肾移植术后肺结核的临床特点及早期诊断的单中心经验

Single center experience on characteristics of pulmonary tuberculosis in renal transplant recipients

目的分析和总结肾移植术后肺结核的临床特征及诊断和治疗的经验。方法 1 394例肾移植受者中,术后有32例诊断为肺结核,回顾性分析32例患者的临床资料。结果本组患者术后肺结核发生率为2.29%,发病时间为术后6～62个月,中位时间19月,其中术后12月内发病12例(37.5%),12～24个月发病9例(28.1%),24～36个月发病6例(18.8%),36个月以后发病5例(15.6%)。本组所有病例均以发热为首发表现或唯一表现,其中高热多见;部分患者伴有呼吸道症状和乏力消瘦等全身症状。5例(15.6%)患者胸片即高度考虑肺结核,其余27例(84.4%)患者随后行胸部CT考虑肺结核可能性大。9例(28.1%)患者根据病史、影像学资料结合痰涂片抗酸杆菌染色阳性确诊。6例(18.8%)患者根据病史、影像学资料结合结核感染T细胞斑点试验(T-SPOT.TB)阳性确诊。其余17例(53.1%)患者根据病史和影像学资料或结合实验性抗结核治疗有效而做出临床诊断。所有患者遵循早期、规律、全程、适量、联合原则进行抗结核治疗。经过规律抗结核治疗后30例患者6～18个月后痊愈。此外,T-SPOT.TB与现有的一些结核诊断手段相比,具有明显的优势,在结核病诊断中有重要价值。结论肾移植术后肺结核临床症状不典型,部分患者也缺乏典型影像学和细菌学证据,诊断困难,而影响治疗和预后。因此对于肾移植术后临床症状不典型,结核菌素试验(PPD)诊断不明确,涂片及培养均为阴性的疑似肺结核患者中,T-SPOT.TB作为一种新的检测结核感染的酶免疫学方法,可以帮助确诊,利于肺结核的早期快速诊断。

Objective To analyze the characteristics of pulmonary tuberculosis（PTB） in renal transplant recipients in this hospital, and to summarize the corresponding experience in diagnosis and management. Methods This study was a retrospective review of clinical data of 1394 renal transplant recipients in this hospital during the period of January 2001 to December 2010. Results Thirty - two recipients with a mean age of 42 （ range from 20 to 72） years old developed PTB. The incidence of PTB was 2.29% and the mean duration from transplantation to occurrence of FIB was 19 （6 -62） months. Clinical manifestations in this group of patients might be atypical and diverse. Tuberculin test had several limita- tions regarding diagnosis in renal transplant recipients. The major symptom was fever （ 100% ）. All these patients received anti - TB treatment with combination therapy of 3 drugs for standard duration of 6 months, then dosage was adjusted based on clinical condition. Because of drug inter- action, patients were increased in dosage of calcineurium inhibitor, but no change in steroid. Four patients had an elevated creatinine （Cr） level. Two patients did not recover owing to tissue - proof chronic aUograft. The other two patients happened tissue - proof acute rejection, and their renal function recovered after treatment. Thirty patients were successfully treated, two patients remained under treatment due to the positive T - SPOT. TB. One patient lost the kidney then returned to hemodialysis and no patient died. Risk factors for PTB in post transplantation were episodes of rejection, modalities for acute rejection （ high - dosage steroid and anti - lymphocyte globulin）, and maintenance therapy with steroid. Conclusion Post transplantation PTB is a serious worldwide problem, and a high index of suspicion is warranted to ensure early diagnosis and prompt initiation of treatment for PTB in renal transplant patients. T - SPOT. TB shows higher sensitivity and specificity than PPD and serum methods.