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实体器官移植受者感染新型冠状病毒的诊疗策略

巨春蓉, 徐鑫, 薛武军. 实体器官移植受者感染新型冠状病毒的诊疗策略[J]. 器官移植, 2023, 14(2): 183-193. doi: 10.3969/j.issn.1674-7445.2023.02.002
引用本文: 巨春蓉, 徐鑫, 薛武军. 实体器官移植受者感染新型冠状病毒的诊疗策略[J]. 器官移植, 2023, 14(2): 183-193. doi: 10.3969/j.issn.1674-7445.2023.02.002
Ju Chunrong, Xu Xin, Xue Wujun. Diagnosis and treatment strategies for solid organ transplant recipients with SARS-CoV-2 infection[J]. ORGAN TRANSPLANTATION, 2023, 14(2): 183-193. doi: 10.3969/j.issn.1674-7445.2023.02.002
Citation: Ju Chunrong, Xu Xin, Xue Wujun. Diagnosis and treatment strategies for solid organ transplant recipients with SARS-CoV-2 infection[J]. ORGAN TRANSPLANTATION, 2023, 14(2): 183-193. doi: 10.3969/j.issn.1674-7445.2023.02.002

实体器官移植受者感染新型冠状病毒的诊疗策略

doi: 10.3969/j.issn.1674-7445.2023.02.002
基金项目: 

科技部国家重点研发计划新冠应急项目 2021YFF0604000

详细信息
    作者简介:
    通讯作者:

    薛武军,Email:xwujun126@xjtu.edu.cn

  • 中图分类号: R617, R373.1

Diagnosis and treatment strategies for solid organ transplant recipients with SARS-CoV-2 infection

More Information
  • 摘要: 实体器官移植受者(SOTR)由于长期服用免疫抑制药,属于各种病原体感染的高危人群,包括新型冠状病毒(新冠病毒)。另外,SOTR往往伴有高血压、糖尿病等慢性基础疾病,感染新冠病毒后重型率和病死率高于普通人群,因此得到移植领域专家的高度重视。奥密克戎株目前为全球范围内的主要流行毒株,快速扩散至全球100多个国家,引起广泛关注。根据最新的国际关于新冠病毒感染诊治指南和我国相关专家共识,结合目前新冠病毒感染疫情形势及我国《新型冠状病毒感染诊疗方案(试行第十版)》,本文从新冠病毒感染的流行病学、临床表现和预后、诊断和临床分型以及治疗方面进行简单述评。

     

  • 图  1  1例肾移植术后受者新冠病毒肺炎的胸部CT表现

    注:A、C图为新冠病毒感染前的CT表现;B、D图为新冠病毒感染后的CT表现,双肺弥漫性磨玻璃样阴影,伴有散在斑片渗出性阴影。

    Figure  1.  CT findings of SARS-CoV-2 pneumonia in a kidney transplant recipient

    图  2  1例肺移植术后受者新冠病毒肺炎的胸部CT表现

    注:A图为双肺移植术后新冠病毒肺炎的胸部CT表现;B图为以支气管泡灌洗液为标本通过二代测序检测RNA病毒结果,检测结果显示新冠病毒RNA的特异序列数>400万,该病毒的分型为BA.5.2.,是中国目前流行的主要病毒株。

    Figure  2.  CT findings of SARS-CoV-2 pneumonia in a lung transplant recipient

    图  3  使用奈玛特韦/利托那韦片期间CNI的药物治疗管理流程图

    注:*如果条件允许,可在第3日监测他克莫司谷浓度,评估是否需要服用1剂他克莫司(0.5 mg)以维持治疗所需的血药浓度。**建议每日给药1次。***建议恢复每日给药2次。预计环孢素比他克莫司能更快恢复到基线剂量。

    Figure  3.  Flow chart of medication management of CNI during the administration of nematvir/ritonavir

    图  4  肺移植受者治疗新冠病毒肺炎过程中的皮下出血示意图

    Figure  4.  Subcutaneous bleeding in lung transplant recipients undergoing treatment for SARS-CoV-2 pneumonia

    图  5  俯卧位肺通气治疗示意图

    Figure  5.  Schematic diagram of prone position for pulmonary ventilation improvement

