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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2023, Vol. 12 ›› Issue (03) : 127 -133. doi: 10.3877/cma.j.issn.2095-3216.2023.03.002

论著

肠源性腹膜透析相关性腹膜炎治疗失败的危险因素：多中心回顾性研究
于梦园, 杨立明, 朱学研, 张晓暄, 刘声茂, 谢舜昀, 倪册, 庄小花, 崔文鹏†()   
  1. 130041　长春，吉林大学第二医院肾病内科
    130031　长春，吉林大学第一医院二部肾病内科
    132011　长春，吉林市中心医院肾病内科
    130011　长春，吉林省一汽总医院肾病内科
  • 收稿日期:2023-04-11 出版日期:2023-06-28
  • 通信作者: 崔文鹏
  • 基金资助:
    吉林省卫生厅项目(2018FP031)

Risk factors for treatment failure of enterogenous PDAP, a multicenter retrospective study

Mengyuan Yu, Liming Yang, Xueyan Zhu, Xiaoxuan Zhang, Shengmao Liu, Shunyun Xie, Ce Ni, Xiaohua Zhuang, Wenpeng Cui†()   

  1. Department of Nephrology, Second Hospital of Jilin University, Changchun 130041
    Department of Nephrology, Second Division of First Hospital of Jilin University, Changchun 130031
    Department of Nephrology, Jilin Central Hospital, Changchun 132011
    Department of Nephrology, Jilin FAW General Hospital, Changchun 130011; Jilin Province, China
  • Received:2023-04-11 Published:2023-06-28
  • Corresponding author: Wenpeng Cui
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引用本文：

于梦园, 杨立明, 朱学研, 张晓暄, 刘声茂, 谢舜昀, 倪册, 庄小花, 崔文鹏. 肠源性腹膜透析相关性腹膜炎治疗失败的危险因素：多中心回顾性研究[J]. 中华肾病研究电子杂志, 2023, 12(03): 127-133.

Mengyuan Yu, Liming Yang, Xueyan Zhu, Xiaoxuan Zhang, Shengmao Liu, Shunyun Xie, Ce Ni, Xiaohua Zhuang, Wenpeng Cui. Risk factors for treatment failure of enterogenous PDAP, a multicenter retrospective study[J]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2023, 12(03): 127-133.

目的

探讨肠源性腹膜透析相关性腹膜炎(PDAP)治疗失败的危险因素。

方法

回顾性收集2013年至2019年吉林省4家三甲医院PDAP患者临床资料，按照PDAP的致病菌类型，将研究对象分为肠源性PDAP组(284例)和非肠源性PDAP组(519例)。采用广义估计方程(GEE)比较两组患者的临床资料、初始疗效、当次PDAP治疗结果以及肠源性PDAP治疗失败的危险因素。

结果

本研究共纳入803例次PDAP，其中肠源性PDAP组为284例次，大肠埃希菌最多，为100例次(35.21%)。与非肠源性PDAP组相比，肠源性PDAP组的女性占比较高(55.99%和47.21%，P＝0.043),且原发病为糖尿病肾病的比例较高(16.96%和11.27%, P＝0.029)。两组患者在年龄、血红蛋白、血清白蛋白水平等方面均未见明显差异(均P>0.05)。与非肠源性PDAP组相比，肠源性PDAP组初始疗效和当次治疗结果均较差(均P<0.001)。多因素GEE分析显示，长透析龄、生活在农村、低血清白蛋白，以及肺炎克雷伯杆菌、铜绿假单胞菌、真菌及混合菌感染均为肠源性PDAP治疗失败的独立危险因素(P<0.05)。

结论

肠源性PDAP的治疗效果比非肠源性PDAP差。长透析龄、农村生活、低血清白蛋白水平及肺炎克雷伯杆菌、铜绿假单胞菌、真菌及混合菌感染是肠源性PDAP治疗失败的独立危险因素。

关键词: 腹膜透析, 腹膜透析相关性腹膜炎, 肠源菌, 危险因素
Objective

To investigate the risk factors for treatment failure of enterogenous peritoneal dialysis-associated peritonitis (PDAP).

