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摘要:
目的 探讨肾移植术后患者慢性腹泻的诊治方案。 方法 回顾性分析2007年1月至2014年6月在西京医院泌尿外科实施同种异体肾移植术并规律随访的353例患者中发生慢性腹泻者的临床资料。观察肾移植术后慢性腹泻的发生情况(发生率、发生时间、病程、并发症),记录慢性腹泻患者的一般状况与辅助检查指标变化(体重指数、贫血情况、辅助检查指标),以及患者的治疗经过与预后。 结果 353例肾移植患者中15例(4.2%)发生慢性腹泻,给予积极对症、病因治疗的时间为(15±7)d,腹泻期间死亡2例(分别死于消化道出血和严重低钾血症猝死),其余患者的腹泻均治愈。13例患者随访期间预后良好5例,死亡2例(均死于肺部感染),移植肾失功5例,移植肾功能不全1例。 结论 肾移植术后慢性腹泻病因复杂,应积极对症、病因治疗,合并严重并发症者预后不良。 Abstract:Objective To investigate the diagnosis and treatment regimen for patients with chronic diarrhea after renal transplantation. Methods The clinical data of 353 patients with chronic diarrhea who underwent renal allograft transplantation at Department of Urology of Xijing Hospital from January 2007 to June 2014 with regular follow-up were analyzed retrospectively. The occurrence of chronic diarrhea after renal transplantation was observed, including incidence, time of occurrence, course of disease and complications. The changes in general conditions and auxiliary examination indexes (body mass index, anemia and other auxiliary examination indexes), treatment and prognosis of the patients with chronic diarrhea were recorded. Results Fifteen cases (4.2%)of 353 renal transplant recipients had chronic diarrhea. The time of symptomatic and etiological treatment was (15±7) d. Two patients died during diarrhea (died from gastrointestinal hemorrhage and sudden death caused by severe hypokalemia respectively) and other patients were recovered. Among the 13 patients, 5 cases had good prognosis, 2 cases died(both died from pulmonary infection), 5 cases suffered from renal allograft dysfunction and 1 case suffered from renal allograft insufficiency during the follow-up. Conclusions The etiology of chronic diarrhea after renal transplantation is complex and the patients should receive symptomatic and etiological treatment. The patients with chronic diarrhea after renal transplantation combined with severe complications have poor prognosis. -
Key words:
- Renal transplantation /
- Chronic diarrhea /
- Immunosuppressant /
- Diagnosis /
- Treatment /
- Complication
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表 1 肾移植术后慢性腹泻患者的一般情况和辅助检查指标变化
Table 1. Changes in general condition and auxiliary examination index of patients with chronic diarrhea after renal transplantation
序次 性别 年龄(岁) 血红蛋白(g/L) BUN(mmol/L) Scr(μmol/L) 粪常规及培养 肠道菌群分析 内镜检查 治疗前 治疗后 治疗前 治疗后 1 女 58 97 8.4 11.2 192 122 正常 Ⅰ度失调 慢性萎缩性胃炎 2 男 59 100 17.2 17.2 339 366 正常 正常 慢性浅表性胃炎、十二指肠息肉 3 男 29 63 30.0 37.7 565 463 转铁蛋白阳性 正常 慢性胃炎、十二指肠炎 4 男 20 72 29.4 19.9 591 261 正常 Ⅰ度失调 未做 5 男 37 106 24.7 6.5 729 153 正常 正常 未做 6 男 23 86 28.9 8.3 512 175 正常 Ⅰ度失调 慢性浅表性胃炎、慢性结肠炎 7 女 69 45 12.1 16.3 371 283 潜血弱阳性 Ⅰ度失调 未做 8 男 34 118 6.4 4.5 141 113 正常 正常 未做 9 男 42 166 9.2 7.3 222 147 正常 Ⅰ度失调 未做 10 男 40 105 30.4 19.7 640 290 正常 正常 慢性浅表性胃炎、慢性结肠炎 11 男 23 125 60.6 - 990 - 正常 正常 未做 12 男 40 113 4.1 2.8 109 103 潜血弱阳性 正常 慢性胃炎、慢性结肠炎 13 女 35 138 8.8 6.2 130 96 艰难梭菌阳性 Ⅰ度失调 未做 14 男 38 58 25.1 38.9 260 326 正常 Ⅰ度失调 未做 15 女 41 98 14.9 6.5 278 179 正常 Ⅱ度失调 未做 注：BUN为血尿素氮，Scr为血清肌酐，-为缺如 
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表 2 肾移植术后慢性腹泻患者的治疗及随访情况
Table 2. Treatment and follow-up of patients with chronic diarrhea after renal transplantation
序次 初始免疫方案 调整后免疫方案 治疗时间(d) 腹泻治疗效果 预 后 1 MMF+CsA+Pred MMF改为MPS，效果不显著，CsA改为西罗莫司 26 治愈 6个月后发生移植肾排斥反应，2.5年后移植肾失功 2 MMF+CsA+Pred MMF改为MPS，CsA减量 12 治愈 3个月后死于肺部感染 3 FK506+西罗莫司 不变 11 治愈 移植肾失功，恢复血液透析 4 MMF+ FK506+Pred 停用MMF 22 死亡 死于消化道出血 5 MMF+CsA+Pred MMF减量 19 治愈 2个月后死于肺部感染 6 MMF+ FK506+Pred MMF减量 14 治愈 良好 7 MMF+ FK506+Pred 西罗莫司+MEP 15 治愈 1个月后移植肾失功，恢复血液透析 8 MMF+ FK506+Pred 不变 16 治愈 良好 9 MPS+CsA+Pred MPS减量，CsA改为FK506 4 治愈 良好 10 MMF+ FK506+Pred MMF减量 12 治愈 4个月后移植肾失功丢失，恢复血液透析 11 MMF+ FK506+Pred 停用MMF，FK506减量 1 死亡 入院后第1日猝死 12 MMF+ FK506+Pred MMF减量 23 治愈 良好 13 MPS+CsA+Pred MPS减量 11 治愈 良好 14 MMF+ FK506+Pred MPS+CsA+Pred 17 治愈 移植肾功能不全，结肠透析 15 MMF+ FK506+Pred MMF改为MPS后停用，FK506改为缓释剂 26 治愈 3个月后移植肾失功，恢复血液透析 注：MEP为甲泼尼龙，Pred为泼尼松
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