    表  1  新冠病毒变异株出现时间及遗传学特征

    Table  1.   Occurrence time and genetic characteristics of SARS-CoV-2 variants

    变异株 首次报道时间和国家 S蛋白基因突变位点
    S1 S2
    受体结合区域 N-端区域 其他
    B.1.1.7 (Alpha) 2020年9月英国 N501Y Δ69-70、Δ144-145 A570D、D614G、P681H T716I、S982A、D1118H
    B.1.351(Beta) 2020年5月南非 K417N、E484K、N501Y D80A、D215G、Δ242-244 D614G A701V
    P.1(Gamma) 2020年11月巴西 K417T、E484K、N501Y L18F、T20N、P26S、D138Y、R190S D614G、H655Y T1027I、V1176F
    B.1.617.2(Delta) 2020年10月印度 L452R、T478K T19R、E156G、Δ157-158 D614G、P681R D950N
    B.1.1.529(Omicron) 2021年11月南非、博兹瓦纳 G339D、S371L、S373P、S375F、K417N、N440K、G446S、S477N、T478K、E484A、Q493R、G496S、Q498R、N501Y、Y505H A67V、Δ69-70、T95I、G142D、Δ143-145、Δ211、L212I、ins214EPE T547K、D614G、H655Y、N679K、P681H N764K、D796Y、N856K、Q954H、N969K、L981F
    下载: 导出CSV

    表  2  国际指南推荐的小分子药的用药注意事项

    Table  2.   International guidelines for the use of small molecule drugs

    药物名称 适用人群 给药方案
    奈玛特韦/利托那韦 FDA紧急授权用于治疗轻至中型新冠病毒感染,适用于年龄≥12岁,体质量≥40 kg的高危人群 eGFR≥60 mL/min:奈玛特韦300 mg(2片)+利托那韦100 mg(1片),每日2次,连续使用5 d
    eGFR 30~59 mL/min:奈玛特韦150 mg(1片)+利托那韦100 mg(1片)每日2次,连续使用5 d
    eGFR<30 mL/min:不建议使用重度肝功能不全(Child-Pugh C级):不建议使用
    瑞德西韦 经FDA批准用于治疗出生时间≥28 d、体质量≥3 kg的新冠病毒感染患者 体质量≥40 kg的成人和儿童的剂量:第1日瑞德西韦200 mg静脉注射,从第2日开始瑞德西韦100 mg静脉注射,每日1次
    体质量3~39 kg,出生时间≥28 d患者的剂量:第1日瑞德西韦5 mg/kg静脉注射,从第2日开始瑞德西韦2.5 mg/kg静脉注射,每日1次
    治疗总时长:非住院患者3 d,住院患者5 d或直到出院
    莫诺拉韦 FDA紧急授权用于治疗年龄≥18岁高危人群的轻至中型新冠病毒感染 莫诺拉韦800 mg(4粒200 mg胶囊)口服,每日2次,连续5 d
    下载: 导出CSV

    表  3  特殊人群用药注意事项及剂量调整

    Table  3.   Medication precautions and dose adjustment for special population

    药品名称 eGFR(mL/min) 重度肝功能不全 血液系统
    ≥60 30~59 16~29 ≤15
    奈玛特韦/利托那韦 奈玛特韦300 mg(2片)+利托那韦100 mg(1片)每日2次 奈玛特韦150 mg(1片)+利托那韦100 mg(1片)每日2次 不建议使用 不建议使用 不建议使用 无影响
    莫诺拉韦 800 mg每日2次 无影响
    巴瑞替尼 4 mg每日1次 2 mg每日1次 1 mg每日1次 不建议使用 不建议使用 淋巴细胞<0.2×109/L或中性粒细胞<0.5×109/L时应暂停
    托珠单抗 8 mg/kg静脉给药,输注时间>1 h,单次剂量不超过800 mg,如果未改善或恶化,可重复给药1次 不建议使用,ALT或AST>10倍正常上限时避免使用 中性粒细胞<1.0×109/L、血小板<50×109/L时应暂停
    注:①ALT为谷氨酸转氨酶。
      ②AST为天冬氨酸转氨酶。
    下载: 导出CSV
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  • 收稿日期:  2023-01-18
  • 网络出版日期:  2023-03-15
  • 刊出日期:  2023-03-15

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