UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

腹膜透析中腹膜炎的临床表现和诊断

Author
John M Burkart, MD
Section Editor
Thomas A Golper, MD
Deputy Editor
Alice M Sheridan, MD
Translators
张晓良, 主任医师，副教授

引言

腹膜炎是腹膜透析(peritoneal dialysis, PD)的一种常见并发症。腹膜炎会造成严重并发症、导管脱落、转至血液透析、暂时性超滤功能丧失、可能的永久性腹膜损伤，有时还会导致死亡[1-6]。

本专题将总结行PD的患者中腹膜炎的临床表现和诊断。本专题的大部分讨论内容是关于细菌性腹膜炎的表现和诊断，但也有少数特定议题仅专注于讨论真菌性和结核性腹膜炎。腹膜炎的预防和治疗将单独讨论。 (参见“腹膜透析中腹膜炎的病理生理学及预防”和“持续腹膜透析中腹膜炎的微生物学和治疗”和“持续腹膜透析中的真菌性腹膜炎”)

定义

对于PD患者，腹膜炎可能为PD相关性，或是继发性(肠源性)。PD相关性腹膜炎是由皮肤致病菌的接触性污染或是由导管相关性感染造成的。继发性腹膜炎是由胃肠道的基础病变所致。

可能导致继发性腹膜炎的情况包括胆囊炎、阑尾炎、憩室破裂、治疗严重便秘、内镜检查时穿孔、肠缺血及嵌顿性疝。继发性腹膜炎比PD相关性腹膜炎少见。例如，在一项回顾性研究中，发生腹膜炎的持续不卧床腹膜透析(chronic ambulatory peritoneal dialysis, CAPD)患者中只有不到6%是由腹内病变造成的[7]。继发性腹膜炎也可能由血行播散或经阴道播散所致，但该情况与上述腹内病因相比要更加少见。

继发性腹膜炎的临床结局比PD相关性腹膜炎要差得多[8-10]。在一项报道中，26例继发性腹膜炎患者中有11例死亡[8]，与之相比，所有发生腹膜炎的PD患者中总体腹膜炎相关死亡率约为2%-3%[11]。在针对继发性腹膜炎的研究中，死亡率与腹膜炎的具体病因(尤其是肠梗死)、诊断的时间及根治性手术干预的时间相关。 (参见“透析患者的胃肠道疾病”)

