肾移植术后巨细胞病毒肺炎免疫抑制剂的应用研究简

目的 研究肾移植术后巨细胞病毒肺炎免疫抑制剂停用时机对患者预后的影响.方法 对82例肾移植术后巨细胞病毒肺炎患者根据从诊断巨细胞病毒肺炎到停用免疫抑制剂时间分成两组（≤3天组为早停组,＞3天为晚停组）,比较两组的预后及存活患者的病情控制时间.结果 两组患者的存活率及存活患者的病情控制时间均有显著统计学差异,早停组患者的存活率明显高于晚停组.结论 肾移植术后巨细胞病毒肺炎一经诊断在停用免疫抑制剂,同时使用小剂量糖皮质激素激素并予以抗病毒、抗感染、营养支持等综合治疗是成功治疗肾移植术后巨细胞病毒肺炎的关键.巨细胞病毒是肾移植术后肺部感染的常见病原体之一,79%发生在肾移植术后3-6个月内,其病情复杂,死亡率高,医疗费用高,成为临床治疗的难点.但近年来,随着救治病例的增多,治疗水平的不断进步,肾移植术后巨细胞病毒肺部感染的治愈率也提高.如何成功救治肺部感染.不同文献对肾移植术后巨细胞病毒肺炎免疫抑制剂停用或减量的时机有不同的报道.现将同济医院2002-2010年呼吸内科救治的82例肾移植术后巨细胞病毒肺炎患者病例进行分析,探讨免疫抑制剂的调整时机对患者预后、存活患者的病情控制的时间.     

外科重症监护病房肾移植术后严重肺部感染患者的处理

探讨外科重症监护病房(SICU)肾移植术后严重肺部感染患者的发病特点,总结诊断和治疗方案的有效性.方法:回顾性分析北京大学第一医院2002年～ 2010年肾移植后因严重肺部感染收入SICU治疗患者的临床资料.结果:8年期间共收治肾移植术后严重肺部感染患者15例,其中肾移植术后6月内12例(80.0%)、3月内9例(60.0%).15例患者中重症肺炎12例(80.0%),其中急性呼吸窘迫综合症6例(40.0%).按照发病地点分:院内获得性肺炎8例(53.3%),社区获得性肺炎7例(46.7%);按照致病病原体分:细菌性肺炎12例,真菌性肺炎4例,卡氏肺孢子虫肺炎1例,病原体不明肺炎3例.12例查明病原体的肺炎患者中4例(33.3%)为多重病原体感染.经过综合治疗后13例(86.7%)痊愈,2例(13.3%)死亡.结论:早期行病原学诊断、根据病原体选择有效抗生素、及时调整免疫抑制方案、加强全身支持治疗、适时应用呼吸机支持纠正低氧血症是成功救治肾移植术后肺部严重感染患者的关键.     

肾移植术后巨细胞病毒肺炎免疫抑制剂的应用研究

目的研究肾移植术后巨细胞病毒肺炎免疫抑制剂停用时机对患者预后的影响。方法对82例肾移植术后巨细胞病毒肺炎患者根据从诊断巨细胞病毒肺炎到停用免疫抑制剂时间分成两组(≤3天组为早停组,3天为晚停组),比较两组的预后及存活患者的病情控制时间。结果两组患者的存活率及存活患者的病情控制时间均有显著统计学差异,早停组患者的存活率明显高于晚停组。结论肾移植术后巨细胞病毒肺炎一经诊断在停用免疫抑制剂,同时使用小剂量糖皮质激素激素并予以抗病毒、抗感染、营养支持等综合治疗是成功治疗肾移植术后巨细胞病毒肺炎的关键。     

