CRRT治疗肾移植术后重症肺部感染12例

肾移植术后患者由于长期服用糖皮质激素及免疫抑制剂导致机体免疫功能低下，故感染是肾移植术后最主要的并发症之一。据统计，在移植后死亡病例中，约70％死于肺部感染。因此，有效治疗肾移植术后重症肺部感染，提高人肾存活率临床意义重大。     

肾移植术后肺部感染状态下免疫抑制剂的调整

目的 探讨肾移植术后肺部感染患者免疫抑制剂的应用与预后的关系.方法 对肾移植术后合并肺部感染的98例患者临床资料进行回顾性分析.将患者分为维持应用免疫抑制剂组(维持剂量组,45例)与免疫抑制剂减量或停用组(调整剂量组,53例).按与感染相关的器官衰竭估计评分(SOFA)标准,在肾移植术后肺部感染较重(SOFA≥12分)和感染较轻(SOFA＜12分)的情况下,分别分析两组患者的死亡率、感染恢复时间和排斥反应发生率的差异.结果 当SOFA≥12分时,调整剂量组死亡率和感染恢复时间明显低于维持剂量组(P＜0.05),而排斥反应发生率在两组之间的差异则无统计学意义(P＞0.05);当SOFA＜12分时,死亡率和感染恢复时间在两组之间差异无统计学意义(P＞0.05),但调整剂量组患者排斥反应发生率明显高于维持剂量组(P＜0.05).结论 在肾移植术后肺部感染较重(SOFA≥12分)时,减量和停用免疫抑制剂有利于降低患者的死亡率和缩短抗感染疗程;但感染较轻(SOFA＜12分)时,建议维持免疫抑制剂原剂量不变.     

肾移植术后并发重症肺部感染的原因与处理

目的:探讨肾移植术后并发重症肺部感染的原因与处理措施。方法:回顾性分析29例肾移植术后并发重症肺部感染患者的临床资料。结果:29例重症肺部感染患者中17例(58.6%)救治成功,12例(41.4%)因合并急性呼吸窘迫综合征抢救无效死亡。结论:重症肺部感染是肾移植受者术后近期死亡的主要原因之一;果断减少或停用免疫抑制剂,早期联合用药抗感染治疗,尽可能早期明确病原学诊断,积极纠正低氧血症和低蛋白血症等,是成功救治的关键。     

肾移植术后肺部感染的免疫抑制剂调整

根据美国UNOS统计,截止2000年,全球肾脏移植总数已达500,000例.近20年来,肾移植病人的短期预后大大改善,但长期存活率改善有限.其中的一个重要原因是术后并发感染.虽近年来国内外不断尝试降低免疫抑制剂用量以减少感染,但过量免疫抑制剂仍是移植后感染-特别是肺部感染的主要原因.与正常人群相比,肾移植术后肺部感染发生率及死亡率更高[1],若冉现急性呼吸衰竭死亡率更高达93.3%[2].肾移植术后病人一旦出现肺部感染,除常规抗感染、通气治疗、营养支持外,极为重要的措施就足调整免疫抑制剂用量.     

肾移植术后肺部感染的免疫抑制剂调整

根据美国UNOS统计,截止2000年,全球肾脏移植总数已达500,000例.近20年来,肾移植病人的短期预后大大改善,但长期存活率改善有限.其中的一个重要原因是术后并发感染.虽近年来国内外不断尝试降低免疫抑制剂用量以减少感染,但过量免疫抑制剂仍是移植后感染-特别是肺部感染的主要原因.与正常人群相比,肾移植术后肺部感染发生率及死亡率更高[1],若冉现急性呼吸衰竭死亡率更高达93.3%[2].肾移植术后病人一旦出现肺部感染,除常规抗感染、通气治疗、营养支持外,极为重要的措施就足调整免疫抑制剂用量.     

肾移植术后肺部感染的免疫抑制剂调整

根据美国UNOS统计,截止2000年,全球肾脏移植总数已达500,000例.近20年来,肾移植病人的短期预后大大改善,但长期存活率改善有限.其中的一个重要原因是术后并发感染.虽近年来国内外不断尝试降低免疫抑制剂用量以减少感染,但过量免疫抑制剂仍是移植后感染-特别是肺部感染的主要原因.与正常人群相比,肾移植术后肺部感染发生率及死亡率更高[1],若冉现急性呼吸衰竭死亡率更高达93.3%[2].肾移植术后病人一旦出现肺部感染,除常规抗感染、通气治疗、营养支持外,极为重要的措施就足调整免疫抑制剂用量.     

