本文選題：腎移植術(shù)后 + 肺部侵襲性真菌病�。� 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：腎臟移植作為治療終末期腎病的重要手段[1],是中國臨床上開展最早、例數(shù)最多、技術(shù)最成熟的大器官移植[2]。2012年《柳葉刀》發(fā)表的首個(gè)中國慢性腎臟疾病調(diào)查研究結(jié)果顯示:我國慢性腎病的患病率為10。8%,預(yù)計(jì)約有1.95億患者,隨年齡增長患病率逐漸增高。腎臟移植作為終末期腎病患者最理想的腎替代治療手段,在全球范圍內(nèi)快速推廣,中國移植科學(xué)登記系統(tǒng)數(shù)據(jù)中心(Chinese Scientific Registry of Kidney Transplantation Data Center,CSRKT)的統(tǒng)計(jì)數(shù)據(jù)表明,2015年,我國共完成了 7131例腎臟移植手術(shù),僅次美國居全球第二位[3]。隨著手術(shù)技術(shù)的成熟及新型免疫抑制藥物的應(yīng)用[4],腎臟移植的近期及遠(yuǎn)期存活率均有顯著提高,但急慢性排斥反應(yīng)、術(shù)后感染等因素嚴(yán)重影響受者的預(yù)后及存活率,尤其腎移植受者侵襲性真菌病,因其發(fā)病隱匿,臨床癥狀無特異性,影像學(xué)檢查復(fù)雜多變給臨床診斷帶來較大困難,已成為實(shí)體器官移植后移植物丟失及患者死亡的重要原因之一。目前國內(nèi)及歐美流行病學(xué)研究顯示:侵蝕性真菌病的發(fā)生率根據(jù)免疫抑制程度、各移植中心環(huán)境及預(yù)防性藥物使用方案不同等因素而不盡相同。TRANSNET長達(dá)五年監(jiān)測對實(shí)體器官移植受者進(jìn)行較為全面研究,結(jié)果表明實(shí)體器官移植受者侵蝕性真菌病以念珠菌最為多見,其次為曲霉菌、隱球菌、非曲霉菌(除外接合菌)、地方性真菌、接合菌及卡氏肺孢子蟲[5]資料顯示,約有75%的腎移植患者術(shù)后1年內(nèi)發(fā)生過不同程度、不同類型的感染,其中約26%患者直接死于感染。雖然腎移植術(shù)后侵襲性真菌病引起了越來越多臨床醫(yī)生的關(guān)注,但由于腎移植術(shù)后患者病情相對復(fù)雜,可歸因的相關(guān)因素較難確定。我國尚無腎移植相關(guān)IFD大規(guī)模循證醫(yī)學(xué)資料,腎移植術(shù)后IFD的預(yù)防及治療尚無被大范圍認(rèn)可的標(biāo)準(zhǔn)方案,大多數(shù)為臨床醫(yī)生經(jīng)驗(yàn)性治療方案。因此對于腎移植術(shù)后侵襲性肺部真菌病臨床特征進(jìn)行分析,提高腎移植術(shù)術(shù)后肺部侵襲性真菌病的檢出和診斷水平對于提高腎移植效果及提高腎移植術(shù)后患者生存率有重大意義。目的研究腎移植術(shù)后肺部侵襲性真菌病(IFD)的臨床特點(diǎn),探討腎移植術(shù)后肺部侵襲性真菌病(IFD)的預(yù)防及治療方案方法回顧分析南方醫(yī)科大學(xué)2010年1月至2015年12月腎移植術(shù)后患者共346例,按照入選標(biāo)準(zhǔn)篩選出診斷為肺部侵襲性真菌病的病例,死亡病例為病例組,非死亡的病例為對照組,分析IFD的發(fā)病時(shí)間、發(fā)病率、死亡率、主要真菌構(gòu)成比以及各種抗真菌藥物的有效性。結(jié)果39例肺部侵襲性真菌病患者中男性30例,女性9例,男:女=3.33:1,平均年齡歲(20-62歲);39例腎移植受者中,5例發(fā)生于腎移植術(shù)后三個(gè)月內(nèi),占總發(fā)病率的12.8%,18例發(fā)生于術(shù)后半年內(nèi),占總發(fā)病率的46.15%,25例發(fā)生于術(shù)后一年內(nèi),占總發(fā)病率的64.1%,8例發(fā)生于術(shù)后兩年后,占總發(fā)病率的20.51%。肺部影像學(xué)表現(xiàn):其中21例表現(xiàn)為彌漫性磨玻璃樣改變,斑片狀影8例,多發(fā)結(jié)節(jié)狀影4例,肺紋理增多4例,單發(fā)結(jié)節(jié)狀影3例,空洞影1例。結(jié)論腎移植術(shù)后肺部侵襲性真菌病多發(fā)于腎移植術(shù)后3-6個(gè)月內(nèi),患者多以發(fā)熱、咳嗽、咳痰就診,臨床癥狀無明顯特異性,病原體檢出率較低,以白色念珠菌多見(36%),肺部CT表現(xiàn)多樣性,以肺部彌漫性磨玻璃樣影多見,影像學(xué)表現(xiàn)對臨床診斷具有指導(dǎo)意義。腎移植術(shù)后肺部侵襲性真菌病發(fā)病迅速,早期診斷鑒別肺部感染類型,早期選擇敏感抗真菌藥物可以大大提高腎移植受者肺部侵襲性真菌病存活率,縮短治療時(shí)間,節(jié)約治療費(fèi)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.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R699.2;R519

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