肾移植术后细菌性肺部感染

肾移植术后细菌感染是常见和棘手的问题,而肺部感染是引起肾移植术后患者死亡的主要原因之一［１］。国外报导肾移植后肺部感染主要是卡氏肺囊虫肺炎（ＰＣＰ）、巨细胞病毒肺炎（ＣＭＶ）、肺结核、肺霉菌病等机会性感染,对于肺部细菌感染报导较少。总结我院１９７８年至１９９６年肾移植手术１０５６例患者中细菌性肺炎或细菌性肺炎合并霉菌,细菌性肺炎合并结核,合并巨细胞病毒感染等患者５１例,报告如下。１临床资料１．１一般资料：５１例患者,男性３３例,女性１８例,年龄１６～６２岁,平均４１．２７±１１．１４岁。其中慢性…     

肾移植术后巨细胞病毒肺炎22例临床分析

对22例肾移植术后发生巨细胞病毒(CMV)肺炎患者作回顾性分析,均通过检测外周血CMV-IgM和CMV-DNA,结合临床症状及X线、CT检查明确诊断.确诊后停用全部免疫抑制剂,给予更昔洛韦、甲泼尼龙(MP)及免疫球蛋白治疗,同时防治混合感染,加强营养支持,并根据动脉血氧分压尽早使用呼吸机.治愈19例,死亡3例,治愈患者移植肾脏功能均正常.认为胸部CT检查及CMV-IgM、CMV-DNA检测联合应用有利于肾移植术后CMV肺炎的早期诊断;停用免疫抑制剂,适量应用糖皮质激素、免疫球蛋白,足量长疗程抗病毒治疗,加强营养支持,及早进行高流量给氧或辅助呼吸等综合治疗可取得满意疗效.     

肾移植术后肺部感染的CT诊断与鉴别诊断

目的分析肾移植术后患者肺部感染的CT表现及鉴别诊断。方法回顾性分析肾移植术后肺部感染87例,分析比较在CT不同病原体的肺部感染病灶的形态、分布、密度等特征和动态变化的规律,并与病原学诊断结果对照。结果CT表现为弥漫性斑片状和磨玻璃状伴点状或网状阴影共20例;表现为小片状或大片状阴影41例;其它表现为散在小结节、小片状或条状不规则影。结论肾移植术后不同肺部感染的CT表现有一定特点,巨细胞病毒性肺炎和卡氏肺囊虫肺炎主要表现为肺间质增厚,细菌性肺炎和真菌性肺炎主要表现为肺实质渗出,肺结核为不均匀粟粒影。CT对鉴别诊断有一定价值。     

糖皮质激素联合免疫抑制剂治疗肾脏疾病并发肺部机会性感染的诊断与治疗

目的 了解糖皮质激素联合免疫抑制剂治疗肾脏疾病并发肺部机会性感染的特点和治疗经验.方法 回顾性总结2007年2月互2008年5月解放军总医院肾脏科和急诊科收治的11例应用糖皮质激素联合免疫抑制剂治疗后出现严重肺部感染的肾脏疾病患者,分析患者的临床资料和随访结果.结果 所有患者呼吸系统症状均在治疗8周后出现,进行性呼吸困难为主要临床表现,5例患者出现呼吸衰竭,肺部影像学显示为两肺局灶性或弥漫性毛玻璃样病变,免疫学检查显示患者免疫功能基本正常,病原学检查所有患者血清人类免疫缺陷病毒(HIV)抗体阴性,1例患者血清巨细胞病毒IgM抗体阳性,1例痰培养烟曲霉菌阳性,其余患者未查到病原体,患者分别给予抗病毒和抗真菌感染或二者联合治疗,根据患者呼吸衰竭严重程度辅以无创或有创呼吸机辅助呼吸,最终2例患者死亡,其余患者病情好转出院,随访1个月至1年肺功能恢复正常.结论 肾脏病患者应用糖皮质激素联合疫抑制剂治疗过程中要警惕肺部机会性感染的发生,及时诊断和早期行综合治疗有利于改善患者预后.     

