Metras D, Viard L, Kreitmann B, Riberi A, Pannetier-Mille A, Garbi O, Marti J Y, Geigle P
Cardiothoracic Surgery Service, La Timone Children's Hospital, Marseilles, France. dmetras@ap-hm
Eur J Cardiothorac Surg. 1999 Apr;15(4):490-4; discussion 495. doi: 10.1016/s1010-7940(99)00059-7.
Pulmonary infections, and particularly cytomegalovirus (CMV) infections, are a major cause of morbidity after lung transplantation. We report here our results in 49 pediatric lung transplantations.
Between may 1988 and 1997, we have done 49 lung transplantations in 42 children (en bloc double lung transplantation (DLT):10, HLTx:7, sequential bilateral sequential-lung transplantation (BSLT):31, single-lung transplantation (SLT): 1). In seven, it was a retransplantation. Among these, 34 were cystic fibrosis (CF) patients, all with multiresistant organisms (Pseudomonas aeruginosa, Burkholderia cepacia, Achromobacter xylososydans, Staphylococcus aureus). All patients were treated with multiantibiotic prophylaxy adapted to the preoperative cultures. Donor-recipient CMV matching was possible in only 31 cases. CMV prophylaxy and immunosuppression protocols have evolved with time, with a current protocol of IV Gancyclovir prophylaxy for 3 months and triple drug immunosuppression without post-operative rabbit anti-thymocyte globulin (RATG) induction. There was no perioperative mortality in the primary transplantations and three early deaths in the whole group (6.1%).
Only five patients had no pulmonary infection. The patients presented 3.2 infection episodes per year, 75% localized on the lungs, 41% during the first 3 months. Among the 13 deaths in the 1st year, 10 were directly related to infection, 60% due to CMV. After the 1st year, in all patients dying of pulmonary dysfunction or obliterative bronchiolitis (OB), bacterial infections were associated. There was no serious fungal infection. Actuarial survival at 3 months, 1, 3, 5 years were 85, 65.7, 47.5 and 28.5%, respectively. There was a significant difference in 3 year survival between patients receiving CMV negative organs (40%) and CMV positive organs (17%).
In our experience, as in other's, pulmonary infection risk is important in lung transplantation. Bacterial infections were mainly an aggravating factor of secondary pulmonary dysfunction or OB, and were not the primary cause of death. CMV infections have been very severe and lead us, despite the scarcity of donors, to avoid positive donors in negative recipients, this leads to disastrous mid-term results in our experience, despite prophylaxis.
肺部感染，尤其是巨细胞病毒（CMV）感染，是肺移植后发病的主要原因。我们在此报告49例小儿肺移植的结果。
1988年5月至1997年期间，我们对42名儿童进行了49例肺移植（整块双肺移植（DLT）：10例，单肺移植（HLTx）：7例，序贯双侧序贯肺移植（BSLT）：31例，单肺移植（SLT）：1例）。其中7例为再次移植。其中34例为囊性纤维化（CF）患者，均感染多重耐药菌（铜绿假单胞菌、洋葱伯克霍尔德菌、木糖氧化无色杆菌、金黄色葡萄球菌）。所有患者均根据术前培养结果接受多种抗生素预防治疗。仅31例患者实现了供体-受体CMV配型。CMV预防和免疫抑制方案随时间演变，目前的方案是静脉注射更昔洛韦预防3个月，三联药物免疫抑制，术后不使用兔抗胸腺细胞球蛋白（RATG）诱导。初次移植患者围手术期无死亡，全组有3例早期死亡（6.1%）。
仅5例患者未发生肺部感染。患者每年出现3.2次感染发作，75%局限于肺部，41%发生在最初3个月内。在第1年的13例死亡病例中，10例直接与感染有关，60%归因于CMV。第1年后，所有死于肺功能障碍或闭塞性细支气管炎（OB）的患者均合并细菌感染。未发生严重真菌感染。3个月、1年、3年、5年的实际生存率分别为85%、65.7%、47.5%和28.5%。接受CMV阴性器官的患者与接受CMV阳性器官的患者3年生存率存在显著差异（分别为40%和17%）。
根据我们的经验，与其他人的经验一样，肺部感染风险在肺移植中很重要。细菌感染主要是继发性肺功能障碍或OB的加重因素，而非主要死亡原因。CMV感染非常严重，尽管供体稀缺，我们仍避免将CMV阳性供体用于CMV阴性受体，根据我们的经验，尽管进行了预防，这仍导致了灾难性的中期结果。
