肾移植术后肺部感染的鉴别诊断

Clinical Differential Diagnosis of Pulmonary Infection after Renal Transplantation

肾移植术后并肺部感染是重症监护病房患者死亡的重要原因,感染的症状及体症呈复杂多样化,变化迅速。肾移植后因长期使用免疫抑制剂,肺部感染的病原体多为混合性感染,常见的病原体如铜绿假单胞杆菌、大肠埃希菌、肺炎克雷伯氏杆菌、金黄色葡萄球菌、尤其是耐甲氧西林的金黄色葡萄球菌、结核杆菌、麻疹病毒、巨细胞病毒、呼吸道合胞病毒、真菌、军团菌及卡氏肺孢子虫等病原体引起的肺部感染,尤其是军团菌及卡氏肺孢子虫在免疫抑制患者中感染逐渐增加。从临床表现判断肺部感染病因的诊断较困难,病原学检查需要特殊的检查手段如肺泡灌洗及保护性样本刷取样,胸部X线表现具有一定的参考价值,尤其早期CT检查更有意义。为了明确肺部感染的病因学,患者表现、实验室检查结果及X线表现进行综合考虑是十分必要的,这有利于肺部感染的预防及控制。

The pulmonary infection after renal transplantation is the main cause of deaths of the patients in intensive care unit （ICU）. The etiological microorganisms of pulmonary infection in post-renal transplantation by using long-term immunosup- pressant were a wide spectrum of bacteria pathogens, including aerobic gram-negative bacilli, such as P.aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species, and gram-positive cocci, Staphylococcus aureus, particularly medthicillin-resistant S.aureus（MRSA）, Mycobacterium tuberculosis,virus such as measles,respiratory syncytial viral, adenovirus,especial cytomegalovirus （CMV）,fungus such as Candida species and Aspergillus fumigatus, and Legionella pneumophila and Pneumocystis carinii （PC）. It is very difficult to make the clinical etiological microorganisms differential diagnosis of the pulmonary infection. The evidence for Legionella pneumophila and Pneumocystis carinii as a cause of pulmonary infection is variable, but is increased in immunocomproraised patients. The bacteriologic strategy requires specialized laboratory and clinical skills. Blind samping can be done by protected specimen brush and bronchoalveolar lavage, or a blind bronchial suction sample can be taken. Usually the X-ray findings of specific pulmonary infection after kidney transplantation are valuable, while chest CT scan is more significant in fmding focuses at ear- ly stage and in differentiated diagnosis. In order to define the etiology of pulmonary infection, it is necessary that the manifestation of patients, laboratory reports and the findings of X-rays are comprehensively considered, which will be favourable for prevention and control of pulmonary infection after renal transplantation.