Association between platelet/lymphocyte ratio and frequent peritoneal dialysis-associated peritonitis in peritoneal dialysis patients

Yuan Jing, Yang Yuqi, Liu Lu, Yu Fangfang, Qie Shuwen, Yang Li, Zha Yan

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Chinese Journal of Nephrology ›› 2021, Vol. 37 ›› Issue (4) : 327-332. DOI: 10.3760/cma.j.cn441217-20200923-00045
Peritoneal Dialysis

Association between platelet/lymphocyte ratio and frequent peritoneal dialysis-associated peritonitis in peritoneal dialysis patients

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Abstract

Objective To explore the association between platelet/lymphocyte ratio (PLR) and frequent peritoneal dialysis (PD)-associated peritonitis (PDAP) in PD patients. Methods The data of PD patients with PDAP from Guizhou Provincial People's Hospital between January 2015 and June 2019 were analyzed retrospectively. The patients were divided into mono group (only once PDAP occurred in one year) and frequent group (2 or more PDAP occurred in one year) according to the frequency of PDAP. The demographic data including gender, age, height and weight, the clinical data including blood pressure, duration of PD, causes of peritonitis, the laboratory data at the first time of PDAP and the prognosis of PDAP were compared between two groups. Logistic regression analysis method was applied to analyze the relationship between PLR and frequent PDAP. The predictive power of PLR was evaluated by receiver operating characteristic curve (ROC). Results A total of 78 PD patients with PDAP were enrolled, including 53 males and 25 females, with average age of 45.2 years. The total person-year was 765.1 person-years and the incidence of peritonitis was 0.10 case/person-year during the median follow-up of 16 months. All patients were divided into two groups: 53 patients in mono group and 25 patients in frequent group. Compared with mono group, the patients in frequent group had lower body mass index, longer dialysis duration, higher systolic blood pressure level, higher PLR level, lower uric acid level, and higher rate of drug-resistant bacteria in peritoneal effusion (all P<0.05). The extubation rate of the frequent group was 44.0%(11/25), which was significantly higher than that [15.1%(8/53)] of mono group (P<0.05). Multivariate logistic regression analysis showed that higher PLR level was an independent related factor for frequent PDAP(OR=1.006, 95%CI 1.002-1.010, P=0.003), and the area under the ROC curve of PLR was 0.783(95%CI 0.663-0.904, P<0.001). Conclusions High PLR level is an independent related factor of frequent PDAP for PD patients, and PLR can be a potential predictor of frequent PDAP.

Key words

Peritoneal dialysis / Peritonitis / Blood platelets / Lymphocytes / Frequency

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Yuan Jing. , Yang Yuqi. , Liu Lu. , Yu Fangfang. , Qie Shuwen. , Yang Li. , Zha Yan. Association between platelet/lymphocyte ratio and frequent peritoneal dialysis-associated peritonitis in peritoneal dialysis patients[J]. Chinese Journal of Nephrology, 2021, 37(4): 327-332. DOI: 10.3760/cma.j.cn441217-20200923-00045.
腹膜透析(peritoneal dialysis,PD)相关性腹膜炎(PD-associated peritonitis,PDAP)是PD患者常见及严重的并发症之一,可导致技术失败、超滤衰竭,进而迫使患者退出PD治疗,转为费用较高的血液透析(hemodialysis,HD),甚至导致死亡[1]。其中,PDAP发生的频率与腹膜炎相关严重事件密切相关,频发性腹膜炎可导致更高的拔管率及退出率[2]。有研究表明,频发性PDAP患者的拔管率高达50%,是单发PDAP患者的8倍[3]。同时,频发性PDAP还是PD患者腹膜感染相关死亡及全因死亡的独立预测因素[4]。因此,早期识别频发性PDAP的危险因素并予以干预对于改善PD患者的预后具有重要的临床意义。
血小板/淋巴细胞比值(platelet/lymphocyte ratio,PLR)是一种新型的炎症标志物,已被证实可用于评估慢性肾脏病(chronic kidney disease,CKD)及维持性透析患者的炎症状态与预后[5-6]。既往有研究表明,PLR是PD患者发生炎症相关疾病的预测因子[7]。但目前尚无研究阐述PLR与频发性PDAP的关系。本研究拟通过回顾性分析贵州省人民医院5年内收治的PDAP患者资料,探讨频发性PDAP的相关因素,为临床上防治PDAP提供理论依据。