肾移植术后早期无尿或少尿的诊治(附66例报告)

目的:探讨肾移植术后早期无尿或少尿的原因及诊治方法.方法:回顾性分析66例肾移植术后早期无尿或少尿患者的发生情况.并分别应用以FK506或CsA为主的免疫抑制剂(FK506/CA+MMF+Pred)等综合治疗方案.结果:66例肾移植术后早期无尿或少尿的主要原因是急性肾小管坏死(77.27%),其次是急性排斥反应(10.61%),其中有2例移植肾原发无功能和移植肾破裂、肾动脉栓塞各1例术后切除移植肾.FK506组的34例移植肾功能在术后5～35天内均恢复正常,CsA组有1例因急性排斥反应合并严重肺部感染而死亡,24例移植肾功能在术后7～48天内均恢复正常,3例血肌酐在142～215 μmol/L之间.结论:肾移植术后早期出现无尿或少尿后应及时分析原因,并给予相应的综合治疗.FK506+MMF+Pred的三联免疫治疗有助于移植肾功能的早期恢复.     

肾移植术后妊娠五例六次

目的 探讨肾移植术后妊娠对受者及移植肾的影响.方法 回顾性分析5例6次肾移植术后妊娠的临床资料.结果 受者妊娠时平均年龄为31.1岁,移植至妊娠的时间平均为3.6年.5例6次妊娠中发生先兆子痫2例次,高脂血症1例次.最终成功分娩4例,分别于38周、35周、35周和38周接受剖宫产,新生儿平均体重为3262.5 g,新生儿Apgar评分均为10分.2例次因减少或停用免疫抑制剂,移植肾功能丧失而终止妊娠,其中1例接受再次肾移植后再次妊娠并成功分娩.结论 对于移植肾功能正常的女性受者,在合理应用免疫抑制剂的前提下妊娠和分娩是可行的,但具有较高风险,需要严密监护.     

肾移植术后西罗莫司联合减量或停用环孢素A的应用体会

,患者存活率为86.7%.至4年随访终点,存活26例患者中25例移植肾功能良好.2例发生急性排斥反应,经甲泼尼龙冲击治疗后逆转.17例次发生感染,经抗感染处理后全部康复.2例术后发生移植肾功能恢复延迟,免疫抑制方案未做调整,分别在术后32 d和58 d恢复泌尿.结论 肾移植术后采用SRL联合CsA和糖皮质激素作为初始治疗,术后3个月开始减少直至停用CsA是有效、安全和可行的.     

乙型肝炎病毒感染患者肾移植术后的治疗和预后分析

目的总结乙型肝炎病毒(HBV)感染患者肾移植术后的治疗和预后,以探讨合理的治疗措施。方法HBV感染肾移植患者21例,术前乙型肝炎病毒表面抗原(HBsAg)阳性和(或)HBV-DNA阳性。术后18例应用拉米夫定、3例应用恩替卡韦抗病毒治疗。随访3个月以上。3例肝肾联合移植的患者术后均使用乙型肝炎人免疫球蛋白。术后定期检测患者的肝功能,肝功能出现异常者及时应用护肝药物,必要时停用钙调磷酸酶抑制剂并对症处理,观察肾功能以及移植肾排斥反应、感染、预后等情况。结果术后随访3～75个月,中位时间17个月。21例中死亡5例,余均存活。12例(57%)术后出现不同程度的肝功能异常;经治疗恢复正常6例,好转3例,死亡3例。移植肾功能正常者13例,肾功能异常但未达到移植肾功能衰竭者6例,2例出现移植肾衰竭,重新恢复血液透析或腹膜透析。术后4例共发生5例次移植肾急性排斥反应,经应用甲泼尼龙冲击治疗或抗胸腺细胞球蛋白治疗后逆转。术后出现感染6例,均伴有肝功能明显异常,经治疗后4例治愈,2例死亡。结论HBV感染患者肾移植术后预防性应用抗HBV药物是必要的和有效的;合理使用免疫抑制剂、应用护肝药物可改善患者的预后。     

