异基因造血干细胞移植患者术后皮肤移植物抗宿主病的临床分析及护理对策

张婷; 韩爱芝; 龙章飚; 葛健; 杨明珍

doi:10.16766/j.cnki.issn.1674-4152.002168

异基因造血干细胞移植患者术后皮肤移植物抗宿主病的临床分析及护理对策

doi: 10.16766/j.cnki.issn.1674-4152.002168

安徽医科大学第一附属医院血液科，安徽合肥 230032

基金项目:

国家自然科学基金项目 81900118

安徽省自然科学基金 1708085MH224

安徽省2019年重点研究与开发计划立项项目 201904a07020057

详细信息

通讯作者:
韩爱芝, E-mail: 136952148@qq.com

中图分类号: R473.55 R733
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- 文章访问数: 93
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- 被引次数: 0
出版历程
- 收稿日期: 2021-02-21
- 网络出版日期: 2022-02-15

Clinical analysis and nursing measures of cutaneous GVHD after allogeneic haematopoietic stem cell transplantation in 152 patients

Department of Hematology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230032, China

摘要

摘要: 目的探讨异基因造血干细胞移植(allogeneic hematopoietic stem cell transplantation，allo-HSCT)术后皮肤移植物抗宿主病(graft-versus-host disease，GVHD)的临床特征和相关危险因素，并提出防治皮肤GVHD的护理对策。方法回顾性分析2008年6月—2019年12月在接受allo-HSCT一次成功且随访半年以上的152例患者的临床资料。记录患者移植相关数据资料，包括皮肤GVHD发生情况、供受者条件、疾病相关信息等。随访至2020年6月22日，采用住院记录、门诊、电话和微信平台等随访方式。皮肤GVHD患者根据其分级或严重程度不同给予个性化的综合护理干预措施。结果 152例allo-HSCT术后患者，共确诊94例皮肤GVHD，发生率为61.84%，其中急性者36例(23.68%)，慢性者69例(45.39%)。多因素分析中，高危患者、血型不相合、HLA配型不合和发生系统性慢性GVHD是皮肤GVHD的重要危险因素。94例皮肤GVHD患者经过治疗护理后，70例患者皮肤损伤好转，24例死亡，病死率为25.53%。结论皮肤GVHD严重影响患者的日常生活和预后，应优先选择血型相合、HLA配型相合的供者，同时需制定出有效的护理干预方案以减轻患者皮肤损伤程度。
- 造血干细胞移植 /
- 移植物抗宿主病 /
- 皮肤 /
- 临床分析 /
- 护理对策
Abstract: Objective To explore the clinical characteristics and risk factors associated with cutaneous graft-versus-host disease (GVHD) after allogeneic haematopoietic stem cell transplantation (allo-HSCT) and put forward prevention and treatment nursing countermeasures for cutaneous GVHD. Methods The clinical data of 152 patients who received successful allo-HSCT from June 2008 to December 2019 and were followed up for more than six months were retrospectively analysed. Data regarding patient transplantation, including the occurrence of cutaneous GVHD, patients' conditions and disease-related information, were recorded. Follow-up to June 22, 2020, using inpatient records, outpatient, telephone and WeChat platform follow-up. Patients with cutaneous GVHD were given individualised comprehensive nursing interventions according to their grade or severity. Results A total of 94 cases of cutaneous GVHD were diagnosed in 152 allo-HSCT patients, with an occurrence rate of 61.84%. Amongst them, 36 cases (23.68%) were acute, and 69 cases (45.39%) were chronic. Multi-factor analysis showed that high-risk patients, blood type mismatch, human leucocyte antigen mismatch and the occurrence of systemic chronic GVHD were important risk factors for cutaneous GVHD. After the treatment and care of 94 cases of cutaneous GVHD, 70 cases of cutaneous injury improved, and 24 cases died. The fatality rate was 25.53%. Conclusion Cutaneous GVHD seriously affects patients' daily life and prognostics. Thus, donors with compatible blood type and HLA type should be preferred, and effective nursing intervention programs should be performed to reduce the degree of cutaneous injury of patients.
- Haematopoietic stem cell transplantation /
- Graft-versus host disease /
- Cutaneous /
- Clinical analysis /
- Nursing measures

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表 1 152例异基因外周造血干细胞移植患者术后皮肤GVHD危险因素的单因素分析[例(%)]

