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Background renal transplantation as a treatment for the most effective means of end-stage renal disease, extensive clinical, but with the large-scale use of the new powerful immunosuppressant and broad-spectrum antibiotics, postoperative deep fungal infections is still important of graft loss and patient death one of the reasons. Invasive pulmonary fungal infections (Invasive Pulmonary Fungal Infections, IPFI) accounted for the deep fungal infection in the first place, no specific clinical, early diagnosis is difficult, easy to misdiagnosis, although diagnostic methods and treatment in recent years has been much progress , mortality in IPFI remains high. American Transplant Infection Surveillance Network (TRANSNET) tracking display of 23 organ transplant centers five years, 8672 cases of renal transplant patients: incidence of invasive fungal infections after renal transplantation was 23.8%, which Aspergillus infection in patients with 1-year survival rate for 59% 1-year survival rate of patients with Candida infections was 66%, 73% 1-year survival rate of patients with cryptococcal infection; multi-center study in India reported: renal transplant recipients with invasive fungal infection incidence of 1.4% to 9.4% the mortality rate of 30% to 70%; domestic Affiliated Hospital of Zhongshan Medical University Transplant Center reported: invasive fungal infections after renal transplantation mortality rate was 39.8%. The present study showed: the major conditional pathogenic fungi cause IPFI pathogens, the most common is Candida and Aspergillus infections. The TRANSNET for up to five years of monitoring shows that: postoperative patients with invasive fungal infections in solid organ transplantation, the most common pathogen Candida (53%), followed by invasive Aspergillus (19%), Cryptococcus ( 8%), non-invasive Aspergillus (8%), endemic fungal disease (5%), joining the genus (2%). Domestic Zhongshan Medical University Affiliated Hospital Transplant Center reports: postoperative IPFI pathogens constitute proportion of renal transplant: Candida albicans (51.8%) (19.2%), Candida glabrata, Candida tropicalis (14.5%), Aspergillus (7.2% ), Mucor (2.4%), Cryptococcus neoformans (2.4%), Pneumocystis carinii (2.4%). Currently more concentrated study of invasive pulmonary fungal infections in cancer patients, ICU patients or ventilator-associated fungal infection patients, nearly 10 years after renal transplantation IPFI because of its high incidence and high mortality, low clinical and caused more and more clinicians concerned about the rate of laboratory-confirmed; kidney transplant patients, the condition is relatively complex, prognostic factors, can be attributed to the impact of prognostic factors is difficult to determine. Abroad over multi-center study of kidney transplantation the postoperative IPFI clinical research, but the domestic relatively small literature review visible minority reports of single-center, but most of them concentrated the study kidney transplant IPFI, risk factors, and the prognostic factors study rarely reported, and there is no clear clinical evaluation for clinical assessment IPFI the disease progress and to determine treatment effect, therefore, timely diagnosis of renal transplant recipients IPFI infection and choose what kind of treatment options are still placed in front of the problem of the clinician. Objective To study the patients after renal transplantation clinical features of invasive pulmonary fungal infections (IPFI) to explore the prognostic influence after renal transplantation IPFI relevant factors and clinical evaluation. Methods A retrospective analysis of the Southern Medical the Zhujiang Hospital from January 2000 to April 2010 1520 cases of patients with kidney transplant surgery, diagnostic inclusion criteria screening for IPFI cases, deaths case group, non-fatal cases of the control group, Analysis the IPFI of morbidity, mortality, imaging findings, the main constituent ratio as well as the effectiveness of antifungal pathogens; records of patients infected within 24 hours of the most serious clinical pulmonary infection score (clinical pulmonary infection score, CPIS) CPIS score, and antifungal therapy five days to analyze the first day and five days of the the CPIS score presence or absence of the death group and survival group statistical differences; single factor analysis and Logistic regression analysis of statistical patient gender, old age, infection type of infection, immune suppression program, whether the use of biological agents, antifungal therapy 5 days after the body temperature normal, renal insufficiency, high fasting glucose, malnutrition, mechanical ventilation therapy, immunoglobulin therapy, anti-fungal treatment for 5 days after the CPIS than The before falling antifungal therapy program 14 factors and prognosis relations. Results of selected cases, 80 