肾移植后肺部弥漫性病变的诊断和治疗

DIAGNOSIS AND TREATMENT OF DIFFUSE PULMONARY LESIONS AFTER RENAL TRANSPLANTATION

２７３例尸体肾移植中有３０例发生肺部弥漫性感染，其中有１８例表现为成人呼吸窘追综合征（ＡＲＤＳ）。经治疗１８例存活（其中ＡＲＤＳ９例），１２例死亡。Ｘ线表现粟粒状病变２例、肉芽肿１例、间质性改变３例、散在斑片状阴影１８例、肺水肿及磨砂玻璃状６例。经尸体解剖、纤支镜、微生物检查证实，肺孢子虫病２例、巨细胞病毒伴曲菌２例，结核病３例，另见血和痰培养有绿脓杆菌及白色念珠菌等。２７例非结核性肺弥漫性病变，其中１５例用四联治疗（同时抗细菌、抗病毒、抗真菌抗、肺孢子虫病），全部治愈；而１２例未用四联治疗的仅１例治愈（Ｐ＜０．０１）。提示肾移植后肺弥漫性病变往往是混合感染，且病因诊断困难，病原体不易检出，宜早期应用联合疗法，以提高救治的成功率。

There were 30 cases with diffuse pulmonary lesions among a recent series of 273 renal transplantations. Male 26 cases, female 4 cases; age 19￣66 years old.The clinical manifestations were fever, expectorate cough with dry and moist rales.There was 18 cases with adult respiratory distress syndromes (ARDS). X-rays showed interstitial lesions (3 cases), sporadic mottling (18 cases), pneumonoedema and a ground-glass appearance (6 cases), granuloma (1 case). All these conditions except one occurred within 6 months after operatively.Bacteriological examination of the 30 cases showed 11 pseudomonas aeruginosa and 11 candida albicans in sputum cultures, 1 pseudomonas aeruginosa and 1 gram-positive eoccus in blood cultures, acid-fast bacillus in one patient's ascitic fluid, 2 pneumocystis carinii and 1 non-pseudomonas aernginosa from bronchoscope or bronchial intubation. cytomegalovirus (CMV) inclusion bodies and yeast were found in lungs of 2 autopsy cases.In 30 cases,15 cases were treated with a tetradregime (anti-bacterial,antiviral, anti-fungal,anti-pneumocystis carinii)and were cured, only one of the other 12 cases without the tetragenous therapy was cured(P<0.01) The above results show that diffuse pulmonary lesions occurring after renal transplantation are offen severe with a high mortality, Etiologically, they are usually mixed infections and diffcult to diagnose. Tetragenic therapeutic obviously increase patient's cure rates.