肾移植术后巨细胞病毒肺炎发生急性呼吸窘迫综合征危险因素分析

目的 探讨肾移植术后巨细胞病毒（CMV）肺炎患者发生急性呼吸窘迫综合征（ARDS）的危险因素,以采取有效预防控制措施.方法 采用回顾性观察方法,收集我院肾移植术后巨细胞病毒肺炎患者的病例资料,分析各项临床因素与发生ARDS的关系.结果 我院2004年5月-2010年3月期间肾移植术后发生巨细胞病毒肺炎共76例,其中32例发生ARDS,发生率为42.11%;采用Logistic回归分析发现,肾移植术后发生巨细胞病毒肺炎时间早、合并糖尿病、发生过排斥反应、炎症病变范围广等因素使ARDs发生率增高,严格控制血糖、早期使用激素治疗可使ARDS发生率降低.结论 肾移植术后早期发生巨细胞病毒肺炎、合并糖尿病、发生过排斥反应、炎症病变范围广等是肾移植术后巨细胞病毒肺炎发生ARDS的高危因素;严格控制血糖、早期使用激素治疗则是保护因素.     

肾移植术后巨细胞病毒肺炎的临床研究

目的:探讨肾移植术后巨细胞病毒(CMV)肺炎的临床特点及诊疗对策。方法:回顾34例肾移植术后CMV肺炎患者临床资料,总结临床特点和治疗措施。结果:34例患者,治愈30例,占88.24%,死亡4例(其中放弃治疗后死亡2例)。治愈患者除1例出现移植肾排斥反应外,其余功能均正常。高剂量更昔洛韦联用糖皮质激素组,在需使用呼吸机几率和死亡率方面均低于未使用糖皮质激素的常规剂量更昔洛韦组(P=0.045和0.010)。结论:早期及时诊断,适时适量应用激素,足剂量长疗程抗病毒治疗,及早进行高流量给氧或辅助呼吸等综合治疗是提高治愈率、降低病死率的关键。     

36例肾移植术后肺部感染患者的临床护理

肾移植是治疗终末期肾病的最佳方法 ,但由于肾移植术后免疫抑制剂的大量应用,患者对各种细菌、病毒、霉菌的抵抗力较正常人弱,肺部感染常是导致患者死亡的重要原因之一.因此,做好肺部感染的预防和治疗,采取有效的护理措施,可有效减少重症肺炎的发生,降低肾移植术后的病死率,报告36例肾移植术后肺部感染患者的临床护理.     

Complications of infections attributed to cytomegalovirus in a group of 52 kidney transplant patients

Cytomegalovirus (CMV) infection after renal transplantation was studied over a one year period in 52 patients receiving immunosuppressive drugs. During the infectious episodes, viral shedding was systematically detected in the blood and urines by culture on MRC5 cells and CMV antibodies were titrated in the serum by ELISA (IgG: M. A. Bioproducts, IgM: immunocapture Wellcome) and compared to the initial antibody titer determined the day of transplantation. Primary CMV infection was observed in 6 of 22 seronegative patients, attested by CMV shedding from urine and/or blood and by the emergence of CMV IgM antibodies. This primary infection was severe, including at least 4 of the following features: fever greater than 38 degrees C, neutropenia, thrombocytopenia, cytolytic hepatitis, pneumonia, impaired renal function, neurological syndrome, usually occurring about 6 weeks after transplantation. Reactivation was found in 12 of 30 seropositive patients, as shown by excretion of CMV in the urine and significant rise of specific antibodies. This reactivation occurring about 9 weeks after surgery was symptomatic in 5 patients with severe illness and associated with the presence of IgM antibodies in 2 cases. Rise of CMV antibodies was observed in 10 seropositive patients without excretion of virus. It coincided with symptomatic infection in only three patients who displayed severe symptoms, with presence of CMV IgM antibodies in one case. As previously reported, we confirm that CMV infection is a frequent complication of organ transplantation. It may be clinically silent in renal transplant patients or cause problems ranging from fever to pneumonia or retinitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Infections in patients with immunodeficiency with thymoma (Good syndrome). Report of 5 cases and review of the literature

