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血透患者发生感染性心内膜炎的临床表现及结局
发布时间:2020-01-13

  摘    要: 目的:分析血液透析(HD)患者并发感染性心内膜炎(IE)的临床表现及结局。方法:收集2013年1月至2017年12月在温州医科大学附属第一医院诊断为终末期肾脏病,并维持HD患者460例的临床资料。结果:9例患者并发IE,男5例,女4例,年龄(58.2±13.8)岁。透析通路均为隧道型中心静脉导管(CVC),中位透析时间20.0(1.8,36.0)个月。发热9例(占100%)为主要临床表现,6例并发脑梗死、心力衰竭和脑出血。所有患者均行血培养,7例阳性,主要细菌是葡萄球菌(占71.4%)。经胸超声心动图(TTE)检查7例,食道超声(TEE)1例,同时行TTE和TEE检查1例,均发现赘生物。累及部位以二尖瓣最常见(5/9),其次为三尖瓣(2/9)。保守治疗8例,外科手术1例;好转出院4例,自动出院5例。结论:用CVC HD患者出现发热症状,要考虑到IE的可能,可以借助TTE或TEE和血培养明确诊断。

  关键词: 血液透析; 感染性心内膜炎; 临床特征;

  Abstract: Objective: To analyze the clinical features and outcomes of hemodialysis(HD) patients complicated with infective endocarditis(IE). Methods: Clinical data of 460 ESRD patients with hemodialysis admitted to the First Affiliated Hospital of Wenzhou Medical University from January 2013 to December 2017 were collected. Results: There were 9 patients with IE, with an average age of 58.2±13.8 years old and five males. The vascular access was long-term central venous catheter with an average dialysis time of 20 months. Fever was the common symptom(100%). Complications occurred in 6 cases: mainly cerebral infarction, heart failure and cerebral hemorrhage. All patients underwent blood culture examination, 7 cases were positive and the main bacteria ware staphylococcus(71.4%). Thoracic echocardiography(TTE) was used in 7 patients, Tran Esophageal Echocardiography(TEE) in 1 patient, and both TTE and TEE examined in 1 patient. Vegetations were found in nine patients. The most common involvement was mitral valve(5/9), followed by tricuspid valve(2/9). Eight patients were treated conservatively. One underwent surgical treatment. Four patients were discharged after improvement and five patients were discharge automatically. Conclusion: Hemodialysis with CVC is a risk factor of IE. Hemodialysis patients, especially dialysating with CVC should be considered infectious endocarditis if they have fever. Echocardiography and blood culture are two main methods for clarifying the diagnosis.

  Keyword: hemodialysis; infective endocarditis; clinical characteristics;

  感染性心内膜炎(infective endocarditis,IE)是血液透析(hemodialysis,HD)的并发症之一,HD患者IE发病风险高,为普通人群的10~18倍[1],但国内这方面报道尚不多。本研究回顾性分析HD患者发生IE的临床表现及结局,现报告如下。

  1、对象和方法

  1.1、对象

  通过电子病历系统搜索2013年1月至2017年12月在温州医科大学附属第一医院诊断为HD患者临床资料,共460例。符合IE诊断标准的共9例,男5例,女4例,年龄(58.2±13.8)岁。9例患者透析通路均为隧道型中心静脉导管(central venous catheter,CVC),中位透析时间为20.0(1.8,36.0)个月。肾脏原发病:3例糖尿病肾病,其中1例行肾移植后慢性移植肾失功;3例高血压肾病;1例慢性肾小球肾炎;1例因肾结核左肾缺如;1例乙肝病毒相关性肾炎。本研究经本院伦理委员会批准。
 

血透患者发生感染性心内膜炎的临床表现及结局
 

  1.2、诊断方法

  诊断方法参照改良Duke诊断标准[2]。纳入标准:(1)临床和辅助检查诊断为IE;(2)年龄≥18岁;(3)均为HD患者。排除标准:(1)化验室及辅助检查等资料缺失;(2)已明确为其他部位感染(导管感染、结核、败血症等)HD患者。

  2、结果

  9例患者均有发热,3例出现心脏杂音,9例CRP升高,9例血红蛋白下降,4例红细胞沉降率增快。6例患者出现并发症:脑梗死合并心衰1例,脑梗死合并脑出血3例,心衰2例。9例患者均行血培养,阳性7例(占77.8%),革兰氏染色阳性菌5例(占71.4%),分别为路邓葡萄球菌3例、表皮葡萄球菌1例和金黄色葡萄球菌1例;革兰氏染色阴性菌2例(占28.6%),肺炎克雷伯杆菌和鲍曼不动杆菌各1例。葡萄球菌选用替考拉或万古霉素治疗,阴性菌用美罗培南或特治星,2例血培养阴性选择2种抗生素联合应用。7例行经胸超声心动图(thoracic echocardiography,TTE)检查,1例行食道超声(tran esophageal echocardiography,TEE),1例同时行TTE和TEE检查;结果9例(占100%)均发现赘生物,累及部位以二尖瓣5例(占55.6%),三尖瓣2例(占22.2%),二尖瓣联合主动脉瓣1例,右心房1例。8例患者选择保守治疗,1例行外科手术治疗;4例患者好转出院,抗生素使用平均时间(37.0±3.5)d,5例因治疗效果不佳,选择自动出院。见表1。