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2015-08-19.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Holley JL, Praino BM. Complications of peritoneal dialysis: Diagnosis and management. Semin Dial 1990; 3:245.
  2. Schreiber M, Burkart JM, et al. Peritonitis remains the leading cause of transfer from PD to HD (abstract). Perit Dial Int 1996.
  3. Woodrow G, Turney JH, Brownjohn AM. Technique failure in peritoneal dialysis and its impact on patient survival. Perit Dial Int 1997; 17:360.
  4. Pérez Fontan M, Rodríguez-Carmona A, García-Naveiro R, et al. Peritonitis-related mortality in patients undergoing chronic peritoneal dialysis. Perit Dial Int 2005; 25:274.
  5. Sipahioglu MH, Aybal A, Unal A, et al. Patient and technique survival and factors affecting mortality on peritoneal dialysis in Turkey: 12 years' experience in a single center. Perit Dial Int 2008; 28:238.
  6. Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis: gram negatives versus gram positives in the Network 9 Peritonitis Study. Kidney Int 1997; 52:524.
  7. Tzamaloukas AH, Obermiller LE, Gibel LJ, et al. Peritonitis associated with intra-abdominal pathology in continuous ambulatory peritoneal dialysis patients. Perit Dial Int 1993; 13 Suppl 2:S335.
  8. Tzamaloukas AH, Murata GH, Fox L. Peritoneal catheter loss and death in continuous ambulatory peritoneal dialysis peritonitis: correlation with clinical and biochemical parameters. Perit Dial Int 1993; 13 Suppl 2:S338.
  9. Harwell CM, Newman LN, Cacho CP, et al. Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis. Perit Dial Int 1997; 17:586.
  10. Kern EO, Newman LN, Cacho CP, et al. Abdominal catastrophe revisited: the risk and outcome of enteric peritoneal contamination. Perit Dial Int 2002; 22:323.
  11. Ghali JR, Bannister KM, Brown FG, et al. Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients. Perit Dial Int 2011; 31:651.
  12. Vas, SI. Peritonitis. In: Peritoneal Dialysis, 3rd ed, Nolph, KD (Eds), Kluwer Academic Publishers, Dordrecht 1989. p.261.
  13. Oliveira LG, Luengo J, Caramori JC, et al. Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center. Int Urol Nephrol 2012; 44:1529.
  14. Shrestha BM, Brown P, Wilkie M. Surgical peritonitis in patients on peritoneal dialysis. Perit Dial Int 2008; 28:331.
  15. Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393.
  16. Voinescu CG, Khanna R. Peritonitis in peritoneal dialysis. Int J Artif Organs 2002; 25:249.
  17. Piraino B, Bailie GR, Bernardini J, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005; 25:107.
  18. Tranaeus A, Heimbürger O, Lindholm B. Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): diagnostic findings, therapeutic outcome and complications. Perit Dial Int 1989; 9:179.
  19. Koopmans JG, Boeschoten EW, Pannekeet MM, et al. Impaired initial cell reaction in CAPD-related peritonitis. Perit Dial Int 1996; 16 Suppl 1:S362.
  20. Flanigan MJ, Freeman RM, Lim VS. Cellular response to peritonitis among peritoneal dialysis patients. Am J Kidney Dis 1985; 6:420.
  21. Twardowski ZJ, Schreiber MJ Jr, Burkart JM. A 55-year-old man with hematuria and blood-tinged dialysate. Perit Dial Int 1992; 12:61.
  22. Eisenberg ES, Leviton I, Soeiro R. Fungal peritonitis in patients receiving peritoneal dialysis: experience with 11 patients and review of the literature. Rev Infect Dis 1986; 8:309.
  23. Cheng IK, Fang GX, Chan TM, et al. Fungal peritonitis complicating peritoneal dialysis: report of 27 cases and review of treatment. Q J Med 1989; 71:407.
  24. Holley HP Jr, Tucker CT, Moffatt TL, et al. Tuberculous peritonitis in patients undergoing chronic home peritoneal dialysis. Am J Kidney Dis 1982; 1:222.
  25. Dunmire RB 3rd, Breyer JA. Nontuberculous mycobacterial peritonitis during continuous ambulatory peritoneal dialysis: case report and review of diagnostic and therapeutic strategies. Am J Kidney Dis 1991; 18:126.
  26. Keane WF, Bailie GR, Boeschoten E, et al. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20:396.
  27. Johnson CA. Intraperitoneal vancomycin administration. Perit Dial Int 1991; 11:9.
  28. Charney DI, Gouge SF. Chemical peritonitis secondary to intraperitoneal vancomycin. Am J Kidney Dis 1991; 17:76.
  29. Ejaz AA, Fitzpatrick PM, Durkin AJ, et al. Pathophysiology of peritoneal fluid eosinophilia in peritoneal dialysis patients. Nephron 1999; 81:125.