对象与方法

一、研究对象

回顾性分析2015年1月至2019年6月于贵州省人民医院PD中心行PD置管术后接受规律PD治疗及随访并发生PDAP的患者。所有患者在开始PD前,均接受严格的健康教育及操作培训,并经考核合格。所有PD患者均使用1.5%或2.5%葡萄糖透析液(6~8 L/d),日间留腹4~6 h,夜间留腹10~12 h。纳入标准:(1)符合PDAP诊断的PD患者;(2)年龄≥18岁。排除标准:(1)首次发生PDAP后1年内死亡、因转HD治疗或行肾移植而退出PD及失访者;(2)合并有血液系统疾病、自身免疫性疾病、恶性肿瘤、严重感染,使用大量糖皮质激素及免疫抑制剂者;(3)资料不完整者。

二、研究方法

1. 分组:根据发生PDAP的次数,将患者分为单发组(1年内仅发生1次PDAP)和频发组(1年内发生2次或2次以上PDAP)。
2. 观察指标:收集患者开始PD时的一般资料,包括年龄、性别、身高、体重、基础疾病、血压及置管时间、发生腹膜炎时间、发病至就诊时间、诱因(包括操作不规范、环境不达标、肠道感染、便秘、出口或隧道感染等)、临床症状(发热、腹痛、恶心、呕吐等)等,实验室资料包括首次发生PDAP时使用抗生素前的白细胞、中性粒细胞、淋巴细胞、血红蛋白、血小板计数、血尿素氮、血肌酐、血尿酸、血钙、血磷、全段甲状旁腺素(intact parathyroid hormone,iPTH)、血清总蛋白、血清白蛋白、C反应蛋白(C-reactive protein,CRP)及治疗前腹膜透出液病原学培养结果。体重指数(kg/m2)=体重(kg)/身高2(m2);中性粒细胞/淋巴细胞比值(NLR)为中性粒细胞总数与淋巴细胞总数的比值;PLR为血小板数与淋巴细胞总数的比值。
3. 诊断:(1)PDAP诊断:对疑似腹膜炎的患者,在抗生素使用前留取留腹时间>2 h的透出液送检。根据2018年国际腹膜透析协会(International Society of Peritoneal Dialysis,ISPD)指南[8]:存在腹膜炎临床症状和体征,例如腹痛和/或透出液浑浊;透出液白细胞计数>100/μl,中性粒细胞百分比>50%;透出液病原菌培养阳性;至少满足以上3条中的2条即可诊断。(2)频发性PDAP:1年内发生2次及2次以上PDAP;单发性PDAP:1年内仅发生1次PDAP。(3)PDAP治疗:根据ISPD指南[8],在留取腹膜透出液标本后联合使用第1代、第3代头孢菌素腹腔灌注行经验性治疗,如感染严重加用静脉滴注抗感染治疗。如培养结果提示对上述抗菌药物不敏感,则根据药敏试验结果改用敏感药物后按疗程治疗。如培养阴性且对上述抗菌药物治疗有效,则疗程为14 d。一旦确诊真菌性腹膜炎则尽快行PD管拔管术,并使用抗真菌药物。(4)治疗有效:应用抗生素治疗3 d后腹痛症状缓解,透出液浑浊转澄清,实验室复查透出液白细胞数较前减少,或恢复正常。(5)无效拔管:PDAP治疗没有效果,或虽经治疗后患者症状好转,但治疗期间出现严重的腹膜功能衰竭或未修补疝而导致PD管拔除者。(6)腹膜炎相关性死亡:患者因活动性腹膜炎死亡,或因腹膜炎住院死亡,或腹膜炎发生2周内死亡。
4. 随访:纳入研究的所有PD患者均于本中心规律随访,直至因死亡、转HD、行肾移植手术等退出PD治疗或失访,未发生上述事件的患者均随访至2020年6月30日。

三、统计学分析

数据采用SPSS 22.0软件进行统计分析,符合正态分布的计量资料以x¯±s形式表示,两组间比较采用两独立样本t检验;不符合正态分布的计量资料以MP25P75)形式表示,两组间比较采用Mann-Whitney U检验;计数资料以例数和百分比(%)表示,两组间比较采用 χ2检验。采用Logistic回归分析法分析PLR水平与频发性PDAP发生风险的关系,采用受试者工作特征曲线(ROC)分析PLR对PD患者发生频发性PDAP的预测价值。双侧检验,P<0.05视为差异有统计学意义。

