真菌性腹膜透析相关性腹膜炎的诊治进展

真菌性腹膜炎是影响腹膜透析的主要因素之一,与细菌性腹膜炎相比,其病亡率更高。尽管随着技术的改进和管理的提升,真菌性腹膜炎的发病率明显降低,全球发病率为2.0%~23.8%,但对于患者个人来说腹膜炎仍是影响其生存及预后的主要因素。国际腹膜透析协会建议一旦确诊为真菌性腹膜炎,需要尽早拔管并继续进行抗感染治疗至少2周,最终才能继续腹膜透析。早期预防和及时规范诊治是维持长期腹膜透析成功的关键,本研究结合近年来国内外的真菌性腹膜炎诊治的研究进展作一综述。     

蛋白结合尿毒症毒素及其清除技术的研究进展

尿毒症毒素是一大组体内代谢的产物,在肾功能衰竭患者体液中水平明显升高,并与尿毒症毒素代谢紊乱或临床表现密切相关。部分毒素可与蛋白结合,形成大分子复合物,称为蛋白结合毒素。它们具有多种生物学作用,产生一系列尿毒症并发症,如心血管疾病、免疫功能紊乱、脏器纤维化等。研究发现:血浆分离吸附、高通量血液透析、服用肠道吸附剂等方法可增加蛋白结合毒素的清除。评价尿毒症患者的透析充分性时,也应考虑到蛋白结合毒素。     

肠道菌群失衡与腹膜透析患者血清炎性因子的相关性及对患者预后的影响CSCD

目的 探讨肠道菌群失衡与腹膜透析患者血清炎性因子的相关性并监测患者的预后。方法 选择2017年12月至2020年12月来我院治疗的140例腹膜透析患者为腹膜透析组;另纳入140例健康体检者作为健康体检组。比较两组对象血清炎性因子[白介素(IL)-6、IL-8、IL-13、IL-18]水平和肠道菌群(双歧杆菌、乳杆菌、肠杆菌、肠球菌)数量,分析肠道菌群与血清炎性因子和预后的相关性。结果 腹膜透析组患者血清IL-6、IL-8、IL-18水平分别为(30.21±1.22)ng/mL、(69.12±10.22)ng/mL、(138.47±19.28)ng/mL,均高于健康体检组;而IL-13的水平为(16.47±1.24)ng/mL,显著低于健康体检组,差异有统计学意义(均P<0.05)。腹膜透析组患者粪便标本中双歧杆菌和乳杆菌数量为(6.67±1.24)lg CFU/g、(6.41±1.04)lg CFU/g,均显著低于健康体检组;而肠杆菌和肠球菌数量为(9.15±0.32)lg CFU/g、(7.63±1.54)lg CFU/g,均高于健康体检组,差异有统计学意义(均P<0.05)。腹膜透析患者血清IL-6、IL-8、IL-18与双歧杆菌、乳杆菌数量呈负相关,与肠杆菌和肠球菌呈正相关;血清IL-13与双歧杆菌和乳杆菌数量呈正相关,与肠球菌和肠杆菌呈负相关,差异均有统计学意义(均P<0.05)。随访半年,140例腹膜透析患者中28例复发腹膜炎,复发者血清IL-6、IL-8、IL-18水平显著高于未复发者,IL-13水平显著低于未复发者,差异均有统计学意义(均P<0.05)。腹膜炎复发者肠道肠杆菌和肠球菌水平显著高于未复发者(均P<0.05),而乳杆菌和双歧杆菌无显著区别(均P>0.05)。结论 腹膜透析患者血清炎性因子水平较高,肠道益生菌减少,致病菌增加;肠道菌群数量与血清炎性因子水平密切相关,二者水平的变化能提示疾病的进展,为腹膜透析患者预后监测提供依据。     