个体化免疫抑制方案在心脏移植高危患者中的应用

目的 探讨个体化免疫抑制方案在心脏移植高危患者中的应用.方法 回顾分析2001年9月至2006年12月51例在围手术期合并HBV感染、糖尿病、肾功能不全或肺部感染的心脏移植病例,全组患者术前均采用达利珠单抗进行免疫诱导治疗,基础免疫抑制方案为环孢霉素A(CsA)、硫唑嘌呤(Aza)或吗替麦考酚酯(MMF)和泼尼松的三联方案.其中术前合并HBV感染10例,术后强调使用MMF,术后1个月停用泼尼松;术前合并糖尿病9例,术后并发移植后糖尿病4例,术后强调使用CsA,不用FK506,减量使用或停用泼尼松,配合胰岛素治疗;术前肾功能不全16例,术后常规使用MMF,术后第5～19天开始使用CsA;术后并发肺部感染12例,减量或暂停使用CsA、MMF和泼尼松.结果 术前合并HBV感染10例,随访1年肝功能稳定,1例于术后第13个月发生急性排斥反应.糖代谢异常13例,术后血糖控制满意,随访6个月无急性排斥反应发生.术前肾功能不全16例,随访1个月无急性排斥反应发生,肾功能恢复正常.术后并发肺部感染12例,2例死于严重的肺部感染,其他患者均存活;随访1个月,1例患者于术后第17天发生急性排斥反应.结论 免疫抑制方案的个体化能使心脏移植的高危患者平稳渡过围手术期,不会增加急性排斥反应的发生率.     

儿童肾移植23例临床分析

目的　探讨儿童肾移植的临床特点及围手术期处理特点。方法　回顾性分析平均年龄(15 4± 1 0 )岁的 2 3例儿童肾移植患者的临床资料 ,统计术后移植肾功能变化、急性排斥及并发症发生率。结果　 2 3例手术过程顺利 ,均未出现外科并发症。 1例治疗非顺应致移植肾失去功能 ,2 2例术后平均 5 5d恢复肾功能。术后 6个月内科并发症包括高血压 13例 (5 7% )、肺部感染 4例 (17% )、骨髓抑制与药物性肝损害各 3例 (13% )。术后 1年内急性排斥反应 4例 (17% )。术后第 1年体重平均增加 2 3kg ,身高平均增高 1 0cm。 1年、3年人 /肾生存率分别为 10 0 % / 96 %、90 % / 80 %。结论　肾移植是治疗儿童终末期肾病的有效治疗措施。合适的术式、术后免疫抑制药物的合理应用、并发症的预防和及时治疗是提高人、肾存活率的关键。     

肾移植后因免疫抑制剂的不良反应转换应用咪唑立宾的效果

目的 探讨肾移植术后因不良反应而将吗替麦考酚酯(MMF)或硫唑嘌呤(Aza)转换为咪唑立宾(MZR)的有效性和安全性.方法 56例肾移植受者术后发生肺部感染23例,骨髓抑制14例,肝功能损害6例,腹泻13例.所有患者均采用以钙调磷酸酶抑制剂(CNI)+MMF(或Aza)+泼尼松(Pred)的免疫抑制方案,出现不良反应时,转换应用了CNI+MZR+Pred.转换治疗后随访(33.2±17.4)个月(11～53个月),观察转换治疗后的效果和不良反应.结果 转换治疗后,23例肺部感染的患者,1例再次出现肺部感染,死于心、肺功能衰竭,其余均未再出现肺部感染;骨髓抑制的14例患者中,13例血常规恢复正常,1例未恢复;肝功能损害的6例患者经转换治疗后,肝功能均恢复正常;13例腹泻患者的症状均缓解.转换前,患者血清肌酐为(123±21.3)μmol/L,转换后,血清肌酐为(119±18.2)μmol/L,二者比较,差异无统计学意义(P＞0.05).转换治疗后,有1例(1.7%)患者发生排斥反应,9例(16.1%)出现不同程度的血尿酸升高,1例出现指(趾)关节疼痛等症状,均经对症治疗后好转.结论 在肾移植术后发生免疫抑制剂不良反应时,转换应用咪唑立宾效果良好,安全性高,为肾移植后患者的个体化免疫抑制方案的应用提供一种新的选择.

