肾移植患者术后重症肺部感染的诊治经验(附46例报告)  

Diagnosis and treatment of severe pulmonary infection after renal transplantation:a report of 46 cases

作　　者：曾力[1] 刘鹏[1] 张雷[1] 傅尚希[1] 韩澍[1] 朱有华[1] 

机构地区：[1]第二军医大学长征医院解放军器官移植研究所,上海200003

出　　处：《器官移植》2011年第3期152-156,共5页Organ Transplantation

摘　　要：目的总结肾移植患者术后重症肺部感染的诊断和救治经验。方法回顾分析2008年1月至2010年12月期间诊治的46例肾移植术后并发重症肺部感染患者的临床资料。结果 38例肾移植术后重症肺部感染患者的发病时间为术后2～6个月,8例发生于术后6个月以上。46例的主要临床表现特点为不同程度的发热、咳嗽、胸闷、气促,其中并发急性呼吸窘迫综合征20例。胸部计算机断层摄影术检查结果均有明显间质性肺炎典型表现。检出病原体36例(78%),未检出10例。细菌性肺炎7例,真菌性肺炎6例,混合感染23例,其中仅有3例为巨细胞病毒感染。治疗采用综合治疗方案,包括经验性降阶梯治疗方案治疗,停用或调整免疫抑制剂用量和组合方案,部分病例采用连续肾脏替代治疗,并予支持治疗、改善通气、纠正低氧血症、免疫替代治疗。46例患者中38例(83%)治愈,8例(17%)死亡。结论肾移植术后重症肺部感染多发生在术后6个月内,病原体呈多样性。及早确诊、积极采用综合治疗方案,包括给予经验性降阶梯治疗措施,及时调整免疫抑制方案,纠正低蛋白血症,加强全身支持治疗,适时应用呼吸机支持和改善通气,纠正低氧血症等是救治成功的关键。Objective To summarize the diagnosis and treatment of severe pulmonary infection after renal transplantation.Method Clinical data of 46 patients with severe pulmonary infection after renal transplantation were retrospectively analyzed from January 2008 to December 2010.Results Severe pulmonary infection occurred in 38 cases during 2-6 months and 8 cases more than 6 months after renal transplantation.The clinical symptoms mostly presented as fever,cough,dyspnea,tachypnea,and 20 patients developed acute respiratory distress syndrome.All cases had typical computed tomography（CT）signs of interstitial pneumonitis.Pathogens were detected in 36 cases（78 %）but not in the other 10 cases.Among the 36 cases with positive pathogens,7 patients were infected with bacteria,6 with fungus,23 with mixed pathogens,and only 3 cases with cytomegalovirus（CMV）.Comprehensive treatment was taken,including empirical de-escalation therapy,immunosuppression dosage and combination adjustment.Continuous renal replacement therapy,support therapy,ventilation function improvement,hyoxemia correction and immune replacement therapy were applied in some cases.In 46 patients,38 patients（83 %）were cured and 8 patients died（17 %）.Conclusions Severe pulmonary infection always occurs in the first 6 months after renal transplantation with various pathogen.Intensive care and energetic treatment should be taken.Successful treatment can be anticipated by using the following measures：empirical de-escalation therapy based on clinical manifestations,effective antibiotic therapy,prompt adjustment of immunosuppression regimen,correction of hypoproteinemia,systemic support as well as improvement of respiratory function and correction of hypoxemia by using ventilator.

关 键 词：肾移植 重症肺部感染 细菌感染 真菌感染 病毒感染 治疗 

分 类 号：R563[医药卫生—呼吸系统]