腹膜透析76例透析效能相关因素分析

目的以尿素清除指数和肌酐清除率为指标,探讨影响透析效能相关因素。方法评估76例透析患者的蛋白分解率及残余肾功能,研究其与尿素清除指数及肌酐清除率之间的关系。结果腹透患者营养状态和残肾功能分别与透析充分性呈正相关。结论加强患者营养状态,保护残余肾功能可提高透析充分性,改善患者生活质量。     

血液透析和腹膜透析对终末期肾病患者预后的影响及其安全性比较

目的:分析和比较血液透析和腹膜透析终末期肾病患者预后的影响及其安全性。方法:选取2010年1月至2016年4月本医院收治的透析患者246例作为研究对象,将其分为血液透析组和腹膜透析组,比较两组患者治疗后的生存情况及并发症的发生情况。结果:两组患者死亡原因是心力衰竭、消化道出血、重度感染、脑梗死,两组的病死率及死因构成比较差异均无统计学意义(P0.05)。腹膜透析组患者1年、3年、5年生存率均显著高于血液透析组(P0.05),两组患者7年生存率比较差异无统计学意义(P0.05)。首次透析年龄超过60岁的终末期肾病患者中,腹膜透析组1年、3年、5年、7年生存率均显著低于血液透析组(P0.05)。血液透析组心力衰竭、动静脉内瘘闭塞发生率显著高于腹膜透析组(P0.05),腹膜透析组腹膜炎的发生率显著高于血液透析组(P0.05),血液透析组总并发症发生率明显高于腹膜透析组(P0.05)。结论:血液透析和腹膜透析各有优缺点,对终末期肾病患者应个体化选择透析方式,减少并发症,提高生活质量及生存率。     

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

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。     

7天健康教育法在降低首次腹透植管患者腹膜炎中的应用

目的探讨7天健康教育方法对首次腹膜透析植管患者腹膜炎的预防及患者对护理满意度的影响。方法将66例首次腹膜透析植管患者随机分为对照组26例和观察组40例,对照组采用传统健康教育法,观察组采用7天健康教育法,比较两组患者腹膜炎的发生率和护理满意度情况,并分析腹膜炎发生诱因。结果 1个月后,观察组患者的护理满意度明显高于对照组;1年后,观察组腹膜炎的发生率明显低于对照组,差异均有显著统计学意义(P0.01)。观察组腹膜炎发生主要诱因是无菌原则不合格,居家操作环境差导致,腹膜炎发生率显著低于对照组(P0.05)。结论 7天健康教育法可有效降低腹膜炎的发生,提高患者护理满意度,从而提高生存质量。     

中分子尿毒症毒素及其清除技术的研究进展

尿毒症毒素是一大组体内代谢的产物,在肾功能衰竭患者体液中水平明显升高,并与尿毒症毒素代谢紊乱或临床表现密切相关。一般认为中分子尿毒症毒素的分子量在500D-5000D之间。此类物质蓄积可促进尿毒症性心血管病变的发生发展、抑制机体免疫功能、加重患者营养不良等。研究发现,通过高通量透析、血液透析滤过和血液灌流等方法增加中分子尿毒症毒素的清除,可以为患者带来更好的生活质量和长期生存获益。     

