小肠移植后并发侵袭性真菌感染的治疗  

Invasive fungal infection after small bowel transplantation

作　　者：李元新[1] 李宁[1] 李幼生[1] 倪小冬[1] 王剑[1] 黎介寿[1] 

机构地区：[1]南京军区南京总医院普通外科研究所,210002

出　　处：《中华器官移植杂志》2010年第2期97-100,共4页Chinese Journal of Organ Transplantation

基　　金：国家科技支撑计划项目（2008BA160B06）

摘　　要：目的总结小肠移植术后侵袭性真菌感染（IFI）的治疗经验和教训。方法将1994年至2009年6月间15例小肠移植患者分为3个阶段，1994—1995年的3例患者为第1阶段，2003—2006年的7例患者为第2阶段，2007年以后的5例患者为第3阶段。第1和第2阶段患者围手术期真菌感染的预防方案采用静脉注射氟康唑，IFI的治疗以静脉注射氟康唑为主，在病情危重时静脉注射两性霉素B或两性霉素B脂质体，首次用量为1～5mg／d（或0．02～0．10mg·kg^-1-d^-1），视患者耐受情况每日增加5mg；第3阶段患者围手术期真菌感染的预防方案采用静脉注射两性霉素B脂质体，治疗IFI时，两性霉素B脂质体首次给药便达到目标治疗剂量，用量高达6mg·kg^-1·d^-1，并严密监测患者的生命体征，肝肾功能及电解质的变化，根据患者病情的变化和肾功能的状况调整剂量。结果15例患者中有4例术后发生IFI，发生率为26．7％，其中第1、2和第3阶段患者中分别有1例、2例和1例发生IFI。第1和第2阶段3例发生IFI的患者经治疗无效死于严重IFI，第3阶段1例发生IFI的患者经两性霉素B脂质体治疗44d后被成功救治。治疗期间，患者尿素氮和血清肌酐水平均显著升高，停药后逐渐下降至正常水平。3个阶段患者总体病死率为75％。结论小肠移植术后IFI是极其凶险的并发症，病死率极高；两性霉素B脂质体能够成功救治IFI患者，在严密监测。肾功能下，大剂量应用两性霉素B脂质体是安全的。Objective Invasive fungal infection （IFI） after small bowel transplantation （SBTx） is aggressive and associated with high mortality rates. This paper reviewed preliminary experience of treatment of IFI in 15 cases after SBTK Methods Fifteen cases of SBTx were divided into 3 groups according to the eras： era I （1994-1995）-3 cases of SBTx treated with cyclosporine-based immunosuppression, era II （ 2003-2006 ）-7 cases of SBTx treated with tacrolimus-based immunosuppression, and era III （2007-present）-5 cases of SBTx treated with Alemtuzumab induction therapy and maintenance tacrolimus monotherapy. During era I and era If, Fluconazole IV was used as prophylaxis and treatment protocol. If the IFI was aggressive, Amphotericin B or Amphotericin B Liposome were also given with initial dose of 1-5 mg/d （or 0. 02-0. 10 mg·kg^-1·d^-1 ）. During era III, 2- weeks Amphotericin B Liposome was used as prophylaxis therapy after SBTx, and the dose of 6 mg·kg^-1·d^-1 of Amphotericin B Liposome was given to treat IFI after SBTx. The administration manner of Amphotericin B Liposome was also improved during era III, and the initial dose achieved 6 mg without gradually increasing process. Closely surveillance of vital sign, liver and renal function, and electrolyte was also carried out, and the doses of Amphotericin B Liposome were titrated according liver and renal function. Results Four of 15 SBTx recipients suffered from IFI with the occurrence rate of 26. 7 %, 1, 2 and 1 recipient（s） suffered from IFI during different 3 eras, respectively. Three recipients died of severe IFI after SBTx during era I and era II. One SBTx recipient with IFI during the era III totally recovered after 44-days treatment of Amphotericin B Liposome with the totally dose of 9100 mg, and the renal dysfunction was observed and.ameliorated after ceasing of Amphotericin B Liposome. The mortality of these 4 IFI after SBTx was 75 %. Conclusion IFI after SBTx is associated with high mortality rate. Amphotericin B Liposome can effe

关 键 词：小肠移植 真菌 感染 两性霉素B 

分 类 号：R519[医药卫生—内科学]