早发性腹膜透析相关性腹膜炎的危险因素及预后研究
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摘要
背景近年来,随着慢性肾衰竭患者例数逐年增加,腹膜透析作为一种操作简单、对残肾功能保护性好的替代治疗方式,逐渐成为关注的重点。腹膜透析相关性腹膜炎(PDAP)是腹膜透析最主要的并发症,因此寻找PDAP的危险因素对避免或延缓PDAP的发生、延长腹膜透析患者生存时间至关重要。目的探讨早发性PDAP的危险因素及预后情况。方法选取2008年1月—2016年6月于中国医科大学附属盛京医院行腹膜透析并发生PDAP的患者116例,根据PDAP首次发生时间将患者分为早发性PDAP组(32例)和晚发性PDAP组(84例)。收集患者的临床资料、实验室检查资料,并培养致病菌。对患者进行随访,记录转归情况及生存时间,随访终点为死亡、长久转为血液透析或随访至2017年3月。结果早发性PDAP组违反无菌操作、居住环境为平房所占比例均高于晚发性PDAP组(P<0.05);两组患者操作者情况比较,差异有统计学意义(P<0.05)。早发性PDAP组血红蛋白、清蛋白水平均低于晚发性PDAP组(P<0.05)。116例PDAP患者中,82例进行了腹膜透析液致病菌培养,59例(72.0%)培养结果为阳性,其中,早发性PDAP组14例,晚发性PDAP组45例。两组致病菌分布情况比较,差异无统计学意义(χ~2=0.982,P=0.612)。二元Logistic回归分析结果显示,违反无菌操作〔OR=4.127,95%CI(1.353,12.589)〕、居住环境为平房〔OR=4.785,95%CI(1.455,15.846)〕、低血红蛋白〔OR=0.947,95%CI(0.917,0.978)〕和低清蛋白水平〔OR=0.890,95%CI(0.799,0.978)〕是早发性PDAP的危险因素(P<0.05)。两组患者治疗转归情况比较,差异无统计学意义(χ~2=1.488,P=0.475)。截至随访终点,早发性PDAP组中位生存时间为24.0(11.2,36.8)个月,晚发性PDAP组为40.0(34.4,45.6)个月。Kaplan-Meier曲线分析显示,早发性PDAP组中位生存时间短于晚发性PDAP组(χ~2=7.221,P=0.007)。结论早发性PDAP患者生存时间短,违反无菌操作、居住环境差、低血红蛋白、低清蛋白是早发性PDAP的危险因素,需采取有效措施给予干预,减少早发性PDAP,延长患者生存时间。
Background With an increasing number of patients with chronic renal failure in recent years,peritoneal dialysis,as a simple alternative treatment for residual renal function,has attracted doctors' attention. Peritoneal dialysis associated peritonitis(PDAP)is the major complication of peritoneal dialysis. Therefore,finding the risk factors of PDAP is crucial to avoid or delay the occurrence of PDAP and prolong the survival time of patients on peritoneal dialysis.Objective To analyze the risk factors and prognosis of early-onset PDAP. Methods We selected 116 patients with PDAP from Shengjing Hospital of China Medical University from January 2008 to June 2016,and divided them into the early-onset PDAP group(n=32) and late-onset PDAP group(n=84) based on the first onset time.We collected the clinical data,laboratory results and bacterial culture results.We recorded their outcomes and survival time obtained from a follow-up that ended on the date of death or ended by March 2017 or by the time that the peritoneal dialysis was superseded by long-term hemodialysis.Results The rates of violation of aseptic manipulation and living in bungalow in the early-onset PDAP group were much higher than those of the lateonset PDAP group(P<0.05).The differences in terms of peritoneal dialysis operators between the two groups were significant(P<0.05).The average hemoglobin and albumin levels of the early-onset PDAP group were obviously lower than those of the late-onset PDAP group(P<0.05).Of the 82 cases underwent bacterial culture of peritoneal dialysis fluid,59(72.0%) had positive results,including 14 of early-onset PDAP and 45 of late-onset PDAP.The distribution of pathogens in the two groups showed no significant differences(χ~2=0.982,P=0.612).Binary Logistic regression analysis revealed that violation of aseptic manipulation 〔OR=4.127,95%CI(1.353,12.589)〕,living in bungalow 〔OR=4.785,95%CI(1.455,15.846)〕,decreased hemoglobin levels 〔OR=0.947,95%CI(0.917,0.978)〕 and decreased albumin levels 〔OR=0.890,95%CI(0.799,0.978)〕 were the risk factors of early-onset PDAP(P<0.05).There were no significant differences in treatment outcomes between the two groups(χ~2=1.488,P=0.475).Kaplan-Meier analysis showed that by the end of the follow-up,the