CAJ | 학술논문

目的总结小肠移植术后侵袭性真菌感染(IFI)的治疗经验和教训.方法将1994年至2009年6月间15例小肠移植患者分为3个阶段,1994-1995年的3例患者为第1阶段,2003-2006年的7例患者为第2阶段,2007年以后的5例患者为第3阶段.第1和第2阶段患者围手术期真菌感染的预防方案采用静脉注射氟康唑,IFI的治疗以静脉注射氟康唑为主,在病情危重时静脉注射两性霉素B或两性霉素B脂质体,首次用量为1～5 mg/d(或0.02～0.10 mg·kg~(-1)·d~(-1)),视患者耐受情况每日增加5 mg;第3阶段患者围手术期真菌感染的预防方案采用静脉注射两性霉素B脂质体,治疗IFI时,两性霉素B脂质体首次给药便达到目标治疗剂量,用量高达6 mg·kg~(-1)·d~(-1),并严密监测患者的生命体征,肝肾功能及电解质的变化,根据患者病情的变化和肾功能的状况调整剂量.结果 15例患者中有4例术后发生IFI,发生率为26.7%,其中第1、2和第3阶段患者中分别有1例、2例和1例发生IFI.第1和第2阶段3例发生IFI的患者经治疗无效死于严重IFI,第3阶段1例发生IFI的患者经两性霉素B脂质体治疗44 d后被成功救治.治疗期间,患者尿素氮和血清肌酐水平均显著升高,停药后逐渐下降至正常水平.3个阶段患者总体病死率为75%.结论小肠移植术后IFI是极其凶险的并发症,病死率极高;两性霉素B脂质体能够成功救治IFI患者,在严密监测肾功能下,大剂量应用两性霉素B脂质体是安全的.
목적 총결소장이식술후침습성진균감염(IFI)적치료경험화교훈.방법 장1994년지2009년6월간15례소장이식환자분위3개계단,1994-1995년적3례환자위제1계단,2003-2006년적7례환자위제2계단,2007년이후적5례환자위제3계단.제1화제2계단환자위수술기진균감염적예방방안채용정맥주사불강서,IFI적치료이정맥주사불강서위주,재병정위중시정맥주사량성매소B혹량성매소B지질체,수차용량위1～5 mg/d(혹0.02～0.10 mg·kg~(-1)·d~(-1)),시환자내수정황매일증가5 mg;제3계단환자위수술기진균감염적예방방안채용정맥주사량성매소B지질체,치료IFI시,량성매소B지질체수차급약편체도목표치료제량,용량고체6 mg·kg~(-1)·d~(-1),병엄밀감측환자적생명체정,간신공능급전해질적변화,근거환자병정적변화화신공능적상황조정제량.결과 15례환자중유4례술후발생IFI,발생솔위26.7%,기중제1、2화제3계단환자중분별유1례、2례화1례발생IFI.제1화제2계단3례발생IFI적환자경치료무효사우엄중IFI,제3계단1례발생IFI적환자경량성매소B지질체치료44 d후피성공구치.치료기간,환자뇨소담화혈청기항수평균현저승고,정약후축점하강지정상수평.3개계단환자총체병사솔위75%.결론 소장이식술후IFI시겁기흉험적병발증,병사솔겁고;량성매소B지질체능구성공구치IFI환자,재엄밀감측신공능하,대제량응용량성매소B지질체시안전적.
Objective Invasive fungal infection (IFI) after small bowel transplantation (SBTx) is aggressive and associated with high mortality rates. This paper reviewed preliminary experience of treatment of IFI in 15 cases after SBTx. Methods Fifteen cases of SBTx were divided into 3 groups according to the eras. era Ⅰ (1994-1995)-3 cases of SBTx treated with cyclosporine-based immunosuppression, era Ⅱ (2003-2006)-7 cases of SBTx treated with tacrolimus-based immunosuppression, and era Ⅲ (2007-present)-5 cases of SBTx treated with Alemtuzumab induction therapy and maintenance tacrolimus monotherapy. During era Ⅰ and era Ⅱ, Fluconazole Ⅳ was used as prophylaxis and treatment protocol. If the IFI was aggressive, Amphotericin B or Amphotericin B Liposome were also given with initial dose of 1-5 mg/d (or 0.02-0.10 mg·kg~(-1)·d~(-1). During era Ⅲ, 2-weeks Arnphotericin B Liposome was used as prophylaxis therapy after SBTx, and the dose of 6 mg· kg~(-1)·d~(-1) of Amphotericin B Liposome was given to treat IFI after SBTx. The administration manner of Amphotericin B Liposome was also improved during era Ⅲ, and the initial dose achieved 6 mg without gradually increasing process. Closely surveillance of vital sign, liver and renal function, and electrolyte was also carried out, and the doses of Amphotericin B Liposome were titrated according liver and renal function. Results Four of 15 SBTx recipients suffered from IFI with the occurrence rate of 26.7%, 1, 2 and 1 recipient(s) suffered from IFI during different 3 eras, respectively. Three recipients died of severe IFI after SBTx during era Ⅰ and era Ⅱ. One SBTx recipient with IFI during the era Ⅲ totally recovered after 44-days treatment of Amphotericin B Liposome with the totally dose of 9100 mg, and the renal dysfunction was observed and.ameliorated after ceasing of Amphotericin B Liposome. The mortality of these 4 IFI after SBTx was 75%. Conclusion IFI after SBTx is associated with high mortality rate. Amphotericin B Liposome can effectively control IFI after SBTx. With closely surveillance of recipient renal function, high dose of Amphotericin B Liposome can be safely used.