肾脏疾病患者继发免疫缺陷与肺孢子菌肺炎

摘要

Objective:To identify clinical significance and prognostic factors of pneumocystis pneumonia (PCP) in chronic kidney disease (CKD) patients with secondary immunodeficiency.Methodology:This is a retrospective analysis.The clinical and laboratory data of CKD patients who diagnosed as PCP were collected.According to the outcome,these patients were divided into survivors and non-survivors,whose clinical significance and the relationship between immunologic function and prognosis were analyzed.Results:Among the fifty two cases,14 were renal transplantation recipients.All of them had received immunosuppressive treatment and circulating CD4+ lymphocyte count were below 200/μl.Clinical presentations of onset were mainly chest stuffiness and fever.The chest radiographic images of all the patients showed bilateral,symmetric,reticular or granular opacities,and serum (1-3) β-D-glucan (BDG) levels were all above normal.13 patients dead while 39 recovered after treatment.Multivariate logistic regression analysis revealed that lower CD4+ lymphocyte count,increased BDG and severe acute respiratory distress syndrome (ARDS) were prognostic factors of PCP.Receiver operating characteristic (ROC) curve indicated that CD4+ lymphocyte count ＞64/μl predicted satisfactory outcome.Covariance analysis of repeated sequencing variables showed the lymphocyte count persisted lower in the first 6 days after hospitalization indicated poor prognosis.Conclusion:Lower CD4+ lymphocyte count,increased BDG and severe ARDS indicated poor prognosis in CKD patients with PCR.The immune state and reconstructive ability were the most important factors affecting the prognosis.%目的:探讨肾脏疾病患者继发免疫缺陷与肺孢子菌肺炎(PCP)的临床特征、并对影响其预后的危险因素进行分析. 方法:回顾性分析肾脏疾病患者继发免疫缺陷临床诊断PCP的资料,根据预后分为好转组和死亡组,分析其临床特点、免疫功能状态与预后的关系. 结果:共入组患者52例,其中14例为同种异体肾移植术后患者,38例自体肾脏病患者.所有患者感染前均曾接受免疫抑制治疗且外周血CD4+淋巴细胞计数均＜200/μl.起病表现以胸闷、发热为主,所有患者肺部影像学均呈双肺弥漫性肺间质浸润影,血清1,3-β-D葡聚糖试验(真菌G试验)阳性.经治疗,好转39例,死亡13例.多因素Logistic回归分析发现CD4+细胞低、真菌G试验进行性升高、重度急性呼吸窘迫综合征(ARDS)提示预后差.受试者工作特征(ROC)曲线提示最低CD4+细胞计数＞64/μl,预后较好.重复测序变量协方差分析提示入院前6天淋巴细胞计数持续低下患者死亡风险明显升高. 结论:重度ARDS、CD4+细胞计数低、真菌G试验进行性升高提示预后差,患者免疫状态和免疫功能重建能力是影响PCP患者预后的重要因素.