抗中性粒细胞胞质抗体相关血管炎合并感染患者的临床特征  

Infectious complications in patients with ANCA associated vasculitis

作　　者：杨柳[1] 谢红浪[1] 刘正钊[1] 陈樱花[1] 成水芹[1] 章海涛[1] 刘志红[1] 胡伟新[1] 

机构地区：[1]南京军区南京总医院肾脏科国家肾脏疾病临床医学研究中心全军肾脏病研究所,南京210016

出　　处：《肾脏病与透析肾移植杂志》2015年第4期331-336,共6页Chinese Journal of Nephrology,Dialysis & Transplantation

基　　金：国家科技支撑计划课题(2013BAI09B04;2015BAI12B05);江苏省临床医学中心项目(BL2012007)

摘　　要：目的：回顾性分析抗中性粒细胞胞质抗体（ANCA）相关血管炎（AAV）治疗过程中合并感染患者的流行病学特点、临床特点、危险因素及预后。方法：1996年1月至2013年12月确诊AAV伴肾脏损害的患者255例,其中男性103例,女性152例,年龄14～78岁（中位年龄55岁）。诱导治疗方案包括单用激素、激素联合间断环磷酰胺静脉冲击疗法（IV-CTX）或吗替麦考酚酯（MMF）、多靶点疗法或雷公藤多苷（TW）。感染诊断依据临床症状、实验室和微生物检查,收集治疗过程中出现的多种中度以上感染患者,分析感染发生的时间、部位、发生率及危险因素。结果：在中位随访15月（1～155月）期间,共86例（33.7%）发生103次感染。单用激素（n=65）、MMF（n=77）、IV-CTX（n=66）和TW（n=40）诱导治疗期内感染发生率分别为38.5%、39.0%、33.3%和22.5%。76次（73.8%）感染发生在治疗6个月内,其中3个月内66次（64.1%）。感染最常见部位为肺（n=74）,其次为皮肤、消化道和泌尿道,6例发展为脓毒症;感染病原体以细菌最常见（78.6%）,其次为真菌（12.6%）和病毒（8.7%）。COX回归模型显示前驱感染（RR=4.105,95%CI=2.557～6.592）、血清肌酐≥530.4μmol/L（RR=1.179,95%CI=1.090～1.276）和使用CTX治疗（RR=1.889,95%CI=1.020～3.500）是感染发生的独立危险因素。肺部影像学征象表现以大叶性肺炎（51.4%）最为多见,依次为弥漫间质性肺炎（28.4%）或多发结节样病灶（17.6%）。12例（11.7%）患者均死于肺部感染。结论：AAV治疗过程中并发感染的发生率高且好发于治疗前3个月内,病变部位以肺最为常见,病原体以细菌感染比例最高。前驱感染、严重肾功能不全和使用CTX治疗是感染发生的独立危险因素。Objective： To investigate the incidence,epidemiologic and clinical characteristics and risk factors of infection in patients with antineutrophil cytoplasmic antibody（ ANCA）-associated vasculitis（ AAV）. Methodology： Two hundred fifty five patients（ male 103 and female 152,age 14 ～ 78 years） with AAV from January 1996 to December 2013 were included into this retrospective study. The patients received induction therapy with corticosteroids with or without intravenous cyclophosphamide（ IV-CYC）,mycophenolate mofetil（ MMF） or multi-target therapy. Infection was defined as major infection and diagnosed by the clinical and radiological manifestation and microbiological evidences. The time,site,incidence and risk factors of severe infection were analyzed. Results： 103 infection episodes were found in 86 patients（ 28. 0%） during follow-up for median 15 months（ 1 ～ 155 months）. The infection rate of induction therapy with corticosteroids（ n = 65）,MMF（ n = 77）,IV-CTX（ n = 66） and Tripterygium wilfordii（ n = 40） were 38. 5%,39. 0%,33. 3% and 22. 5% respectively. 73. 8%（ 76 /103） of the infection episodes occurred within 6 months of the induction treatment,66 of them（ 64. 1%） occurred within 3 months. The most common infection site was lung（ n = 74）. The others included skin,digestive tract and urinary tract,and six cases developed sepsis. The most common pathogen was bacteria（ 78. 6%）,followed by fungus（ 12. 6%） and virus（ 8. 7%）. COX model manifested that beforehand infection prior to the onset of AAV（ RR = 4. 105,95% CI = 2. 557- 6. 592）,serum creatinine ≥6 mg / dl（ RR = 1. 179,95% CI = 1. 090-1. 276）,and cyclophosphamide（ RR = 1. 889,95% CI = 1. 020- 3. 500） were independent risk factors for the development of infection. The main thoracic manifestations include consolidation（ 51. 4%）,diffused interstitial pneumonia（ 28. 4%） and multiple nodules（ 17. 6%）. 34 cases reached end stage of renal disease during follow-up. 12 of

关 键 词：抗中性粒细胞胞质抗体相关血管炎 感染 发生率 危险因素 

分 类 号：R593.2[医药卫生—内科学]