Abstract：

Objective To investigate the efficacy and safety of conversion therapy to mizoribine (MZR) for renal transplant patients who suffered MMF or Aza adverse reaction. Methods In 56 patients with adverse reactions at different time points after renal transplantation, there were 23 cases of pulmonary infection, 14 cases of bone marrow depression, 6 cases of hepatic functional lesion and 13 cases of diarrhea. The immunosuppressive protocols of these patients were changed to CNI + MZR + Pre when the adverse reaction occurred. During the follow-up period (11 to 53 months), the effect and adverse events of conversion treatment were observed. Results After conversion treatment, 1 of 23 patients with pulmonary infection was re-infected after 26 months and finally died of heart and lung function failure. In 14 patients with bone marrow depression, blood test returned to normal in 13cases. Six patients with hepatic functional lesion were administered hepatoprotection treatment and their liver function was restored without recurrence of impaired liver function. All 13 patients with diarrhea were relieved without recurrence. The serum creatinine was 123 ± 21.3 μmol/L and 119±18. 2 μmol/L before and after the conversion therapy respectively (P＞0. 05). During the follow-up period, all patients' graft function was good. The incidence of rejection was 1.7 % (1 case). Nine patients (16. 1 %) had a higher level of uric acid after conversion. One patient had finger and toe joint pain. The symptoms were relieved after symptomatic treatment. Conclusion There were high security and good effect of conversion therapy to MZR due to MMF or Aza adverse reaction. Besides, MZR conversion therapy for renal transplantation patients provided a new option for individual immunosuppression.     

女性肾移植受者术后生育22例报告

目的 探讨女性肾移植受者术后生育对子代、移植肾及自身健康的影响.方法 回顾分析8个器官移植中心自1989年8月至2007年2月的资料,共有22例女性肾移植受者术后妊娠,并各生育子女1名.由专人负责收集、整理受者及其子女的资料,包括受者的年龄、病程、肾移植时间、免疫抑制剂的应用、结婚及孕产时间、妊娠和分娩情况、子女出生情况、喂养方式等,并对其中的18名子女进行了体格检查,记录其身高和体重.结果 22例生育时的年龄为(27.8±2.7)岁,分娩时间为术后(35.1±13.2)个月,孕产期问免疫抑制方案为环孢素A(或他克莫司)、硫唑嘌呤(或霉酚酸酯)和泼尼松联用.其中21例为剖宫产,1例为自然分娩;6名(27.3%)为早产,其余为足月产.22名子女出生时体重为(2944±585)g,均人工喂养,现年龄最大者为18岁,最小者为8个月.3岁、4岁和5岁者的体重分别为(15.2±1.3)kg、(17.0±0.9)kg和(17.8±0.4)kg,身高分别为(99.0±3.6)cm、(106.4±1.3)cm和(109.5±0.7)cm,其他年龄段因样本数太少,未行统计.未发现明显畸形.22例受者在孕产期间并发高血压9例次,肾功能异常和蛋白尿各5例次,肺部感染和心力衰竭各4例次,尿路感染3例次,6例移植肾功能丧失,2例因肺部感染、心力衰竭死亡,1例因慢性排斥反应、移植肾功能丧失、心力衰竭死亡.结论 女性肾移植受者术后若情况允许,可以生育,但有时可对移植肾及自身健康有一定的影响,整个妊娠、生育过程应有产科、移植科以及心内科等医生共同参与指导.     