median survival time of the early-onset PDAP group was shorter than that of the late-onset PDAP group 〔24.0(11.2,36.8)months vs 40.0(34.4,45.6) months(χ~2=7.221,P=0.007)〕.Conclusion Patients with early-onset PDAP often have shorter survival time.Violation of aseptic manipulation,poor living environment,decreased hemoglobin and albumin were the independent risk factors of early-onset PDAP.It is necessary to take effective measures to prevent and decrease the incidence of early-onset PDAP and prolong the survival of such patients.
Background With an increasing number of patients with chronic renal failure in recent years,peritoneal dialysis,as a simple alternative treatment for residual renal function,has attracted doctors' attention. Peritoneal dialysis associated peritonitis(PDAP)is the major complication of peritoneal dialysis. Therefore,finding the risk factors of PDAP is crucial to avoid or delay the occurrence of PDAP and prolong the survival time of patients on peritoneal dialysis.Objective To analyze the risk factors and prognosis of early-onset PDAP. Methods We selected 116 patients with PDAP from Shengjing Hospital of China Medical University from January 2008 to June 2016,and divided them into the early-onset PDAP group(n=32) and late-onset PDAP group(n=84) based on the first onset time.We collected the clinical data,laboratory results and bacterial culture results.We recorded their outcomes and survival time obtained from a follow-up that ended on the date of death or ended by March 2017 or by the time that the peritoneal dialysis was superseded by long-term hemodialysis.Results The rates of violation of aseptic manipulation and living in bungalow in the early-onset PDAP group were much higher than those of the lateonset PDAP group(P<0.05).The differences in terms of peritoneal dialysis operators between the two groups were significant(P<0.05).The average hemoglobin and albumin levels of the early-onset PDAP group were obviously lower than those of the late-onset PDAP group(P<0.05).Of the 82 cases underwent bacterial culture of peritoneal dialysis fluid,59(72.0%) had positive results,including 14 of early-onset PDAP and 45 of late-onset PDAP.The distribution of pathogens in the two groups showed no significant differences(χ~2=0.982,P=0.612).Binary Logistic regression analysis revealed that violation of aseptic manipulation 〔OR=4.127,95%CI(1.353,12.589)〕,living in bungalow 〔OR=4.785,95%CI(1.455,15.846)〕,decreased hemoglobin levels 〔OR=0.947,95%CI(0.917,0.978)〕 and decreased albumin levels 〔OR=0.890,95%CI(0.799,0.978)〕 were the risk factors of early-onset PDAP(P<0.05).There were no significant differences in treatment outcomes between the two groups(χ~2=1.488,P=0.475).Kaplan-Meier analysis showed that by the end of the follow-up,the median survival time of the early-onset PDAP group was shorter than that of the late-onset PDAP group 〔24.0(11.2,36.8)months vs 40.0(34.4,45.6) months(χ~2=7.221,P=0.007)〕.Conclusion Patients with early-onset PDAP often have shorter survival time.Violation of aseptic manipulation,poor living environment,decreased hemoglobin and albumin were the independent risk factors of early-onset PDAP.It is necessary to take effective measures to prevent and decrease the incidence of early-onset PDAP and prolong the survival of such patients.
