Schneeberger Stefan, Lucchina Stefano, Lanzetta Marco, Brandacher Gerald, Bösmüller Claudia, Steurer Wolfgang, Baldanti Fausto, Dezza Clara, Margreiter Raimund, Bonatti Hugo
Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria.
Transplantation. 2005 Aug 27;80(4):441-7. doi: 10.1097/01.tp.0000168454.68139.0a.
Up to date, 24 hands/thumbs have been transplanted in 18 patients. We herein report on cytomegalovirus (CMV) infection, disease, and the adopted treatment.
Immunosuppression consisted of tacrolimus-based triple-drug therapy with antithymocyte globuline or CD25-receptor antagonist induction. Donor/recipient CMV match was negative/negative (n=8), negative/positive (n=3), positive/positive (n=3), positive/negative (n=3) and unknown in one case. Six patients (three +/-, two +/+, and one -/+) received gancyclovir i.v. followed by oral gancyclovir or valgancyclovir for prophylaxis.
Patient and graft survival at a mean follow-up of 42.9 months were 100% and 91%, respectively. Of all patients tested for CMV, 45.5% developed CMV infection or disease. Two patients that were given a CMV-positive graft showed very high viral loads (550 and 1200/200000 leukocytes) after transplantation. Gancyclovir treatment failed to permanently control CMV in 80% of the patients experiencing CMV infection. Those patients requiring more toxic second-line therapies (foscarnet/cidofovir) suffered from side effects such as nephrotoxicity, nausea, vomiting, and diarrhea.
CMV infection/disease complicated the postoperative course after composite tissue allograft (CTA) transplantation in five of nine recipients challenged with the virus. The close time correlation suggests an association between virus replication and rejection in some cases. CMV represents the major infectious threat in CTA transplantation. Therefore, CMV-mismatch should be avoided and prophylaxis with valgancyclovir and anti-CMV hyperimmunoglobulin should be mandatory.
迄今为止，已为18例患者移植了24只手/拇指。我们在此报告巨细胞病毒（CMV）感染、疾病及所采用的治疗方法。
免疫抑制采用以他克莫司为基础的三联药物疗法，并联合抗胸腺细胞球蛋白或CD25受体拮抗剂进行诱导治疗。供体/受体CMV配型情况为阴性/阴性（n = 8）、阴性/阳性（n = 3）、阳性/阳性（n = 3）、阳性/阴性（n = 3），1例情况不明。6例患者（3例+/-、2例+/+、1例-/+）静脉注射更昔洛韦，随后口服更昔洛韦或缬更昔洛韦进行预防。
平均随访42.9个月时，患者生存率和移植物生存率分别为100%和91%。在所有接受CMV检测的患者中，45.5%发生了CMV感染或疾病。2例接受CMV阳性移植物的患者在移植后病毒载量非常高（分别为550和1200/200000白细胞）。在发生CMV感染的患者中，80%的患者接受更昔洛韦治疗未能永久控制CMV。那些需要使用毒性更强的二线治疗药物（膦甲酸钠/西多福韦）的患者出现了肾毒性、恶心、呕吐和腹泻等副作用。
在9例受到病毒挑战的复合组织异体移植（CTA）受者中，有5例术后病程因CMV感染/疾病而复杂化。时间上的密切相关性表明，在某些情况下病毒复制与排斥反应之间存在关联。CMV是CTA移植中主要的感染威胁。因此，应避免CMV配型不匹配，并且必须使用缬更昔洛韦和抗CMV高免疫球蛋白进行预防。