  3、讨论

  感染是导致维持性HD患者死亡的第二大常见原因[3]。在慢性肾脏病和HD患者中IE的发病率逐渐升高[4]。ABBOTT等[1]一项回顾性研究发现HD患者IE的发病率为2%~6%,本研究HD患者IE的发病率为1.9%,与文献相似。HD患者容易发生感染的主要原因是血管通路(动静脉内瘘和中心静脉导管)在使用时增加了血液与病原菌接触的机会[5],其次终末期肾脏病患者由于代谢异常、营养不良和毒素累积[6]等因素,导致免疫力低下,容易发生菌血症[7]。MONTASSER等[8]强调深静脉血透导管是HD患者感染IE的主要途径,风险高于动静脉内瘘。国际肾脏机构指南[9]建议自体动静脉内瘘为最佳的血管通路。本研究中9例患者血管通路均为颈内静脉导管,说明深静脉导管患者容易发生IE。血培养和TTE是诊断IE的主要方法[2]。本研究发现血培养结果阳性率为77.8%,这可能与早期应用抗生素有关[5]。IE的主要致病菌为葡萄球菌,与LUDVIGSEN等[10]研究相一致。如果怀疑患者可能发生IE,通常首选TTE检查,如果尚未明确,再做TEE检查。HD-IE患者累及的瓣膜主要是二尖瓣[11],本研究结果与文献相符。其次累及瓣膜为三尖瓣,可能与右颈内静脉置管有关。抗生素是治疗IE的重要措施,用药原则包括早期、足量应用,静脉用药为主,保持高浓度的血药浓度,根据血培养结果选择合适的抗生素,疗程通常为4~6周。本研究4例好转出院患者的抗生素使用时间均达到了治疗疗程。但是仅用抗生素治疗并不能治愈每位患者,有1/3的IE患者需要在急性期行手术治疗[12]。然而透析患者并发心内膜炎时通常病情危重,患者及家属一般选择保守治疗。9例患者中仅1例患者行手术治疗,其余患者均选择保守治疗。5例患者因药物治疗效果不佳选择自动出院,病死率超过50%。台湾的一项关于IE的研究[13]显示男性、年龄、糖尿病、心力衰竭、神经系统并发症、肾功能不全、呼吸衰竭、休克和葡萄球菌感染是IE患者住院病死的独立预测因子。本研究中HD患者男性5例,年龄为(58.2±13.8)岁,合并心脑血管并发症有6例,且致病微生物主要为葡萄球菌,提示本研究中住院病死率独立预测因子与台湾的研究结果相符。

  表1 HD患者合并IE的临床分析
表1 HD患者合并IE的临床分析

  HD患者是IE的高危人群。HD患者出现发热,要考虑到IE的可能,可借助TTE或TEE,以及血培养明确。一旦确诊IE,其病死率高、并发症多、预后差。

  参考文献

  [1] ABBOTT K C, AGODOA L Y. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States[J]. Nephron, 2002, 91(2):203-209.
  [2] LI J S, SEXTON D J, MICK N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis[J]. Clin Infect Dis, 2000, 30(4):633-638.
  [3] JAGER K J, LINDHOLM B, GOLDSMITH D, et al. Cardiovascular and non-cardiovascular mortality in dialysis patients:where is the link?[J]. Kidney Int Suppl, 2011, 1(1):21-23.
  [4] SPIES C, MADISON J R, SCHATZ I J, et al. Infective endocarditis in patients with end-stage renal disease:clinical presentation and outcome[J]. Arch Intern Med, 2004,164(1):71-75.
  [5] STEVENSON K B, HANNAH E L, LOWGER C A, et al.Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data:predicting the impact of NKF-DOQI clinical practice guidelines for vascular access[J]. Am J Kidney Dis, 2002, 39(3):549-555.
  [6] 陈辉乐,徐昌隆,徐晓杰,等.终末期肾脏病患者脂联素、炎症和氧化应激变化、透析的影响及其机制[J].温州医科大学学报, 2015, 45(3):190-193.
  [7] UMANA E, AHMED W, ALPERT M A. Valvular and perivalvular abnormalities in end-stage renal disease[J]. Am J Med Sci, 2003, 325(4):237-242.
  [8] MONTASSER D, BAHADI A, ZAJJARI Y, et al. Infective endocarditis in chronic hemodialysis patients:experience from Morocco[J]. Saudi J Kidney Dis Transpl, 2011, 22(1):160-166.
  [9] III. NKF-K/DOQI clinical practice guidelines for vascular access:update 2000[J]. Am J Kidney Dis, 2001, 37(1 Suppl1):S137-181.
  [10] LUDVIGSEN L U, DALGAARD L S, WIGGERS H, et al.Infective endocarditis in patients receiving chronic hemodialysis:A 21-year observational cohort study in Denmark[J].Am Heart J, 2016, 182:36-43.
  [11] LESTER S J, WILANSKY S. Endocarditis and associated complications[J]. Crit Care Med, 2007, 35(8 Suppl):384-391.
  [12] CICIONI C, LUZIO V D, EMIDIO L D, et al. Limitations and discrepancies of transthoracic and transoesophageal echocardiography compared with surgical findings in patients submitted to surgery for complications of infective endocarditis[J]. J Cardiovasc Med, 2006, 7(9):660-666.
  [13] CHOU M T, WANG J J, SUN Y M, et al. Epidemiology and mortality among dialysis patients with acute coronary syndrome:Taiwan National Cohort Study[J]. Int J Cardiol,2013, 167(6):2719-2723.

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