学资料结合病原学阳性确诊,5例根据病史、影像学资料结合肺穿刺活检组织病理学阳性确诊,其余4例根据病史、影像学资料结合实验性抗结核治疗有效而做出临床诊断。患者肺部体征早期不明显,胸部CT有助于早期诊断和鉴别诊断。所有患者遵循早期、规律、全程、适量、联合原则进行抗结核治疗,疗程一般6-10个月,经给予联合抗结核感染药物、调整免疫抑制剂及五酯胶囊保肝等综合治疗,13例患者均存活,未出现死亡病例。2例由于感染早期未及时正规治疗,发生急性排斥反应,导致移植肾功能丧失而恢复血液透析,其余患者均痊愈出院,随访6个月肾功能正常(查血肌酐变化)。 说明肾移植后并发肺结核病的患者应早发现、早诊断、早治疗。CT引导下穿刺活检可作为肾移植后菌阴肺结核诊断和鉴别的有效且可行的手段。在调整免疫方案和抗结核治疗同时给予五酯胶囊可显著减少钙调神经蛋白抑制剂类药物剂量,减轻钙调神经蛋白抑制剂类药不良反应。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

Contrasting roles of macrophages and dendritic cells in controlling initial pulmonary Brucella infection

Control of pulmonary pathogens constitutes a challenging task as successful immune responses need to be mounted without damaging the lung parenchyma. Using immunofluorescence microscopy and flow cytometry, we analyzed in the mouse the initial innate immune response that follows intranasal inoculation of Brucella abortus. Bacteria were absent from parenchymal dendritic cells (DC) but present in alveolar macrophages in which they replicated. When the number of alveolar macrophages was reduced prior to Brucella infection, small numbers of pulmonary DC were infected and a massive recruitment of TNF-α- and iNOS-producing DC ensued. Coincidentally, Brucella disseminated to the lung-draining mediastinal lymph nodes (LN) where they replicated in both migratory DC and migratory alveolar macrophages. Together, these results demonstrate that alveolar macrophages are critical regulators of the initial innate immune response against Brucella within the lungs and show that pulmonary DC and alveolar macrophages play rather distinct roles in the control of microbial burden.     

Clostridium difficile infection among kidney transplant recipients: frequency,clinical presentation,and outcome

The objective of this study was to evaluate the frequency of Clostridium Difficile Infection (CDI) among kidney transplant recipients and describe the clinical picture in correlation with the presence of certain risk factors. We included kidney transplant recipients with a functioning graft, who were admitted during the period 1/2012‐12/2013, and patients with ESRD who were admitted to undergo Kidney Transplantation (KTx) from a deceased or a living donor in the same period. Patients were screened following clinical indication of gastrointestinal infection. CDI diagnosis was based on a positive stool sample for CD toxins and stool culture. Within the period 2012‐2013, we recorded 24 cases of CDI in 19 patients, accounting for a frequency of 5.4% of CDI in our population. In addition to diarrhea, 63.15% of the patients presented with fever, 31.25% with anorexia, while abdominal pain was a rare symptom (0.53%). None of the patients had ileus, bowel obstruction or megacolon. Fourteen patients (73.7%) had a history of recent exposure (15 days) to antimicrobial agents prior to the evolution of CDI symptoms. A relapse of the CDI infection was identified in five cases. CDI infection is a significant factor of morbidity in patients with KTx and should be considered in the clinical setting of diarrhea, even in cases with no exposure to antibiotic agents.