HD、HD+ HDF及PD对老年尿毒症患者皮肤瘙痒症的疗效比较

目的:对比分析血液透析(HD)、血液透析联合血液透析滤过(HD+HDF)、腹膜透析(PD)三种方式对老年尿毒症患者皮肤瘙痒症的疗效,为老年尿毒症患者皮肤瘙痒症的治疗提供参考。方法:选取2010年3月至2014年3月来我院就诊的老年尿毒症皮肤瘙痒症患者共100例作为研究对象,采用随机数表法随机分为HD组(33例)、联合组(33例)、PD组(34例),在初次透析前后、透析后1个月、透析后2个月记录患者皮肤瘙痒评分,并检测患者全段甲状旁腺激素(i PTH)、β2-微球蛋白(β2-MG)的水平。透析2个月后比较三组对皮肤瘙痒症的疗效。结果:联合组和PD组透析2月后β2-MG水平、i PTH水平、瘙痒症评分明显低于HD组,差异具有统计学意义(P<0.05)。PD组透析2月后β2-MG水平低于联合组,但差异不具有统计学意义(P>0.05)。PD组透析2月后i PTH水平明显低于联合组,差异具有统计学意义(P<0.05)。PD组透析2月后评分明显低于联合组,差异具有统计学意义(P<0.05)。PD组、联合组有效率明显高于HD组,差异具有统计学意义(P<0.05);PD组有效率高于联合组,但差异怒具有统计学意义(P>0.05)。结论 :血液透析联合血液透析滤过与腹膜透析均可以明显降低患者全段甲状旁腺激素、β2-微球蛋白的水平,缓解患者瘙痒症状,提升患者生活质量,值得临床推广。     

高通量血液透析治疗慢性肾衰竭尿毒症的疗效及对尿毒症毒素、免疫球蛋白及肺功能指标的影响

目的:探讨高通量血液透析(HFHD)治疗慢性肾衰竭尿毒症的疗效及对尿毒症毒素、免疫球蛋白及肺功能指标的影响。方法:选取90例于2012年1月-2017年3月期间在喀什地区第一人民医院治疗的慢性肾衰竭尿毒症患者,依据随机数字表法将其分为对照组(n=45)和观察组(n=45),对照组给予血液透析滤过(HDF)治疗,观察组给予HFHD治疗,两组均透析治疗1个月。对比两组患者透析前后症状缓解情况及尿毒症毒素、免疫球蛋白及肺功能指标水平,记录两组相关并发症的发生情况。结果:透析治疗结束后观察组患者缓解率为91.11%(41/45),高于对照组的73.33%(33/45)(P0.05)。两组患者透析后血磷(P~-)、血钾(K~+)、甲状旁腺激素(PTH)、β2-微球蛋白(β2-MG)水平明显低于透析前,血钙(Ca~(2+))水平明显高于透析前(P0.05);观察组透析后K~+、Ca~(2+)、P~-等尿毒症毒素水平与对照组比较差异无统计学意义(P0.05),观察组透析后PTH、β2-MG水平明显低于对照组(P0.05)。透析后,两组患者的免疫球蛋白Ig M、Ig A、Ig G水平均较透析前上升,且观察组高于对照组(P0.05)。透析后,两组患者残气量(RV)均低于治疗前,最大肺活量(FVC)、肺活量(VC)、肺总量(TLC)均高于治疗前,且观察组RV低于对照组,FVC、VC、TLC均高于对照组(P0.05)。观察组并发症发生率为8.89%(4/45),低于对照组的24.44%(11/45)(P0.05)。结论:HFHD治疗慢性肾衰竭尿毒症能够安全有效地清除尿毒症毒素,缓解患者的临床症状,且能够提高患者的免疫功能和肺功能。     

Rat adipose tissue-derived stem cells attenuate peritoneal injuries in rat zymosan-induced peritonitis accompanied by complement activation