结果

1. 两组患者的基础资料比较:2015年1月至2019年6月于本中心规律行PD的患者共252例,符合纳入标准的PDAP患者共86例。其中排除首次发生PDAP后1年内转HD患者3例、行肾移植2例、死亡1例、失访2例,最后共纳入78例。中位随访时间16个月中,总人年数为765.1人年,总腹膜炎发生率为0.10例次/人年。纳入患者中男53例,女25例,平均年龄为45.2岁,主要的基础疾病为慢性肾小球肾炎[39例(50.0%)]、糖尿病肾病[19例(24.4%)]和高血压肾损害[16例(20.5%)]。根据发生PDAP的次数分组,单发组53例,频发组25例。与单发组患者相比,频发组患者体重指数更低,收缩压更高,透析龄更长(均P<0.05);而年龄、性别、诱因等之间的差异均无统计学意义(均P>0.05),见表1
表1 两组患者临床资料比较
项目 总体(n=78) 单发组(n=53) 频发组(n=25) t/χ2/Z P
男性[例(%)] 53(67.9) 35(66.0) 18(72.0) 0.269 0.604
年龄(岁) 45.2±16.0 44.4±15.7 47.2±16.6 -1.064 0.291
体重指数(kg/m2) 21.6±3.8 22.5±4.1 20.3±3.1 2.231 0.030
透析龄(月) 16.0(4.0,26.5) 9.0(4.0,25.0) 21.0(16.0,30.5) -2.373 0.018
基础病[例(%)] 0.458 0.928
慢性肾小球肾炎 39(50.0) 24(45.3) 13(52.0)
糖尿病肾病 19(24.4) 14(26.4) 5(20.0)
高血压肾损害 16(20.5) 11(20.8) 5(20.0)
其他 6(7.7) 4(7.5) 2(8.0)
诱因[例(%)] 4.063 0.255
操作不当 35(44.9) 26(49.1) 9(36.0)
环境不达标 8(10.3) 3(5.7) 5(20.0)
肠道感染 32(41.0) 22(41.5) 10(40.0)
出口隧道感染 3(3.8) 2(3.8) 1(4.0)
收缩压(mmHg) 146.2±24.3 140.4±25.9 153.3±19.9 -2.058 0.044
舒张压(mmHg) 90.6±15.6 88.0±17.0 93.0±14.3 -1.180 0.243
发病至就诊时间(d) 3.0(1.0,5.0) 3.0(1.0,5.0) 2.9(1.0,5.6) -0.861 0.389
注:1 mmHg=0.133 kPa;数据形式除已注明外,呈正态分布的计量资料采用x¯±s形式表示,非正态分布的计量资料采用MP25P75)形式表示
2. 两组患者的实验室资料比较:与单发组相比,频发组患者的PLR水平更高,血尿酸水平更低(均P<0.05)。而白细胞计数、中性粒细胞、淋巴细胞、NLR、红细胞计数、血红蛋白、血小板计数、血尿素氮、血肌酐、血钙、血磷、血iPTH、血清总蛋白、血清白蛋白、CRP之间的差异均无统计学意义(均P>0.05)。见表2
表2 两组患者实验室指标比较
实验室指标 总体(n=78) 单发组(n=53) 频发组(n=25) t/Z P
白细胞计数(×109/L) 7.4±3.6 7.7±3.6 6.7±3.6 1.067 0.289
中性粒细胞(×109/L) 5.8±3.8 6.1±3.9 5.1±3.5 1.068 0.289
淋巴细胞(×109/L) 1.1±0.6 1.0±0.6 1.1±0.6 -0.272 0.786
NLR 5.4(3.1,9.9) 5.8(3.3,10.5) 4.0(2.3,8.0) -1.381 0.167
红细胞计数(×1012/L) 3.4±0.9 3.4±1.0 3.3±0.7 0.378 0.707
血红蛋白(g/L) 95.1±22.2 94.1±23.6 97.1±19.2 -0.548 0.586
血小板计数(×109/L) 213.7±84.1 221.5±91.0 197.1±65.9 1.196 0.235
