中国持续性非卧床腹膜透析患者真菌性腹膜炎不良预后的危险因素。
Risk factors for poor outcome of fungal peritonitis in Chinese patients on continuous ambulatory peritoneal dialysis.
机构信息
Renal Unit, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.
出版信息
Perit Dial Int. 2003 Dec;23 Suppl 2:S123-6.
OBJECTIVE
Fungal peritonitis is rare among end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD), but when it occurs, it is associated with a high risk of mortality and peritoneal membrane failure. In the present study, we identified risk factors for poor outcome and examined the effect of treatment profile on outcome in fungal peritonitis.
PATIENTS AND METHODS
We identified cases of fungal peritonitis in CAPD patients in a regional dialysis center and analyzed the possible risk factors for poor outcome in fungal peritonitis. To estimate the amount of dextrose presented to the peritoneum, we scored the dextrose content of the peritoneal dialysis fluid used by the patient at the time of admission to hospital (1 point to each bag of 1.5% fluid, 2 points to each bag of 2.3% or 2.5% fluid, and 3 points to each bag of 4.25% fluid daily).
RESULTS
Among 471 episodes of CAPD-related peritonitis in 7.8 years, we identified 22 episodes of fungal peritonitis (4.7%). The ratio of men to women in the fungal peritonitis group was 1.4:1. Seventeen patients (77.3%) practiced dialysis without a helper. Within the 3 months preceding the fungal peritonitis, 12 patients (55%) had had bacterial peritonitis. Among the cases of fungal peritonitis, we identified 9 cases of Candida parapsilosis and 13 cases of non C. parapsilosis. All of the patients received fluconazole, and 7 patients (31.8%) also received flucytosine. The Tenckhoff catheter was removed in 17 patients (77.3%). Eight patients (36.4%) either died or lost peritoneal function. The risk of mortality was increased if the fungal organism was C. parapsilosis [odds ratio (OR): 4.25; 95% confidence interval (CI): 1.8 to 10.0; p = 0.002], if a helper was involved (OR: 11.3; 95% CI: 1.1 to 114; p = 0.024), or if CAPD duration was more than 26 months (OR: 2.2; 95% CI: 1.3 to 3.5; p = 0.034). Addition of flucytosine to fluconazole did not significantly improve the mortality rate in either the C. parapsilosis or non C. parapsilosis group. Multivariate analysis showed that C. parapsilosis was an independent factor associated with mortality (p = 0.013). A dextrose score greater than 5 was associated with a trend toward increased risk of peritoneal failure (OR: 3.4; 95% CI: 1.6 to 7.1; p = 0.021).
CONCLUSION
C. parapsilosis is an independent risk factor for mortality in fungal peritonitis.
目的
真菌性腹膜炎在接受持续不卧床腹膜透析（CAPD）治疗的终末期肾病患者中较为罕见，但一旦发生，其死亡率和腹膜衰竭的风险很高。本研究旨在确定不良预后的危险因素，并探讨治疗方案对真菌性腹膜炎预后的影响。
方法
我们在一个区域透析中心确定了 CAPD 患者中真菌性腹膜炎的病例，并分析了真菌性腹膜炎不良预后的可能危险因素。为了估计葡萄糖在腹膜内的摄入量，我们对入院时患者腹膜透析液中的葡萄糖含量进行评分（每袋 1.5%的液体记 1 分，每袋 2.3%或 2.5%的液体记 2 分，每袋 4.25%的液体记 3 分）。
结果
在 7.8 年内的 471 例 CAPD 相关腹膜炎发作中，我们发现了 22 例真菌性腹膜炎（4.7%）。真菌性腹膜炎组中男女比例为 1.4:1。17 名患者（77.3%）在没有助手的情况下进行透析。在真菌性腹膜炎发生前的 3 个月内，12 名患者（55%）发生过细菌性腹膜炎。在真菌性腹膜炎病例中，我们发现了 9 例近平滑念珠菌和 13 例非近平滑念珠菌。所有患者均接受氟康唑治疗，7 例（31.8%）还接受了氟胞嘧啶治疗。17 名患者（77.3%）取出了 Tenckhoff 导管。8 名患者（36.4%）死亡或丧失腹膜功能。如果真菌为近平滑念珠菌（比值比 [OR]：4.25；95%置信区间 [CI]：1.8 至 10.0；p = 0.002）、有助手参与（OR：11.3；95%CI：1.1 至 114；p = 0.024）或 CAPD 持续时间超过 26 个月（OR：2.2；95%CI：1.3 至 3.5；p = 0.034），则死亡率增加。氟康唑联合氟胞嘧啶治疗并未显著降低近平滑念珠菌或非近平滑念珠菌组的死亡率。多变量分析显示，近平滑念珠菌是与死亡率相关的独立危险因素（p = 0.013）。葡萄糖评分大于 5 与腹膜衰竭风险增加呈趋势相关（OR：3.4；95%CI：1.6 至 7.1；p = 0.021）。
结论
近平滑念珠菌是真菌性腹膜炎患者死亡的独立危险因素。
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