从肾移植术后感染新冠肺炎谈免疫宿主低下人群的管理

Management of immunocompromised renal transplant patients infected with coronavirus disease 2019

目的通过分析1例肾移植术后感染新型冠状病毒肺炎(新冠肺炎)患者的治疗过程,谈对免疫宿主低下人群的管理策略。方法回顾本医疗队在新疆维吾尔自治区霍尔果斯市定点医院2021年10月收治的1例肾移植术后合并新冠肺炎患者的诊治经过,分析其病史、实验室及影像学检查、治疗方案及转归。结果受者为中年男性,在肾移植后3年发病,以中低热起病,伴咳嗽、乏力。胸部CT示双肺胸膜下多发磨玻璃影,以双下肺为著,渐进性加重,直至出现"白肺",早期合并肾功能及心功能不全。在治疗过程中,免疫抑制剂应用减量,并增大了糖皮质激素的用量,早期因肾功能不全和高钾血症透析3次,给予阿比多尔及连花清瘟胶囊口服抗病毒治疗,抗感染治疗,使用特种免疫球蛋白及恢复期血浆静脉滴注增强患者的免疫力,最终患者临床治愈。结论肾移植术后合并新冠肺炎患者的临床表现及诊断与其他人群无明显差异,但此类免疫宿主低下患者更易出现器官功能的损害,肾移植受者合并重型新冠肺炎治疗过程中免疫抑制剂及糖皮质激素用量如何调整、呼吸支持、抗菌药物选择、器官保护、营养支持及中医药干预等方面需要进一步探讨。

Objective To analyze the treatment process of a renal transplant patient infected with coronavirus disease 2019(COVID-19),and discuss the management strategy for the immunocompromised hosts.Methods The diagnosis and treatment of a case of transplant patients with COVID-19 admitted to Horgos designated hospital of Xinjiang Uygur Autonomous Region in October 2021 were reviewed.The medical history and laboratory and imaging examination treatment and outcome of this case were analyzed.Results The recipient was a middle-aged male with a time from renal transplantation of 3 years.The onset was moderate to low fever,accompanied by cough and fatigue.Chest CT showed multiple ground glass shadows under the pleura of both lungs,mainly in both lower lungs,gradually worsening until"white lung"appeared,with early renal and cardiac insufficiency.In the course of treatment,immunosuppressants were reduced and the dosage of glucocorticoid was increased.In the early stage,due to renal insufficiency and hyperkalemia,dialysis was conducted for 3 times.Oral abidol and Lianhua Qingwen capsule were given as antiviral and anti-infection treatment.Special immunoglobulin and convalescent plasma of COVID-19 were used to boost the immunity of patients.The patient was eventually clinically cured.Conclusions The clinical manifestations and diagnosis of COVID-19 for the kidney transplantation recipient are not significantly different from other populations,but immunocompromised hosts are more likely to suffer from organ dysfunction.The adjustment of immunosuppressants and glucocorticoids,respiratory support,selection of antibiotics,organ protection,nutritional support and traditional Chinese medicine intervention in the treatment of renal transplant recipients with severe COVID-19 need further discussion.