腹膜透析患者胸腹瘘的临床特征及诊治分析

Clinical features,diagnosis and treatment of pleuroperitoneal communication in peritoneal dialysis patients

目的探讨腹膜透析(peritoneal dialysis,PD)患者胸腹瘘的临床特征及诊治。方法入选北京大学人民医院肾内科PD中心2006年1月1日~2021年9月30日确诊胸腹瘘的患者,收集一般资料、PD方案、胸腹瘘症状、体征、实验室检查、确诊方法、治疗及转归进行分析。结果①共纳入胸腹瘘患者5例,发生率0.96%。②5例胸腹瘘均在透析3~13周增加单次存腹剂量过程中发生,均为右侧,80%为女性,女性、老年高龄、低体表面积可能为危险因素。临床多表现为胸闷、呼吸困难、超滤减少等。③诊断方法:胸片提示右侧中到大量胸腔积液。可通过胸水葡萄糖高于血糖、亚甲蓝注入试验或CT腹腔造影确诊。④治疗方式:确诊后立即暂停PD转为血液透析(hemodialysis,HD),部分患者永久转至HD,或通过低剂量递增性PD逐渐恢复并长期PD治疗。结论胸腹瘘为PD少见并发症,常在开始透析后增加单次存腹剂量的过程中发生,CT腹腔造影已成为最简便有效的确诊方式,治疗上需暂停PD,转为HD,或通过低剂量递增性恢复PD。如条件许可,手术治疗是解决胸腹瘘的有效措施。在透析液增量过程中应密切监测高危患者胸腹瘘相关症状体征、腹腔内压力变化,并减少目标存腹剂量,以预防胸腹瘘的发生。

Objective To explore the clinical features,diagnosis and treatment of pleuroperitoneal communication in peritoneal dialysis(PD)patients.Methods The PD patients diagnosed with pleuroperitoneal communication during January 1,2006 to September 30,2021 and treated in the PD Center of Peking University People's Hospital were enrolled in this study.General information,PD procedures,symptoms and signs,laboratory results,diagnosis methods,treatment and outcome were collected and analyzed.Results①Five PD patients with pleuroperitoneal communication were diagnosed with the incidence of 0.96%.②Pleuroperitoneal communication occurred in the period of increasing dialysate dwelling dose during the first 3~13 weeks of PD and at the right side in all of the 5 cases.Four of the five cases were females.Female,older age and low body surface area may be the risk factors.The major clinical manifestations included chest tightness,dyspnea and decreased ultrafiltration volume.③Chest X-ray revealed moderate to large pleural effusion in right side.Glucose concentration in pleural fluid higher than that in blood,methylene blue injected into abdominal cavity,and CT peritoneography were the methods to confirm the diagnosis.④Once diagnosed,PD should be interrupted immediately and changed to hemodialysis temporarily or permanently.In some cases,PD may be continued beginning from lower dialysate dwelling dose and gradual increase of the dose to reconstitute the long-term PD.Conclusions Pleuroperitoneal communication is a rare complication of PD,frequently occurring in the period of increasing dialysate dwelling dose at the early stage of PD.CT peritoneography has been the most simple and effective diagnosis method.After diagnosis,PD should be switched to hemodialysis temporarily or permanently,or reconstituted starting from lower dialysate dwelling dose and gradual increase of the dose.If possible,surgical treatment is an effective measure for this complication.To prevent the occurrence of pleuroperitoneal communication in PD patients with the risk factors,symptoms and signs relating to pleuroperitoneal communication and changes of intraperitoneal pressure should be closely monitored in the period of increasing dialysate dose at the early stage of PD,and the dialysate dwelling dose should be reduced when necessary.