调整免疫抑制剂对肝移植感染预后的影响

Effect of adjusting the immunosuppressants on the prognosis of the infection in the patients with liver transplantation

目的探讨肝移植感染调整免疫抑制剂的方法。方法2005年1月-2007年12月采用感染相关器官衰竭评分（SOFA）在肝移植后发生感染者SOFA≥15分时，停用免疫抑制剂，并予综合治疗；再根据SOFA评分将其进一步分为SOFA 15～17分（A组，10例）和≥18分（B组，16例）两组，并以2003年3月-2004年12月肝移植后发生感染未停用免疫抑制剂者为对照（C组，13例），观察调整免疫抑制剂对排斥反应和预后的影响，及其发生时间和SOFA评分的关系。结果调整免疫抑制剂后，随着感染的控制，有9例发生排斥反应，A组5例（50．0％），B组4例（25．0％），C组无一例发生；3组间比较差异有统计学意义（X^2=8．0，P=0．02），但A、B组间差异无统计学意义（x^2=1．70，P=0．19）。发生排斥反应时，SOFA评分较停用抗排斥反应药物时明显降低[（9．78±3．14）分比（17．22±1．86）分，t=6．10，P=0．00D。发生排斥反应的时间平均为停用免疫抑制剂后（17．56土2．60）d。共死亡25例患者，其中A组5例（50．0％），B组7例（43．8％），C组13例（100．0％）；发生排斥反应的患者无一例死于严重感染所致多器官衰竭；调整免疫抑制剂可降低肝移植感染的病死率（x^2=7．60，P=0．02）。结论SOFA可用于指导肝移植感染免疫抑制剂的调整，当SOFA≥15分时停用免疫抑制剂，可以不增加排斥反应的发生率，且能减少病死率.SOFA评分越低，病情好转越快，但越容易发生排斥反应。为及时调整免疫抑制剂的使用，可缩短SOFA评分间隔。

Objective To explore the method of adjusting the immunosuppressants in serious infection after liver transplantation. Methods With reference to sepsis-related organ failure assessment （SOFA）, 2005.1 - 2007.12, when the patient＇s score ≥15, the immunosuppressants were withdrawn, and the patients were given powerful antibiotics and the other treatments in combination. They were further divided into two groups, SOFA 15 - 17 （group A, 10 cases） and ≥18 （group B, 16 cases）. They were compared, and also with the patients without stoppage of immunosuppressants （group C, 13 cases, 2003.3 2004.12）. After withdrawing the immunosuppressant, the rejection incidence and times, the changes in SOFA score and mortality and their relationships were analyzed. Results After adjusting the immunosuppressant and with control of serious infections, rejection occurred in 9 patients, with 5 cases in group A （50. 0%）, 4 in B （25.0%）, none in C. The differences among groups showed statistically significant difference （X^2= 8.0, P=0. 02）, but no difference was seen between group A and B （g2： 1.70, P： 0. 19）. When the rejection developed, the SOFA score decreased obviously （9.78±3.14 vs. 17.22±1.86, t=6.10, P=0.00）. The time of rejection was （17.56±2.60） days after stopping the immunosuppressant. All 25 deaths were due to serious infection with multiple organ dysfunction syndrome, but not rejection. Five deaths occurred in group A （50. 0%）, 7 in B （43.8%）, 13 in C （100. 0%）. Not a single patient with rejection died from infection. Proper adjustment of the immunosuppressants could decrease the mortality （X^2 = 7.60, P = 0.02）. Conclusion SOFA score could be used to guide the adjustment of the immunosuppressants, when SOFA≥ 15, the immunosuppressants could be stopped, which would not increase the rejection incidence and decrease mortality. The lower the SOFA score is, the faster the patients recuperate better, but more rejection develops. In order to adjust the immunosuppressant in time, the period with high SOFA score should be shortened.