39例肾移植术后肺部侵袭性真菌病临床分析

发布时间：2018-04-21 11:23

本文选题：肾移植术后 + 肺部侵袭性真菌病　；参考：《南方医科大学》2017年硕士论文

【摘要】：肾脏移植作为治疗终末期肾病的重要手段[1],是中国临床上开展最早、例数最多、技术最成熟的大器官移植[2]。2012年《柳叶刀》发表的首个中国慢性肾脏疾病调查研究结果显示:我国慢性肾病的患病率为10。8%,预计约有1.95亿患者,随年龄增长患病率逐渐增高。肾脏移植作为终末期肾病患者最理想的肾替代治疗手段,在全球范围内快速推广,中国移植科学登记系统数据中心(Chinese Scientific Registry of Kidney Transplantation Data Center,CSRKT)的统计数据表明,2015年,我国共完成了 7131例肾脏移植手术,仅次美国居全球第二位[3]。随着手术技术的成熟及新型免疫抑制药物的应用[4],肾脏移植的近期及远期存活率均有显著提高,但急慢性排斥反应、术后感染等因素严重影响受者的预后及存活率,尤其肾移植受者侵袭性真菌病,因其发病隐匿,临床症状无特异性,影像学检查复杂多变给临床诊断带来较大困难,已成为实体器官移植后移植物丢失及患者死亡的重要原因之一。目前国内及欧美流行病学研究显示:侵蚀性真菌病的发生率根据免疫抑制程度、各移植中心环境及预防性药物使用方案不同等因素而不尽相同。TRANSNET长达五年监测对实体器官移植受者进行较为全面研究,结果表明实体器官移植受者侵蚀性真菌病以念珠菌最为多见,其次为曲霉菌、隐球菌、非曲霉菌(除外接合菌)、地方性真菌、接合菌及卡氏肺孢子虫[5]资料显示,约有75%的肾移植患者术后1年内发生过不同程度、不同类型的感染,其中约26%患者直接死于感染。虽然肾移植术后侵袭性真菌病引起了越来越多临床医生的关注,但由于肾移植术后患者病情相对复杂,可归因的相关因素较难确定。我国尚无肾移植相关IFD大规模循证医学资料,肾移植术后IFD的预防及治疗尚无被大范围认可的标准方案,大多数为临床医生经验性治疗方案。因此对于肾移植术后侵袭性肺部真菌病临床特征进行分析,提高肾移植术术后肺部侵袭性真菌病的检出和诊断水平对于提高肾移植效果及提高肾移植术后患者生存率有重大意义。目的研究肾移植术后肺部侵袭性真菌病(IFD)的临床特点,探讨肾移植术后肺部侵袭性真菌病(IFD)的预防及治疗方案方法回顾分析南方医科大学2010年1月至2015年12月肾移植术后患者共346例,按照入选标准筛选出诊断为肺部侵袭性真菌病的病例,死亡病例为病例组,非死亡的病例为对照组,分析IFD的发病时间、发病率、死亡率、主要真菌构成比以及各种抗真菌药物的有效性。结果39例肺部侵袭性真菌病患者中男性30例,女性9例,男:女=3.33:1,平均年龄岁(20-62岁);39例肾移植受者中,5例发生于肾移植术后三个月内,占总发病率的12.8%,18例发生于术后半年内,占总发病率的46.15%,25例发生于术后一年内,占总发病率的64.1%,8例发生于术后两年后,占总发病率的20.51%。肺部影像学表现:其中21例表现为弥漫性磨玻璃样改变,斑片状影8例,多发结节状影4例,肺纹理增多4例,单发结节状影3例,空洞影1例。结论肾移植术后肺部侵袭性真菌病多发于肾移植术后3-6个月内,患者多以发热、咳嗽、咳痰就诊,临床症状无明显特异性,病原体检出率较低,以白色念珠菌多见(36%),肺部CT表现多样性,以肺部弥漫性磨玻璃样影多见,影像学表现对临床诊断具有指导意义。肾移植术后肺部侵袭性真菌病发病迅速,早期诊断鉴别肺部感染类型,早期选择敏感抗真菌药物可以大大提高肾移植受者肺部侵袭性真菌病存活率,缩短治疗时间,节约治疗费用。
[Abstract]:Renal transplantation is an important means of treating end-stage renal disease ([1]). The first Chinese chronic kidney disease (lancet) published in [2].2012, the earliest large organ transplant in China, has been published in the first Chinese chronic kidney disease. The result shows that the incidence of chronic renal disease in China is 10.8%, and about 195 million patients are expected to increase with age. The rate of long illness increased gradually. As the most ideal renal replacement therapy for patients with end-stage renal disease, kidney transplantation was popularized around the world. The statistical data of Chinese Scientific Registry of Kidney Transplantation Data Center, CSRKT) in the Chinese transplant science registration system showed that in 2015, 7131 of our country had completed a total of 7131 Renal transplantation, only the second [3]. in the United States, with the maturation of the surgical technique and the application of new immunosuppressive drugs, the short-term and long-term survival rates of renal transplantation have been significantly improved. However, the prognosis and survival of the recipients are seriously affected by acute and chronic rejection and postoperative infection, especially in renal transplant recipients. Mycosis, due to its occult disease, clinical symptoms, and complex imaging examination, has brought great difficulties to clinical diagnosis. It has become one of the important reasons for the loss of graft and the death of the patients after the body organ transplantation. The five year long five year monitoring of different transplant center environment and preventive drug use has been carried out for five years. The results show that the most common fungal diseases are Candida albicans, followed