Complications infectieuses graves chez le transplanté rénal en réanimation
Tóm tắt
La transplantation rénale représente la première transplantation d’organe solide. Les avancées réalisées dans la gestion du traitement immunosuppresseur et le développement de nouveaux médicaments ont permis d’élargir les critères d’éligibilité des donneurs et des receveurs, de réduire de façon importante l’incidence des rejets aigus et d’améliorer la survie des greffons à long terme. Cependant, malgré une meilleure prescription des prophylaxies, la transplantation de patients présentant des comorbidités plus sévères et l’utilisation de traitements immunosuppresseurs plus lourds s’accompagnent d’une incidence accrue des complications infectieuses. Celles-ci représentent la première cause d’admission en réanimation après une transplantation rénale. Le renforcement du traitement immunosuppresseur pour un rejet aigu précède l’admission en réanimation dans 20 à 30 % des cas. De plus, une réactivation récente ou concomitante du cytomégalovirus, dont les effets immunomodulateurs pourraient favoriser la survenue des infections, est retrouvée chez 16 à 36 % des patients. Le site infecté et les pathogènes en cause dépendent du délai écoulé depuis la greffe mais surtout de la profondeur de l’immunodépression. Les pneumonies, bactériennes dans deux tiers des cas, sont au premier rang. Pneumocystis jirovecii est le pathogène opportuniste le plus fréquent. La mortalité hospitalière est comprise entre 20 et 60 %, et une dysfonction du greffon persiste chez 40 % des survivants. Il apparaît donc important pour les réanimateurs de connaître l’épidémiologie, les facteurs de risque, la présentation parfois atypique et le traitement des principales complications infectieuses observées chez le transplanté rénal.
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