Immunodeficiency with thymoma (Good syndrome, GS) is a rare, adult-onset condition that is characterized by thymoma, hypogammaglobulinemia, and low numbers of peripheral B cells. CD4+ T lymphopenia and an inverted CD4:CD8+ T-cell ratio may be present. Here we report 5 patients with GS and infectious complications who were seen at 3 institutions between 1983 and 1999. Three patients had recurrent sinopulmonary infections, 3 had severe cytomegalovirus (CMV) disease, and 1 had Pneumocystis carinii pneumonia. Review of the literature identified 46 other reports of infections in GS patients. The infections reported in all 51 patients included recurrent sinopulmonary infection (19 cases with documented respiratory pathogens), generally with encapsulated bacteria, most often Haemophilus influenzae (11 cases); CMV disease (5 cases); bacteremia (7 cases); oral or esophageal candidiasis (6 cases); persistent mucocutaneous candidiasis (5 cases); chronic diarrhea (5 cases with documented stool pathogens); urinary tract infections (4 cases); P. carinii pneumonia (3 cases); tuberculosis (2 cases); Kaposi sarcoma (1 case); disseminated varicella (1 case); candidemia (1 case); wound infection with Clostridium perfringens (1 case); Mycoplasma arthritis (1 case); and other infections. Patients with GS present with a spectrum of sinopulmonary infections and pathogens similar to common variable immunodeficiency (CVID). Compared with patients with CVID, opportunistic infections, including severe CMV disease, P. carinii pneumonia, and mucocutaneous candidiasis, appear to be more common in patients with GS, and patients with GS may have a worse prognosis. GS should be ruled out in patients with thymoma or CVID who develop severe, especially opportunistic, infections. Treatment with intravenous immune globulin is recommended for all patients with GS.     

Cytomegalovirus infection of the major duodenal papilla in a renal allograft recipient with severe biliary obstruction and acalculous cholecystitis

Cytomegalovirus (CMV) can cause severe infections with serious consequences in renal transplant recipients. Disseminated CMV infections can affect almost every organ, but obstructive cholestasis and cholangitis, as a consequence of a CMV‐induced papillitis, is extremely rare. We are reporting a rare case of obstructive cholestasis and cholecystitis due to CMV‐related inflammation of the major duodenal papilla in a 60‐year‐old woman 3 months after renal transplantation. In addition, the patient suffered from a disseminated CMV infection with ulcerative esophagitis and gastritis. Because of the severe CMV infection, failure of the renal graft occurred. Obstructive cholestasis was resolved through internal stenting, and the progressive cholecystitis necessitated an emergency cholecystectomy. Following antiviral therapy with ganciclovir, the gastrointestinal ulcerations regressed and renal function was restored. Diagnosis of the CMV‐related disease was established only in tissue samples, whereas standard serologic tests had failed.     

CYTOMEGALOVIRUS‐ASSOCIATED GASTRIC ULCERS IN IMMUNOCOMPROMISED PATIENTS

Gastric ulceration is a rare manifestation of cytomegalovirus (CMV) infection in the immunocompromised host. Two cases with CMV‐associated gastric ulcers in immunocompromised patients are reported. Case 1 involved a 65‐year‐old male who underwent a cadaveric renal transplantation because of chronic renal failure. He was treated with immunosuppressive agents and steroids. After 3 months of the treatment, he developed CMV‐associated gastric ulcers with evidence of CMV inclusion bodies, CMV antigen and CMV–DNA in the gastric ulcers. After three courses of ganciclovir therapy for 5 months, endoscopic images revealed complete healing of the gastric ulcers. This case supports the use of ganciclovir, which can lead to complete healing of gastric ulcers caused by CMV. Case 2 involved a 69‐year‐old male with interstitial pneumonia who was admitted to hospital because of rapid progression of interstitial pneumonia. He was treated with repeated pulses of methylprednisolone and cyclophosphamide. He developed CMV‐associated gastric ulcers with evidence of CMV inclusion bodies, CMV antigen and CMV–DNA in the gastric ulcers after 1 month of the treatment with high doses of methylprednisolone and cyclophosphamide. Endoscopic images revealed multiple ulcers and erosions in the gastric antrum. Ganciclovir treatment was started, but he died of interstitial pneumonia. In this case, the ulcers were considered to be precipitated by CMV infection and the use of a high dose methylprednisolone. These cases emphasize the need for a careful histological examination for CMV in gastric ulcers in immunocompromised patients.     

