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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: 赢发彩票代理目的: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:赢发彩票代理 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;

赢发彩票代理   GANRANXINGXINNEIMOYAN(infective endocarditis,IE)SHIXUEYETOUXI(hemodialysis,HD)DEBINGFAZHENGZHIYI,HDHUANZHEIEFABINGFENGXIANGAO,WEIPUTONGRENQUNDE10~18BEI[1],DANGUONEIZHEIFANGMIANBAODAOSHANGBUDUO。BENYANJIUHUIGUXINGFENXIHDHUANZHEFASHENGIEDELINCHUANGBIAOXIANJIJIEJU,XIANBAOGAORUXIA。

  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

赢发彩票代理   ZHENDUANFANGFACANZHAOGAILIANGDukeZHENDUANBIAOZHUN[2]。NARUBIAOZHUN:(1)LINCHUANGHEFUZHUJIANCHAZHENDUANWEIIE;(2)NIANLING≥18SUI;(3)JUNWEIHDHUANZHE。PAICHUBIAOZHUN:(1)HUAYANSHIJIFUZHUJIANCHADENGZILIAOQUESHI;(2)YIMINGQUEWEIQITABUWEIGANRAN(DAOGUANGANRAN、JIEHE、BAIXUEZHENGDENG)HDHUANZHE。

  2、结果

赢发彩票代理   9LIHUANZHEJUNYOUFARE,3LICHUXIANXINZANGZAYIN,9LICRPSHENGGAO,9LIXUEHONGDANBAIXIAJIANG,4LIHONGXIBAOCHENJIANGLVZENGKUAI。6LIHUANZHECHUXIANBINGFAZHENG:NAOGENGSIHEBINGXINSHUAI1LI,NAOGENGSIHEBINGNAOCHUXUE3LI,XINSHUAI2LI。9LIHUANZHEJUNXINGXUEPEIYANG,YANGXING7LI(ZHAN77.8%),GELANSHIRANSEYANGXINGJUN5LI(ZHAN71.4%),FENBIEWEILUDENGPUTAOQIUJUN3LI、BIAOPIPUTAOQIUJUN1LIHEJINHUANGSEPUTAOQIUJUN1LI;GELANSHIRANSEYINXINGJUN2LI(ZHAN28.6%),FEIYANKELEIBOGANJUNHEBAOMANBUDONGGANJUNGE1LI。PUTAOQIUJUNXUANYONGTIKAOLAHUOWANGUMEISUZHILIAO,YINXINGJUNYONGMEILUOPEINANHUOTEZHIXING,2LIXUEPEIYANGYINXINGXUANZE2ZHONGKANGSHENGSULIANHEYINGYONG。7LIXINGJINGXIONGCHAOSHENGXINDONGTU(thoracic echocardiography,TTE)JIANCHA,1LIXINGSHIDAOCHAOSHENG(tran esophageal echocardiography,TEE),1LITONGSHIXINGTTEHETEEJIANCHA;JIEGUO9LI(ZHAN100%)JUNFAXIANZHUISHENGWU,LEIJIBUWEIYIERJIANBAN5LI(ZHAN55.6%),SANJIANBAN2LI(ZHAN22.2%),ERJIANBANLIANHEZHUDONGMAIBAN1LI,YOUXINFANG1LI。8LIHUANZHEXUANZEBAOSHOUZHILIAO,1LIXINGWAIKESHOUSHUZHILIAO;4LIHUANZHEHAOZHUANCHUYUAN,KANGSHENGSUSHIYONGPINGJUNSHIJIAN(37.0±3.5)d,5LIYINZHILIAOXIAOGUOBUJIA,XUANZEZIDONGCHUYUAN。JIANBIAO1。

