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中华移植杂志(电子版) ›› 2024, Vol. 18 ›› Issue (06) : 321 -333. doi: 10.3877/cma.j.issn.1674-3903.2024.06.001

标准与指南

中国肾移植受者侵袭性曲霉病临床诊疗指南
中华医学会器官移植学分会, 中国医师协会器官移植医师分会, 中国医疗保健国际交流促进会肾移植学分会   
  • 收稿日期:2024-09-20 出版日期:2024-12-25
  • 基金资助:
    国家自然科学基金项目(82470782,82370755,82070768)

Clinical diagnosis and treatment guideline for invasive aspergillosis in kidney transplant recipients in China

of Organ Transplantation of Chinese Medical Association Branch, of Organ Transplant Physicians of Chinese Medical Doctor Association Branch, of Kidney Transplantation, China International Exchange and Promotive Association for Medical and Health Care Branch   

  • Received:2024-09-20 Published:2024-12-25
引用本文:

中华医学会器官移植学分会, 中国医师协会器官移植医师分会, 中国医疗保健国际交流促进会肾移植学分会. 中国肾移植受者侵袭性曲霉病临床诊疗指南[J/OL]. 中华移植杂志(电子版), 2024, 18(06): 321-333.

of Organ Transplantation of Chinese Medical Association Branch, of Organ Transplant Physicians of Chinese Medical Doctor Association Branch, of Kidney Transplantation, China International Exchange and Promotive Association for Medical and Health Care Branch. Clinical diagnosis and treatment guideline for invasive aspergillosis in kidney transplant recipients in China[J/OL]. Chinese Journal of Transplantation(Electronic Edition), 2024, 18(06): 321-333.

为进一步提升我国肾移植受者侵袭性曲霉病(IA)的临床诊疗水平,中华医学会器官移植学分会组织器官移植和感染学专家,依据现有的临床指南、系统评价、病例研究和专家共识等资料,总结近年来国内外在肾移植受者IA 诊疗中遇到的问题,并进行整合。 经多次专家研讨达成一致意见后,撰写成《中国肾移植受者侵袭性曲霉病临床诊疗指南》。 本指南围绕10 个临床问题,形成13 条推荐意见,并根据2009 版英国牛津大学循证医学中心的证据分级与推荐强度标准,对每个临床问题的推荐意见强度与证据级别进行分级。 本指南旨在指导临床实践,帮助提升肾移植受者长期存活率。

To enhance the clinical expertise in the diagnosis and treatment of invasive aspergillosis(IA)in kidney transplant recipients in China, the Branch of Organ Transplantation of Chinese Medical Association organized experts from both organ transplantation and infectious disease specialties.Drawing from existing clinical guidelines, systematic reviews, case studies and expert consensus, they synthesized and consolidated challenges encountered in the diagnosis and treatment of IA in kidney transplant recipients at home and abroad in recent years.Following multiple rounds of expert discussions that culminated in consensus, the Clinical diagnosis and treatment guideline for invasive aspergillosis in kidney transplant recipients in China were developed.This guideline encompasses 10 clinical questions and formulates 13 recommendations.Based on the 2009 Oxford University Center for Evidence-Based Medicine′s criteria for evidence grading and recommendation intensity, the strength of recommendations and the level of evidence for each clinical question were categorized.This guideline aims to enhance clinical practice and improve the long-term survival rate of kidney transplant recipients.

表1 2009 版牛津大学循证医学中心证据分级与推荐意见强度分级标准
表2 治疗IA 的抗真菌药物
药物 剂型 适应证 用量
伏立康唑 片剂、干混悬剂(口服) 成人和≥2 岁以上儿童IA患者 负荷剂量(适用于第1 个24 h):体质量≥40 kg,400 mg/ 次,每12 小时1 次;体质量<40 kg,200 mg/ 次,每12 小时1 次。维持剂量(开始用药24 h 后):体质量≥40 kg,200 mg/ 次,2 次/ d;体质量<40 kg,100 mg/ 次,2 次/ d
干混悬剂(静脉滴注)、注射用无菌粉末(静脉滴注) 负荷剂量(适用于第1 个24 h):6 mg/ kg,每12 小时1 次;维持剂量(开始用药24 h 后):4 mg/ kg,2 次/ d
艾沙康唑 注射剂型、口服胶囊 成人IA、侵袭性毛霉病 负荷剂量:前48 h 内,200 mg/ 次,每8 小时1 次,共6 次;维持剂量:从末次负荷剂量给药后12 ~24 h 开始,200 mg/ 次,1 次/ d
泊沙康唑 注射液、肠溶片和口服混悬液,注射液和肠溶片可进行剂型转换,剂型转换时不需采用负荷剂量 成人患者IA 的治疗; ≥13 岁以上因重度免疫缺陷患者侵袭性曲霉和念珠菌感染预防 负荷剂量:第1 天,300 mg/ 次,2 次/ d;维持剂量:第2 天开始,300 mg/ 次,1 次/ d;预防侵袭性曲霉和念珠菌感染:200 mg/ 次,3 次/ d。治疗疗程根据患者基础疾病的严重程度和临床应答而定,推荐总疗程为6 ~12 周;预防疗程根据中性粒细胞减少症或免疫抑制的恢复程度而定
脂质体两性霉素B 注射剂型 曲霉引起的成人以及1 个月至18 岁的儿童系统性真菌感染 成人患者根据其具体情况调整给药剂量。
治疗系统性真菌感染:初始治疗剂量为1. 0 mg·kg -1 ·d -1 ,根据需要逐步增至3.0 mg·kg -1 ·d -1 。典型累积剂量为3 ~4 周内1. 0 ~3. 0 g
两性霉素B 胆固醇硫酸酯复合物 注射剂型 深部真菌感染:因肾损伤或药物毒性而无法使用有效剂量的两性霉素B,或两性霉素B 治疗无效 3. 0 ~4. 0 mg·kg -1 ·d -1 。若无改善或真菌感染恶化,剂量可增至6 mg·kg -1 ·d -1
表3 IPA 治疗疗效评价标准(参照2021 年SOT 受者IPA 指南[1])
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