Polyomavirus nephropathy after renal transplantation: a single centre experience

BACKGROUND: Polyomavirus associated nephropathy (PVN) in renal transplant recipients has been observed with increasing frequency recently and has emerged as a cause of allograft failure linked to highly potent new immunosuppressive regimens containing tacrolimus or mycophenolate mofetil (MMF). METHODS: Polyomavirus associated nephropathy was identified in nine out of 182 patients who received renal transplantation between October 1998 and July 2003. PVN was confirmed by allograft biopsy. The clinical records of these nine patients were reviewed, as were all of the allograft biopsies. Electron microscopy was performed in all nine cases. After the diagnosis of PVN, maintenance immunosuppression was reduced. The clinical course and outcome of the PVN patients were reviewed in relation to manipulation of immunosuppressive agents. RESULTS: There were nine cases of PVN in renal transplant recipients and the incidence of PVN was 4.9%. All patients with PVN were under triple immunosuppression comprising tacrolimus and MMF. The mean time to a diagnosis of PVN was 7.8 months after transplantation. Three of the nine patients received antirejection therapy prior to PVN. Seven out of nine PVN patients presenting acute allograft dysfunction were initially treated with high-dose intravenous steroid pulse or OKT3 before reduction of the immunosuppression. After reduction of the immunosuppression, seven patients stabilized their renal function. Two (22%) lost their grafts due to persistent PVN and chronic rejection. Two (22%) patients later developed acute rejection after reduction of the immunosuppression. CONCLUSION: PVN can cause allograft dysfunction and graft loss. Renal allograft recipients who are at risk of PVN should be routinely screened with urine cytology and quantitative measurements of viral load in the blood, particularly patients who had graft dysfunction. Early diagnosis and judicious alteration of immunosuppressive agents might permit a superior prognosis and reduce the graft loss from PVN in renal transplant recipients.     

儿童亲属肾脏移植的临床研究

目的 探讨儿童亲属患者肾移植的疗效及其优越性,研究儿童肾脏移植手术方案、术后免疫抑制药物应用的特点以及术后并发症的处理.方法 分析14例肾移植患儿的临床资料、肾脏移植手术方法、免疫抑制剂应用和随访情况.结果 移植术后早期主要并发症:移植肾急性排斥反应2例,严重高钠血症3例,泌尿系感染1例,移植肾周积液3例.长期主要并发症:高血压6例、高脂血症3例、各种感染4例、药物性肝损害5例.1年人/肾存活率均为100%,研究结束时,14例患儿平均血肌肝为96.43 mmol/L(43～125 mmol/L),所有患儿均认为移植术后生活质量明显提高. 结论 亲属肾移植是治疗儿童慢性肾功能不全最为理想的方法,儿童肾移植的术式应根据受者血管情况选择.术后免疫抑制治疗建议联合应用他克莫司+霉酚酸酯+激素.     

Improved clinical outcomes in Chinese renal allograft recipients receiving lower dose immunosuppressants

BACKGROUND: The application of potent immunosuppressants has decreased the incidence of acute rejection and increased short- and long-term graft survival; however, these drugs cause a variety of complications. In China, many transplant centers have adopted the immunosuppressive protocols based on the white population, neglecting the differences between the races. The purpose of this study was to explore a suitable immunosuppressive regimen for Chinese renal allograft recipients. METHODS: Two hundred cadaveric renal allograft recipients who underwent transplantation between July 1999 and October 2001 were observed. Before October 2000, 104 recipients received the conventional dose of immunosuppressants; thereafter, 96 recipients received lower dose treatment. Doses of immunosuppressive agents, the incidence of acute rejection and pulmonary infection, and patient and graft survival rates were compared between the two groups. RESULTS: Doses of mycophenolate mofetil (MMF) and cyclosporine A (CsA) administered in the conventional dose group were significantly higher than in the lower dose group at 3 months posttransplant, as was prednisone at 6 months posttransplant. The incidence of acute rejection and subclinical rejection that was biopsy-proven or diagnosed by clinical manifestations was 17.3% and 19.8%, respectively, in the conventional dose group and the lower dose group within the first 6 months, and no significant difference was noted (P=0.55). The incidence of pulmonary infection, especially severe infection, was much higher in the conventional treatment group (40.1% and 26.9%, respectively) than that in the lower dose group (11.5% and 5.2%, respectively), and the differences were statistically significant (P<0.001). The corresponding 1-year survival rate of patients was 87.4% and 97.9% (P<0.01), and that of renal grafts was 85.5% and 96.9% (P<0.01), for patients receiving conventional dose and lower dose immunosuppressive drugs, respectively. The rate of death with a functioning allograft caused by infection in the conventional dose group was significantly higher than that in the lower dose group (12.5% vs. 0%, P<0.01). CONCLUSIONS: The regimen of lower dose MMF, CsA, and prednisone in combination can significantly reduce the incidence of pulmonary infection, especially severe pulmonary infection, without increasing the incidence and severity of allograft rejection.     

