肾移植后重症肺炎11例临床分析

目的回顾性分析和总结肾移植后重症肺炎的诊断和治疗要点。方法自1999年1月至2003年12月期间共有172例成年患者在我院接受尸体供。肾同种异体肾移植手术,17例发生肺炎,对其中11例移植后的重症肺炎患者,应用经验性抗感染治疗,包括氨曲南、红霉素和更昔洛韦,并进一步根据病原学诊断选择敏感抗生素治疗。通过肺泡灌洗液(BAL)、痰及血标本的检查进行病原学诊断,包括细胞分类、病理学检查及细菌、真菌和病毒的培养等。减少免疫抑制剂用量。选择双水平气道正压通气(BiPAP)或机械辅助通气等缓解缺氧。结果172例。肾移植患者的肺炎发生率为9．9％(17／172),重症肺炎11例占65％,1例(9％)死亡。发热为最常见初发症状(82％,9／11),45％(5／11)同时存在发热、咳嗽和呼吸困难的典型重症肺炎三联征。BAL培养和血液培养获得病原诊断的阳性率分别为100％和46％。6例需BiPAP辅助通气,2例接受气管插管机械通气。结论BAL检查是获得病原学诊断的首选方法;及时减少免疫抑制剂剂量、应用适当的经验性抗生素治疗、选用恰当的辅助通气对于改善预后和降低死亡率甚为重要。

Analysis of eleven cases of severe pneumonia in kidney transplant recipients

Objective To analyse retrospectively the diagnosis and treatment of severe pneumonia in kidney transplantation recipients. Methods Between January 1999 and December 2003, 172 adult patients underwent kidney transplantation at our department. In all severe pneumonia cases,empirical therapy was initiated with aztreonam,erythromycin and ganciclovir.And the therapy was switched to proper antibiotics according to the results of sensitivity testing.Responsible pathogen was detected by study of BAL(bronco-alveolar-lavage),sputum and blood specimen. Analyses included cell differential count, cytopathologic examination and cultures for bacteria, fungi and viruses. The immunosuppressive therapy was drastically reduced.Hypoxia was relieved by BiPAP (Bi-level Positive Airway Pressure) or mechanical ventilation if necessary. Results Seveteen cases(9.9%) of pneumonia were observed in the 172 recipients,only 11(65%) patients expirenced severe pneumonia,1(9%)of them died. Fever was the most common symptom on presentation (82%). On presentation 46% of the patients presented with classical clinical syndrome of fever accompanied by cough and dyspnea. Positive rate of BAL and blood cluture were 100% and 46% respectively. BiPAP and mechanical ventilation were required in 6 and 2 cases respectively.(Conclusion BAL is preferred) for early detection of responsible pathogen. A combination of drastic reduction of the immunosuppressive regimen,implementation of appropriate empirical antibiotics, proper BiPAP or mechanical ventilation are important.