强的松龙预防耐多药结核病患者发生免疫重建综合征

S. Matvyeyeva
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引用次数: 0

摘要

免疫综合征炎症性重建(IRIS)是一种免疫反应,其特征是在18%的人类免疫缺陷病毒(HIV)感染患者接受抗逆转录病毒治疗(ART)后不久出现复发性或新的结核(TB)炎症体征。该综合征的特征包括反复出现的症状:发热、淋巴结炎和影像学上肺部浸润的扩散。较低的CD4水平和抗逆转录病毒治疗间隔较短会增加发生结核病相关免疫系统恢复综合征的风险。临床试验表明,在CD4细胞计数为50细胞/μl的结核病患者中,早期开始抗逆转录病毒治疗比开始治疗约8周后开始抗逆转录病毒治疗的生存率更高。这些发现与世界卫生组织的建议一致,该组织强调结核病患者和低CD4水平患者加速接受抗逆转录病毒治疗。然而,尽管抗逆转录病毒治疗具有生存优势,但早期给予抗逆转录病毒治疗不仅增加了发生与结核病相关的IRIS的风险。目前尚无预防与结核病相关的IRIS的循证战略。评估辅助糖皮质激素治疗各种形式结核病的研究表明,结核病患者的死亡率降低,结核病患者的并发症减少。该研究的目的是评估预防性使用强的松龙,以安全地减少多药耐药结核病(MDR TB)患者发生结核病相关IRIS的风险。我们观察了开始抗逆转录病毒治疗(以前没有接受过抗逆转录病毒治疗)的hiv感染患者,并在开始抗逆转录病毒治疗前30天内开始结核病治疗,CD4细胞计数为50细胞/μl。患者要么接受强的松龙标准治疗(剂量为每天40毫克,持续14天,然后每天20毫克,持续14天),要么只接受不使用强的松龙的标准治疗。主要终点是抗逆转录病毒治疗开始后12周内结核相关结核的发展。64例患者中,平均年龄36岁,60%为男性,73%为微生物确诊结核;CD4细胞中位数为49个/μl,病毒载量中位数为5.5 log 10拷贝/μl。患者分为两组。每组包括32例耐多药结核/艾滋病合并感染患者。强的松龙治疗组和对照组分别有10例(31.25%)和17例(53.14%)合并IRIS合并结核(p<001)。因此,在艾滋病毒相关抗逆转录病毒治疗开始后的头4周,对合并感染的耐多药结核病患者进行泼尼松龙治疗,导致结核病相关IRIS的发病率低于对照组,没有证据表明严重感染或癌症的风险增加。
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Use of prednisolone to prevent the development of immunity reconstitution syndrome in patients with multidrug-resistant tuberculosis
Inflammatory reconstitution of immune syndrome (IRIS) is an immunological reaction characterized by recurrent or new inflammatory signs of tuberculosis (TB) that occur shortly after antiretroviral therapy (ART) in 18 % of patients infected with human immunodeficiency virus (HIV). Features of the syndrome include recurrent symptoms: fever, lymphadenitis and the spread of pulmonary infiltrates on radiography. Low CD4 levels and a short interval between the onset of ART increase the risk of developing TB-associated immune system recovery syndrome. Clinical trials show that early onset of ART results in higher survival rates than ART initiated approximately 8 weeks after the start of TB treatment in patients with a CD4 count of 50 cells/μl. These findings are in line with the recommendations of the World Health Organization, which emphasize the acceleration of the onset of ART in patients with TB and low CD4 levels. However, despite the advantage of survival, early administration of ART more than increases the risk of developing IRIS associated with TB. There is no evidence-based strategy for the prevention of IRIS associated with TB. Studies evaluating adjuvant glucocorticoids for the treatment of various forms of TB have shown reduced mortality among TB patients and fewer complications among TB patients. The aim of the study was to evaluate the prophylactic use of prednisolone to safely reduce the incidence of TB-associated IRIS in patients with multidrug resistant TB (MDR TB) is at high risk of developing the syndrome. We observed HIV-infected patients who started ART (and had not previously received ART) and started TB treatment within 30 days before the start of ART and had a CD4 count of 50 cells/μl. Patients received either standard therapy with prednisolone (at a dose of 40 mg per day for 14 days, then 20 mg per day for 14 days) or only standard therapy without prednisolone. The main endpoint was the development of TB associated with TB within 12 weeks after the onset of ART. Among the 64 patients observed, the mean age was 36 years, 60 % were male, and 73 % had microbiologically confirmed TB; the median amount of CD4 was 49 cells/μl, and the median viral load was 5.5 log 10 copies/μl. Patients were divided into 2 groups. Each group included 32 patients with MDR TB / HIV co-infection. IRIS associated with TB was diagnosed in 10 patients (31.25 %) in the prednisolone group and in 17 (53.14 %) in the control group (p<001). Thus, prednisolone treatment of co-infected patients with MDR TB for the first 4 weeks after the onset of HIV-related ART resulted in a lower incidence of TB-associated IRIS than in the control group, with no evidence of an increased risk of severe infections or cancer.
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