Background aimsIn patients receiving peritoneal dialysis, fungal or yeast peritonitis has a poor prognosis. In rat peritoneum with mechanical scraping, severe peritonitis can be induced by zymosan, a component of yeast (Zy/scraping peritonitis). Administration of rat adipose tissue-derived stromal cells (ASCs) potentially can improve several tissue injuries. The present study investigated whether rat ASCs could improve peritoneal inflammation in Zy/scraping peritonitis.MethodsRat ASCs were injected intraperitoneally on a daily basis in rats with Zy/scraping peritonitis.ResultsPeritoneal inflammation accompanied by accumulation of inflammatory cells and complement deposition was suppressed by day 5 after injection of rat ASCs. The peritoneal mesothelial layer in Zy/scraping peritonitis with rat ASC treatment was restored compared with the peritoneal mesothelial layer without rat ASC treatment. Injected rat ASCs co-existed with mesothelial cells in the sub-peritoneal layer. In vitro assays showed increased cellular proliferation of rat mesothelial cells combined with rat ASCs by co-culture assays, confirming that fluid factors from rat ASCs might play some role in facilitating the recovery of rat mesothelial cells. Hepatocyte growth factor was released from rat ASCs, and administration of recombinant hepatocyte growth factor increased rat mesothelial cell proliferation.ConclusionsBecause the peritoneal mesothelium shows strong expression of membrane complement regulators such as Crry, CD55 and CD59, restoration of the mesothelial cell layer by rat ASCs might prevent deposition of complement activation products and ameliorate peritoneal injuries. This study suggests the therapeutic possibilities of intraperitoneal rat ASC injection to suppress peritoneal inflammation by restoring the mesothelial layer and decreasing complement activation in fungal or yeast peritonitis.     

Use of the Deane prosthesis in patients on long-term peritoneal dialysis

The Deane peritoneal prosthesis has been used successfully in the treatment of 21 patients with chronic renal failure who were maintained on peritoneal dialysis for periods of up to 20 months. All patients were dialyzed for 24 hours twice weekly. While the prosthesis was still in place, transplantation was carried out in seven patients and laparotomy in three. The prosthesis was also used temporarily whenever a permanent peritoneal catheter (Tenckhoff''s) failed because of infection; it was used until the signs of infection disappeared, then the permanent catheter could be replaced safely. From a total of 1136 dialyses 36 positive cultures were reported. Clinical peritonitis was found on only four occasions.     

Selenium Suppresses Lipopolysaccharide-Induced Fibrosis in Peritoneal Mesothelial Cells Through Inhibition of Epithelial-to-Mesenchymal Transition

Peritoneal fibrosis resulting from long-term clinical peritoneal dialysis has been the main reason of dropout from peritoneal dialysis. Peritonitis as a common complication of peritoneal dialysis treatment may lead to the occurrences of peritoneal fibrosis. We cultured peritoneal mesothelial cells with lipopolysaccharides (LPS) in order to stimulate the environment of peritonitis and investigate whether lipopolysaccharides could induce epithelial-to-mesenchymal transition (EMT). Oxidative stress could stimulate fibrogenesis while selenium has antioxidant properties. So, this study also explored whether selenium supplementation affects lipopolysaccharide-induced EMT and fibrosis. We found that lipopolysaccharides could activate EMT changes such as the loss of E-cadherin and the increase of α-smooth muscle actin (α-SMA), collagen I, vimentin, and fibronectin (FN), while selenium inhibits EMT by modulating reactive oxygen species (ROS) generation and ROS/MMP-9 signaling pathways in peritoneal mesothelial cells. Moreover, it was revealed that selenium decreased the EMT events of peritoneal mesothelial cells via inhibition of PI3k/AKT pathways. In conclusion, these findings enable a better understanding of the mechanism of peritoneal fibrosis and explore a new idea for the prevention and treatment.     

Peritonitis prevented in continuous ambulatory peritoneal dialysis by using the Hong Kong connection.

Based on the hypothesis that air contamination is an important cause of peritonitis in continuous ambulatory peritoneal dialysis, a simple and cheap connection system was developed whereby a clear polyethylene bag containing an antiseptic gauze was used as a sterilising chamber, effectively enclosing the connection procedure. Seven modifications to the connection technique were introduced over 32 months in 28 patients during 27.9 patient years of experience. The overall rate of peritonitis was 0.6 episode/patient year, but after a final modification at the beginning of the third year the rate fell to 0.17, without a single case of peritonitis occurring attributable to a connection failure in 11.5 patient years. These findings show that in patients receiving continuous ambulatory peritoneal dialysis peritonitis may be prevented by enclosing the connection process and sterilising the introduced air and tubing ends.     

