米卡芬净致急性溶血反应并肾衰竭

1例76岁男性患者因肺部感染给予米卡芬净50 mg加入0.9%氯化钠注射液100 ml静脉滴注，1次/d。首次用药后90 min，患者出现寒战、发热，尿色呈暗褐色。实验室检查：外周血白细胞计数25.2×10^9/L，血红蛋白73 g/L，血小板计数179×10^9/L，尿素氮6.4 mmol/L，肌酐96μmol/L，降钙素原14.13 ng/ml，凝血酶原时间17 s，活化部分凝血活酶时间44 s，D-二聚体8.7 mg/L；尿白细胞（＋＋＋），隐血（＋＋＋），尿胆原（＋＋＋），酮体（＋＋＋），尿蛋白（＋＋＋），亚硝酸盐阳性。考虑为急性溶血反应。停用米卡芬净，静脉注射甲泼尼龙40 mg，并给予水化利尿和碱化尿液治疗。患者尿量在4 h内由100-150 ml/h减至10-20 ml/h，尿色呈酱油样。次日复查：白细胞计数18.6×10^9/L，红细胞计数1.7×10^12/L，血红蛋白57 g/L，血小板计数116×10^9/L，网织红细胞0.05；白蛋白25 g/L，间接胆红素20.4μmol/L，天冬氨酸转氨酶108 U/L，丙氨酸转氨酶42 U/L，尿素氮17.9 mmol/L，肌酐230μmol/L，直接抗人球蛋白试验阳性。考虑并发急性肾衰竭。给予积极抗感染治疗，同时行连续性肾脏替代性治疗、输注红细胞悬液、输注血浆。10 d后，患者仍处于无尿状态，黄疸进行性加重，家属放弃治疗。

Micafungin induced acute hemolytic reaction and acute kidney failure

A 76-year-old male patient received an IV infusion of micafungin 50 mg in 0. 9% sodium chloride 100 ml once daily for pulmonary infection. Ninety minutes after the first infusion,the patient presented with chills,fever and dark brown urine. Laboratory testing showed the following levels：white blood cells count 25. 2 × 10^9/L,hemoglobin 73 g/L,platelet count 179 × 10^9/L,blood urea nitrogen 6. 4 mmol/L,serum creatinine 96 μmol/L,procalcitonin 14. 13 ng/ml,prothrombin time 17 s,activated partial thromboplastin time 44 s,D-dimer 8. 7 mg/L,and routine urine tests showed white blood cells（ ＋＋＋）, urine occult blood test（ ＋＋＋）,urobilinogen（ ＋＋＋）,urine ketones（ ＋＋＋）,urine protein（ ＋＋＋）＆amp;nbsp;and nitrite positive. The patient was considered as acute hemolysis. Micafungin was stopped. He was given an IV injection of methylprednisolone 40 mg and hydration and urinary alkalinization. However,his urine volume was reduced from 100-150 ml/h to 10-20 ml/h in 4 hours and developed dark urine. The following day,his white blood cells count was 18. 6 × 10^9/L,red cells count was 1. 7 × 10^12/L,hemoglobin was 57 g/L,platelet count was 116 × 10^9/L,reticulocytes was 0. 05,albumin was 25 g/L,indirect bilirubin was 20. 4 μmol/L,aspartate transaminase was 108 U/L,alanine aminotransferase was 42 U/L,blood urea nitrogen was 17. 9 mmol/L,serum creatinine was 230μmol/L,and direct antiglobulin test was positive. He was considered to have acute kidney failure. The patient received anti-infective treatment,continuous renal replacement therapy,and infusion of erythrocyte suspension and plasma. Ten days later,the patient was still anuric and presenting worsening jaundice,family members gave up treatment.