Benedetti E, Gruessner A C, Troppmann C, Papalois B E, Sutherland D E, Dunn D L, Gruessner R W
Department of Surgery, University of Minnesota Hospital, Minneapolis 55455, USA.
J Am Coll Surg. 1996 Oct;183(4):307-16.
Intra-abdominal infections account for 15 percent of technical failures after pancreatic transplantation. Although some data are available about intra-abdominal bacterial infections, no study has analyzed the incidence, treatment, and outcome of intra-abdominal fungal infections.
We retrospectively studied 445 consecutive pancreatic transplantations--45 percent were simultaneous pancreatic and renal, 24 percent pancreatic after renal, and 31 percent pancreatic transplantations alone--in patients with Type I diabetes mellitus. Donors were cadavers in 92 percent and living relatives in 8 percent. Primary transplantations were done in 80 percent and retransplantation in 20 percent. Of these 445 pancreatic transplantations, 90 percent were bladder-drained, 9 percent enteric-drained, and 1 percent duct-injected. Only symptomatic patients with documented culture-positive intra-abdominal fungal infections were included.
Intra-abdominal fungal infections occurred after pancreatic transplantation in 41 (9.2 percent) of 445 patients. Donor age, but not recipient age, was a significant risk factor. The rate of infections was higher for enteric-drained (21 percent) than for bladder-drained (10 percent) transplantations; for organs donated by living relatives (16 percent) than for those from cadavers (9 percent); and for pancreatic after renal (12 percent) and simultaneous pancreatic-renal (11 percent) than for pancreatic-only (5 percent) recipients. The rate of intra-abdominal fungal infections was 6 percent for recipients who were given antifungal prophylaxis (fluconazole, 400 mg/day for seven days after transplantation) compared with 10 percent for those without prophylaxis. The one-year graft survival rate for recipients with infection was 17 percent compared with 65 percent for those without (p = 0.0001); the survival rate was 70 percent compared with 92 percent for patients with and without infection, respectively (p = 0.0007). In 22 percent of recipients, the infection resolved and graft function persisted; in 58 percent, the infection resolved after transplant pancreatectomy; and in 20 percent, death occurred despite transplant pancreatectomy. Recipients with sole fungal or fungal and bacterial infection (n = 41) were 50 percent less likely to recover with a functioning graft and had a risk of death that was three times higher (p < or = 0.05) than those with sole bacterial infection (n = 48).
Intra-abdominal fungal infections after pancreatic transplants are associated with high morbidity and mortality rates, significantly higher than for sole bacterial infections. In addition to aggressive treatment, including transplant pancreatectomy and reduction of immunosuppression, efforts must be made toward better prevention of intra-abdominal fungal infections.
腹腔内感染占胰腺移植术后技术失败的15%。虽然已有一些关于腹腔内细菌感染的数据，但尚无研究分析腹腔内真菌感染的发生率、治疗及转归。
我们回顾性研究了445例连续性胰腺移植患者，其中45%为胰肾联合移植，24%为肾移植后胰腺移植，31%为单纯胰腺移植，均为I型糖尿病患者。92%的供体为尸体，8%为活体亲属。80%为初次移植，20%为再次移植。在这445例胰腺移植中，90%采用膀胱引流，9%采用肠道引流，1%采用导管注入。仅纳入有记录的腹腔内真菌感染且有症状的患者。
445例患者中有41例（9.2%）在胰腺移植后发生腹腔内真菌感染。供体年龄是一个显著的危险因素，而受体年龄不是。肠道引流移植（21%）的感染率高于膀胱引流移植（10%）；活体亲属供体器官（16%）的感染率高于尸体供体器官（9%）；肾移植后胰腺移植（12%）和胰肾联合移植（11%）的感染率高于单纯胰腺移植受体（5%）。接受抗真菌预防（氟康唑，移植后7天每天400mg）的受体腹腔内真菌感染率为6%，未接受预防的为10%。感染受体的1年移植物存活率为17%，未感染受体为65%（p = 0.0001）；感染患者和未感染患者的存活率分别为70%和92%（p = 0.0007）。22%的受体感染得到缓解且移植物功能持续；58%的受体在移植胰腺切除术后感染得到缓解；20%的受体尽管进行了移植胰腺切除术仍死亡。单纯真菌感染或真菌合并细菌感染的受体（n = 41）移植肾功能恢复的可能性比单纯细菌感染的受体（n = 48）低50%，死亡风险高出3倍（p≤0.05）。
胰腺移植后腹腔内真菌感染与高发病率和死亡率相关，显著高于单纯细菌感染。除了积极治疗，包括移植胰腺切除术和降低免疫抑制外，必须努力更好地预防腹腔内真菌感染。
