Cytomegalia jako powikłanie po przeszczepieniu nerki
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Cytomegalia jako powikłanie po przeszczepieniu nerki

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Przeszczep nerki, jak każda operacja transplantacyjna niesie ze sobą ryzyko wystąpienia powikłań. Jednym z nich jest zakażenie wirusem cytomegalii (CMV), który jest główną przyczyną zachorowalności i śmiertelności wśród biorców przeszczepu. Występuje u 30-80% biorców.

Zakażenie wirusem cytomegalii najczęściej pojawia się w pierwszych 2-4 miesiącach od zabiegu. Zaobserwowano, iż stosowanie różnych form profilaktyki przeciwwirusowej, istotnie obniżyło liczbę przypadków objawowych i zgonów związanych z tym zakażeniem. Natomiast wydłużyło okres, w którym to zakażenie może się rozwinąć.

Wirus cytomegalii znajduje się w ślinie, łzach, moczu, nasieniu i wydzielinie z dróg rodnych. Zakażona może być również krew, mleko kobiece oraz przeszczepiany organ.

Aktywne (produktywne) zakażenie CMV może występować w trzech formach:

  • pierwotnej infekcji u osoby seronegatywnej,
  • zakażenia wtórnego związanego z reaktywacją latetnej postaci CMV lub zakażenia egzogennego,
  • będącego konsekwencją nadkażenia odmiennym szczepem wirusa.

Źródłem zakażenia wirusem CMV może być przeszczepiany narząd, przetaczana krew, a także  preparaty krwiopochodne.

Wśród głównych czynników ryzyka produktywnego zakażenia CMV po przeszczepie są:

  • status serologiczny biorcy i dawcy przeszczepu,
  • zgodność w układzie HLA pomiędzy dawcą a biorcą,
  • rodzaj i czas utrzymywania terapii immunosupresyjnej,
  • stosowanie surowic antylimfocytarnych,
  • stopień zaawansowania procesu odrzucania przeszczepu i choroby,
  • przeszczep przeciw biorcy (GvHD) po wszczepieniu komórek krwiotwórczych,
  • związana z tym konieczność agresywnej immunosupresji.

Leczenie cytomegalii

W leczeniu cytomegalii stosuje się leki przeciwwirusowe, takie jak gancyklowir i jego pochodna – walgancyklowir (leki I rzutu). Natomiast jeżeli tego rodzaju terapia nie sprawdzi się, najlepszym rozwiązaniem dla pacjenta będzie przyjmowanie leków – foskarnet i cydofowir (leki II rzutu).

Na czym polega profilaktyczna terapia przeciwwirusowa po przeszczepie nerki?

Najważniejszym celem profilaktycznej terapii przeciwwirusowej jest zapobieganie rozwojowi najcięższej formy zakażenia, czyli wielonarządowej chorobie cytomegaliowej.

Profilaktykę uniwersalną stosuje się najczęściej u biorców przeszczepów narządowych, w szczególności tych z grup wysokiego ryzyka. Wszystkim pacjentom od momentu przeprowadzenia transplantacji do mniej więcej 3-6 mies. podaje się leki I rzutu, takie jak gancyklowir i walgancyklowir.

Niekiedy stosuje się również terapię wyprzedzającą, która polega na selektywnym stosowaniu leków przeciwwirusowych (zanim pojawią się symptomy zakażenia) u osób z potwierdzoną laboratoryjnie replikacją CMV. Tego rodzaju terapia ma szansę na sukces, tylko w przypadku stałego, regularnego monitorowania pacjenta.

Co to jest i kiedy może się pojawić? – późna choroba CMV

Po zakończeniu standardowej 3-miesięcznej terapii profilaktycznej późna choroba CMV dotyka nawet  17-37 proc. biorców wysokiego ryzyka. Zazwyczaj choroba ta pojawia się między 3-6 miesiącem, jednak nie wykluczone, że pojawi się później.

Do innych powikłań po transplantacji nerki zaliczyć należy zakażenie m.in. wirusem opryszczki (herpes), półpaścem, ospą wietrzną, grzybicą, infekcją pneumocystą, zakażeniem rany, zakażeniem w drogach moczowych czy zakażeniem ujścia skórnego cewnika do dializ otrzewnowych.

Źródło:

[1] Zawilińska B., Zakażenia po transplantacji – wpływ bezpośredni i pośredni replikacji CMV na stan kliniczny biorców narządów miąższowych i komórek krwiotwórczych, Borgis – Postępy Nauk Medycznych 4b/2015, s. 55-60

[2] mp.pl

Przeczytaj także: Zapobieganie odleżynom u pacjentów ze szczególnych grup

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