引文
[1]YAO Q,DUDDINGTON M.Peritoneal dialysis in China[J].Perit Dial Int,2014,34(Suppl 2):S29-30.DOI:10.3747/pdi.2013.00203.
[2]LI P K,CHOW K M,VAN DE LUIJTGAARDEN M W,et al.Changes in the worldwide epidemiology of peritoneal dialysis[J].Nat Rev Nephrol,2017,13(2):90-103.DOI:10.1038/nrneph.2016.181.
[3]PULLIAM J,LI N C,MADDUX F,et al.First-year outcomes of incident peritoneal dialysis patients in the United States[J].Am J Kidney Dis,2014,64(5):761-769.DOI:10.1053/j.ajkd.2014.04.025.
[4]BOUDVILLE N,KEMP A,CLAYTON P,et al.Recent peritonitis associates with mortality among patients treated with peritoneal dialysis[J].J Am Soc Nephrol,2012,23(8):1398-1405.DOI:10.1681/ASN.2011121135.
[5]WANG Z,JIANG L,FENG S,et al.Early peritonitis is an independent risk factor for mortality in elderly peritoneal dialysis patients[J].Kidney Blood Press Res,2015,40(3):298-305.DOI:10.1159/000368505.
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[7]SZETO C C,WONG T Y,CHOW K M,et al.The clinical course of culture-negative peritonitis complicating peritoneal dialysis[J].Am J Kidney Dis,2003,42(3):567-574.DOI:10.1016/S0272-6386(03)00790-X.
[8]MARTIN L C,CARAMORI J C,FERNANDES N,et al.Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study(BRAZPD)patients[J].Clin J Am Soc Nephrol,2011,6(8):1944-1951.DOI:10.2215/CJN.11431210.
[9]TSAI C C,LEE J J,LIU T P,et al.Effects of age and diabetes mellitus on clinical outcomes in patients with peritoneal dialysisrelated peritonitis[J].Surg Infect(Larchmt),2013,14(6):540-546.DOI:10.1089/sur.2012.195.
[10]CHERN Y B,HO P S,KUO L C,et al.Lower education level is a major risk factor for peritonitis incidence in chronic peritoneal dialysis patients:a retrospective cohort study with 12-year followup[J].Perit Dial Int,2013,33(5):552-558.DOI:10.3747/pdi.2012.00065.
[11]VARGAS E,BLAKE P G,SANABRIA M,et al.Early peritonitis in a large peritoneal dialysis provider system in Colombia[J].Perit Dial Int,2017,37(1):30-34.DOI:10.3747/pdi.2016.00030.
[12]SEE E J,JOHNSON D W,HAWLEY C M,et al.Early peritonitis and its outcome in incident peritoneal dialysis patients[J].Perit Dial Int,2017.pii:pdi.2017.00029.DOI:10.3747/pdi.2017.00029.
[13]FENG S,WANG Y,QIU B,et al.Impact of early-onset peritonitis on mortality and technique survival in peritoneal dialysis patients[J].Springerplus,2016,5(1):1676.DOI:10.1186/s40064-016-3369-9.
[14]TIAN Y,XIE X,XIANG S,et al.Risk factors and outcomes of early-onset peritonitis in Chinese peritoneal dialysis patients[J].Kidney Blood Press Res,2017,42(6):1266-1276.DOI:10.1159/000485930.
[15]SZETO C C,LI P K,JOHNSON D W,et al.ISPD catheterrelated infection recommendations:2017 update[J].Perit Dial Int,2017,37(2):141-154.DOI:10.3747/pdi.2016.00120.
[16]LOBBEDEZ T,MOLDOVAN R,LECAME M,et al.Assisted peritoneal dialysis.Experience in a French renal department[J].Perit Dial Int,2006,26(6):671-676.
