Chow Kai Ming, Szeto Cheuk Chun, Cheung Kitty Kit-Ting, Leung Chi Bon, Wong Sunny Sze-Ho, Law Man Ching, Ho Yiu Wing, Li Philip Kam-Tao
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
Clin J Am Soc Nephrol. 2006 Jul;1(4):768-73. doi: 10.2215/CJN.01010306. Epub 2006 May 31.
Early prediction of outcomes has major potential implications regarding the management of dialysis-related peritonitis. The outcomes of 565 consecutive episodes of peritonitis complicating peritoneal dialysis between August 2001 and July 2005 were evaluated in relation to the dialysate cell counts. Discriminatory power, based on the area under the receiver-operating characteristic (ROC) curves, of the cell counts was assessed. The findings then were validated externally in a cohort of 217 peritonitis episodes from another dialysis unit. During the study period, 565 episodes of peritonitis were included for analysis, 465 of which had treatment success defined as complete resolution of peritonitis without the need for Tenckhoff catheter removal. Of the remaining 100 episodes (treatment failure), 70 required Tenckhoff catheter removal and 30 had peritonitis-related death. The peritoneal dialysate total white blood cell count on day 3 of peritonitis predicted treatment failure independent of standard risk factors, and it had a higher area under the ROC curve than the dialysate white cell count on day 1 (0.80 versus 0.58; P < 0.0001). Using a peritoneal dialysate white count cut point > or = 1090/mm3 on day 3, the sensitivity was 75% and the specificity was 74% for the prediction of treatment failure (defined as catheter loss or peritonitis-related death). In multiple logistic regression analyses, peritoneal dialysate white count > or = 1090/mm3 on day 3 was an independent prognostic marker for treatment failure after adjustment for conventional risk factors (hazard ratio 9.03; 95% confidence interval 4.40 to 18.6; P < 0.0001). Number of years on peritoneal dialysis; diabetes; gram-negative organisms; and Pseudomonas, fungal, or Mycobacterium species were other independent risk factors that were predictive of treatment failure. Findings from an independent validation set of peritonitis (217 episodes after exclusion of Mycobacterium and fungal causes) also favored the peritoneal dialysate white count on day 3, as compared with day 1 and day 2, to predict treatment failure. Area under the ROC curve for the white counts on day 3 was 0.98 (95% confidence interval 0.95 to 0.99) in the validation set. This study demonstrated and cross-validated the superiority of peritoneal dialysate white cell count on day 3 to predict outcomes of dialysis-related peritonitis. These results call attention to the value of validating prognostic factors of peritonitis complicating peritoneal dialysis.
结局的早期预测对于透析相关性腹膜炎的管理具有重大潜在意义。对2001年8月至2005年7月期间连续发生的565例并发腹膜透析的腹膜炎病例的结局与透析液细胞计数进行了评估。基于受试者操作特征（ROC）曲线下面积评估细胞计数的鉴别能力。然后在来自另一个透析单元的217例腹膜炎病例队列中对这些发现进行外部验证。在研究期间，纳入565例腹膜炎病例进行分析，其中465例治疗成功定义为腹膜炎完全缓解且无需拔除Tenckhoff导管。其余100例（治疗失败）中，70例需要拔除Tenckhoff导管，30例死于腹膜炎相关原因。腹膜炎第3天的腹膜透析液总白细胞计数可独立于标准危险因素预测治疗失败，其ROC曲线下面积高于第1天的透析液白细胞计数（0.80对0.58；P<0.0001）。使用第3天腹膜透析液白细胞计数切点≥1090/mm³时，预测治疗失败（定义为导管丢失或腹膜炎相关死亡）的敏感性为75%，特异性为74%。在多因素logistic回归分析中，校正传统危险因素后，第3天腹膜透析液白细胞计数≥1090/mm³是治疗失败的独立预后标志物（风险比9.03；95%置信区间4.40至18.6；P<0.0001）。腹膜透析年限、糖尿病、革兰阴性菌以及假单胞菌、真菌或分枝杆菌属是预测治疗失败的其他独立危险因素。来自独立验证组的腹膜炎病例（排除分枝杆菌和真菌病因后的217例）的结果也表明，与第1天和第2天相比，第3天的腹膜透析液白细胞计数更有利于预测治疗失败。验证组中第3天白细胞计数的ROC曲线下面积为0.98（95%置信区间0.95至0.99）。本研究证明并交叉验证了第3天腹膜透析液白细胞计数在预测透析相关性腹膜炎结局方面的优越性。这些结果提醒人们关注验证并发腹膜透析的腹膜炎预后因素的价值。
