维持性腹膜透析患者并发真菌性腹膜炎的易感因素和结局分析

摘要/Abstract

摘要： 目的分析腹膜透析相关性真菌性腹膜炎（FP）发生率、致病菌、治疗情况和预后。方法回顾性分析2010年1月至2019年10月陆军军医大学第二附属医院腹膜透析中心发生的18例FP，选择与同期收治非真菌性腹膜炎113例比较，记录所有FP患者的临床资料，治疗方法和转归，分析FP发生的易感因素和结局。结果腹膜透析相关性腹膜炎共389例次，FP 18例次，占4.6%。其中白念珠菌6例（33.3%）、近平滑念珠菌5例（27.8%）、无名念珠菌3例（16.7%）、光滑念珠菌2例（11.1%）、热带念珠菌1例（5.6%）和克柔念珠菌（5.6%）1例。与非真菌性腹膜炎相比较，FP组腹透时间更长（P<0.001）、既往抗生素使用率高（P<0.001）、血浆白蛋白（ALB）更低（P<0.001）、C反应蛋白（CRP）更高（P<0.001）、甲状旁腺激素（PTH）和血磷（P）水平更高（P<0.001）。Logistic回归分析结果显示腹透时间越长、1个月内使用抗生素、低ALB和高CRP是发生FP的危险因素（P<0.05）。18例次FP中，14例患者拔管转血透（77.8%），4例患者死亡（22.2%），FP组腹膜透析技术失败率和死亡率明显高于BP组。结论腹透时间越长、既往使用抗生素、低ALB和高CRP是FP的易感因素。FP是腹膜透析的严重并发症，是导致技术失败的主要原因，确诊后早期拔管可降低死亡率。

关键词: 腹膜透析, 真菌性腹膜炎, 抗真菌治疗, 易感因素

Abstract: Objective To evaluate the incidence, pathogenic fungi, treatment and prognosis of peritoneal dialysis-associated fungal peritonitis (FP). Methods The clinical data of 18 cases of FP in the peritoneal dialysis center of the Second Affiliated Hospital of the Army Medical University from January 2010 to October 2019 were retrospective analyzed. The clinical data, treatment methods and outcomes of all FP patients were recorded and compared with those of 113 cases of no fungal peritonitis. Results Three hundred and eighty nine cases of peritoneal dialysis-related peritonitis were reviewed, FP accouted for 4.6%. There were 6 cases (33.3%) of Candida albicans, 5 cases (27.8%) of Candida parapsilosis, 3 cases (16.7%) of Candida famata, 2 cases (11.1%) of Candida smooth, 1 case of Candida tropical (5.6%) and 1 case of Candida krusei(5.6%). Compared to no fungal peritonitis group, The FP group showed the longer duration of peritoneal dialysis (P<0.001), higher rate of previous antibiotic use (P<0.001), lower serum albumin (P<0.001), higher c-reactive protein (P<0.001), higher intact parathyroid hormone (P<0.001) and higher phosphorus (P<0.001). Logistic regression analysis showed that the longer duration of peritoneal dialysis, antibiotic use within 1 month, hypoalbuminemia and high c-reactive protein were risk factors for FP (P<0.05). Among the 18 FP patients, 14 patients (77.8%) were removed the catheter to maintenance hemodialysis and 4 patients (22.2%) died. The technique failure rate of peritoneal dialysis and mortality in FP group was significantly higher than that in no fungal peritonitis group. Conclusion Long term peritoneal dialysis, previous use of antibiotics, hypoalbuminemia and high c-reactive protein were high risk factors for FP. FP was a serious complication of peritoneal dialysis and a major cause of technical failure. Early catheter removal after diagnosis could reduce the mortality of FP.

Key words: peritoneal dialysis, fungal peritonitis, antifungal treatment, predisposing factors

中图分类号:

李艺, 郭佳, 王竟爽, 印苏培, 赵景宏, 黄云剑. 维持性腹膜透析患者并发真菌性腹膜炎的易感因素和结局分析[J]. 中国真菌学杂志, 2021, 16(1): 29-34.