PLR 217.9(143.1,385.2) 173.9(136.4,236.5) 428.3(214.3,586.3) -4.021 <0.001
血尿素氮(mmol/L) 14.5±7.9 14.5±8.5 14.4±6.8 0.045 0.964
血肌酐(μmol/L) 854.9±338.9 898.2±350.4 764.9±300.4 1.635 0.106
血尿酸(μmol/L) 359.4±95.3 375.5±104.4 328.4±66.3 2.047 0.044
血钙(mmol/L) 2.1±0.3 2.1±0.3 2.1±0.2 -0.150 0.881
血磷(mmol/L) 1.4±0.6 1.5±0.6 1.3±0.5 1.440 0.154
血清总蛋白(g/L) 56.4±8.6 56.7±8.5 55.6±9.0 0.524 0.602
血清白蛋白(g/L) 26.6±6.8 26.9±7.5 25.9±5.3 0.569 0.571
iPTH(ng/L) 192.8(85.5,412.1) 254.6(106.6,466.5) 137.2(83.0,227.5) 1.790 0.074
CRP(mg/L) 52.5(14.9,138.0) 38.1(12.5,126.4) 68.8(15.0,160.0) -0.599 0.549
注:NLR:中性粒细胞/淋巴细胞比值;PLR:血小板/淋巴细胞比值;iPTH:全段甲状旁腺素;CRP:C反应蛋白;呈正态分布的计量资料采用x¯±s形式表示,非正态分布的计量资料采用MP25P75)形式表示
3. 两组患者病原菌特征比较:透出液病原菌培养结果提示,两组患者的革兰阳性菌、革兰阴性菌、真菌致病菌组成差异无统计学意义(均P>0.05)。相比单发组,频发组患者培养阴性的比例更低,而耐药菌生长比例更高(均P<0.05)。见表3
表3 两组患者病原菌组成比较
菌种 总体(n=78) 单发组(n=53) 频发组(n=25) χ2 P
革兰阳性菌[例(%)] 30(38.5) 19(35.8) 11(44.0) 0.477 0.328
革兰阴性菌[例(%)] 16(20.5) 9(17.0) 7(28.0) 1.265 0.203
真菌[例(%)] 2(2.6) 1(1.9) 1(4.0) 0.271 0.447
培养阴性[例(%)] 30(38.5) 24(45.3) 6(24.0) 3.251 0.040
耐药菌[例(%)] 20(25.6) 8(15.1) 12(48.0) 9.647 0.002
4. 频发性PDAP发生的相关因素分析:单因素Logistic回归分析结果显示,PD患者体重指数下降、PLR升高、血尿酸下降是频发性PDAP发生的影响因素(均P<0.05)。进一步多因素分析,结果显示,高PLR水平是PD患者发生频发性PDAP的独立相关因素(OR=1.006,95%CI 1.002~1.010,P=0.003),见表4。ROC曲线分析结果显示,PLR预测PD患者频发性PDAP的曲线下面积为0.783(95%CI 0.663~0.904,P<0.001),PLR的截断值为257.76,特异度为81%,敏感度为68%。见图1
表4 频发性腹膜透析相关性腹膜炎发生的相关因素(Logistic回归分析,n=78)
因素 单因素分析 多因素分析
OR 95%CI P OR 95%CI P
透析时间(月) 1.032 0.996~1.070 0.086 1.039 0.986~1.095 0.148
体重指数(kg/m2) 0.823 0.685~0.989 0.037 0.879 0.705~1.097 0.255
收缩压(mmHg) 1.025 1.000~1.050 0.052 1.008 0.971~1.046 0.684
血小板/淋巴细胞比值 1.007 1.004~1.011 <0.001 1.006 1.002~1.010 0.003
血尿酸(μmol/L) 0.994 0.987~1.000 0.049 0.995 0.987~1.004 0.304
注:1 mmHg=0.133 kPa
图1 血小板/淋巴细胞比值预测频发性腹膜透析相关性腹膜炎的ROC曲线

