| Background and PurposePeritoneal dialysis(PD)is one of renal replacement therapy for end-stage renal disease.Peritonitis is the main and most serious complications of PD. PD-related peritonitis willaccelerate the loss of peritoneal function, decline of residual renal function in PD patients,and was the most common cause of technical failure and hospitalization[1]. Related studiesshow that the technology survival rate was93%,73%and63%after1,3,5years treatment,and the main reason leading to technical failure was peritonitis, accounting for about78%[2].Patients with severe peritonitis can also lead to death directly. Research shows, peritonitisassociated with92%of deaths caused by infections in PD patients[3]. The rate of deathcaused by peritonitis directly was1to6%[4], and in16%of PD patients death peritonitis isa direct "participation factor"[5].The r esearch have s hown t hat t he p eritonitis episode previous will c ontinuing andsignificantly a ffecting the risk of peritonitis even after6m onths[6]. Multiple p eritonitisepisodes will inevitably lead to persistent inflammation, so that the adverse effects of asingle event is a ccumulated, result in more s erious ad verse e ffects on t he p eritonealfunction, residual renal function, nutrition and immune status, and accelerating technologyfailure and dropout of PD patients. The clinical data of our PD centre in recent seven yearsshows that, the rate of catheter removal was6.35%in PD patients with single peritonitis episode, while the r ate o f catheter removal was50.00%in PD patients with multipleperitonitis episodes. M oreover, t he frequency of p eritonitis is as sociate w ith s evereperitonitis episode, a nd is a n i ndependent pr edictor of pe ritonitis-related d eaths[1]. Thefrequency of peritonitis is also the independent risk factor for the mortality of PD patients;studies show that the frequency of peritonitis increased by0.5per/year, the risk of death inpeople ove r60years old increased b y11%, a4%i ncrease in non-diabetic patients[2].Previous studies explore the risk factors for the peritonitis, in order to avoid the occurrenceof peritonitis, but how t o pr event multiple r ecurrent peritonitis episode, as w ell a s itsspecific risk factors seem to be lack of reports.A single-center retrospective study was carried out in this paper, to explore the riskfactors of repeated PD-related peritonitis. The high-risk groups can be located in clinicaland individualized intervention against the relevant factors can be carried out, in order toreduce the frequency of PD-related peritonitis, improve the quality of life of patients andimprove patient outcomes.Subjects and methods1. The definition involved in this study as follows:⑴Failed to timely treatment: theinterval between symptoms of p eritonitis occurred and initiate empiric anti-infectivetherapy greater t han24hour s.⑵Effective anti-infection: after3d ays of a ntibioticstreatment, abdominal p ain of patients was relieved, dialysate turned cl ear and dialysateleukocyte counts were lower or normal.2.The89cases maintain the PD treatment and with peritonitis during the November1,2007to April30,2014in our hospital were included in the study. Peritonitis diagnosisaccording to the guidelines of International Society for Peritoneal Dialysis(ISPD)[3]. Thepatients with peritonitis episode greater t han or equal t o2times in one year s erved asmultiple gr oup, and w ith pe ritonitis episode once i n o ne year s erved a s s ingle group.Exclusion of one children patient,20pa tients exit(transfer to hemodialysis, death)withinone year after the first peritonitis episode, one case lost to follow-up, a total of44patients were included in the study. According to pathogen of multiple peritonitis episode, multiplegroup was divided into two subgroups：same pathogen group, different pathogen groups.3.Carried out empiric anti-infective therapy according to ISPD guidelines[1]. In our PDcenter, t he regimen of empiric anti-infective is first-generation c ephalosporins combinethird-generation cephalosporins, or first-generation cephalosporin combine aminoglycosideantibiotics; using intermittent intraperitoneal administration. Adjusted antibiotic regimenwhen the treatment is ineffective, or obtained the results of dialysate culture and antibioticsusceptibility. The course of anti-infection based on the ISPD guidelines[1].4. All of the patients’ demographic, clinical and biochemical data were collected. Thetime-average (TA) variable value was calculated as overall comparison base on all of thebiochemical data from starting PD treatment to the end of observe. TheTA variable valuewas calculated as baseline base on all of the data from starting PD treatment to the fistperitonitis episode. Moreover, The TA variable value was calculated base on all of the dataduring peritonitis episode and was compared.5. Establish a " Scale Of S tandard Operating In PD" based o n PD-related