  30. Fontán MP, Rodríguez-Carmona A, Galed I, et al. Incidence and significance of peritoneal eosinophilia during peritoneal dialysis-related peritonitis. Perit Dial Int 2003; 23:460.
  31. Caruana RJ, Burkart J, Segraves D, et al. Serum and peritoneal fluid amylase levels in CAPD. Normal values and clinical usefulness. Am J Nephrol 1987; 7:169.
  32. Burkart JM, Khanna R. A 69-year-old male with elevated amylase in bloody and cloudy dialysate. Perit Dial Int 1993; 13:142.
  33. Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003; 42:1082.
  34. Morduchowicz G, van Dyk DJ, Wittenberg C, et al. Bacteremia complicating peritonitis in peritoneal dialysis patients. Am J Nephrol 1993; 13:278.
  35. Szeto CC, Wong TY, Chow KM, et al. The clinical course of culture-negative peritonitis complicating peritoneal dialysis. Am J Kidney Dis 2003; 42:567.
  36. Eisele G, Adewunni C, Bailie GR, et al. Surreptitious use of antimicrobial agents by CAPD patients. Perit Dial Int 1993; 13:313.
  37. Sewell DL, Golper TA, Hulman PB, et al. Comparison of large volume culture to other methods for isolation of microorganisms from dialysate. Perit Dial Int 1990; 10:49.
  38. Lye WC, Wong PL, Leong SO, Lee EJ. Isolation of organisms in CAPD peritonitis: a comparison of two techniques. Adv Perit Dial 1994; 10:166.
  39. Alfa MJ, Degagne P, Olson N, Harding GK. Improved detection of bacterial growth in continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN bottles. J Clin Microbiol 1997; 35:862.
  40. Rocklin MA, Teitelbaum I. Noninfectious causes of cloudy peritoneal dialysate. Semin Dial 2001; 14:37.
  41. de Freitas DG, Gokal R. Sterile peritonitis in the peritoneal dialysis patient. Perit Dial Int 2005; 25:146.
  42. Yoshimoto K, Saima S, Nakamura Y, et al. Dihydropyridine type calcium channel blocker-induced turbid dialysate in patients undergoing peritoneal dialysis. Clin Nephrol 1998; 50:90.
  43. Bargman JM, Zent R, Ellis P, et al. Diagnosis of lymphoma in a continuous ambulatory peritoneal dialysis patient by peritoneal fluid cytology. Am J Kidney Dis 1994; 23:747.
  44. Pérez Fontán M, Pombo F, Soto A, et al. Chylous ascites associated with acute pancreatitis in a patient undergoing continuous ambulatory peritoneal dialysis. Nephron 1993; 63:458.
  45. Rocklin MA, Quinn MJ, Teitelbaum I. Cloudy dialysate as a presenting feature of superior vena cava syndrome. Nephrol Dial Transplant 2000; 15:1455.
  46. Streather CP, Carr P, Barton IK. Carcinoma of the kidney presenting as sterile peritonitis in a patient on continuous ambulatory peritoneal dialysis. Nephron 1991; 58:121.
  47. Vlahakos D, Rudders R, Simon G, Canzanello VJ. Lymphoma-mimicking peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1990; 10:165.
  48. MacGinley R, Cooney K, Alexander G, et al. Relapsing culture-negative peritonitis in peritoneal dialysis patients exposed to icodextrin solution. Am J Kidney Dis 2002; 40:1030.
  49. Tintillier M, Pochet JM, Christophe JL, et al. Transient sterile chemical peritonitis with icodextrin: clinical presentation, prevalence, and literature review. Perit Dial Int 2002; 22:534.
  50. Boer WH, Vos PF, Fieren MW. Culture-negative peritonitis associated with the use of icodextrin-containing dialysate in twelve patients treated with peritoneal dialysis. Perit Dial Int 2003; 23:33.
  51. Glorieux G, Lameire N, Van Biesen W, et al. Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids. Nephrol Dial Transplant 2003; 18:1648.
  52. Martis L, Patel M, Giertych J, et al. Aseptic peritonitis due to peptidoglycan contamination of pharmacopoeia standard dialysis solution. Lancet 2005; 365:588.
  53. Rozenberg R, Magen E, Weissgarten J, Korzets Z. Icodextrin-induced sterile peritonitis: the Israeli experience. Perit Dial Int 2006; 26:402.
  54. Bunke M, Brier ME, Golper TA. Culture-negative CAPD peritonitis: the Network 9 Study. Adv Perit Dial 1994; 10:174.
  55. Choi P, Nemati E, Banerjee A, et al. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. Am J Kidney Dis 2004; 43:103.
  56. Royse VL, Jensen DM, Corwin HL. Pancreatic enzymes in chronic renal failure. Arch Intern Med 1987; 147:537.
  57. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990; 98:127.
  58. Suresh KR, Port FK. Air under the diaphragm in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989; 9:309.
  59. Yehia M, de Zoysa JR, Collins JF. Is computerized tomography useful in identifying abdominal catastrophes in patients presenting with peritonitis? Perit Dial Int 2008; 28:385.