Full size|PPT slide

5. 两组患者预后比较:频发组治疗有效患者(8例,40.0%)明显低于单发组(43例,81.1%)(P<0.05);11例(15.1%)因治疗无效拔管,明显高于单发组[8例(15.1%)](P<0.05);4例(16.0%)发生腹膜炎相关性死亡,虽高于单发组[2例(3.8%)],但差异无统计学意义,见表5
表5 两组患者转归情况比较[例(%)]
转归 总体(n=78) 单发组
(n=53)
频发组
(n=25)
χ2 P
治疗有效 53(67.9) 43(81.1) 10(40.0) 13.196 <0.001
死亡
6(7.7) 2(3.8) 4(16.0) 3.576 0.068
无效拔管
19(24.4) 8(15.1) 11(44.0) 7.703 0.006

讨论

本研究通过回顾性分析本中心近5年的PDAP患者病例资料,探讨频发性PDAP发生的相关因素,结果发现高PLR水平是频发性PADP发生的独立相关因素。
本中心近5年PDAP发生率为0.10例次/人年,低于既往研究报道[2,4],本研究发现患者感染诱因以操作不当(44.9%)、肠道感染(41.0%)为主,同时也包括环境不达标(10.3%)、出口隧道感染(3.8%)等原因。根据本中心腹膜炎诊治经验,尽可能建立完善的医护随访体系,充分宣教以减少腹膜炎诱因的发生尤为重要。置管后对患者进行视频宣教、护理培训及出院前考核是减少患者因操作不当引起腹膜炎行之有效的管理办法。同时,在规律随访中反复对患者操作、饮食进行宣教,专科腹透医师对患者进行治疗方案的个体化调整能减少肠源性感染、操作相关感染。虽然本中心腹膜炎患者首次感染后治疗有效率达67.9%,但仍有近四分之一患者因治疗无效而拔管。同时,频发组患者拔管率更高达44.0%,相关死亡达16.0%,均明显高于单发组。这一结果与既往的研究结果相仿[9]。频发性PDAP是PD患者过早退出PD治疗的直接原因,具有较高的拔管率、退出率、高住院率;且反复感染可能引起多发耐药,严重影响患者的生存质量和远期预后;PDAP是PD患者死亡的独立危险因素。本研究结果再次论证了频发性腹膜炎对PD技术失败的影响。
本研究发现,高PLR是PD患者发生频发性PDAP的独立相关因素。PLR是近年来提出的一种可较为稳定反映机体炎症状态的新型炎症指标,在肿瘤、心血管疾病等多种疾病中可提示炎症,并与预后有关[10]。研究已证实PLR水平与CKD患者的炎症状态密切相关,可用于评估透析患者的微炎症状态[11-12]。本研究PLR水平高者发生频发性PDAP比例高,考虑与频发性PDAP患者常合并有抗感染疗程不足、耐药菌生长,使患者长期处于高水平炎症状态有关。本研究中ROC分析PLR预测频发性PDAP的曲线下面积为0.783,提示有相对较高的预测价值。已有研究发现,营养不良与频发性PDAP的发生密切相关,提示频发性PDAP患者营养不良状况比单发性PDAP患者更差[13]。CKD患者长期微炎症状态可加重营养不良程度;反过来,营养不良发生可导致机体进一步释放炎症介质,形成恶性循环以维持微炎症状态,最终可导致蛋白质-能量消耗(protein-energy wasting,PEW)的发生。本中心既往1项横断面研究表明,在HD患者中PLR升高可预测PEW的发生[14]。因此,患者机体内PLR处于高水平状态时,常提示患者存在营养不良,感染的易感性增加,感染频率增加。
NLR同PLR类似,也被用于评估CKD患者的炎症状态。有研究发现,高水平NLR是PDAP的危险因素[15]。而本研究中NLR并不能预测频发性PDAP的发生。但也有学者比较了PLR与NLR在终末期肾病患者中的炎症状态评估能力,结果发现PLR比NLR能更好地预测炎症[7]。同时,本中心既往的研究也发现,NLR同样不能预测HD患者PEW的发生[14]。中性粒细胞升高往往提示感染性疾病,即有明确病原微生物入侵机体。在初发PDAP进行规范性抗感染治疗的背景下,频发性PDAP的预测主要与初次感染后患者长期、慢性、持续的微炎症状态有关,而并非取决于直接侵入性显性感染的程度。既往尚无大样本研究探讨NLR、PLR与频发性PDAP的相关性,本研究的结论仍需更大样本量、随访时间长的研究进一步验证。
PLR可以通过血常规中的血小板、淋巴细胞计数直接计算获得,无需额外抽血,且较单一指标更为稳定,目前已成为一种简便、经济、可靠的新型炎症指标。本研究揭示了高PLR水平是PD患者发生频发性PDAP的独立危险因素,提示临床中监测PLR水平的重要性,为预防频发性PDAP发生提供了一定的理论基础,但本研究为单中心回顾性研究,仅代表单个PD中心的结论,仍需多中心、更大样本量、前瞻性研究进一步验证。