operateprocedure. The scale assess catheter and exit-site care, preparations, connection, washingand separation procedure in bag exchange, a total of19score points. The score based on therisk of peritonitis o f each procedure, s tatistics the proportion of misoperation in eachprocedure, calculate total score as the score of misoperation based on the risk of proceduremultiply by the proportion of misoperation.6. Application of SPSS18.0software for statistical analysis. P values less than o requal to0.05is defined as statistically significant; P values greater than0.05but less than0.1is d efined as marginally s ignificant. The indicators of significant d ifferences bycomparison, c ombined w ith the clinical e xpertise, filter o ut meaningful in dicators asindependent variables. ROC curve analysis the variables above, to determine the optimalcut-off point based on the max Youden index (sensitivity+specificity-1), and assign eachvariable according to the cut-off point. After the assignment of the variable above, Logisticregression m odels were applied to d etermine th e risk fa ctors for multiple p eritonealdialysis-related peritonitis. Results(1).Multiple group versus single group1.compare demographic characteristics and clinical data： Study included44patients, including12females, accounting for27.27%，32males, accounting for72.73%，aged17to82years, mean age50.55±15.83years old. The rate of catheter removal washigh in multiple group, account for50.00%. There were no significant differences betweenthe two groups in gender, age, education level, BMI, protopathy, PD operator and the scoreof PD misoperation.2. compare baseline biochemical indicators: Baseline serum albumin of multiplegroup was significantly lower than the single group; the mean of baseline prealbumin inmultiple gr oup was also l ower t han single group, but t he ove rall difference w as n otstatistically s ignificant. There w ere n o s ignificant d ifferences in t he r emaining baselinebiochemical indicators.3. compare time-average biochemical indicators: Time-average serum albumin andprealbumin of multiple group was significantly lower than the single group. There were nosignificant differences in the remaining time-average biochemical indicators.4. compare clinical and biochemical indicators of the first peritonitis episode: Inthe f irst p eritonitis e pisode, th e dialysis duration median of multiple gr oups was13.00months, t he25-75th percentile was2.50-23.75m onths; the dialysis duration median ofsingle groups was5.50m onths, t he25-75th percentile was1.75-13.00months. Furtheranalysis showed that the ratio of dialysis duration less than12months of multiple groupwas significantly lower than single group, the ratio of dialysis duration between12t o23months and greater than or equal to24months of multiple group was significantly higherthan single group. Compared to the dialysis duration less than12months, the OR was3.60for dialysis duration between12t o23m onths (95%CI:0.90-14.37),10.00for dialysisduration greater than or e qual t o24m onths(95%CI:0.99-100.61). T he r atio of timelytreatment of multiple gr oup was s ignificantly lower t han s ingle group; t he r atio ofcompleting the course of anti-infection of multiple group was l ower t han s ingle group,P=0.099, was marginally significant. There were no significant differences between the twogroups in empiric anti-infective, incentives, dialysate WBC count, Hb, WBC, CRP, albuminand prealbumin. 5. compare the pathogens of the first peritonitis episode: In the first peritonitisepisode, there were no significant differences between the two groups in constituent ratio ofpathogens; the ratio of dialysate culture negative of multiple group was significantly lowerthan single group. Further analysis s howed t hat there w ere no s ignificant di fferencesbetween the two groups in constituent ratio of gram-positive bacterium and gram-negativebacterium.6. Determine the optimal cut-off point and the assignment of variables: Theindicators of significant differences by comparison, combined with the clinical expertise,determine the independent variables included in Logistic regression analysis. ROC curveanalysis the variables above, to determine th e o ptimal cut-off poi nt based o n t he m axYouden index (sensitivity+specificity-1), and assign each variable(0or1) according to thecut-off point. Moreover，assignment of dialysis duration less than12months was1，2fordialysis duration between12t o23m onths, and3f or greater than or equal to24months.Assignment of timely treatment was0, and1for failing to timely treatment.7. Analysis of the risk factors for multiple peritoneal dialysis-related peritonitis:The dialysis dur ation, failed to time ly tr eatment, baseline serum albumin, time-averageserum albumin, and time-average serum prealbumin was included in Logistic regressionmodel. The r esults s howed t hat the risk f actors fo r multiple p eritoneal d ialysis-relatedperitonitis was dialysis duration≥12months, baseline serum albumin＜27.45g/L, and thetime-average serum pr ealbumin＜306.71mg/L. Failed to time ly t reatment ma y lead tomultiple peritonitis episode, P=0.094, was marginally significant.