LI Yi, GUO Jia, WANG Jingshuang, YIN Shupei, ZHAO Jinghong, HUANG Yunjian. The analysis of risk factors and outcomes of peritoneal dialysis-related fungal peritonitis[J]. Chinese Journal of Mycology, 2021, 16(1): 29-34.

参考文献

[1] Wang AY, Yu AW, Li PK, et al. Factors predicting outcome of fungal peritonitis in peritoneal dialysis:analysis of a 9-year experience of fungal peritonitis in a single center[J]. Am J Kidney Dis, 2000, 36(4):1183-1192.
[2] Bargman JM, Hospital TG. Characteristics and outcomes of fungal peritonitis in a modern North American cohort[J]. Perit Dial Int, 2015, 35(1):78-84.
[3] Miles R, Hawley CM, McDonald SP, et al. Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients[J].Kidney Int, 2009, 76(6):622-628.
[4] Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations:2010 update[J].Perit Dial Int, 2010, 30(4):393-423
[5] Matuszkiewicz-Rowinska J. Update on fungal peritonitis and its treatment[J]. Perit Dial Int, 2009, 29:161-165.
[6] Oygar DD, Altiparmak MR, Murtezaoglu A, et al. Fungal peritonitis in peritoneal dialysis:risk factors and prognosis[J]. Ren Fail, 2009, 31(1):25-28.
[7] Goldie SJ, Kiernan-Tridle L, Torres C, et al. Fungal peritonitis in a large chronic peritoneal dialysis population:a report of 55 episodes[J]. Am J Kidney Dis,1996, 28(1):86-91.
[8] Shouci Hu, Ren Tong, Yang Bo, et al. Fungal peritonitis in peritoneal dialysis:5-year review from a North China center[J].Infection, 2019, 47(1):35-43.
[9] 赵洪静,许坤,吴永贵.腹膜透析相关性真菌性腹膜炎易感因素及预后分析[J]. 安徽医学,2015, 1(36):26-29.
[10] Szeto CC, Li PK. Peritoneal dialysis-associated peritonitis[J].Clin J Am Soc Nephrol, 2019,14(7):1100-1105.
[11] Hu S, Ming P, Qureshi AR, et al. Peritonitis:episode sequence, microbiological variation, risk factors and clinical outcomes in a North China peritoneal dialysis center[J]. Kidney Blood Press Res, 2018, 43(5):1573-1584.
[12] Zalunardo NY, Rose CL, Ma IW, et al. Higher serum C-reactive protein predicts short and long-term outcomes in peritoneal dialysis-associated peritonitis[J].Kidney Int, 2007, 71(7):687-692.
[13] Pfaller MA, Castanheira M, Messer SA, et al. In vitro anti-fungal susceptibilities of isolates of Candida spp. and Aspergillus spp. from China to nine systemically active antifungal agents:data from the SENTRY antifungal surveillance program, 2010 through 2012[J]. Mycoses, 2015, 58(4):209-214.
[14] Kumar KV, Mallikarjuna HM, Gokulnath. Fungal peritonitis in continuous ambulatory peritoneal dialysis:the impact of antifungal prophylaxis on patient and technique outcomes[J]. Indian J Nephrol, 2014, 24(5), 297-301.
[15] Rajendran R, Williams C, Lappin DF et al. Extracellular DNA release acts as an antifungal resistance mechanism in matureAspergillus fumigatus biofilms[J]. Eukaryot Cell, 2013,12(3):420-429.
[16] Auricchio S, Giovenzana ME, Pozzi M et al. Fungal peritonitis in peritoneal dialysis:a 34-year single centre evaluation[J]. Clin Kidney J, 2018, 11(6); 874-880.
[17] Munshi R, Sethna CB, Richardson, et al. Fungal peritonitis in the standardizing care to improve outcomes in pediatric end stage renal disease (SCOPE) collaborative[J]. Pediatric Nephrology, 2018, 33(5):873-880.
[18] Wong PN, Lo KY, Tong GM, et al. Prevention of fungal peritonitis with nystatin prophylaxis in patients receiving CAPD[J]. Perit Dial Int, 2007, 27(5):531-536.