References

[1]
Boudville N, Kemp A, Clayton P, et al. Recent peritonitis associates with mortality among patients treated with peritoneal dialysis[J]. J Am Soc Nephrol, 2012, 23(8): 1398-1405. DOI: 10.1681/ASN.2011121135.
Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.
[2]
Burke M, Hawley CM, Badve SV, et al. Relapsing and recurrent peritoneal dialysis-associated peritonitis: a multicenter registry study[J]. Am J Kidney Dis, 2011, 58(3): 429-436. DOI: 10.1053/j.ajkd.2011.03.022.
The causes, predictors, treatment, and outcomes of relapsed and recurrent peritoneal dialysis (PD)-associated peritonitis are poorly understood.Observational cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data.All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of peritonitis.Demographic, clinical, and facility variables and type of peritonitis; relapse (same organism or culture-negative episode occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); recurrence (different organism occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); control (first peritonitis episode without relapse or recurrence).Hospitalization, catheter removal, hemodialysis therapy transfer, death.Of 6,024 PD patients studied, first episodes of relapsed, recurrent, and control peritonitis occurred in 356, 165, and 2,021 patients, respectively. Coagulase-negative staphylococci and Staphylococcus aureus accounted for 48% of relapsing peritonitis (adjusted OR, 1.26 [95% CI, 0.94-1.70] and 1.54 [95% CI, 1.08-2.19], respectively), but were much less likely to be isolated in recurrent peritonitis. Recurrent peritonitis was associated more frequently with fungi (13%; OR, 2.16; 95% CI, 1.12-4.17). The empirical antimicrobial approaches to relapsing and recurrent peritonitis were similar and their subsequent clinical outcomes were comparable. Compared with uncomplicated peritonitis, relapsed and recurrent peritonitis were associated with higher rates of catheter removal (22% vs 30% vs 37%, respectively; P < 0.001) and permanent hemodialysis therapy transfer (20% vs 25% vs 32%; P < 0.001), but similar rates of hospitalization (73% vs 70% vs 70%) and death (2.8% vs 2.0% vs 1.2%).Limited covariate adjustment. Residual confounding and coding bias could not be excluded.Relapsed and recurrent peritonitis are caused by different spectra of micro-organisms, but are not readily clinically distinguishable at presentation. Empirical treatment with broad-spectrum antibiotics and subsequent adjustment according to antimicrobial susceptibilities results in similar clinical outcomes, albeit with appreciably higher rates of catheter removal and hemodialysis therapy transfer than for uncomplicated peritonitis.Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.
[3]
万程, 杨聚荣, 张炜炜, 等. 腹膜透析相关腹膜炎危险因素分析[J]. 临床内科杂志, 2014, 31(4): 240-242. DOI: 10.3969/j.issn.1001-9057.2014.04.006.
[4]
唐碧雯, 方炜, 严豪, 等. 371例次腹膜透析相关性腹膜炎的预后分析[J]. 中华肾脏病杂志, 2013, 29(11): 808-811. DOI: 10.3760/cma.j.issn.1001-7097.2013.11.003.
目的&nbsp;&nbsp;&nbsp; 分析本中心腹膜透析(腹透)相关性腹膜炎患者治疗的转归与预后,为腹透相关性腹膜炎的防治提供依据。 方法&nbsp;&nbsp;&nbsp; 入选2004年1月1日至2010年12月31日在上海交通大学医学院附属仁济医院腹透中心接受腹透治疗并发生腹透相关性腹膜炎的所有患者,分析7年间腹透相关性腹膜炎患者的转归与预后。 结果&nbsp;&nbsp;&nbsp; 研究期间共有220例患者发生了371次腹膜炎,腹膜炎发生率为1次/54.4患者&middot;月。其中285 例次(76.8%)的腹膜炎治愈,17例次(4.6%)的腹膜炎导致患者拔管转临时血液透析(血透),46例次(12.4%)的腹膜炎引起患者拔管转永久血透治疗,21例次(5.7%)的腹膜炎导致患者死亡。难治性腹膜炎患者的超滤能力(4 h-UF)较腹膜炎发生前明显减少(330比270 ml,P=0.036),4 h D/Pcr较腹膜炎发生略有前升高[(0.55&plusmn;0.08)比(0.58&plusmn;0.10),P=0.086]。 结论&nbsp;&nbsp;&nbsp; 腹透相关性腹膜炎是导致腹透技术失败及患者死亡的重要原因,难治性腹膜炎可损害患者腹膜功能。&nbsp;
[5]
Yaprak M, Turan MN, Dayanan R, et al. Platelet-to-lymphocyte ratio predicts mortality better than neutrophil-to-lymphocyte ratio in hemodialysis patients[J]. Int Urol Nephrol, 2016, 48(8): 1343-1348. DOI: 10.1007/s11255-016-1301-4.
Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were established showing the poor prognosis in some diseases, such as cardiovascular diseases and malignancies. The risk of mortality in patients with end-stage renal disease (ESRD) was higher than normal population. In this study, we aimed to investigate the relationship between NLR, PLR, and all-cause mortality in prevalent hemodialysis (HD) patients.Eighty patients were enrolled in study. NLR and PLR obtained by dividing absolute neutrophil to absolute lymphocyte count and absolute platelet count to absolute lymphocyte count, respectively. The patients were followed prospectively for 24 months. The primary end point was all-cause mortality.Mean levels of neutrophil, lymphocyte, and platelet were 3904 ± 1543/mm(3), 1442 ± 494/mm(3), 174 ± 56 × 10(3)/mm(3), respectively. Twenty-one patients died before the follow-up at 24 months. Median NLR and PLR were 2.52 and 130.4, respectively. All-cause mortality was higher in patients with high NLR group compared to the patients with low NLR group (18.8 vs. 7.5 %, p = 0.031) and in patients with higher PLR group compared to patients with lower PLR group (18.8 vs. 7.5 %, p = 0.022). Following adjusted Cox regression analysis, the association of mortality and high NLR was lost (p = 0.54), but the significance of the association of high PLR and mortality increased (p = 0.013).Although both NLR and PLR were associated with all-cause mortality in prevalent HD patients, only PLR could independently predict all-cause mortality in these populations.