Methods

Retrospective collection of clinical data on PDAP patients from four hospitals in Jilin Province from 2013 to 2019. According to the type of pathogenic bacteria from PDAP, the study subjects were divided into the enterogenous PDAP group (284 cases) and the non-enterogenous PDAP group (519 cases). The generalized estimation equation (GEE) was used to compare the two groups in clinical data, initial therapeutic effect, and current therapeutic effect of PDAP, as well as risk factors for treatment failure of enterogenous PDAP.

Results

This study included a total of 803 cases of PDAP, including 284 cases in the enterogenous PDAP group, with E. coli being of the highest number of 100 cases and accounting for 35.21% of the enterogenous PDAP group. Compared with the non-enterogenous PDAP group, the enterogenous PDAP group showed higher proportion of female patients (55.99% versus 47.21%, P=0.043), and higher proportion of diabetic nephropathy as primary disease (16.96% versus 11.27%, P=0.029). There was no significant difference between the two groups in age, hemoglobin level, and serum albumin level (all P>0.05). Compared with the non-enterogenous PDAP group, the enterogenous PDAP group showed worse initial therapeutic effect and current therapeutic effect of PDAP (both P<0.001). Multivariate GEE analysis showed that long dialysis age, living in rural areas, low serum albumin, Klebsiella pneumoniae, Pseudomonas aeruginosa, fungi, and mixed bacteria were independent risk factors for the treatment failure of enterogenous PDAP (P<0.05).

Conclusion

The therapeutic effect of the enterogenous PDAP was worse than that of the non-enterogenous PDAP. The independent risk factors for treatment failure of the enterogenous PDAP included long dialysis age, living in rural areas, low serum albumin levels, and related types of enterogenous microorganisms.