Clinical analysis of community-acquired pneumonia and pulmonary tuberculosis in the elderly and advances in treatment]

We treated 510 elderly case (over 65 years old) among 1,017 patients with community-acquired pneumonia and 60 similar cases among 112 patients with pulmonary tuberculosis in Kawasaki Medical School Kawasaki Hospital during approximately the past 15 years. These were compared with non-elderly cases (below 65 years old). In the elderly cases with community-acquired pneumonia, atypical clinical symptoms or physical signs were frequent and the mortality rate was high because of severe underlying diseases, and poor general and nutritional conditions. Regarding a prospective study of 84 elderly cases with community-acquired pneumonia during the past two years, S. pneumoniae, Respiratory virus, Gram-negative bacilli, H. influenzae, M. Tuberculosis were frequently isolated. In addition, mixed viral and bacterial infections, which were frequently noted during the winter, were significantly related to the increased frequency of community-acquired pneumonia. In treating elderly cases with community-acquired pneumonia, immunization therapy (e.g., influenza vaccine), second cephalosporin and/or macrolide antimicrobial agents for outpatients with mild pneumonia, and carbapenem and/or macrolide antimicrobial agents for hospitalized patients with moderate or severe pneumonia were most effective. The number of elderly cases with pulmonary tuberculosis has recently increased and the recognition of 10 cases was delayed because of a low percentage of positive smears, but no resistance to antituberculosis drugs have been observed. Regarding the treatment of pulmonary tuberculosis, fluoroquinolone and rifamycin derivative antibiotics have been developed as antituberculosis drugs with strong antituberculous activity. However, due to the high percentage of adverse effects in elderly patients, careful treatment with desensitization therapy for antituberculosis drugs is considered important.     

老年患者医院获得性肺炎病原菌及耐药性监测

目的 明确广州地区老年医院获得性肺炎(hospital-acquired pneumonia,HAP)患者致病菌的构成情况及耐药情况,以期指导临床治疗.方法 2004年1月至2005年10月在广州市4家医院住院、年龄≥60岁且分离出致病菌的HAP患者共206例,进行致病菌的分离鉴定,采用纸片扩散法进行细菌药敏检测.结果 本组206例老年HAP患者平均年龄(76.6±8.3)岁,平均发病时间为21 d,94.4%为迟发型HAP.共分离致病菌308株,其中革兰阴性细菌占65.3%,革兰阳性细菌占26.3%,白色念珠菌占8.4%.前3位致病菌分别为铜绿假单胞菌(19.2%)、金黄色葡萄球菌(12.7%)、肺炎克雷伯菌(9.1%).革兰阳性菌和革兰阴性菌均耐药情况严重.金黄色葡萄球菌中耐甲氧西林金黄色葡萄球菌比例高达92.3%,溶血性葡萄球菌100%为耐甲氧西林溶血性葡萄球菌.金黄色葡萄球菌对万古霉素耐药率为2.6%.革兰阴性细菌对三代头孢菌素均严重耐药,铜绿假单胞菌呈广泛性严重耐药,有15株铜绿假单胞菌对所有抗生素均耐药.结论 广州地区老年HAP患者细菌耐药性严重,必须加强措施防治其发病.     

Respiratory syncytial virus-related pneumonia after stem cell transplantation successfully treated with palivizumab and steroid therapy

A case is reported of a 56-y-old woman with a second relapse of Hodgkin's disease who early developed after autologous stem cell transplantation (ASCT) a severe RSV-related interstitial pneumonia successfully treated with 1-d intravenous palivizumab 8 mg/kg plus low-dose systemic steroid therapy. B-cells suppression with CMV antigenaemia were then observed and required treatment with ganciclovir and liposomal amfotericine B.     

