免疫抑制剂撤除治疗肝移植术后重症感染

Immunosuppressant withdrawal for the management of severe infection in liver transplantation recipients

目的 对肝移植术后围手术期并发重症感染患者,在检测CD4＋T细胞计数及ATP数值的前提下,暂时停用免疫抑制剂,并探讨治疗的有效性和安全性.方法 根据发生重症感染后是否停用免疫抑制剂,将51例患者分为对照组（24例）和试验组（27例）.试验组参考所检测CD4＋T细胞及ATP数值,停用免疫抑制剂；在感染得到控制后,逐渐恢复原免疫抑制治疗方案.对患者的肝功能、急性排斥反应及存活率等进行随访监测,并观察2组患者在治疗期间发生的不良反应.结果 51例患者中39例患者痊愈,12例死亡,其中对照组死亡9例,试验组死亡3例.试验组停用免疫抑制剂的时间为6 ～22 d,平均（15.5 ±4.8）d.CD4＋T细胞计数由（65.60±32.58）/μ1回升至（103.04±12.39）/μl,ATP由（79±23）μg/L回升至（112±11）μg,/L；与此同时,患者体温由38.3℃±1.2℃降至36.4℃±1.1℃,白细胞计数由（15.7±4.4）×109/L降至（6.3±3.8）×109/L,C反应蛋白由（153.4±37.1） mg/L降至（16.5±4.8）mg/L.在围手术期停用免疫抑制剂期间,未发生急性排斥反应以及肝功能恢复不良情况；试验组较对照组抗感染治疗效果好,存活例数高,且感染控制时间明显缩短（分别F=5.32,8.37,9.12,均P＜0.05）.结论 可以根据CD4＋T细胞计数及ATP数值量化评估肝移植受者的细胞免疫功能,在加强抗感染治疗的同时,配合撤除免疫抑制剂,有助于病情的控制.

Objective To explore the effectiveness and safety of temporary immunosuppressant withdrawal for the management of severe infection after liver transplantation.Methods Fifty-one patients with severe infection after liver transplantation were divided into control group （24 cases） and withdrawal group （27 cases ） according to the immunosuppression protocol.In the withdrawal group, the immunosuppressive drugs were temporarily suspended according to ATP values of CD4 ＋ T cell and CD4 ＋ T lymphocyte subsets counting until infection was controlled.The liver function,the incidence of acute rejection and the graft survival rate were monitored during the process.The side effects were observed.Result Severe infection was cured in 39 patients.There were 9 deaths in the control group in which the immunosuppressant was continued during the course of infection and 3 in the withdrawal group,respectively.The median suspension of immunosuppressant in trial group was （ 15.5 ± 4.8 ） d （ 6 ～ 22 d） ; CD4 ＋ T lymphocyte subsets counting rose from （65.60 ± 32.58）/μl to （103.04 ± 12.39）/μl,ATP values of CD4 ＋ T cell rose from （79 ±23） μg/L to （ 112 ± 11 ） μg/L; meanwhile,the temperature dropped from （38.3 ± 1.2） ℃ to （36.4 ± 1.1） ℃,WBC dropped from （15.7 ± 4.4） × 109/L to （6.3 ± 3.8） × 109/L,CRP dropped from （ 153.4 ± 37.1 ） mg/L to （ 16.5 ± 4.8） mg/L.During the course of treatment and follow-up,liver function of patients in the trial group remained normal and no acute rejection occurred.Compared with the control group,the temperature recovery time in the trial group was shorter （ respectively F =5.32,8.37,9.12,all P 〈 0.05） and the therapeutic outcome was better.Conclusions The cellular immune function test could be evaluated according to the ATP values of CD4 ＋ T cell and CD4 ＋ T lymphocyte subsets counting.For severe infection after liver transplantation, anti-infection treatment and simultaneously withdrawing immunosuppressants help to control the infection.