小肠移植术后巨细胞病毒感染二例的治疗体会

Cytomegalovirus infection after small bowel transplantation

目的总结小肠移植术后巨细胞病毒（CMV）感染的治疗经验。方法1994年至2009年间完成15例小肠移植，分为3个阶段：1994--1995年为第1阶段（3例），2003--2006年为第2阶段（7例），2007年以后为第3阶段（5例）。第1阶段术后未进行CMV感染的预防；第2阶段通过肠镜、病理检查和血清学检查（CMVIgM、CMVpp65和CMVDNA）进行CMV感染的诊断，术后静脉注射更昔洛韦2～3周，口服阿昔洛韦3个月以预防CMV感染；第3阶段在第2阶段的基础上，应用实时定量PCR技术检测CMVDNA，并制定计划性监测方案，术后静脉注射更昔洛韦2～3周，口服更昔洛韦3个月预防CMV感染，采用CMV感染的抢先治疗方案。结果15例患者中有2例（13．3％）术后发生CMV感染。其中第2阶段1例术后45d发生移植肠CMV肠炎，术后64d并发CMV肺炎，应用更昔洛韦和胸腺肽，并停用他克莫司，最终转为重度排斥反应后死亡；第3阶段1例术后第3个月发生CMV感染，经CMV抢先治疗后治愈。结论小肠移植术后应进行CMV的预防性治疗，严密监测CMV血清学指标，适时进行抢先治疗。对于CMV侵袭性疾病在进行有效治疗的同时应注意排斥反应的发生。

Objective Cytomegalovirus （CMV） has remained the most significant pathogen that threatens the outcome of small bowel transplantation （SBTx）. This paper To outline preliminary experience of prophylaxis and treatment of cytomegalovirus （CMV） in 15 cases subject to small bowel transplantation （SBTx） and also review current progress of diagnosis and treatment of CMV. Methods Fifteen cases of SBTx were divided into 3 eras： era Ⅰ （1994--1995）-3 SBTx treated with cyclosporine-based immunosuppressiom era Ⅱ （2003--2006）-7 SBTx treated with taerolimus-based immunosuppression; and era Ⅲ （2007-present）-5 SBTx treated with Alemtuzumab induction therapy and maintenance tacrolimus monotherapy. No antiviral prophylaxis after SBTx was applied during eraⅠ ; in era Ⅱ, ileoscopic and pathological diagnosis of CMV graft enteritis was defined, and plasma diagnosis tools including CMVdgM, CMV pp65 and CMV DNA with PCR were introduced. 2-3 weeks intravenous ganciclovir prophylaxis of CMV was underway, followed by 3 months oral acyclovin In eraⅢ, more precise real-time PCR technique was used to detect CMV DNA copies, and the schedule of the CMV surveillance was set up, antiviral prophylaxis therapy was modified to 2 3 weeks intravenous ganciclovir and 3 months oral ganciclovir, and preemptive therapy to halt the progression of asymptomatic infection to clinical disease was also introduced. Results Two of 15 SBTx recipients suffered from CMV with the occurrence rate of 13.30/oo. One recipient in era Ⅱsuffered from CMV graft enteritis on postoperative day 45, and CMV pneumonia on postoperative day 64, he received intravenous ganciclovir and thymus peptide, paused tacrolimus maintenance, and finally he died from severe acute cellular rejection. 94 100 copies/ml of CMV DNA in periphery blood of a recipient in era Ⅲ was detected with real-time PCR at 3rd month after SBTx, and a preemptive therapy successfully halted the CMV infection. Conclusion Antiviral prophylaxis therapy and close surveillance of CMV infection after SBTx should be performed, and preemptive therapy can also halt the CMV infection. When CMV disease occurs, the recipient should receive effective antiviral therapy, and acute cellular rejection also should be closely monitored at same time.