Perera Ganesha B, Mueller Mark P, Kubaska Stephen M, Wilson Samuel E, Lawrence Peter F, Fujitani Roy M
Division of Vascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA 92868, USA.
Ann Vasc Surg. 2004 Jan;18(1):66-73. doi: 10.1007/s10016-003-0094-y. Epub 2004 Jan 20.
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K/DOQI) guidelines have advocated autogenous arteriovenous fistulae as a primary procedure for hemodialysis access. This study compared the clinical outcomes between autogenous and prosthetic arteriovenous hemodialysis accesses, determining factors contributing to primary and secondary patency and function. Associated risk factors and number of interventions required to maintain secondary patency in each cohort were also assessed. A vascular database review of consecutive hemodialysis access procedures performed during a 36-month period (January 1999 to December 2001) at an academic institution was conducted. Life-table and log-rank analyses were used to analyze patency rates. Univariate and multivariate analysis was used to analyze risk factor influence on patency and function. A total of 231 upper extremity arteriovenous access procedures were performed in 209 patients during this period. One hundred autogenous accesses were created in 100 patients, 68 being forearm Brescia-Cimino arteriovenous fistulae. A total of 131 prosthetic accesses (ePTFE) grafts were also placed during this period in 109 patients. The demographic profiles of both cohorts were similar. Primary patency at 1 and 2 years was 56% (CI 45-76%) and 39% (CI 28-50%), respectively, in the autogenous group, and 36% (CI 26-45%) and 9% (CI 3-14%), respectively, in the prosthetic group. Differences in secondary patency at 1 year and 2 years were not significant (64% [CI 54-74%] and 53% [CI 42-65%] in the autogenous group vs. 65% [CI 55-73%] and 46% [CI 36-55%] in the prosthetic group). Secondary interventions were required in 87% of the prosthetic cohort (average 0.92 procedures/patient/year) and 57% of the autogenous cohort (average 0.53 procedures/patient/year). Multivariate analysis of associated risk factors demonstrated no significant effects on either primary or secondary patency in both groups. Autogenous accesses have superior primary patency and maintain equal secondary patency with significantly fewer interventions. These data strongly support the NKF K/DOQI guidelines recommending creation of autogenous access whenever possible. These outcomes can provide significant health-care cost benefits when using an algorithm favoring primary creation of autogenous access for hemodialysis.
美国国家肾脏基金会的肾脏病预后质量倡议（NKF K/DOQI）指南提倡将自体动静脉内瘘作为血液透析通路的首选方法。本研究比较了自体和人工动静脉血液透析通路的临床结局，确定了影响初次和二次通畅及功能的因素。还评估了每个队列中维持二次通畅所需的相关危险因素和干预次数。对某学术机构在36个月期间（1999年1月至2001年12月）进行的连续性血液透析通路手术进行了血管数据库回顾。采用寿命表和对数秩检验分析通畅率。采用单因素和多因素分析来分析危险因素对通畅和功能的影响。在此期间，209例患者共进行了231例上肢动静脉通路手术。100例患者建立了100条自体通路，其中68条为前臂布雷西亚-奇米诺动静脉内瘘。在此期间，109例患者还共置入了131条人工血管（ePTFE）移植物。两个队列的人口统计学特征相似。自体组1年和2年的初次通畅率分别为56%（95%CI 45%-76%）和39%（95%CI 28%-50%），人工血管组分别为36%（95%CI 26%-45%）和9%（95%CI 3%-14%）。1年和2年的二次通畅率差异无统计学意义（自体组为64%[95%CI 54%-74%]和53%[95%CI 42%-65%]，人工血管组为65%[95%CI 55%-73%]和46%[95%CI 36%-55%]）。人工血管队列中87%的患者需要进行二次干预（平均0.92次手术/患者/年），自体队列中57%的患者需要进行二次干预（平均0.53次手术/患者/年）。对相关危险因素的多因素分析表明，两组的初次或二次通畅均无显著影响。自体通路具有更好的初次通畅率，且维持相同的二次通畅率，所需干预显著减少。这些数据有力地支持了NKF K/DOQI指南，即建议尽可能建立自体通路。当使用优先建立自体血液透析通路的算法时，这些结果可带来显著的医疗成本效益。
