肾移植术后重症肺炎撤除免疫抑制剂治疗的安全性评估

Safety assessment of immunosuppressive therapy discontinuation in severe pneumonia patients after kidney transplantation

目的 探讨肾移植术后重症肺炎的诊治经验.方法 回顾性分析16 例肾移植术后重症肺炎患者的临床资料.16 例患者均撤除了全部基础免疫抑制剂,经验性使用抗感染药物,并进行病原学检查,根据检查结果调整抗感染方案;同时静脉给予小剂量甲泼尼龙、营养支持治疗;如出现呼吸困难、血气分析显示低氧血症,则立即给予无创通气或气管插管治疗,评价其安全性.结果 16 例患者无一例出现急性排斥反应;重症肺炎常发生在肾移植术后3～4 个月,但移植一年以上的重症肺炎也有一定比例18.75%(3/16);发热和胸闷是最常见首发症状,仅有18.75%(3/16)的患者具有明显的咳嗽、咳痰症状;血培养、痰、咽拭子培养病原体检出率较低(43.75%).13 例重症肺炎患者治疗有效,3 例死亡,死亡病例均为移植1 年以上,有移植肾功能不全的诊断.结论 肾移植术后重症肺炎,病情严重、死亡率高.早期诊断、早期经验性抗感染治疗,撤除全部基础免疫抑制剂,静脉使用激素,进行无创通气及加强全身支持治疗,是肾移植术后重症肺炎治疗成功的关键.治疗期间全部撤除免疫抑制剂药物对患者安全有益,短期内对移植肾无害.

Objective To explore the experience of diagnosis and treatment of severe pneumonia after kidney transplantation.MethodsClinical data of16cases with severe pneumonia after kidney transplantation were retrospectively analyzed. All16patients were discontinued based immunosuppressant,antibiotics was empirically used and etiology was checked. Antibiotics were adjusted according to the test results. At the same time small dose of prednisolone and nutrition support were prescribed venously. Once there was difficulty in breathing and blood gas analysis suggested hypoxemia,an immediate noninvasive ventilation or endotracheal intubation treatment was initiated and its safety was evaluated. Results16 patients did not show acute rejection. Severe pneumonia often occurred in 3 to 4 months after kidney transplantation. The proportion of patients with severe pneumonia happened after 1 year was 18. 75 %(3 / 16). Fever and dyspnea was the most common onset symptom; there were 18. 75 %(3 / 16) of patients with obvious cough and sputum; pathogen detection rate of blood, phlegm and pharynx swab was low(43. 75 %). 13 cases of severe pneumonia patients recovered while 3 died, all who got transplantation over 1 year and had a diagnosis of transplant renal insufficiency. Conclusions Patients with severe pneumonia after kidney transplantation is severe with high mortality. Early diagnosis, early empirical anti-infection treatment, discontinuation of all based immunosuppressants, intravenous corticosteroids, noninvasive ventilation and strengthen the body support therapy are key points of successful treatment of severe pneumonia after kidney transplantation. Discontinuation of all immunosuppressant during the treatment is good for patients' safety,and is harmfulless to the transplanted kidney in the short term.