CAJ | 학술논문

目的总结肾移植术后卡氏肺囊虫肺炎(PCP)的治疗经验及病情特点,以提高对该病的认识.方法 186例肾移植术后患者发生PCP 28例.61例.肾移植术前使用抗CD_25~+单克隆抗体免疫诱导者中发生PCP 10例(16.4%),125例单纯激素免疫诱导者中发生PCP 18例(14.4%).52例术后免疫抑制方案为他克莫司(FK506)加霉酚酸酯(MMF)加泼尼松者中发生PCP 10例(19.2%),134例环孢素(CsA)加MMF加泼尼松者中发生PCP 18例(13.4%).临床表现为发热28例、干咳28例,胸闷气短12例.发病时间在肾移植术后1.5～7个月.发病至就诊时间＜7 d,确诊时间为发病后4～10 d.发病时实验室检查SCr 70～106 μmol/L;治疗前及痊愈后外周血CD_4~+淋巴细胞数分别为(245±32)、(536±25)/μl.胸部影像学检查28例患者表现为双肺片状毛玻璃样阴影,患者均经支气管镜肺泡灌洗液检查诊断为PCP.治疗采取减少免疫抑制剂用量,口服复方磺胺甲恶唑(SMZco)100 mg·kg~(-1)·d~(-1),持续使用2～3周;19例血氧分压＜70 mm Hg(1 mm Hg=0.133kPa)者静脉给予小剂量激素治疗.结果 28例治疗2～3周后均痊愈出院.1例6个月后复发,继续应用SMZco 2个月后双肺间质炎症消失.5例治疗后实验室检查SCr升高,停用SMZco 1个月后肾功能恢复正常.CsA与FK506组、抗CD_(25)~+单克隆抗体免疫诱导与单纯激素免疫诱导组PCP发病率比较差异无统计学意义(P＞0.05).治疗前与痊愈后外周血CD_4~+淋巴细胞数比较差异有统计学意义(P=0.001).结论肾移植术后早期出现发热、干咳、低氧血症,胸部影像学表现双肺间质性炎症者,应高度考虑PCP的可能.SMZco治疗效果良好.
목적 총결신이식술후잡씨폐낭충폐염(PCP)적치료경험급병정특점,이제고대해병적인식.방법 186례신이식술후환자발생PCP 28례.61례.신이식술전사용항CD_25~+단극륭항체면역유도자중발생PCP 10례(16.4%),125례단순격소면역유도자중발생PCP 18례(14.4%).52례술후면역억제방안위타극막사(FK506)가매분산지(MMF)가발니송자중발생PCP 10례(19.2%),134례배포소(CsA)가MMF가발니송자중발생PCP 18례(13.4%).림상표현위발열28례、간해28례,흉민기단12례.발병시간재신이식술후1.5～7개월.발병지취진시간＜7 d,학진시간위발병후4～10 d.발병시실험실검사SCr 70～106 μmol/L;치료전급전유후외주혈CD_4~+림파세포수분별위(245±32)、(536±25)/μl.흉부영상학검사28례환자표현위쌍폐편상모파리양음영,환자균경지기관경폐포관세액검사진단위PCP.치료채취감소면역억제제용량,구복복방광알갑악서(SMZco)100 mg·kg~(-1)·d~(-1),지속사용2～3주;19례혈양분압＜70 mm Hg(1 mm Hg=0.133kPa)자정맥급여소제량격소치료.결과 28례치료2～3주후균전유출원.1례6개월후복발,계속응용SMZco 2개월후쌍폐간질염증소실.5례치료후실험실검사SCr승고,정용SMZco 1개월후신공능회복정상.CsA여FK506조、항CD_(25)~+단극륭항체면역유도여단순격소면역유도조PCP발병솔비교차이무통계학의의(P＞0.05).치료전여전유후외주혈CD_4~+림파세포수비교차이유통계학의의(P=0.001).결론 신이식술후조기출현발열、간해、저양혈증,흉부영상학표현쌍폐간질성염증자,응고도고필PCP적가능.SMZco치료효과량호.
Objective To improve the awareness,diagnosis and treatment of pneumocystis carinii pneumonia (PCP) after renal transplantation.Methods A retrospective review was performed in 28 patients who underwent renal transplantation and developed PCP afterwards.The main clinical manifestations were fever(28 cases),nonproductive cough(28 cases),chest distress (12 cases).Occurrences of PCP were described 1.5 to 7 months after the renal transplantation.There were 10 patients treated with tacrolimus (FK506 2-6 rag/d,FK506 concentration 4-10 ng/ml) and 18 patients treated with cyclosporine (CsA 200-500 mg/d,CsA trough level:150-250 ng/ml) based immunosuppressive regimen.Anti-CD_(25)~+ monoclonal antibody (anti-CDCD_(25)~+mAb) was used in 10 cases for immune induction before operation while single steroid in 18 cases.Creatinine of patients with PCP was 70 to 106 μmol/L.CD_4~+ lymphocyte counts of the peripheral blood were 245±32/μl before PCP treatment and 536±25/μl after recovery.The most abnormal chest radiological findings were bilateral patchy ground-glass opacity.All the patients were diagnosed with PCP by bronchoalveolar lavage.Treatment was performed by reducing immunosuppressive agents and giving SMZco.Nineteen patients who had a PaP2 less than 70 mm Hg were given intravenous small-dose steroid.Results All the patients recovered from PCP 2 to 3 weeks after treatment.One patient experienced recurrence half year later.Five patients with higher creatinine after treatment recovered to normal levels after stopping the treatment of SMZco.No significant differences were seen in PCP patients treated with CsA and FK506,P＞0.05.The similar results were observed in use of anti-CDCD_(25)~+ mAb and single steroid,P＞0.05.Significant differences were observed in PCP patient peripheral blood CD_4~+ lymphocyte counts before and after treatment (P=0.001).Conclusions Patients who have fever,cough and hypoxia,chest imaging showing bilateral lung interstitial inflammation,might be PCP patients in the early post-renal transplantation period.Effective treatment should be performed by reducing immunosuppressive agents and giving SMZco.