肾移植受者并发甲型流感病毒性肺炎的临床特点分析

Clinical characteristics of influenza A virus-induced pneumonia in renal transplantation recipients

目的分析肾移植受者罹患甲型流感病毒性肺炎的临床特点、预后及影响因素。方法前瞻性纳入首都医科大学附属北京朝阳医院2015—2019年流感季节住院的肾移植后甲型流感病毒性肺炎受者21例(肾移植组),并按1∶2比例匹配后纳入非免疫受损的甲型流感病毒性肺炎住院患者42例(非免疫受损组),收集并统计两组临床资料预后及出院后随访情况,分析肾移植后并发甲型流感病毒性肺炎的临床特点。计量资料应用独立样本t检验或秩和检验,计数资料应用卡方检验进行统计学分析。结果肾移植组罹患甲型流感病毒性肺炎的移植后中位时间为5(0.88,10.50)年,均未进行当季流感疫苗接种,接种率为0;非免疫受损组的当季流感疫苗接种率为42.86%(18/42),组间比较,差异有统计学意义(P<0.001)。实验室检查方面,肾移植组罹患甲型流感病毒性肺炎后血红蛋白、天冬氨酸转氨酶、丙氨酸转氨酶、乳酸脱氢酶水平分别为(108.47±22.39)g/L、21.00(16.00,46.50)U/L、15.00(12.00,21.00)U/L、314.00(207.25,374.00)U/L,均低于非免疫受损组(130.24±21.74)g/L、48.50(36.00,79.50)U/L、32.00(20.00,52.25)U/L、466.00(227.00,781.75)U/L,组间比较,差异均有统计学意义(P=0.001、P<0.001、P<0.001、P=0.005)。肾移植组就诊时血尿素氮和血清肌酐水平分别为8.27(6.69,12.48)mmol/L和130.30(94.15,204.70)μmol/L,与非免疫受损组5.42(3.37,7.65)mmol/L和65.90(48.98,82.13)μmol/L比较,差异均有统计学意义(P均<0.001)。炎症指标中,肾移植组和非免疫受损组C反应蛋白和降钙素原水平比较,差异均无统计学意义(P=0.774和0.821)。肾移植组血沉水平、入院时的氧合指数分别为39.00(13.00,53.00)mm/h和306.95±90.97,均高于非免疫受损组18.00(11.50,23.00)mm/h和200.17±116.35比较,差异均有统计学意义(P=0.045和0.001)。影像学检查显示,无论是肾移植组还是非免疫受损组,多肺叶受累的磨玻璃影均为其影像主要特点。肾移植组受者肺内实变和胸腔积液的概率分别为33.33%(7/21)和42.86%(9/21);前者较非免疫受损组64.29%(27/42)低,但后者明显较高16.67%(7/42),组间差异均有统计学意义(P=0.020和0.024)。相比非免疫受损组,肾移植组受者罹患甲型流感病毒性肺炎后,有创通气、连续性床旁血液滤过治疗使用率和病死率分别为42.86%(9/21)、23.81%(5/21)、28.57%(6/21),均较非免疫受损组21.43%(9/42)、9.52%(4/42)、9.52%(4/42)高,但组间差异均无统计学意义(P=0.076、0.252、0.113)。应用CURB-65评估两组甲型流感病毒性肺炎病情中位得分均为1(0.5,1.0)分。结论肾移植后罹患甲型流感病毒性肺炎住院受者肾损害较为突出,肺内病变以多肺叶受累的磨玻璃影为主,这类受者机械通气率和连续性床旁血液滤过使用率高、病死率高、预后不良,无论入院时病情严重程度如何,均需密切监测病情积极处置。

Objective To explore the clinical characteristics,outcomes and influencing factors of influenza A virus-induced pneumonia in renal allograft recipients.Methods During the 2015-2019 influenza season,21 patients with influenza A virus-induced pneumonia after renal transplantation(RT)were prospectively recruited with 42 matched non-immunocompromised inpatients with influenza A virus-induced pneumonia.Clinical data,outcomes and follow-up observations after discharge were collected for analyzing the clinical characteristics of influenza A virus-induced pneumonia after RT.Continuous variables were compared by t-test or Mann-Whitney U test.And categorical variables were compared by Chi-Square test.Results The median time after RT was 5(0.88,10.50)years for RT recipients.In RT group,none received seasonal influenza vaccination with a vaccination rate of zero.The influenza vaccination rate of non-immunocompromised patients in current season was 42.86%(18/42)and inter-group difference was statistically significant(P<0.001).The levels of hemoglobin,aspartate aminotransferase,alanine aminotransferase and lactate dehydrogenase in RT recipients were(108.47±22.39)g/L,21.00(16.00,46.50)U/L,15.00(12.00,21.00)U/L and 314.00(207.25,374.00)U/L.And the values were lower than those of non-immunocompromised patients[(130.24±21.74)g/L,48.50(36.00,79.50)U/L,32.00(20.00,52.25)U/L and 466.00(227.00,781.75)U/L].The differences were statistically significant(P=0.001,P<0.001,P<0.001,P=0.005).The levels of blood urea nitrogen and serum creatinine were 8.27(6.69,12.48)mmol/L and 130.30(94.15,204.70)mmol/L versus 5.42(3.37,7.65)mmol/L and 65.90(48.98,82.13)mmol/L in non-immunocompromised patients.The differences were statistically significant(all P<0.001).No significant differences existed in the levels of C-reactive protein and procalcitonin between RT recipients and non-immunocompromised patients(P=0.774 and 0.821).The level of ESR and oxygenation index at admission were 39.00(13.00,53.00)mm/h and(306.95±90.97)in renal recipients and 18.00(11.50,23.00)mm/h and(200.17±116.35)in non-immunocompromised patients.The differences were statistically significant(P=0.045 and 0.001).Imaging studies indicated that multiple lobar involvement was a major imaging feature in both renal recipients and non-immunocompromised patients.The probability of pulmonary consolidation was 33.33%(7/21)in renal recipients and it was lower than that in non-immunocompromised patients.And the probability of pleural effusion was 42.86%(9/21)and it was higher than control.The inter-group differences were statistically significant(P=0.020&0.024).Rate of mechanical ventilation,CRRT and mortality were 42.86%(9/21),23.81%(5/21)and 28.57%(6/21).All of them were higher than non-immunocompromised patients[21.43%(9/42),9.52%(4/42)and 9.52%(4/42)].However,there was no significant inter-group difference(P=0.076,0.252&0.113).The median score of CURB-65 was 1(0.5,1).Conclusions Renal damage is prominent in hospitalized patients with influenza A virus-induced pneumonia after RT.There are a high rate of mechanical ventilation and CRRT during hospitalization and a high mortality.The prognosis remains poor for hospitalized patients with influenza A virus-induced pneumonia after RT.No matter how serious their conditions are at admission,they need to be closely monitored and aggressively treated.