Cameron J S
Renal Unit, Division of Medicine, UMDS, London, UK.
Pediatr Nephrol. 1995 Oct;9(5):647-62. doi: 10.1007/BF00860966.
Continuous ambulatory peritoneal dialysis (CAPD) has come to be extensively used for the treatment of end-stage renal failure in children, and especially infants, such that now more than half of children on dialysis worldwide receive treatment by this means. Peritonitis, however, is commoner in children than in adults receiving treatment, and is a major source of morbidity and treatment failure in children started on CAPD. Only recently has the immunology of the normal peritoneum been studied extensively, with the need to assess the impact of the installation of large volumes of fluid into the peritoneal sac during dialysis. The main phagocytic defences of the peritoneum depend upon a unique set of macrophages which are present free in the peritoneal fluid but also in the submesothelium and in perivascular collections together with B lymphocytes in the submesothelial area. Both the number of macrophages per unit volume and the concentration of opsonic proteins, such as IgG, complement and fibronectin, are reduced to between only 1% and 5% when dialysis fluid is continuously present in the peritoneal sac. In addition, the fluids used for CAPD are toxic to both macrophages and to mesothelial cells. Thus minor degrees of contamination frequently lead to peritonitis and in addition the majority of patients have catheters inserted in their peritoneum which become colonised with organisms capable of producing exopolysaccharide (slime), which promotes adhesion of the organism to the plastic and protects them against phagocytic attack and the penetration of antibiotics. Thus the peritoneum is in a state of continual inflammation, as well as being a markedly more vulnerable site than the normal peritoneum to the entry of organisms. Whether clinical peritonitis appears in this state of chronic contamination probably depends on perturbation in the balance between host defences and the organism. Whilst Staphylococcus epidermidis is the commonest cause of peritonitis, Staphylococcus aureus and Gram-negative organisms are much more serious and more frequently lead either to temporary catheter removal or discontinuation of dialysis altogether. This review describes the peritoneal defences in relation to the genesis of peritonitis.
持续非卧床腹膜透析（CAPD）已被广泛用于治疗儿童，尤其是婴儿的终末期肾衰竭，以至于现在全球接受透析治疗的儿童中，超过一半是通过这种方式接受治疗的。然而，与接受治疗的成人相比，腹膜炎在儿童中更为常见，并且是开始接受CAPD治疗的儿童发病和治疗失败的主要原因。直到最近，正常腹膜的免疫学才得到广泛研究，因为需要评估透析期间大量液体注入腹膜腔的影响。腹膜的主要吞噬防御依赖于一组独特的巨噬细胞，这些巨噬细胞不仅存在于腹膜液中，也存在于间皮下和血管周围集合中，以及间皮下区域的B淋巴细胞中。当腹膜腔内持续存在透析液时，单位体积内巨噬细胞的数量以及调理蛋白（如IgG、补体和纤连蛋白）的浓度都会降至仅1%至5%之间。此外，用于CAPD的液体对巨噬细胞和间皮细胞都有毒性。因此，轻微程度的污染经常会导致腹膜炎，此外，大多数患者的腹膜内插入了导管，这些导管会被能够产生胞外多糖（黏液）的微生物定植，这会促进微生物与塑料的粘附，并保护它们免受吞噬攻击和抗生素的渗透。因此，腹膜处于持续炎症状态，并且比正常腹膜更容易受到微生物的侵入。在这种慢性污染状态下是否会出现临床腹膜炎可能取决于宿主防御和微生物之间平衡的扰动。虽然表皮葡萄球菌是腹膜炎最常见的原因，但金黄色葡萄球菌和革兰氏阴性菌更为严重，更频繁地导致暂时拔除导管或完全停止透析。这篇综述描述了与腹膜炎发生相关的腹膜防御。
