Scalamogna Antonio, Nardelli Luca, Cosa Francesco, Pisati Silvia, Messa Piergiorgio
UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italia.
UOC di Nefrologia, Dialisi e Trapianti di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italia; Scuola di Specializzazione in Nefrologia, Università degli Studi di Milano, Milano, Italia.
G Ital Nefrol. 2021 Feb 16;38(1):2021-vol1.
Infections continue to be a major cause of morbidity and mortality in patients on renal replacement therapy with peritoneal dialysis (PD). Despite great efforts in the prevention and treatment of infective complications over the two past decades, catheter-related infections represent the most relevant cause of technical failure. Recent studies support the idea that exit-site/tunnel infections (ESI/TI) have a direct role in causing peritonitis. Since the episodes of peritonitis secondary to TI lead to catheter loss in up to 86% of cases, it is advised to remove the catheter when the ESI/TI does not respond to medical therapy. This approach necessarily entails the interruption of PD and, after the placement of a central venous catheter, the shift to haemodialysis (HD). In order to avoid the change of dialytic method, the simultaneous removal and replacement (SCR) of the PD catheter has also been proposed. Although SCR avoids temporary HD, it requires the removal/reinsertion of the catheter and the immediate initiation of PD, with the risk of mechanical complications such as leakage and malfunction. Several mini-invasive surgical techniques have been employed as rescue procedures: curettage, cuff-shaving, the partial reimplantation of the catheter and the removal of the superficial cuff with the creation of a new exit-site. These procedures allow to save the catheter and have a success rate of 70-100%. Therefore, in case of ESI/TI refractory to antibiotic therapy, a mini-invasive surgical revision must always be considered before removing the catheter.
感染仍然是接受腹膜透析（PD）的肾脏替代治疗患者发病和死亡的主要原因。尽管在过去二十年中，人们在预防和治疗感染性并发症方面付出了巨大努力，但导管相关感染仍是技术失败的最主要原因。最近的研究支持出口部位/隧道感染（ESI/TI）在引起腹膜炎方面具有直接作用这一观点。由于TI继发的腹膜炎发作在高达86%的病例中会导致导管丢失，因此建议在ESI/TI对药物治疗无反应时移除导管。这种方法必然会导致PD中断，并且在放置中心静脉导管后，转而进行血液透析（HD）。为了避免透析方法的改变，也有人提出同时移除和更换（SCR）PD导管。虽然SCR避免了临时HD，但它需要移除/重新插入导管并立即开始PD，存在诸如渗漏和故障等机械并发症的风险。几种微创外科技术已被用作挽救措施：刮除术、袖套切除术、导管部分再植入术以及移除浅表袖套并创建新的出口部位。这些操作可以挽救导管，成功率为70%至100%。因此，在ESI/TI对抗生素治疗无效的情况下，在移除导管之前必须始终考虑进行微创外科修复。