  3、讨论

  GANRANSHIDAOZHIWEICHIXINGHDHUANZHESIWANGDEDIERDACHANGJIANYUANYIN[3]。ZAIMANXINGSHENZANGBINGHEHDHUANZHEZHONGIEDEFABINGLVZHUJIANSHENGGAO[4]。ABBOTTDENG[1]YIXIANGHUIGUXINGYANJIUFAXIANHDHUANZHEIEDEFABINGLVWEI2%~6%,BENYANJIUHDHUANZHEIEDEFABINGLVWEI1.9%,YUWENXIANXIANGSI。HDHUANZHERONGYIFASHENGGANRANDEZHUYAOYUANYINSHIXUEGUANTONGLU(DONGJINGMAINEILOUHEZHONGXINJINGMAIDAOGUAN)ZAISHIYONGSHIZENGJIALEXUEYEYUBINGYUANJUNJIECHUDEJIHUI[5],QICIZHONGMOQISHENZANGBINGHUANZHEYOUYUDAIXIEYICHANG、YINGYANGBULIANGHEDUSULEIJI[6]DENGYINSU,DAOZHIMIANYILIDIXIA,RONGYIFASHENGJUNXUEZHENG[7]。MONTASSERDENG[8]QIANGDIAOSHENJINGMAIXUETOUDAOGUANSHIHDHUANZHEGANRANIEDEZHUYAOTUJING,FENGXIANGAOYUDONGJINGMAINEILOU。GUOJISHENZANGJIGOUZHINAN[9]JIANYIZITIDONGJINGMAINEILOUWEIZUIJIADEXUEGUANTONGLU。BENYANJIUZHONG9LIHUANZHEXUEGUANTONGLUJUNWEIJINGNEIJINGMAIDAOGUAN,SHUOMINGSHENJINGMAIDAOGUANHUANZHERONGYIFASHENGIE。XUEPEIYANGHETTESHIZHENDUANIEDEZHUYAOFANGFA[2]。BENYANJIUFAXIANXUEPEIYANGJIEGUOYANGXINGLVWEI77.8%,ZHEIKENENGYUZAOQIYINGYONGKANGSHENGSUYOUGUAN[5]。IEDEZHUYAOZHIBINGJUNWEIPUTAOQIUJUN,YULUDVIGSENDENG[10]YANJIUXIANGYIZHI。RUGUOHUAIYIHUANZHEKENENGFASHENGIE,TONGCHANGSHOUXUANTTEJIANCHA,RUGUOSHANGWEIMINGQUE,ZAIZUOTEEJIANCHA。HD-IEHUANZHELEIJIDEBANMOZHUYAOSHIERJIANBAN[11],BENYANJIUJIEGUOYUWENXIANXIANGFU。QICILEIJIBANMOWEISANJIANBAN,KENENGYUYOUJINGNEIJINGMAIZHIGUANYOUGUAN。KANGSHENGSUSHIZHILIAOIEDEZHONGYAOCUOSHI,YONGYAOYUANZEBAOKUOZAOQI、ZULIANGYINGYONG,JINGMAIYONGYAOWEIZHU,BAOCHIGAONONGDUDEXUEYAONONGDU,GENJUXUEPEIYANGJIEGUOXUANZEHESHIDEKANGSHENGSU,LIAOCHENGTONGCHANGWEI4~6ZHOU。BENYANJIU4LIHAOZHUANCHUYUANHUANZHEDEKANGSHENGSUSHIYONGSHIJIANJUNDADAOLEZHILIAOLIAOCHENG。DANSHIJINYONGKANGSHENGSUZHILIAOBINGBUNENGZHIYUMEIWEIHUANZHE,YOU1/3DEIEHUANZHEXUYAOZAIJIXINGQIXINGSHOUSHUZHILIAO[12]。RANERTOUXIHUANZHEBINGFAXINNEIMOYANSHITONGCHANGBINGQINGWEIZHONG,HUANZHEJIJIASHUYIBANXUANZEBAOSHOUZHILIAO。9LIHUANZHEZHONGJIN1LIHUANZHEXINGSHOUSHUZHILIAO,QIYUHUANZHEJUNXUANZEBAOSHOUZHILIAO。5LIHUANZHEYINYAOWUZHILIAOXIAOGUOBUJIAXUANZEZIDONGCHUYUAN,BINGSILVCHAOGUO50%。TAIWANDEYIXIANGGUANYUIEDEYANJIU[13]XIANSHINANXING、NIANLING、TANGNIAOBING、XINLISHUAIJIE、SHENJINGXITONGBINGFAZHENG、SHENGONGNENGBUQUAN、HUXISHUAIJIE、XIUKEHEPUTAOQIUJUNGANRANSHIIEHUANZHEZHUYUANBINGSIDEDULIYUCEYINZI。BENYANJIUZHONGHDHUANZHENANXING5LI,NIANLINGWEI(58.2±13.8)SUI,HEBINGXINNAOXUEGUANBINGFAZHENGYOU6LI,QIEZHIBINGWEISHENGWUZHUYAOWEIPUTAOQIUJUN,TISHIBENYANJIUZHONGZHUYUANBINGSILVDULIYUCEYINZIYUTAIWANDEYANJIUJIEGUOXIANGFU。

  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

  HDHUANZHESHIIEDEGAOWEIRENQUN。HDHUANZHECHUXIANFARE,YAOKAOLVDAOIEDEKENENG,KEJIEZHUTTEHUOTEE,YIJIXUEPEIYANGMINGQUE。YIDANQUEZHENIE,QIBINGSILVGAO、BINGFAZHENGDUO、YUHOUCHA。

  参考文献

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