Abstract:

肾移植 ； 肺部感染 ； 宏基因二代测序 ； 治疗经验

Key words:

Renal transplantation, Pulmonary infection, Metagenomic next generation sequencing, Treatment experience

摘要：

目的 总结异体肾移植状态患者肺部感染特点及单中心治疗经验。方法 回顾自 2022 年 12 月6 日— 2023 年 2 月 2 日昆 明 市 第 一 人 民 医 院 收治的使用宏基因二代测序（metagenomic next generation sequencing，mNGS）技术进行诊断的 28 例异体肾移植状态肺部感染患者的支气管肺泡灌洗液（bronchoalveolar lavage fluid，BALF）结果，分析该类患者肺部感染特点、临床表现、mNGS 诊断的有效性、治疗及转归的单中心经验。结果 28 例患者临床表现不特异，其中 ：单纯咳嗽 2 例（7.1%），咳嗽、咳痰 5 例（17.86%），发热 4 例（14.29%），咳嗽、咳痰、发热 7 例（25%），合并胸闷、气促、发热的患者 5 例（17.86%），纳差、乏力、腹泻、尿少等全身症状的患者 5例（17.86%）。检出明确病原菌 22例（78.57%），单一病原体致病菌 15例（53.57%），其中以耶氏肺孢子菌（pneumocystis jiroveci，PJ）8 例（53.33%）为主，混合感染 7 例（25%），多为球菌、真菌混合感染。检出病原微生物频次共 34 次，PJ 12 次、CMV 4 次、EBV 3 次、屎肠球菌 4 次、白色假丝酵母菌 3 次、烟曲霉菌 2 次，疱疹病毒 7 型和 1 型各 1 次、大肠埃希菌、惠普尔养障体、马尔尼菲蓝状菌、解脲脲原体各 1 次。治愈后 CD4 T 淋巴细胞绝对值计数明显高于入院时，差异有统计学意义（P ＝ 0.00063）。结论mNGS 在异体肾移植肺部感染患者诊断中具有快速、准确优势，感染的病原体以 PJ 及 CMV 为主，对该类患者应早期诊断、合理地运用抗感染药物、配合激素免疫替代及充分改善肺功能是治疗的核心，药物提高机体免疫功能及免疫调节并不决定疾病的预后，淋巴细胞计数能提示治疗是否有效。 

关键词:

ObjectiveTo summarize the characteristics of lung infection in patients with allogeneic kidney transplantation status during a certain period and the treatment experience in a single center. MethodsTheresults of Bronchoalveolar lavage fluid （BALF） in 28 patients with lung infection in allogeneic kidney transplantation status admitted to our department from December 6, 2022 to February 2, 2023 were reviewed. The diagnosis wasconfirmed using metagenomic next generation sequencing （mNGS） technology, the characteristics of pulmonary infection, clinical manifestations, the effectiveness of mNGS diagnosis, treatment and outcome of this kind of patients were analyzed. ResultsA total number 28 patients had non-specific clinical manifestations, including 2 cases of simple cough （7.1%） and 5 cases of cough and sputum （17.86%）. There were 4 cases with fever （14.29%）, 7 cases with cough, sputum, and fever （25%）, and 5 cases （17.86%） of patients with chest tightness, shortness of breath, and fever. There were 5 patients （17.86%） with systemic symptoms such as poor appetite, fatigue, diarrhea, and oliguria. Pathogenic bacteria was detected in 22 cases （78.57%）, and 15 cases （53.57%） had single pathogenic bacteria. Among them, 8 cases （53.33%） were mainly caused by Pneumocystis jiroveci（PJ）. There were 7 cases （25%） with mixed infections, mostly mixed infections were cocci and fungi. The frequency of detecting pathogenic microorganisms was 34 times, including 12 times for PJ, 4 times for CMV, 3 times for EBV, 4 times for Enterococcus faecalis, 3 times for Candida albicans, 2 times for Aspergillus fumigatus, 1 time each for herpes virus type 7 and 1, and 1 time each for Escherichia coli, Helicobacter pylori, Streptococcus marneffei, and Ureaplasma urealyticum. The absolute count of CD4 T lymphocytes after treatment was significantly higher than that at admission, with a statistically significant difference （P ＝ 0.00063）. ConclusionThe application of mNGS in the diagnosis of lung infection patients after allogeneic kidneytransplantation has the advantages of speed and accuracy ； The main pathogens of infection are PJ and CMV. Early diagnosis, proper use of anti-infection drugs, combination with hormone immune replacement, and sufficient improvement of lung function are the core of treatment for these patients. Improving the immune function and immune regulation of the body does not determine the prognosis of the disease, and lymphocyte count can indicate whether the treatment is effective.