Home peritoneal dialysis: 3 years' experience in Toronto.

From November 1972 to November 1975, 52 males and 39 females aged 11 to 71 years were trained for home peritoneal dialysis. Dialysis was performed through a permanent catheter 4 nights a week. The first 11 patients used the manual system, exchanging 2 / of dialysate solution every 50 to 60 minutes. Subsequently 73 patients used the automatic cycler and commercially available dialysate and 7 patients used Tenckhoff''s reverse osmosis peritoneal dialysis machine. The average duration of training was 15, 11.6 and 15 dialysis days, respectively, for the three methods. For the 83 patients followed up, the average duration of home dialysis was 8.3 months (range, 0.5 to 33 months); the total number of dialyses at home was 10 571. Ten received a transplant, 20 were transferred to hospital peritoneal dialysis or hemodialysis, 8 died and 48 continued with home dialysis. Twenty-three patients had a total of 33 episodes of peritonitis, an incidence of 27.7% among the patients in the program for up to 3 years or 0.3% among all the dialyses. By November 1975, 46 patients had returned to their predialysis lifestyle, 18 were working part-time, 10 were able to work but were not doing so, and 9 were unable to work or care for themselves.     

Candidiasis peritoneal: prevalencia y factores de riesgo

BackgroundA peritoneal fluid with a positive culture for Candida in patients with associated clinical symptoms enables peritoneal candidiasis (PC) to be diagnosed. This etiology is related to a poor prognosis, thus, it is important to know all the risk factors and to start early an empirical treatment. The risk factors associated with this kind of peritonitis are to receive prolonged antibiotic treatment, nosocomial infection, female gender, involvement of the upper gastro-intestinal (UGI) tract, and the ocurrence of an intraoperative cardiovascular failure (CVF).AimsThe principal aim was to determine the prevalence of PC in our hospital, and the secondary aims to determine the associated risk factors.MethodsWe obtained samples from 74 patients diagnosed with peritonitis, consecutively from 2007 to 2010. Cultures were performed with the free peritoneal fluid aspirated during surgery.ResultsThe prevalence of PC obtained in our hospital was 17.6%, from which 46.15% corresponded to Candida albicans. The involvement of the UGI tract and the onset of CVF can be considered risk factors for the development of this pathology. Age, gender, nosocomial infection and previous antibiotic treatment were not related to this pathology.ConclusionsOur prevalence of PC is 17.6%. The risk factors that could predispose are the involvement of the UGI tract as the cause of peritonitis, and CVF during surgical procedure.     

血清klotho、FGF水平与腹膜透析患者颈动脉粥样硬化的相关性

摘要 目的：观察腹膜透析患者颈动脉粥样硬化（As）情况及血清klotho、成纤维细胞生长因子（FGF）的表达,分析血清klotho、FGF表达与腹膜透析患者颈动脉As的关系。方法：选取我院2016年12月-2017年10月接受腹膜透析治疗的154例患者作为研究对象,统计颈动脉As发生情况,检测血清klotho、FGF水平。结果：154例腹膜透析患者患者中,颈动脉As发生率为51.16 %;发生颈动脉As患者的血清klotho水平低于未发生患者,血清FGF水平高于未发生患者,差异有统计学意义（P＜0.05）;采用双变量Pearson直线相关性分析发现,腹膜透析患者血清klotho水平与FGF水平呈负相关（r＜0,P＜0.001）;经多项Logistic回归分析结果显示,血清klotho低表达、血清FGF过表达均是腹膜透析患者发生颈动脉As的影响因素（OR＞1,P＜0.05）; ROC曲线结果显示,血清klotho、FGF预测腹膜透析患者发生颈动脉As风险的AUC均＞0.80。结论：腹膜透析患者颈动脉As的发生可能与血清klotho低表达、血清FGF过表达有关,建议临床通过检测患者血清klotho、FGF水平,预测颈动脉As发生风险。