造血干细胞移植相关早期并发症的防治

Prevention and treatment of early transplantation-related complications after hematopoietic stem cell transplantation

目的总结造血干细胞移植(HSCT)相关早期并发症的预防和治疗经验。方法 50例恶性血液病患者接受不同方法治疗,其中自体HSCT20例、异基因HSCT19例、混合HSCT10例和脐血HSCT1例。预处理方案包括白消安+环磷酰胺,卡莫司汀+依托泊苷+阿糖胞苷+马法兰,大剂量马法兰等。异基因HSCT患者采用环孢素+甲氨蝶呤为主的移植物抗宿主病(GVHD)预防方案,其中非亲缘异基因HSCT患者则采用环孢素+甲氨蝶呤+吗替麦考酚酯+抗胸腺细胞免疫球蛋白为主的GVHD强化预防方案。所有患者均采用小剂量肝素及复方丹参,部分联合前列腺素E1脂质体微球预防肝静脉闭塞病。所有献血员进行CMV特异性抗体筛查和分次全身照射。结果 50例患者中发生肝静脉闭塞病1例(2.0%),该患者合并Ⅳ度GVHD,症状持续加重且治疗无效,于+26d死亡。CMV血症4例(8.0%),1例发生CMV间质性肺炎,经过抗病毒治疗后痊愈。30例异基因及混合HSCT患者中16例(53.3%)发生急性GVHD,其中Ⅰ度3例、Ⅱ度6例和Ⅲ～Ⅳ度7例,经过治疗后,4例重度患者死亡,其余12例病情控制;6例(20.0%)发生慢性GVHD。发生出血性膀胱炎2例(4%),经对症治疗后痊愈。结论通过筛查献血员CMV-IgM和CMV-IgA抗体,输注经照射及白细胞滤除的血制品,监测CMV-pp65及抗CMV抗体,预防性使用抗病毒药物及分次全身照射等综合措施可以有效地防治CMV感染。对不同移植种类的受者采用不同强度的GVHD预防方案十分必要。

Objective To summarize the single-center experience in prevention and treatment of transplant-related complications after hematopoietic stem cell transplantation(HSCT).Methods Clinical data of 50 HSCT recipients were retrospectively analyzed.Conditioning regimens included busulfan/cyclophosphamid,carmustine/etoposide/cytarabine/melphalan,and high dose melphalan.Cyclosporine and short-term methotrexate were given to prevent graft-versus-host disease(GVHD) in allogeneic HSCT recipients,among which mycophenolate mofetil and antithymocyte globulin were added to prevent GVHD in unrelated donor transplantations.Low-dose unfractionated heparin and compound Dangseng and prostaglandin E1 were given to prevent hepatic veno-occlusive disease.Antibody of CMV and CMVpp65 in recipients and blood donors were detected and screened to prevent CMV infection.Results Of the 50 patients,one patient(2%) had hepatic veno-occlusive disease and 4 patients(8%) had CMV infection.Acute GVHD occurred in 16 patients(53.3%,16/30),including 3 patients of gradeⅠ,6 patients of gradeⅡ,and 7 patients of grade Ⅲ to Ⅳ.Four patients died from severe acute GVHD after treatment and the other 12 were cured.Six patients(20.0%) developed chronic GVHD.Hemorrhagic cystitic(gradeⅡ) developed in 2 patients(4.0%).Conclusion Detecting antibodies of CMV and CMVpp65,screening of blood donors,and using antiviral drugs and fractioned total body irradiation can make CMV infection easier to control.Different protocols to prevent GVHD should be adopted according to different types of HSCT.