[17]XU R,ZHUO M,YANG Z,et al.Experiences with assisted peritoneal dialysis in China[J].Perit Dial Int,2012,32(1):94-101.DOI:10.3747/pdi.2010.00213.
[18]KOTSANAS D,POLKINGHORNE K R,KORMAN T M,et al.Risk factors for peritoneal dialysis-related peritonitis:can we reduce the incidence and improve patient selection?[J].Nephrology(Carlton),2007,12(3):239-245.DOI:10.1111/j.1440-1797.2006.00756.x.
[19]王璐瑶,窦艳娜,肖静,等.早发性腹膜透析相关性腹膜炎的危险因素研究[J].中国全科医学,2017,20(4):454-458.DOI:10.3969/j.issn.1007-9572.2017.04.015.WANG L Y,DOU Y N,XIAO J,et al.Risk factors for earlyonset peritoneal dialysis-associated peritonitis[J].Chinese General Practice,2017,20(4):454-458.DOI:10.3969/j.issn.1007-9572.2017.04.015.
[20]WU H,HUANG R,YI C,et al.Risk factors for earlyonset peritonitis in Southern Chinese peritoneal dialysis patients[J].Perit Dial Int,2016,36(6):640-646.DOI:10.3747/pdi.2015.00203.
[21]LOBO J V,VILLAR K R,DE ANDRADE JúNIOR M P,et al.Predictor factors of peritoneal dialysis-related peritonitis[J].JBras Nefrol,2010,32(2):156-164.DOI:10.1590/S0101-28002010000200004.
[22]FOURTOUNAS C,SAVIDAKI E,DOUSDABANIS P,et al.Peritonitis during the first year after commencement of peritoneal dialysis has an impact on technique survival and patient morbidity[J].Adv Perit Dial,2006,22:50-54.
[23]HSIEH Y P,WANG S C,CHANG C C,et al.The negative impact of early peritonitis on continuous ambulatory peritoneal dialysis patients[J].Perit Dial Int,2014,34(6):627-635.DOI:10.3747/pdi.2013.00024.
[2]LI P K,CHOW K M,VAN DE LUIJTGAARDEN M W,et al.Changes in the worldwide epidemiology of peritoneal dialysis[J].Nat Rev Nephrol,2017,13(2):90-103.DOI:10.1038/nrneph.2016.181.
[3]PULLIAM J,LI N C,MADDUX F,et al.First-year outcomes of incident peritoneal dialysis patients in the United States[J].Am J Kidney Dis,2014,64(5):761-769.DOI:10.1053/j.ajkd.2014.04.025.
[4]BOUDVILLE N,KEMP A,CLAYTON P,et al.Recent peritonitis associates with mortality among patients treated with peritoneal dialysis[J].J Am Soc Nephrol,2012,23(8):1398-1405.DOI:10.1681/ASN.2011121135.
[5]WANG Z,JIANG L,FENG S,et al.Early peritonitis is an independent risk factor for mortality in elderly peritoneal dialysis patients[J].Kidney Blood Press Res,2015,40(3):298-305.DOI:10.1159/000368505.
[6]LI P K,SZETO C C,PIRAINO B,et al.ISPD peritonitis recommendations:2016 update on prevention and treatment[J].P e r i t D i a l I n t,2 0 1 6,3 6(5):4 8 1-5 0 8.D O I:10.3747/pdi.2018.00030.
[7]SZETO C C,WONG T Y,CHOW K M,et al.The clinical course of culture-negative peritonitis complicating peritoneal dialysis[J].Am J Kidney Dis,2003,42(3):567-574.DOI:10.1016/S0272-6386(03)00790-X.
[8]MARTIN L C,CARAMORI J C,FERNANDES N,et al.Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study(BRAZPD)patients[J].Clin J Am Soc Nephrol,2011,6(8):1944-1951.DOI:10.2215/CJN.11431210.
[9]TSAI C C,LEE J J,LIU T P,et al.Effects of age and diabetes mellitus on clinical outcomes in patients with peritoneal dialysisrelated peritonitis[J].Surg Infect(Larchmt),2013,14(6):540-546.DOI:10.1089/sur.2012.195.