因素	发生皮肤GVHD(n=94)	未发生皮肤GVHD(n=58)	χ²值	P值
患者年龄			1.124	0.289
18~40岁	62(59.05)	43(40.95)
≥40岁	32(68.09)	15(31.91)
患者性别			1.945	0.163
男性	64(65.98)	33(34.02)
女性	30(54.55)	25(45.45)
疾病诊断			4.160	0.385
AML	29(54.72)	24(45.28)
ALL	18(66.67)	9(33.33)
CML	16(55.17)	13(44.83)
AA	15(68.18)	7(31.82)
其他	16(76.19)	5(23.81)
疾病性质			0.676	0.411
良性	16(55.17)	13(44.83)
恶性	78(63.41)	45(36.59)
危险度分层			6.516	0.011
中危	22(46.81)	25(53.19)
高危	72(68.57)	33(31.43)
是否合并慢性病			0.039	0.843
是	9(64.29)	5(35.71)
否	85(61.59)	53(38.41)
供受者性别匹配			0.765	0.382
相同	45(58.44)	32(41.56)
不同	49(65.33)	26(34.67)
供者年龄是否大于受者			4.131	0.042
是	58(69.05)	26(30.95)
否	36(52.94)	32(47.06)
供受者血型匹配			16.652	< 0.001
相合	43(48.31)	46(51.69)
不相合	51(80.95)	12(19.05)
HLA配型结果			13.747	< 0.001
全相合	48(50.53)	47(49.47)
不全相合	46(80.70)	11(19.30)
供受者关系			0.240	0.624
亲缘供者	80(61.07)	51(38.93)
非亲缘供者	14(66.67)	7(33.33)
预处理方案			10.256	0.036
Flu+BU/CY	7(70.00)	3(30.00)
BU/CY或改良BU/CY+Ara-C	31(51.67)	29(48.33)
BU/CY+IDA	2(66.67)	1(33.33)
CTX+ATG	5(38.46)	8(61.54)
BU/CY+ATG或BU/CY+Ara-C+ATG	49(74.24)	17(25.76)
预防GVHD方案			8.708	0.013
CSA+MTX	33(66.00)	17(34.00)
CSA+MTX+MMF	38(51.35)	36(48.65)
CSA+MTX+MMF+PTCY	23(82.14)	5(17.86)
移植类型			0.269	0.604
外周造血干细胞移植	38(64.41)	21(35.59)
骨髓移植+外周造血干细胞移植	56(60.22)	37(39.78)
患者是否出现系统性急性GVHD			3.023	0.082
是	20(76.92)	6(23.08)
否	74(58.73)	52(41.27)
患者是否出现系统性慢性GVHD			14.272	< 0.001
是	34(87.18)	5(12.82)
否	60(53.10)	53(46.90)
注：AML为急性髓系白血病；ALL为急性淋巴细胞白血病；CML为慢性粒细胞白血病；AA为再生障碍性贫血；HLA为人类白细胞抗原；Flu为氟达拉滨；BU/CY为白消安+环磷酰胺；Ara-C为阿糖胞苷；IDA为去甲氧柔红霉素；ATG为抗胸腺细胞球蛋白；CSA为环孢素；MTX为甲氨蝶呤；MMF为吗替麦考酚酯；PTCY为移植后环磷酰胺。

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表 2 152例异基因外周造血干细胞患者移植术后皮肤GVHD的多因素logistic分析

影响因素	B	SE	Wald χ²	P值	OR值	95% CI
高危患者	-0.938	0.432	4.725	0.030	0.391	0.168~0.912
血型不相合	-1.212	0.435	7.764	0.005	0.298	0.127~0.698
HLA配型不相合	-1.878	0.455	17.032	< 0.001	0.153	0.063~0.373
发生慢性系统性GVHD	2.167	0.571	14.393	< 0.001	8.734	2.851~26.759
注：赋值标准如下，危险度分层，中危=0，高危=1；供受者血型匹配, 相合=0，不相合=1；HLA配型结果, 全相合=0，不全相合=1；患者出现系统性慢性GVHD, 否=0，是=1。

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参考文献(18)

