肾移植术后重症肺炎的诊治经验

目的:探讨肾移植术后重症肺炎的诊断和治疗.方法:对52例肾移植术后并发重症肺炎患者的临床资料进行回顾性分析.结合临床症状、胸片及胸部CT确诊后,给予撤除免疫抑制剂、经验性抗感染药物、甲基强的松龙等治疗,同时防治继发感染,加强营养支持,必要时配合使用呼吸机.并通过支气管肺泡灌洗液(BAL)、痰、咽拭子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.结果: 877例肾移植患者中有76例患者出现肺炎,发生率为8.7%,其中重症肺炎52例,占68%.发热和胸闷是最常见初发症状(100%),但仅有19%的患者(10/52)具有明显的咳嗽、咳痰症状.BAL的病原体检出率为69%(31/45),血培养结合痰、咽拭子培养病原体检出率为38%(20/52).经过治疗,39例治疗有效,其中治愈34例,好转5例,死亡13例,有效率75%.结论:重症肺炎多发于肾移植术后6月以内,是危及肾移植受者生命的严重并发症,应早期应用BAL检查进行病原学诊断,及时撤除免疫抑制剂、经验性抗感染药物和小剂量甲基强的松龙的应用是救治成功的关键.

Experience in diagnosis and treatment of severe pneumonitis following renal transplantation

AIM: To explore the diagnosis and treatment of severe pneumonitis following renal transplantation. METHODS: A retrospective analysis was made on the clinical data of 52 renal transplant recipients with severe pneumonitis, which were diagnosed by the clinical symptoms, chest X-ray and CT. The treatments included withdrawal of immunosuppressive agents, administration of empirical anti-infective drugs and methylprednisolone, prevention and treatment of secondary infection, reinforcement of nutritional support and use of respirator if necessary. Simultaneously responsible pathogen was detected by analyses of BAL (broncho-alveolar lavage), sputum and blood specimen, with regard to cell differential count, cytopathologic examination and cultures for bacteria, fungi and viruses. RESULTS: Seventy-six cases (8.7%) of pneumonia were found in the 877 renal transplant vecipients, which included 52 (68%) patients with severe pneumonia. Fever and chest distress were the most common initial symptoms of severe pneumonia (100%). However, obvious cough and expectoration were observed only in 10 patients (19%). Positive rate of BAL alone and of blood culture combined with pharynx swab and sputum were 69%(31/45) and 38%(20/52), respectively. The treatments were effective in 39 with 34 being cured and 5 being improved; 13 of 52 finally died. The effective rate was 75%. CONCLUSION: Severe pneumonitis is a most common life-threatening complication in renal transplant recipient, which mostly occurs during 6 months after renal transplantation. BAL should be performed early for detection of responsible pathogen. The key points of successful treatment involve withdrawal of immunosuppressive agents, administration of empirical anti-infective drugs and methylprednisolone.