(2) same pathogen group versus different pathogen group1.compare demographic characteristics and clinical data：The same p athogengroup including13cases, and the different pathogen group including6cases. Subgroupanalysis i ncluded19patients, i ncluding5females, accounting for26.32%,14males,accounting for73.68%, aged17to82years, mean age50.12±16.32years old. There wereno significant differences between the two groups in gender, age, education level, BMI,protopathy, PD operator, the score of PD misoperation, and the rate of catheter removal.2. compare baseline biochemical indicators: The mean of baseline albumin in samepathogen group was higher than different pathogen group, but the overall difference wasnot statistically significant. There were no significant differences between the two groups in the remaining baseline biochemical indicators.3. compare time-average biochemical indicators: The m ean o f time-averagealbumin in same pathogen group was higher than different pathogen group, but the overalldifference was not statistically significant. There were no significant differences betweenthe two groups in the remaining time-average biochemical indicators.4. compare clinical and biochemical indicators of the first peritonitis episode: Inthe first peritonitis episode, the dialysis duration median of same pathogen group was13.00months, t he25-75th percentile was1.00-29.50months; the dialysis duration median ofdifferent pathogen group was15.00months, the25-75th percentile was9.25-28.25months.Further analysis showed that there were no significant differences between the two groupsin constituent ratio of dialysis duration. The ratio of completing the course of anti-infectionof different pathogen group was significant lower than same pathogen group. The mean ofalbumin in different pathogen group was lower than same pathogen group, but the overalldifference was not statistically significant. There were no significant differences betweenthe two groups in timely treatment, empiric anti-infective, incentives, dialysate WBC count,Hb, WBC, CRP and prealbumin.5. compare the pathogens of the first peritonitis episode: In the first peritonitisepisode, there were no significant differences between the two groups in constituent ratio ofpathogens. The ratio of gram-positive bacterium between the two groups was similar; theratio of g ram-negative ba cterium in same p athogen group was h igher t han d ifferentpathogen group; and the ratio of dialysate culture negative in different pathogen group washigher than same pathogen group. Further analysis showed that there were no significantdifferences between t he t wo groups i n constituent ratio of gram-positive ba cterium andgram-negative bacterium. Compare gram-positive bacterium between the two groups, theratio of S taphylococcus e pidermidis in same pathogen gr oup was higher t han di fferentpathogen group; and Compare gram-negative bacterium between the two groups, the ratioof Escherichia coli in same pathogen group was higher than different pathogen group.conclusion1. The r ate o f cat heter r emoval was hi gh i n multiple gr oup, a ccount f or50.00%,indicating that multiple peritonitis episodes were adverse factors for technology failure anddropout of PD patients. 2. P atients w ith hypoalbuminemia, longer du ration of di alysis pr one t o multipleperitonitis episode. T he study f urther to d etermine time-average serum pr ealbumin＜306.71mg/L, baseline serum albumin＜27.45g/L, and dialysis duration≥12months was therisk factors for multiple peritoneal dialysis-related peritonitis. For such high-risk population,we should focus and intervene positively.3. Fa iled to t imely t reatment, unf inished t he c ourse of anti-infection in th e f irstperitonitis e pisode ma y also result in multiple p eritonitis. Unfinished t he c ourse o fanti-infection in th e f irst p eritonitis e pisode ma y r esult in re-infection by d ifferentpathogens. There w as no s ignificant di fference be tween t he t wo groups i n e mpiricalanti-infection, i t r evealed t hat t he r esistance o f p athogenic b acteria t o em piricalanti-infection is not a risk factor for multiple peritonitis.4. O ur s tudy shows that the ri sk fa ctors o f P D related multiple p eritonitis are al lcontrollable, e xcept for dialysis duration. T herefore, a ctive i mprovement of p atients’nutritional status, correction of hypoproteinemia, informed patients to visit PD centers intime when p eritonitis s ymptom occurs, r egular anti-infection therapy, an d act ivecooperation with doctors for the completion of course of anti-infection therapy are effectivemeasures to reduce the frequency of peritonitis. |
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