肾移植术后肺部真菌感染的临床特征

目的：探讨肾移植术后肺部真菌感染的临床特征。方法：报告27例肾移植术后肺部真菌感染患者的临床资料。27例均有发热、咳嗽，17例出现胸闷、低氧血症。病原学检查发现白色念珠菌6例，克柔念珠菌5例，平滑念珠菌4例，12例阴性，混合细菌感染15例，巨细胞病毒感染4例。结果：单纯应用酮康唑治愈者10例，应用两性霉素B脂质体治愈10例，7例死亡。结论：真菌是肾移植术后肺部感染主要原因之一，早期发现、及时治疗、合理应用免疫治疗方案是治疗成功的关键。     

肾上腺皮质激素在肾移植术后肺部感染治疗中的应用研究

目的探讨肾上腺皮质激素(激素)在治疗肾移植术后肺部感染中的应用价值。方法收集2008年1月至2012年6月解放军第281医院肾移植中心收治的78例肾移植术后肺部感染患者的临床资料,所有患者均签署知情同意书,符合医学伦理学规定。肺部感染发生于肾移植术后2～6个月52例,7～18个月15例,18个月以后11例。其中单纯巨细胞病毒(CMV)感染24例,单纯细菌性感染17例,混合性感染28例,病原体不明感染9例。根据患者情况,予调整或停用免疫抑制剂,应用激素及针对病原学进行抗感染治疗,其后根据患者临床症状及肺部计算机断层摄影术(CT)表现,激素逐渐减量。同时予钙剂预防骨质疏松,予抗凝及调脂药物预防血栓形成,予抑酸剂预防消化道溃疡的发生。结果 78例患者中,治愈73例,死亡3例,并发脑出血放弃治疗1例,转院1例。3例死亡病例中,2例死于多器官功能衰竭,1例死于急性呼吸衰竭。2例患者发生急性排斥反应,其中1例患者免疫抑制方案改为抗人T细胞免疫球蛋白(ALG)+MMF+FK506+甲泼尼龙治疗,另1例通过血液透析过渡,免疫抑制方案改为MMF+FK506+甲泼尼龙治疗,均得以成功逆转。发生下肢静脉血栓2例,脑血栓2例,予对症治疗后好转。结论肾移植术后肺部感染的治疗,应在调整免疫抑制剂方案和抗感染治疗的同时配合激素治疗,可取得良好的治疗效果。     

Rescue hepatectomy for initial graft non-function after liver transplantation

BACKGROUND: Early retransplantation is the therapy of choice in patients with initial graft nonfunction (INF). In rare cases the patients' conditions deteriorate dramatically with severe cardiovascular and/or pulmonary insufficiency while on the waiting list for retransplantation. In this life-threatening situation removal of the graft and temporary portocaval shunt before allocation of a new liver proved to be effective. Our experience with this two-stage hepatectomy and subsequent liver transplantation in patients with complicated INF is reported. METHODS: Hepatectomy was performed in 20 patients with INF associated with severe cardiovascular and pulmonary insufficiency while on the waiting list for emergency liver retransplantation. The mean age was 41.75+/-16.64 years. The time period between primary transplantation and hepatectomy was 2.80+/-2.84 days with a range from 1 to 9 days. RESULTS: Hepatectomy reduced the need for vasopressive agents and improved pulmonary function in the majority of patients. Four patients died before a liver was available due to brain death in one patient and multiorgan failure in three patients. In the remaining 16 patients liver transplantation could be performed after 19.82+/-15.34 hr (range 6.58 to 72.50 hr). Two of the 16 transplanted patients died on the first postoperative day due to multiorgan failure and pneumonia. The remaining 14 of 16 patients survived retransplantation, but 7 died between days 13 and 105 mostly due to sepsis. Seven patients were discharged from the hospital in good condition and show long-term survival. CONCLUSION: Hepatectomy was able to stabilize the cardiovascular and pulmonary function. This study confirms the beneficial effects of hepatectomy and subsequent liver transplantation as a life-saving procedure in patients with INF complicated by cardiovascular and/or pulmonary instability.