[6]
Catabay C, Obi Y, Streja E, et al. Lymphocyte cell ratios and mortality among incident hemodialysis patients[J]. Am J Nephrol, 2017, 46(5): 408-416. DOI: 10.1159/000484177.
Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been previously suggested as oncologic prognostication markers. These are associated with malnutrition and inflammation, and hence, may provide benefit in predicting mortality among hemodialysis patients.Among 108,548 incident hemodialysis patients in a large U.S. dialysis organization (2007-2011), we compared the mortality predictability of NLR and PLR with baseline and time-varying covariate Cox models using the receiver operating characteristic curve (AUROC), net reclassification index (NRI), and adjusted R2.During the median follow-up period of 1.4 years, 28,618 patients died. Median (IQR) NLR and PLR at baseline were 3.64 (2.68-5.00) and 179 (136-248) respectively. NLR was associated with higher mortality, which appeared stronger in the time-varying versus baseline model. PLR exhibited a J-shaped association with mortality in both models. NLR provided better mortality prediction in addition to demographics, comorbidities, and serum albumin; ΔAUROC and NRI for 1-year mortality (95% CI) were 0.010 (0.009-0.012) and 6.4% (5.5-7.3%) respectively. Additionally, adjusted R2 (95% CI) for the Cox model increased from 0.269 (0.262-0.276) to 0.283 (0.276-0.290) in the non-time-varying model and from 0.467 (0.461-0.472) to 0.505 (0.500-0.512) in the time-varying model. There was little to no benefit of adding PLR to predict mortality.High NLR in incident hemodialysis patients predicted mortality, especially in the short-term period. NLR, but not PLR, added modest benefit in predicting mortality along with demographics, comorbidities, and serum albumin, and should be included in prognostication approaches.© 2017 S. Karger AG, Basel.
[7]
Turkmen K, Erdur FM, Ozcicek F, et al. Platelet-to-lymphocyte ratio better predicts inflammation than neutrophil-to-lymphocyte ratio in end-stage renal disease patients[J]. Hemodial Int, 2013, 17(3): 391-396. DOI: 10.1111/hdi.12040.
Neutrophil-to-lymphocyte ratio (NLR) was introduced as a potential marker to determine inflammation in end-stage renal disease (ESRD) patients. Recently, platelet-to-lymphocyte ratio (PLR) and NLR were found to positively correlated with inflammatory markers including tumor necrosis factor-α (TNF-α) and interleukin (IL)-6 in cardiac and noncardiac patients. Data regarding PLR and its association with inflammation are lacking in hemodialysis (HD) and peritoneal dialysis (PD) patients. Hence, we aimed to determine the relationship between PLR, NLR, and inflammation in ESRD patients. This was a cross-sectional study involving 62 ESRD patients (29 females, 33 males; mean age, 49.6 ± 14.6 years) receiving PD or HD for ≥6 months in the Dialysis Unit of Necmettin Erbakan University. PLR, NLR, C-reactive protein, TNF-α, IL-6 levels were measured. PLR, NLR, serum high sensitive C-reactive protein, IL-6, and TNF-α levels were significantly higher in PD patients when compared with HD patients. ESRD patients with PLR ≥ 140 had significantly higher NLR, IL-6, and TNF-α levels when compared to patients with PLR < 139. In the bivariate correlation analysis, PLR was positively correlated with NLR, IL-6, and TNF-α in this population. When we compared the association of PLR and NLR with IL-6 (r = 0.371, P = 0.003 vs. r = 0.263, P = 0.04, respectively) and TNF-α (r = 0.334, P = 0.008 vs. r = 0.273, P = 0.032, respectively), PLR was found to be superior to NLR in terms of inflammation in ESRD patients. Simple calculation of PLR can predict inflammation better than NLR in ESRD patients. © 2013 The Authors. Hemodialysis International © 2013 International Society for Hemodialysis.
[8]
Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment[J]. Perit Dial Int, 2016, 36(5): 481-508. DOI: 10.3747/pdi.2016.00078.
[9]
赖玮婧, 何可, 高芳, 等. 频发腹膜透析相关性腹膜炎的危险因素分析[J]. 四川大学学报(医学版), 2019, 50(2): 264-267. DOI: 10.13464/j.scuxbyxb.2019.02.025.
[10]
Paquissi FC. The role of inflammation in cardiovascular diseases: the predictive value of neutrophil-lymphocyte ratio as a marker in peripheral arterial disease[J]. Ther Clin Risk Manag, 2016, 12: 851-860. DOI: 10.2147/TCRM.S107635.