[10]CHERN Y B,HO P S,KUO L C,et al.Lower education level is a major risk factor for peritonitis incidence in chronic peritoneal dialysis patients:a retrospective cohort study with 12-year followup[J].Perit Dial Int,2013,33(5):552-558.DOI:10.3747/pdi.2012.00065.
[11]VARGAS E,BLAKE P G,SANABRIA M,et al.Early peritonitis in a large peritoneal dialysis provider system in Colombia[J].Perit Dial Int,2017,37(1):30-34.DOI:10.3747/pdi.2016.00030.
[12]SEE E J,JOHNSON D W,HAWLEY C M,et al.Early peritonitis and its outcome in incident peritoneal dialysis patients[J].Perit Dial Int,2017.pii:pdi.2017.00029.DOI:10.3747/pdi.2017.00029.
[13]FENG S,WANG Y,QIU B,et al.Impact of early-onset peritonitis on mortality and technique survival in peritoneal dialysis patients[J].Springerplus,2016,5(1):1676.DOI:10.1186/s40064-016-3369-9.
[14]TIAN Y,XIE X,XIANG S,et al.Risk factors and outcomes of early-onset peritonitis in Chinese peritoneal dialysis patients[J].Kidney Blood Press Res,2017,42(6):1266-1276.DOI:10.1159/000485930.
[15]SZETO C C,LI P K,JOHNSON D W,et al.ISPD catheterrelated infection recommendations:2017 update[J].Perit Dial Int,2017,37(2):141-154.DOI:10.3747/pdi.2016.00120.
[16]LOBBEDEZ T,MOLDOVAN R,LECAME M,et al.Assisted peritoneal dialysis.Experience in a French renal department[J].Perit Dial Int,2006,26(6):671-676.
[17]XU R,ZHUO M,YANG Z,et al.Experiences with assisted peritoneal dialysis in China[J].Perit Dial Int,2012,32(1):94-101.DOI:10.3747/pdi.2010.00213.
[18]KOTSANAS D,POLKINGHORNE K R,KORMAN T M,et al.Risk factors for peritoneal dialysis-related peritonitis:can we reduce the incidence and improve patient selection?[J].Nephrology(Carlton),2007,12(3):239-245.DOI:10.1111/j.1440-1797.2006.00756.x.
[19]王璐瑶,窦艳娜,肖静,等.早发性腹膜透析相关性腹膜炎的危险因素研究[J].中国全科医学,2017,20(4):454-458.DOI:10.3969/j.issn.1007-9572.2017.04.015.WANG L Y,DOU Y N,XIAO J,et al.Risk factors for earlyonset peritoneal dialysis-associated peritonitis[J].Chinese General Practice,2017,20(4):454-458.DOI:10.3969/j.issn.1007-9572.2017.04.015.
[20]WU H,HUANG R,YI C,et al.Risk factors for earlyonset peritonitis in Southern Chinese peritoneal dialysis patients[J].Perit Dial Int,2016,36(6):640-646.DOI:10.3747/pdi.2015.00203.
[21]LOBO J V,VILLAR K R,DE ANDRADE JúNIOR M P,et al.Predictor factors of peritoneal dialysis-related peritonitis[J].JBras Nefrol,2010,32(2):156-164.DOI:10.1590/S0101-28002010000200004.
[22]FOURTOUNAS C,SAVIDAKI E,DOUSDABANIS P,et al.Peritonitis during the first year after commencement of peritoneal dialysis has an impact on technique survival and patient morbidity[J].Adv Perit Dial,2006,22:50-54.
[23]HSIEH Y P,WANG S C,CHANG C C,et al.The negative impact of early peritonitis on continuous ambulatory peritoneal dialysis patients[J].Perit Dial Int,2014,34(6):627-635.DOI:10.3747/pdi.2013.00024.