激素或免疫抑制剂治疗的肾病综合征伴发侵袭性真菌病的相关因素及疗效观察

发布时间：2018-04-25 00:07

本文选题：肾病综合征 + 侵袭性真菌病　；参考：《重庆医科大学》2017年硕士论文

【摘要】：目的:通过分析激素或(及)免疫抑制剂治疗的肾病综合征合(NS)患者伴发侵袭性真菌病(IFD)的相关因素以及疗效,为更好的防治肾病综合征病人伴发侵袭性真菌病提供依据。方法:选取2012年1月1日至2017年1月1日于重庆医科大学附属第二医院肾内科住院的接受激素或(及)免疫抑制剂治疗的NS伴发IFD的患者21例(IFD组),并选择同期接受激素或(及)免疫抑制剂治疗的肾病综合征未伴发IFD的患者42例(No-IFD组)。分别收集两组患者的一般情况、临床资料、发生IFD前的药物治疗情况进行相关因素分析。并对IFD组进行亚组分析,进一步比较亚组中患者激素和免疫抑制的治疗时间与IFD发生的关系,以及亚组中患者的临床表现、诊断方法、治疗方案及疗效,总结肾病综合征伴发侵袭性真菌病的诊治经验。结果:(1)肾病综合征患者接受激素或(及)免疫抑制剂治疗发生IFD的发病率为10.3%。(2)一般资料中:IFD组平均年龄较No-IFD组大(p0.05),男女比例无差异。IFD组既往肺部影像学检查提示肺间质纤维化的比例较No-IFD组更高(p0.05),而既往肺部疾病病史两组差异无显著性。(3)临床资料对比显示:相较于No-IFD组,IFD组患者24小时尿蛋白定量水平、肌酐水平,细菌培养阳性率明显升高,IgM水平、淋巴细胞比例及淋巴细胞计数均明显降低,差异具有统计学意义(P0.05)。而两组患者的血浆白蛋白、IgG、IgA、C3水平则差异不大。(4)IFD发生前的NS治疗情况:IFD组加用免疫制剂治疗的比例更高,差异显著(P0.01)。免疫抑制的使用种类对IFD的发生没有显著的影响(P0.05)。IFD组使用4天以上广谱抗生素、以及联用两种或两种以上抗生素治疗的比例更高(P0.05)。而激素冲击治疗的比例两组无明显差异(P0.05)。(5)亚组分析结果显示:在强的松1mg/kg·d-1的剂量治疗下,1月后IFD发生率增加,并于1-2月时达最高峰。使用免疫抑制剂4周内易发生IFD,且使用不同的免疫抑制剂,发生IFD的时间不同。发热为IFD的早期症状,呼吸道IFD的发生率最高。1-3-β-D葡聚糖检测NS合并IFD的敏感性为95.24%。伊曲康唑与伏立康唑对于IFD治疗的有效率存在差异,但差异无统计学意义。结论:(1)接受激素或(及)免疫抑制剂治疗的NS患者伴发IFD与年龄、影像学肺间质改变、24小时尿蛋白定量水平、血肌酐水平、IgM、淋巴细胞比例及计数、细菌培养阳性、使用及联用广谱抗生素、加用免疫抑制剂有关。(2)激素使用1月后、免疫抑制剂使用4周内为IFD的易感时期。(3)1-3-β-D葡聚糖检测NS合并IFD的敏感性高,可用于早期诊断IFD。(4)伊曲康唑与伏立康唑治疗IFD的有效率差异无显著性,早期治疗是改善IFD预后的关键。
[Abstract]:Objective: to provide evidence for better prevention and treatment of invasive mycosis in patients with nephrotic syndrome (NS) treated by hormone or / or immunosuppressive agents. Methods: from January 1, 2012 to January 1, 2017, 21 patients with NS associated with IFD who received hormone or / and immunosuppressive therapy in Department of Nephrology, second affiliated Hospital, Chongqing Medical University, were selected. 42 patients with nephrotic syndrome without IFD who received hormone or / and immunosuppressive therapy were treated with No-IFD. The general condition, clinical data and drug treatment before IFD were collected and analyzed. The relationship between the time of hormone and immunosuppressive therapy and the occurrence of IFD, the clinical manifestation, diagnostic method, treatment plan and curative effect of the patients in the IFD group were compared. To summarize the experience of diagnosis and treatment of nephrotic syndrome with invasive mycosis. Results the incidence of IFD in patients with nephrotic syndrome treated with hormone or / and immunosuppressant was 10.3%.) the average age of IFD group was larger than that of No-IFD group (P 0.05). There was no difference between male and female. The ratio of pulmonary interstitial fibrosis was higher than that of No-IFD group, but there was no significant difference between the two groups in the history of pulmonary disease. The level of creatinine, the positive rate of bacteria culture significantly increased the level of IgM, the proportion of lymphocytes and the lymphocyte count decreased obviously, the difference was statistically significant (P 0.05). However, there was no significant difference between the two groups in the level of IgGG, IgA, C 3. The proportion of NS treatment before the occurrence of IFD was higher in the control group than that in the control group, and the difference was significant (P 0.01). The type of immunosuppressive therapy had no significant effect on the occurrence of IFD. The proportion of two or more antibiotics was higher in the P0.05. IFD group than that in the P0.05. IFD group, which was treated with broad-spectrum antibiotics for more than 4 days. However, there was no significant difference in the proportion of hormone shock therapy between the two groups. The results of subgroup analysis showed that the incidence of IFD increased after 1 month of prednisone 1mg/kg d-1 treatment, and reached its peak in January and February. Immunosuppressive agents were easy to occur in 4 weeks, and different immunosuppressants were used for different time of occurrence of IFD. Fever was the early symptom of IFD. The incidence of respiratory IFD was the highest. The sensitivity of NS with IFD was 95.24. There was a difference between itraconazole and voleconazole in the effective rate of IFD, but the difference was not statistically significant. Conclusion IFD and age, 24 hour urinary protein quantitative level, serum creatinine level, lymphocyte percentage and count, positive bacterial culture were found in patients with NS treated with hormone or / or immunosuppressant. After using and combining with broad-spectrum antibiotics and adding immunosuppressant related hormone, the sensitivity of NS combined with IFD was high when immunosuppressant was used for 4 weeks as the susceptible period of IFD. There was no significant difference in the effective rate between itraconazole and voleconazole in the treatment of IFD. Early treatment was the key to improve the prognosis of IFD.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692;R519

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