肝移植术后结核感染患者临床特征及危险因素分析

Clinical features and risk factor analysis of patients with tuberculosis infection after liver transplantation

目的总结肝移植合并结核病患者的临床特点、诊断措施和治疗方法,分析结核发病的相关危险因素、生存及预后情况,为肝移植术后结核病的诊断、治疗、预防提供参考。方法收集2003年1月至2017年1月在首都医科大学附属北京佑安医院及首都医科大学附属北京胸科医院收治的肝移植患者的临床资料进行回顾性分析,分为结核组(21例)和对照组(84例)。分析肝移植受体发生结核病的相关危险因素及患者的生存及预后情况。结果结核组21例,男19例,女2例;平均年龄(47.9±8.1)岁;移植术后确诊结核感染中位时间为10个月(0.7～182.4个月);2例患者因肝功能衰竭和肝癌复发死亡。单变量分析表明ABO血型相容不相同、T-BIL≥51μmol/L、SCr异常、腹水、术后细菌或真菌感染、巨细胞病毒(cytomegalovirus, CMV)感染、术后平均住院日等指标2组间差异有统计学意义。多因素回归分析显示,ABO血型相容不相同的肝移植(P=0.011,OR=14.316,95%CI:1.845～111.080)、SCr异常(P=0.005,OR=8.353,95%CI:1.928～36.184)、术后平均住院日(P=0.022,OR=1.032,95%CI:1.005～1.060)、CMV感染(P=0.008,OR=10.348,95%CI:1.820～58.836)是肝移植术后发生结核感染的危险因素。结论 ABO血型相容不相同、SCr异常、术后平均住院日较长、CMV感染是活动性结核感染的高危因素,肝移植术前应对潜伏性结核行感染筛查,确诊患者应术前进行抗结核治疗。

Objective To summarize clinical characteristics, diagnostic methods and treatment of tuberculosis（TB） patients after liver transplantation（LT）, and to analyze risk factors, survival rates and prognosis of TB infection after LT, in order to offer some theoretical references for future diagnosis, treatment and prevention of TB infection after liver transplantation. Methods Patients undergone orthotopic liver transplantation during January 2003 to January 2017 were collected retrospectively from Beijing You’an Hospital, Capital Medical University and Beijing Chest Hospital, Capital Medical University. All clinical data of enrolled patients were collected. Risk factors associated with TB infection after LT and survival after TB were analyzed. Results Twenty-one patients were diagnosed as TB（TB group）, including 19 male and 2 female, mean age was（47.9±8.1） years old and the prevalence of TB was 1.81%. The median diagnosis time after LT was 10 months（0.7～182.4 months）. No latent TB patients received isoniazid anti-TB treatment before LT. TB infection was well-controlled after anti-TB treatment in all patients. Two patients died of liver failure and recurrence of liver cancer.Eighty-four LT patients without TB were matched as control group. In univariate analysis, transplant with ABO bloodtype compatible but not identical（TB group 28.57% vs. control group 2.38%, P = 0.001）, T-BIL≥51 μmol/L（TB group47.62% vs. Control group 22.62%, P = 0.022）, abnormal creatinine level（TB group 38.10% vs. Control group 5.95%, P 〈0.001）, ascites（TB group 52.38% vs. Control group 27.38%, P = 0.029）, bacteria and/or fungus infection around LT（TB group 57.14% vs. Control group 28.57%, P = 0.014）, CMV infection（TB group 23.81% vs. Control group 3.57%, P =0.008） and mean hospital stay after LT（TB group vs. Control group, 39.52±13.68 vs. 29.54±18.89, P = 0.025） showed significant difference between two groups. According to multivariable analysis, main risk factors of TB infection after liver transplantation included transplant with ABO blood-type compatible but not identical（P = 0.011; OR=14.316; 95% CI：1.845～111.080）, abnormal creatinine level before LT（P = 0.005; OR=8.353; 95%CI：1.928～36.184）, mean hospital stay after LT（P = 0.022; OR=1.032; 95%CI：1.005～1.060） and CMV infection（P = 0.008; OR=10.348; 95%CI：1.820～58.836）.Conclusion Main risk factors of active TB infection may include transplant with ABO blood-type compatible but not identical, abnormal creatinine level before LT, long hospital stay after LT and CMV infection. Screening of latent TB should be addressed and preventive treatment should be achieved before LT in patients with TB diagnosis.