Muñoz Patricia, Giannella Maddalena, Alcalá Luís, Sarmiento Elisabeth, Fernandez Yañez Juan, Palomo Jesus, Catalán Pilar, Carbone Javier, Bouza Emilio
Division of Clinical Microbiology and Infectious Diseases, Clinical Immunology Unit, Department of Cardiology, Hospital General Universitario Gregorio Marañón, University of Madrid, Madrid, Spain.
J Heart Lung Transplant. 2007 Sep;26(9):907-14. doi: 10.1016/j.healun.2007.07.010.
Information regarding Clostridium difficile-associated diarrhea (CDAD) after solid-organ transplantation (SOT) is scarce, particularly after heart transplantation (HT). Although host immune response to C. difficile plays a substantial role in the outcome of this infection, the responsibility of hypogammaglobulinemia (HGG) as a predisposing condition for CDAD has not been studied in SOT. We analyzed the incidence, clinical presentation, outcome and risk factors, including HGG, of CDAD after HT.
Two hundred thirty-five patients who underwent HT (1993 to 2005) were included. Transplantation procedure and immunosuppression were standard. From January 1999 HGG was systematically searched and corrected when IgG levels were <400 mg/dl or severe infection was present. Toxin-producing C. difficile was detected by means of cytotoxin assay and culture of stool samples. Patients with and without CDAD were compared for identification of risk factors.
CDAD was detected in 35 patients (14.9%). Incidence decreased significantly since HGG was sought and treated: 29 (20.6%) in the first period, and 6 (6.4%) in the second (p = 0.003). CDAD appeared a mean of 32 days (range 5 to 3,300 days) after HT. No related death or episode of fulminant colitis was detected. At least one episode of recurrence was noted in 28.6% of patients. Severe HGG was found to be the only independent risk factor for CDAD after HT (RR 5.8; 95% CI: 1.05 to 32.1; p = 0.04).
C. difficile is a significant cause of diarrhea in HT recipients and post-transplant HGG is independently associated with an increased risk. The potential role of immunoglobulin administration in this population requires further study.
关于实体器官移植（SOT）后艰难梭菌相关性腹泻（CDAD）的信息很少，尤其是在心脏移植（HT）后。尽管宿主对艰难梭菌的免疫反应在这种感染的结果中起重要作用，但在SOT中，低丙种球蛋白血症（HGG）作为CDAD的易感因素的作用尚未得到研究。我们分析了HT后CDAD的发病率、临床表现、结局和危险因素，包括HGG。
纳入235例接受HT的患者（1993年至2005年）。移植程序和免疫抑制是标准的。从1999年1月起，当IgG水平<400mg/dl或存在严重感染时，系统地检测并纠正HGG。通过细胞毒素测定和粪便样本培养检测产毒素艰难梭菌。比较有和没有CDAD的患者以确定危险因素。
35例患者（14.9%）检测到CDAD。自从寻找并治疗HGG以来，发病率显著下降：第一阶段为29例（20.6%），第二阶段为6例（6.4%）（p=0.003）。CDAD出现在HT后平均32天（范围5至3300天）。未检测到相关死亡或暴发性结肠炎发作。28.6%的患者至少有一次复发。严重HGG被发现是HT后CDAD的唯一独立危险因素（RR 5.8；95%CI：1.05至32.1；p=0.04）。
艰难梭菌是HT受者腹泻的重要原因，移植后HGG与风险增加独立相关。免疫球蛋白给药在该人群中的潜在作用需要进一步研究。
