肾移植患者肺部重症感染的原因及救治措施分析

Causes and treatments of severe pulmonary infection in kidney transplant recipients

目的探讨。肾移植术后重症肺部感染的原因、特点及救治措施，以提高人肾存活率。方法分析总结2009年1月至2012年8月收治的24例同种异体尸肾移植术后重症肺部感染患者的临床资料。结果24例患者中细菌感染8例，先后以静脉注射头孢哌酮／他唑巴坦和美罗培南治疗；巨细胞病毒感染3例，予静脉注射更昔洛韦治疗；真菌感染2例，静脉应用伊曲康唑或两性霉素B脂质体治疗；结核杆菌感染1例，口服四联抗结核药物治疗；混合感染5例，分别为巨细胞病毒＋细菌混合感染（3例），白念珠菌＋细菌（1例）、卡氏肺囊虫＋细菌（1例），依病原体类型，静脉联合用药；5例未获得病原学依据，根据影像学特点，予经验性联合用药抗感染治疗。24例患者予面罩吸氧或气管插管辅助通气纠正低氧血症、减少免疫抑制剂用量，并静脉应用丙种球蛋白提高免疫力等综合治疗。24例患者中治愈19例，临床治愈并继续抗结核治疗l例；死亡4例，其中移植肾带功死亡2例，移植肾失功死亡2例。结论肾移植术后重症肺部感染患者病情凶险，进展迅速，易导致患者死亡。尽早明确病原体，果断及时采取抢救措施是救治成功的关键。

Objective To summarize the causes, features and treatments of severe pulmonary infec-tion （PI） in kidney transplant （KT） recipients for improved outcomes. Methods Clinic data for 24 KT recipients with severe PI were analyzed between Jan 2009 and Aug 2012. Results Eight patients were in-fected with bacteria, intravenous Cefoperazone/Tazobactam and Meropenem were administered to these pa-tients; 3 were diagnosed with cytomegalovirus （CMV） infection, and intravenous ganciclovir was given therefore. Two were infected by fungus, and was treated with Itraconazole or Amphotericin B. Oen was diag-nosed with Mycobacterium tuberculosis, and was treated with oral quadruple anti-tuberculosis drugs; 5 were infected with mixed pathogens： 3 CMV and bacterium, 1 Candida albicans and bacterium, and 1 Casparian pneumocystis and bacterium. The treatment for these 5 patients were combined regimens. Five cases were diagnosed with severe PI with unknown pathogens. Mask oxygen inhalation/mechanical ventilation for hypox-emia, immunosuppressant reduction and intravenous immunoglobulin were all applied for 24 patients. 19 of 24 patients were completely cured, 1 obtained clinical remission with continuous oral anti-tuberculosis drugs, 2 were dead with functioning grafts and 2 were dead after graft loss. Conclusions Severe PI after KT is an important complication with rapid progression and poor outcomes. The keys to successful rescue for severe PI are identification for the pathogens and prompt treatment after diagnosis.