供者来源CRKP导致肾移植受者感染、出血的诊疗经验

Experience in diagnosis and treatment of infection and bleeding caused by DCD-derived CRKP in kidney transplant recipients

目的探讨DCD供者来源耐碳青霉烯类肺炎克雷伯杆菌(Carbapenem-resistant Klebsiella pneumoniae, CRKP)感染导致肾移植受者感染、出血的临床特点,总结诊断、治疗及预防经验。方法回顾性分析2016年7月至2017年12月在医院产生的4例CRKP感染DCD供者及其相应的7例肾移植受者在感染及移植肾出血等方面的临床资料。结果4例供者在CRKP培养方面,分别为1例血培养阳性、1例尿培养阳性1例痰培养阳性及1例血、尿、痰培养全阴性。相对应的7例受者在肾移植术后血培养均为阳性,4例尿培养阳性,3例痰培养阳性,5例移植肾周引流液培养阳性。7例受者中,4例出现移植肾动脉出血,其中1例死亡,出血发生时间平均为术后17.75 d(14~19 d)。7例受者肾移植术后C反应蛋白(C-reactive protein, CRP)均升高,3例死亡受者CRP持续性高于正常,4例存活受者的CRP在有效抗感染治疗后逐渐降至正常范围。7例受者均应用碳青霉烯类抗生素治疗。2例受者未联合使用阿维巴坦治疗,均死亡;5例受者联合应用阿维巴坦和碳青霉烯类抗生素治疗,1例死亡,1例移植肾功能恢复良好。结论DCD供者的血、尿、痰等体液培养CRKP阳性,均可以导致肾移植受者感染CRKP。即使供者各体液培养全阴性,仍不能除外假阴性结果。术后CRP的持续或再次增高,对受者的CRKP感染有预警作用。且CRP可作为评估抗CRKP治疗是否有效的指标。联合应用阿维巴坦和碳青霉烯类抗生素,对于供者来源的CRKP治疗有效。

Objective To investigate the clinical characteristics of DCD donor-derived CRKP infection and bleeding in kidney transplantation, and to summarize the experience of diagnosis, treatment and prevention. Methods A retrospective analysis was carried out from July 2016 to December 2017 in hospital, containing clinical data of 4 cases of CRKP-infected DCD donors and 7 cases of kidney transplantation recipients. Results In the CRKP culture of 4 cases of DCD donors, 1 case was positive for blood culture, 1 case was positive for urine culture, 1 case was positive for sputum culture, and 1 case was negative for blood, urine and sputum culture. The corresponding 7 recipients were all positive for blood culture after renal transplantation, 4 cases were positive for urine culture, 3 cases were positive for sputum culture, and 5 cases were positive for perirenal drainage. Of the 7 patients, 4 cases had renal artery hemorrhage, 1 of them was died. The average bleeding time was 17.75 days after operation (14-19 days). In 7 patients with renal transplantation, CRP increasd. And in 3 cases of deaths, CRP was stably higher than normal. Meanwhile, CRP in 4 surviving patients gradually decreased to the normal range after effective anti-infection treatment. All 7 patients were treated with carbapenems;2 patients were dead without avibactam therapy;and 5 cases were treated with avibactam and carbapenems and survived, 1 case died and 1 case had good renal function recovery. Conclusion Positive CRKP in blood, urine and sputum of DCD donors can lead to CRKP infection in kidney transplant recipients. Even if the body fluids of donors are all negative, the false negative results could not be excluded. Persistent or increased high-level CRP after operation is an early warning on CRKP infection. And CRP can be used as an indicator for evaluating the effectiveness of anti CRKP therapy. The combination of avibactam and carbapenem antibiotics is an effective regimen in the treatment of DCD donor-derived CRKP.