cases, including 54 cases of male and 26 females; minimum age of 21 years, maximum 67 years, mean age (47.21 ± 10.479) y; pulmonary fungal infections occurred at a time: 1 to 3 months after surgery 47 cases (58.8%), 3 to 6 months, 17 cases (21.2%), 6 months to 1 year by three cases (3.8%) for more than 1 year in 13 cases (16.2%). Chest imaging: exudative lesions, 28 cases (26.42%), cavitary lesions (0.94%), nodular lesions in 11 cases (10.38%), the mass-like lesions in 4 cases (3.77%), interstitial lesions in 42 cases (39.62%), pleural effusion performance of the 12 cases (11.32%), and consolidation of eight cases (7.55%); including empty cases of Microbiology prove lesions Aspergillus infection, nodular lesions microbiology confirmed Aspergillus 6 infection, Candida infection cases. Diagnosis of Pneumocystis carinii infection in 32 cases (40%) bacteria, Candida albicans infection in 21 cases (26.25%), Aspergillus infection in 16 cases (20%), Candida krusei infection in 5 cases (6.25% ), mucormycosis 2 cases (2.5%), smooth yeast infection in 2 cases (2.5%), Candida tropicalis infection in 1 case (1.25%), the nearly smooth Candida yeast infection in 1 case (1.25%). 40 cases (50%) were diagnosed diagnosis, 28 patients (35%) for the clinical diagnosis of 12 cases (15%) were diagnosed. 24 patients (30%) of pure fungal infections, 8 cases (10%) with CMV infection, 33 cases (41.2%) patients with bacterial infection, 15 cases (18.8%) for the three mixed infections. Sputum and BALF cultured isolates a total of 69, of which Candida albicans 39 (56.52%), Aspergillus, 11 (15.94%), the krusei 9 (13.04%), 4 (5.80% glabrata ), Candida tropicalis 3 (4.35%), parapsilosis 2 (2.90%), Mucor 1 (1.45%). 24 deaths (30% mortality), 56 cases were cured; antifungal therapy shortest five days, the longest 43 days, an average of 14.81 days antifungal therapy time, 24 patients underwent mechanical ventilation therapy, 2 artificially noninvasive mechanical ventilation treatment 22 man-invasive treatment of mechanical ventilation, mechanical ventilation in patients with a total of 19 deaths, a mortality rate of 79.2%. Oxazole 61 cases (50%), use antifungal compound sulfamethoxazole efficiency of 72.13%, amphotericin B lipid bodies of 15 cases (12.29%), 66.67%, fluconazole 31 cases (25.41 %), efficiency of 48.39%, micafungin 12 cases (9.84%), 25% efficiency, voriconazole seven cases (2.46%), 85.71%. Infection one day the CPIS score death group (4.04 ± 2.053), the survival group (3.89 ± 1.796), no significant difference in the death group and survival group (t = 0.325, P = 0.595); treatment five days CPIS score death group (7.96 ± 2.116), survival group (1.93 ± 1.971) and death group was significantly higher than the survival group, the two groups were significantly different (t = -12.266, P = 0.000). Prognosis Univariate analysis showed that: antifungal therapy 5 days after the temperature is normal (x2 = 5.079, P = 0.024), fasting glucose (χ 2 = 10.430, P = 0.001), renal insufficiency (X2 = 9.267, P = 0.002), nutrition adverse (χ2 = 5.612, P = 0.018), and 5 days after infection (χ2 = 7.979, P = 0.046), and anti-fungal treatment CPIS lower (χ2 = 64.292, P = 0.000), mechanical ventilation (χ2 = 5.873, P = 0.000), seven variables have statistically significant into the Logistic multivariate regression analysis showed that: renal insufficiency (P = 0.033, OR = 18.096), mechanical ventilation (P = 0.001, OR = 130.7), anti-fungal treatment 5 days CPIS lower (P = 0.033, OR = 0.011) is of influence after renal transplantation IPFI mortality independent prognostic factors, including the treatment of the first five days CPIS reduce protective factors. Conclusion 1. Pneumocystis carinii after renal transplantation IPFI infection with high mortality and poor prognosis, the study incidence rate IPFI in 5.3%, after infection, the mortality rate was 30%, the top three of the pathogen infection were bacteria ( 40%), Candida albicans (26.25%), Aspergillus (20%); 2. infection after renal transplantation IPFI imaging findings diverse specificity is not high; 3. treatment for IPFI patients, the disease is complex patients, especially if the conditions underlying diseases elderly should be timely choose voriconazole, amphotericin B liposome novel antifungal agents, so as not to miss the timing of treatment, voriconazole In the present study demonstrated better efficacy and lower side effects; 4.CPIS clinical scores as a standard suitable for renal allograft invasive pulmonary fungal infections prognosis; 5 patients in the early stages of infection renal insufficiency, respiratory failure and poor prognosis, should be early empirical preemptive applications antifungal line renal replacement therapy as soon as possible and in accordance with the five days CPIS score to adjust treatment regimens of important value to improve the the renal transplantation IPFI prognosis.
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