伴肺部侵袭性真菌病史的血液病患者行异基因造血干细胞移植的临床分析

Clinical analysis of recipients of allogeneic hematopoietic stem cell transplantation with a history of pulmonary invasive fungal disease

目的探讨血液病伴肺部侵袭性真菌病（IFD）病史患者行异基因造血干细胞移植（allo-HSCT）后其肺部IFD的复发、疗效及影响因素。方法2005年3月至2006年10月南方医科大学南方医院14例肺部IFD病史的血液病患者接受allo-HSCT，移植前经抗真菌治疗10例完全缓解（CR），4例部分缓解（PR），移植中均给予预防性抗真菌治疗。调查移植后肺部IFD的复发、疗效，IFD相关病死率，Logistic回归模型分析移植方式、移植前IFD状态、预处理方案、移植物抗宿主病（GVHD）预防方案[含抗胸腺球蛋白（ATG）和不含ATG]、供受关系、急性GVHD（aGVHD）及WBC重建对移植后肺部IFD转归的影响。结果移植后肺部IFD的复发率为71.4％（10／14），移植前10例CR患者6例复发，4例PR患者全部复发；其复发时间分别为移植后3个月内7例，4～6个月内3例；10例复发患者中9例接受抗真菌治疗后4例获CR，2例PR，3例无效（NR），总有效率为6／9；移植后IFD相关病死率为35.7％（5／14）；二性霉素B、伊曲康唑及佚立康唑预防肺部IFD的复发率差异无显著性意义（P=0.122）；经Logisitic回归分析未发现与移植后肺部IFD复发相关的危险因素及影响其转归的危险因素。结论肺部IFD病史不是allo-HSCT的绝对禁忌证；有肺部IFD病史的患者，其移植后IFD复发率及相关病死率高。

Objective To explore the relapse, therapeutic effect, risk and prognostic factors of the pulmonary invasive fungal disease（IFD） in patients with a history of pulmonary IFD following allogeneic hematopoietic stem cell transplantation（allo-HSCT）. Methods Fourteen patients with a history of pulmonary IFD received allo-HSCT between March 2005 and October 2006. Before transplantation, 10 patients obtained complete remission（CR） and 4 partial remission（PR） after antifungal therapy. Autifungal prophylaxis was initiated on the first day of the conditioning therapy. Logistic regression models were used for multivariable analyses. Results The relapse rate of pulmonary IFD after allo-HSCT was 71.43% （10/14）. Of 10 patients in CR,6 relapsed and all four patients in PR relapsed. Seven patients relapsed less than 3 months and 3 relapsed between four and six months after transplantation. Among the 10 patients with a history of IFD who relapsed after transplantation,9 patients received antifungal therapy ,4 obtained CR,2 PR again and the other 3 didn＇t obtain remission. The effective rate of antifungal therapy was 66.67% and the pulmonary IFD-related mortality was 35.71% （5/14）. There was no significant difference between amphotericin B, itraconazde and voriconazole for antifungal prophylaxis in patients with a history of pulmonary IFD（P=0.122 ）. No risk and prognostic factors of the pulmonary IFD was identified by multivariable analyses. Conclusion Pulmonary was not an absolute contraindication for allo-HSCT, and patients with a history of pulmonary IFD had a higher relapse rate and transplant-related mortality after receiving allo-HSCT.