肾移植术后监测CD4^＋T淋巴细胞对防治巨细胞病毒肺炎的临床意义

CD4^+ T lymphocyte detection in renal transplant recipients and its clinical value for cytomegalovirus pneumonia treatment

目的探讨监测CD4+T淋巴细胞对防治肾移植术后巨细胞病毒(cytomegalovirus,CMV)肺炎的临床意义。方法2005年1月至2008年3月,监测133例肾移植术后受者外周血CD4+细胞计数的动态变化,根据其变化调整免疫抑制剂(CsA/FK506+MMF+Pred)的用量,观察调整用药对CMV肺炎发病的影响。结果共有36例受者CD4+细胞明显下降,发生在术后45～72(61.5±9.3)d,均给予减少或停用免疫抑制剂处理。133例受者有12例出现CMV肺炎,发病在术后58～118(76.2±11.6)d,其中7例伴有急性呼吸窘迫综合征(ARDS)。CD4+细胞下降受者CMV肺炎的发病率(27.8%,10/36)明显高于CD4+细胞稳定受者(2.1%,2/97)(P<0.01),在调整用药期间有2例发生急性排斥反应,发生率无明显增加(P>0.05)。12例CMV肺炎病人8例(66.7%,8/12)治愈,4例(33.3%,4/12)死亡。24例未发病受者在调整用药后CD4+细胞迅速上升,在14d恢复到术前水平;8例CMV肺炎治愈者上升较缓慢,在21d恢复;而4例死亡病人持续保持在低水平。结论肾移植术后CD4+细胞的变化与CMV肺炎发病有密切相关性,依据其变化在CMV肺炎发病之前减少或停用免疫抑制剂是安全的,为预防和救治CMV肺炎提供一条新的方法。

Objective To explore the clinical value of CD4^＋T lymphocyte detection in the treatment of cytomegalovirus （CMV） pneumonia following kidney transplantation. Methods From January 2005 to May 2008,133 recipients of kidney transplantation were enrolled in this study. The number of CD4^＋ cells in peripheral blood was examined. According to the changes of CD4^＋T cell, immunosuppressive agents （CsA/FK506＋MMF＋Pred）were adjusted, and the effects of CMV pneumonia occurring were investigated. Results In the period of 45-72 day after renal transplantation, 36 cases were found＇ to have significantly lower number of CD4^＋T cells than that before operation. Of the 133 recipients, 12（9.0%, 12/133） had severe pneumonia, during 58-118 days after operation, including 7 with acute respiratory distress syndrome （ARDS）; 4 patients （33.3%, 4/12） died and 8（66.7%, 8/12） were cured. The incidence of CMV pneumonia（27.8%, 10/36） in the low- CD4^＋ cell recipients was significantly higher than that（2.1%, 2/97） in patients with normal T cell level（P〈0.01）. During the withdrawal of immunosuppressive agents, 34 patients had normal kidney function （serum creatinine 71-126 umol/L）, except 2 cases underwent mild acute rejection. In 24 non-pneumonia recipients, the number of CD4^＋T cell kept growing as the withdrawal, on 14, 21 day after the withdrawal increased markedly compared with that on 0 day. In 8 survival patients with CMV pneumonia, the number of CD4^＋ cell rose slowly, on 21 day after the withdrawal increased to the normal level. But in 4 non-survival patients, the number of CD4^＋T cell kept continuously in lower level. Conclusion CMV pneumonia is associated with lower CD4^＋ cell level in kidney transplant recipients. Determination of CD4^＋ T cell could reflect the status of cellular immunity and give directions of the withdrawal. Discontinuance of immunosuppressive agents in severe CMV pneumonia patients was safe. However, it may be helpful to guide the clinical treatment.