[1]	中国异基因造血干细胞移植治疗血液系统疾病专家共识(Ⅲ)——急性移植物抗宿主病(2020年版)[J]. 中华血液学杂志, 2020, 41(7): 529-536.
[2]	PASSWEG J R, BALDOMERO H, BADER P, et al. Use of haploidentical stem cell transplantation continues to increase: The 2015 European Society for Blood and Marrow Transplant activity survey report[J]. Bone Marrow Transplant, 2017, 52(6): 811-817. doi: 10.1038/bmt.2017.34
[3]	SCHOEMANS H M, LEE S J, FERRARA J L, et al. EBMT-NIH-CIBMTR task force position statement on standardized terminology & guidance for graft-versus-host disease assessment[J]. Bone Marrow Transplant, 2018, 53(11): 1401-1415. doi: 10.1038/s41409-018-0204-7
[4]	STRONG R K, OLIVEIRA-RIBEIRO C, DE ABREU F S, et al. Cutaneous Graft-Versus-Host disease: Diagnosis and treatment[J]. Am J Clin Dermatol, 2018, 19(1): 33-50. doi: 10.1007/s40257-017-0306-9
[5]	PENACK O, MARCHETTI M, RUUTU T, et al. Prophylaxis and management of graft versus host disease after stem-cell transplantation for haematological malignancies: Updated consensus recommendations of the European Society for Blood and Marrow Transplantation[J]. Lancet Haematol, 2020, 7(2): e157-e167. doi: 10.1016/S2352-3026(19)30256-X
[6]	DIGNAN F L, CLARK A, AMROLIA P, et al. Diagnosis and management of acute graft-versus-host disease[J]. Br J Haematol, 2012, 158(1): 30-45. doi: 10.1111/j.1365-2141.2012.09129.x
[7]	沈悌, 赵永强. 血液病诊断及疗效标准[M]. 4版. 北京: 科学出版社, 2018.
[8]	JAGASIA M H, GREINIX H T, ARORA M, et al. National institutes of health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: Ⅵ. the 2014 diagnois and staging working group report[J]. Biol Blood Marrow Transplant, 2015, 21(3): 389-401. doi: 10.1016/j.bbmt.2014.12.001
[9]	王佳丽, 韩明哲. 异基因造血干细胞移植后植入功能不良发生机制研究进展[J]. 中华血液学杂志, 2019, 40(9): 792-795.
[10]	SHI C R, HUANG J T, NAMBUDIRI V E. Pediatric cutaneous graft versus host disease: A review[J]. Curr Pediatr Rev, 2017, 13(2): 100-110. http://www.onacademic.com/detail/journal_1000040278208610_02d2.html
[11]	胡宇晴, 张建中. 同时具有硬皮病样和皮肤异色病样皮损的慢性移植物抗宿主病[J]. 临床皮肤科杂志, 2020, 49(2): 95-97. https://www.cnki.com.cn/Article/CJFDTOTAL-LCPF202002010.htm
[12]	SANTOS E P, BENNETT C L, CHAKRAVERTY R. Unraveling the mechanisms of cutaneous Graft-Versus-Host disease[J]. Front Immunol, 2018, 9: 963. doi: 10.3389/fimmu.2018.00963
[13]	田伟, 郑雅男, 冯昌银, 等. 急性皮肤型移植物抗宿主病8例临床分析并文献复习[J]. 临床皮肤科杂志, 2015, 44(11): 682-684. https://www.cnki.com.cn/Article/CJFDTOTAL-LCPF201511003.htm
[14]	杨欢, 李志涛, 林韧, 等. 造血干细胞移植后硬皮病样慢性移植物抗宿主病的临床表现[J]. 南方医科大学学报, 2016, 36(6): 807-813. doi: 10.3969/j.issn.1673-4254.2016.06.13
[15]	NANDA A, HUSAIN M A A, AL-HERZ W, et al. Chronic cutaneous graft-versus-host disease in children: A report of 14 patients from a tertiary care pediatric dermatology clinic[J]. Pediatr Dermatol, 2018, 35(3): 343-353. doi: 10.1111/pde.13432
[16]	常英军. 我如何选择异基因造血干细胞移植供者[J]. 中华血液学杂志, 2016, 37(8): 643-649. https://www.cnki.com.cn/Article/CJFDTOTAL-SDYY200732003.htm
[17]	李蒙娜, 闫言, 王宝玺. 紫草素促进皮肤伤口愈合机制研究进展[J]. 中医药学报, 2018, 46(2): 124-128. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYXB201802032.htm
[18]	余新翠. 运用微信平台延伸护理服务对类风湿关节炎患者的影响[J]. 中华全科医学, 2017, 15(8): 1444-1446. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY201708051.htm