by Aspergillus, Cryptococcus, and Aspergillus (except for the mycosis). [5] data of local fungi, conjugation bacteria and Pneumocystis carinii showed that about 75% of patients with renal transplantation had different degrees and different types of infection within 1 years after the operation, of which about 26% patients died of infection. Although invasive mycosis after renal transplantation has aroused more and more attention from clinicians, the patient's disease after kidney transplantation The attributable related factors are relatively difficult to be determined. There is no large scale evidence-based medicine for renal transplantation related to IFD in China. The prevention and treatment of IFD after renal transplantation has not been approved by a large scale, most of which are the empirical treatment for clinicians. Therefore, the clinical characteristics of invasive pulmonary mycosis after renal transplantation are introduced. To improve the detection and diagnosis of pulmonary invasive fungal disease after renal transplantation, it is of great significance to improve the effect of renal transplantation and to improve the survival rate of patients after renal transplantation. Objective to study the clinical characteristics of pulmonary invasive fungal disease (IFD) after renal transplantation and to explore the prevention and prevention of pulmonary invasive fungal disease (IFD) after renal transplantation. A total of 346 patients after renal transplantation from January 2010 to December 2015 in Southern Medical University were reviewed and analyzed. The patients were diagnosed as pulmonary invasive mycosis according to the criteria of admission. The death cases were case groups, and the non dead cases were the control group. The time, incidence, mortality and main fungal constituent ratio of IFD were analyzed. Results and the effectiveness of various antifungal agents. Results in 39 cases of pulmonary invasive mycosis, 30 cases were male, 9 women, male: female =3.33:1, average age (20-62 years); 39 cases of renal transplant recipients, 5 cases occurred within three months after kidney transplantation, accounting for 12.8% of the total incidence, 18 cases occurred in 46.15%, 25 cases within the total incidence rate within six months after the operation. Within one year after the operation, 64.1% of the total incidence was found. 8 cases occurred in the 20.51%. lung imaging findings in the total incidence two years after the operation: 21 of them were diffuse glass like changes, 8 patchy shadows, 4 multiple nodular shadows, 4 pulmonary veins, 3 solitary nodules, and 1 cavity shadows. 3-6 months after renal transplantation, invasive mycosis was mostly caused by fever, cough and expectoration. The clinical symptoms were not distinct, the rate of pathogenic examination was low, the prevalence of Candida albicans (36%), the diversity of CT in the lungs, and diffuse glass like shadow in the lungs were more common. Early diagnosis and identification of pulmonary infection type and early selection of sensitive antifungal drugs can greatly improve the survival rate of pulmonary invasive mycosis in renal transplant recipients, shorten the treatment time and save the cost of treatment.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699.2;R519

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