Small bowel obstruction caused by inflammatory cytomegalovirus tumor in a renal transplant recipient: report of a rare case and review of the literature

Cytomegalovirus (CMV) infection in renal transplant recipients can present as asymptomatic viremia or CMV syndrome or, in more severe cases, as tissue‐invasive disease. CMV enteritis, a common manifestation of CMV invasive disease, usually presents with fever, abdominal pain, anorexia, nausea, and diarrhea, and can be rarely complicated by colon perforation, hemorrhage, or megacolon. CMV infection occurs primarily in the first 6 months post transplantation, when immunosuppression is more intense. We describe the case of a female renal transplant recipient with small bowel obstruction caused by CMV disease 7 years post renal transplantation. The patient presented with diarrhea and abdominal pain. Because of elevated CMV viral load, she was initially treated with antiviral therapy with transient response. Endoscopy and imaging tests showed obstruction of the terminal ileum and, subsequently, the patient underwent exploratory laparotomy when a right hemicolectomy was performed. Biopsy results confirmed the diagnosis of CMV enteritis. Epidemiologic characteristics, clinical presentation, diagnostic workup, therapeutic options, and morbidity–mortality rates of CMV infection/disease, in renal transplant recipients, are reviewed.     

Infective endocarditis in the setting of renal transplantation: Case report and review of the literature

The potent immunosuppressive drugs used by transplant recipients place them at risk of infections. Data on infective endocarditis (IE) in the setting of renal transplantation (RT) are sparse. We describe a 36‐year‐old woman referred to a tertiary medical center for evaluation of elevated creatinine levels 1 month after a second RT. Work‐up revealed the presence of all four of Duke's criteria: fever, persistent bacteremia, new‐onset tricuspid regurgitation, and masses suspected to be vegetation attached to the tricuspid annulus. Symptoms resolved with antibiotic treatment and fluids. Fluorodeoxyglucose‐positron emission tomography/computed tomography (FDG‐PET/CT) revealed hypermetabolic absorption in the femoral vascular graft that had been used for hemodialysis prior to transplantation. The graft was removed by open surgery, and the patient was discharged home in good condition with continued antibiotic treatment. Review of the literature yielded 73 previously reported cases of IE in renal transplant recipients. Several differences were noted from IE in the general population: lower male predominance, younger age (<60 years), absence in most cases of a preexisting structural cardiac anomaly, and more variable causative pathogens. Our case also highlights the importance of FDG‐PET/CT for detecting the source of IE and alerts clinicians to the sometimes unexpected course of the disease in renal transplant recipients.     

Cytomegalovirus inclusions in the gastroduodenal mucosa of patients after renal transplantation.

Biopsies collected from gastroduodenal mucosa during endoscopic examination of 20 patients having undergone renal transplantation and subsequent immunosuppressive therapy showed cytomegalovirus (CMV) inclusion bodies in nine cases. CMV antibody titres were tested in all patients before and after the transplant procedure. Not all patients exhibited viraemia-related symptoms at the time of endoscopy. No correlation was found between the presence of CMV-type cells within the gastroduodenal mucosa, endoscopic and histological findings, the duration of the transplant, and the dosage of immunosuppressive drugs. The duodenum seems to be the elective site of CMV. The involvement of gastric mucosa seems to represents a worsening of the illness. Eight of nine patients with positive biopsies for CMV inclusion had negative pretransplant antibody titres to CMV. All nine patients were seropositive after transplantation and showed seroconversion. Five of 11 recipients with negative biopsies for CMV inclusion bodies, were seronegative before transplantation. Seroconversion occurred in five patients after the transplant; the other six had no rise in antibody titres. The lack of pre-transplant CMV antibody titre and its subsequent increase after transplantation identifies a greater risk of developing post-transplant CMV infection.