Key words: Peritoneal dialysis, Peritoneal dialysis-associated peritonitis, Enterogenous microorganisms, Risk factors
图1 筛选病例流程图注：PDAP：腹膜透析相关性腹膜炎。
表1 两组患者的临床资料对比
临床资料 总体(n＝803) 肠源性PDAP组(n＝284) 非肠源性PDAP组(n＝519) Wald χ2值 P值
年龄(岁) 56.88(47，68) 57.79(48，69) 56.39(46，68) 1.239 0.266
女性[例(%)] 404(50.31) 159(55.99) 245(47.21) 4.099 0.043
当次PDAP透析龄(月) 23.45(7，33) 25.05(7，39.75) 22.57(7，31) 1.911 0.167
农村生活 249(31.01) 78(27.46) 171(32.95) 2.069 0.150
之前是否应用抗生素[例(%)] 80(9.96) 32(11.27) 48(9.25) 0.766 0.382
当次PDAP实验室指标          
血白细胞(109/L) 9.63(6.40，11.54) 9.60(6.32，11.92) 9.65(6.40，11.40) 0.018 0.893
血红蛋白(g/L) 99.43(85，113) 100.52(86，114.75) 98.83±20.04 1.152 0.283
血白蛋白(g/L) 28.81(24.70，33.19) 28.67±6.23 28.89(25，33.20) 0.183 0.669
血清钾(mmol/L) 3.83(3.29，4.26) 3.89(3.33，4.37) 3.79(3.29，4.22) 2.282 0.131
估算的肾小球滤过率[ml/(min·1.73 m2)] 6.46(4.44，7.65) 6.33(4.28，7.66) 6.52(4.48，7.62) 0.569 0.451
原发病[例(%)]          
肾小球肾炎 362(45.08) 136(47.89) 226(43.55) 1.003 0.316
糖尿病肾病 205(25.53) 73(25.70) 132(25.43) 0.005 0.941
高血压肾病 120(14.94) 32(11.27) 88(16.96) 4.742 0.029
多囊肾病 42(5.23) 17(5.99) 25(4.82) 0.262 0.609
间质性肾病 32(3.99) 16(5.63) 16(3.08) 3.377 0.066
其他原发病 42(5.23) 10(3.52) 32(6.17) 1.708 0.191
疾病情况[例(%)]          
合并糖尿病 282(35.12) 95(33.45) 187(36.03) 0.409 0.523
合并高血压 698(86.92) 244(85.92) 454(87.48) 0.282 0.596
合并腹泻或便秘 246(30.64) 94(33.10) 152(29.29) 1.124 0.289
当次PDAP性质[例(%)]          
首发 465(57.91) 162(57.04) 303(58.38) 0.116 0.734
复发 47(5.85) 19(6.69) 28(5.39) 0.390 0.532
再发 46(5.73) 17(5.99) 29(5.59) 0.053 0.818
重现 42(5.23) 13(4.58) 29(5.59) 0.330 0.565
其他 203(25.28) 73(25.70) 130(25.05) 0.037 0.847
表2 肠源性PDAP组致病菌构成
病原菌 株数(株) 构成比(%)
革兰氏阴性菌 187 65.85
大肠埃希菌 100 35.21
肺炎克雷伯杆菌 21 7.40
肠杆菌 30 10.56
铜绿假单胞菌 13 4.58
其他 23 8.10
革兰氏阳性菌 19 6.69
肠球菌 19 6.69
真菌 28 9.86
厌氧菌 1 0.35
混合菌 49 17.25
表3 非肠源性PDAP组致病菌构成
病原菌 株数(株) 构成比(%)
革兰氏阳性菌    
凝固酶阴性葡萄球菌 232 44.70
金黄色葡萄球菌 48 9.25
链球菌 92 17.72
其他 33 6.36
革兰氏阴性菌    
不动杆菌 25 4.82
假单胞菌 11 2.12
其他 24 4.62
真菌 14 2.70
抗酸杆菌 10 1.93
混合菌 30 5.78
表4 两组患者的治疗结果对比
组别 初始治疗评价[例(%)] 后续治疗评价[例(%)]
有效 无效 完全治愈 复发 拔管 PDAP相关性死亡
肠源性PDAP组 185(65.14) 99(34.86) 174(61.27) 30(10.56) 58(20.42) 22(7.75)
非肠源性PDAP组 437(84.20) 82(15.80) 433(83.43) 37(7.13) 30(5.78) 19(3.66)
Wald χ2值 30.912 42.920
P值 <0.001 <0.001
表5 肠源性PDAP组发生腹膜透析相关性腹膜炎治疗失败的危险因素
变量 单因素 多因素
OR值 95%CI P值 B值 OR值 95%CI P值 B值 Wald χ2值
年龄 1.004 0.987~1.021 0.645 0.004          
男性 0.740 0.435~1.260 0.268 －0.301          
当次PDAP透析龄(月) 1.025 1.015~1.036 <0.001 0.025 1.037 1.021~1.052 <0.001 0.036 21.795
入院前使用抗生素 2.938 1.424~6.060 0.004 1.078 0.998 0.390~2.554 0.997 －0.002 <0.001
农村生活 1.799 1.029~3.144 0.039 0.587 2.087 1.056~4.122 0.034 0.736 4.485
当次PDAP实验室指标                  
血清白蛋白(g/L) 0.965 0.919~1.013 0.150 －0.036 0.930 0.869~0.996 0.038 －0.072 4.296
血红蛋白(g/L) 1.002 0.989~1.016 0.716 0.002          
血尿素氮 0.954 0.915~0.995 0.029 －0.047 0.949 0.900~1.001 0.055 －0.052 3.671
病原菌类型                  
G－菌                  
大肠埃希菌 参考                
肺炎克雷伯杆菌 2.457 0.854~7.072 0.096 0.899 3.831 1.242~11.816 0.019 1.343 5.464
肠杆菌 0.683 0.174~2.683 0.585 －0.382 1.014 0.234~4.397 0.985 0.014 <0.001
铜绿假单胞菌 5.265 1.441~19.240 0.012 1.661 9.631 1.667~55.630 0.011 2.265 6.408
其他G－菌 0.921 0.239~3.552 0.905 －0.082 1.952 0.494~7.710 0.340 0.669 0.912
真菌 51.190 10.921~239.945 <0.001 3.936 99.607 16.280~609.447 <0.001 4.601 24.789
混合菌 5.005 2.249~11.140 <0.001 1.610 9.677 3.692~25.365 <0.001 2.270 21.314
G+菌                  
肠球菌 0.341 0.041~2.827 0.319 －1.075 0.576 0.059~5.599 0.634 －0.552 0.227
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