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背景:肾移植后感染已成为肾移植患者移植肾失功和死亡的主要原因之一,肾移植后感染目前尚无统一、标准的治疗方案。目的:探讨肾移植患者后感染临床特点及诊治方法,提高肾移植后感染的治愈率。设计、时间及地点:回顾性病例分析,于2006-02/2008-02在昆明医学院第一附属医院器官移植中心完成。对象:84例肾移植患者中18例移植后的感染者。方法:所有患者入院后均行胸部X射线检查,X射线检查未提示肺部明显病变或肺部感染症状及体征明显者行肺部CT检查。行病原学检测,包括血、尿、痰、鼻拭子、咽拭子培养,痰涂片+培养查真菌,抽血查CMV、EB-DNA及支原体,痰查抗酸杆菌。对所有肺部感染患者均采用综合治疗,即抗菌素+抗病毒药物+抗真菌药物,根据患者病情、血常规淋巴细胞绝对值及CD4+T细胞绝对值计数调整免疫抑制剂用量对患者感染发生时间、临床症状、辅助检查及诊断和治疗策略进行分析。主要观察指标:①感染发生时间及症状。②影像学表现和病原学检测结果。③抗生素的选用和免疫抑制剂调整。结果:18例患者中,11例(61.2%)为尸体供肾肾移植患者。12例(66.7%)发生于移植后3月内,15例(83.3%)发生于移植后6月内。14例(77.8%)以发热为主要症状,呼吸道感染15例(83.3%),其中13(72.2%)例为肺部感染。6例病原学检查提示真菌感染,且以念珠菌为主。3例(16.7%)死亡其中2例合并巨细胞病毒感染,均为混合性感染。结论:肾移植后感染患者病原体呈多样性,但以细菌、真菌和病毒为主。重症肺炎合并CMV感染提示预后不良,真菌和病毒感染在肾移植后感染患者中应引起足够重视。治疗以综合降阶梯治疗为主,及时调整免疫抑制剂治疗方案甚至停用免疫抑制剂是治疗的关键之一。
BACKGROUND: Infection after kidney transplantation has become one of the main causes of graft failure and death in renal transplant recipients. There is no uniform standard treatment for renal transplant infection. OBJECTIVE: To investigate the clinical features, diagnosis and treatment of infection after renal transplantation and to improve the cure rate of infection after kidney transplantation. DESIGN, TIME AND SETTING: Retrospective case analysis was performed at the Organ Transplant Center, First Affiliated Hospital of Kunming Medical College from February 2006 to February 2008. PARTICIPANTS: Eighteen cases of transplant recipients in 84 renal transplant recipients. Methods: All patients underwent chest X-ray examination after admission, X-ray examination did not prompt significant lung disease or pulmonary infection symptoms and signs of significant lung CT examination. Pathogen detection, including blood, urine, sputum, nasal swabs, throat swab culture, sputum smear + culture fungi, blood tests CMV, EB-DNA and mycoplasma, sputum check acid-fast bacilli. For all patients with pulmonary infection are used in the comprehensive treatment of antibiotics + antiviral drugs + antifungal drugs, according to the patient’s condition, blood lymphocytes absolute value and absolute CD4 + T cell count to adjust the amount of immunosuppressive agents in patients with infection time , Clinical symptoms, laboratory examinations and diagnosis and treatment strategies. MAIN OUTCOME MEASURES: ①Infection time and symptoms. ② imaging findings and pathogen test results. ③ selection of antibiotics and immunosuppressants adjustment. Results: Of the 18 patients, 11 (61.2%) were cadaveric renal allografts. Twelve (66.7%) occurred within 3 months after transplantation and 15 (83.3%) occurred within 6 months after transplantation. Fourteen patients (77.8%) had fever as the main symptom, and 15 (83.3%) were respiratory infections, of which 13 (72.2%) were pulmonary infections. 6 cases of pathological examination suggest fungal infection, and mainly Candida. Three patients (16.7%) died and two of them died of combined cytomegalovirus infection, both of which were mixed infections. CONCLUSIONS: Pathogens were found to be diverse in patients who became infected after kidney transplantation, but mainly bacteria, fungi and viruses. Severe pneumonia with CMV infection prompted a poor prognosis, fungal and viral infections should be given enough attention in patients after kidney transplantation. Treatment of the main step down the ladder, the timely adjustment of immunosuppressive agents or even stop the use of immunosuppressive agents is one of the key to treatment.