[11]
Ahbap E, Sakaci T, Kara E, et al. Neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in evaluation of inflammation in end-stage renal disease[J]. Clin Nephrol, 2016, 85(4): 199-208. DOI: 10.5414/CN108584.
To evaluate the relationship between neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and inflammation in end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD).100 ESRD patients on maintenance HD (mean ± SD age: 52.3 ± 1.7 years, 52% were males) were included in this cross-sectional study. Data on patient demographics, dry weight, body mass index, duration of HD (months), etiology of ESRD, delivered dose of dialysis (spKt/V), complete blood count, blood biochemistry and inflammatory markers including hs-CRP (mg/L), TNF-α (pg/mL), NLR, and PLR were recorded in all patients and compared in patients with hs-CRP levels of ≤ 3 mg/L vs. > 3 mg/L. other study parameters were also recorded.Compared to patients with lower hs-CRP levels, patients with hs-CRP levels of > 3 mg/L had significantly higher values for NLR (3.7 ± 0.2 vs. 2.7 ± 0.2, p < 0.01) and PLR (150.7 ± 6.9 vs. 111.8 ± 7.0, p < 0.001). Both NLR and PLR were positively correlated with hs-CRP (r = 0.333, p = 0.01 and r = 0.262, p = 0.001, respectively) and negatively correlated with transferrin saturation (%) (r = -0.418, p = 0.001 and r = -0.309, p = 0.002, respectively).Our findings in a cohort of ESRD patients on maintenance HD revealed higher values for NLR and PLR in patients with higher levels of inflammation along with a significant positive correlation of both NLR and PLR with hs-CRP levels. Being a simple, relatively inexpensive and universally available method, whether or not calculation of NLR and PLR offers a plausible strategy in the evaluation of inflammation in ESRD patients in the clinical practice should be addressed in larger scale randomized and controlled studies.
[12]
Chávez Valencia V, Orizaga de la Cruz C, Mejía Rodríguez O, et al. Inflammation in hemodialysis and their correlation with neutrophil-lymphocyte ratio and platelet-lymphocyte ratio[J]. Nefrologia, 2017, 37(5): 554-556. DOI: 10.1016/j.nefro.2016.12.006.
[13]
Wang J, Zhang H, Liu J, et al. Implementation of a continuous quality improvement program reduces the occurrence of peritonitis in PD[J]. Ren Fail, 2014, 36(7): 1029-1032. DOI: 10.3109/0886022X.2014.927771.
To investigate the causes of peritonitis in patients with peritoneal dialysis (PD) using continuous quality improvement (CQI) to develop effective interventions and reduce the occurrence of peritonitis.A quality control team consisting of 10 members, including the department head, four nephrologists and four nurses, all specialized in PD care, and the head nurse, was established at the Peritoneal Dialysis Center of the Third Xiangya Hospital of Central South University. All patients with peritonitis occurring between 1 July 2010 and 31 December 2011 (pre-CQI period) were analyzed and compared with data obtained between January 2012 (implementation of CQI) and March 2013 to investigate possible causes of peritonitis and to develop corresponding interventions. Fishbone analysis, including laboratory parameters, was carried out monthly.Gastrointestinal tract dysfunction, nonstandard procedures and malnutrition were found to be the top three risk factors for peritonitis. Gastrointestinal tract dysfunction was the likely cause of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p<0.05). Nonstandard procedures were the cause of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (p<0.05). The overall incidence of peritonitis reduced from once every 40.1 patient months before the CQI to once every 70.8 patient months after CQI (p<0.05). The incidence of Gram-positive bacteria peritonitis reduced from once every 96.9 patients per month before CQI to once every 209.1 patient months after CQI (p<0.05), whereas the incidence of Gram-negative bacteria peritonitis reduced from once every 234.2 patient months before CQI to once every 292.8 patient months after CQI.CQI can effectively reduce the occurrence of PD-related peritonitis.
[14]
胡杉杉, 周朝敏, 李倩, 等. 血小板/淋巴细胞、中性粒细胞/淋巴细胞比值与血液透析患者蛋白质能量消耗的关系[J]. 中华医学杂志, 2019, 99(8): 587-592. DOI: 10.3760/cma.j.issn.0376-2491.2019.08.005.
[15]
詹秋楠, 陈晓莉, 李丹丹, 等. 中性粒细胞与淋巴细胞比值在腹膜透析相关性感染中的临床意义[J]. 中国血液净化, 2018, 17(7): 446-449. DOI: 10.3969/j.issn.1671-4091.2018.07.004.

Funding

Science and Technology Cooperation Program of Guizhou Province(QKH[2019]1194)
Guizhou Provincial Health Commission Project(gzwjkj2019-1-109)
Guizhou Provincial Health Commission Project(gzwjkj2018-1-015)
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