Oliver Matthew J, Rothwell Deanna M, Fung Kinwah, Hux Janet E, Lok Charmaine E
Division of Nephrology, Sunnybrook and Women's Health Sciences Centre, Toronto, Ontario, Canada.
J Am Soc Nephrol. 2004 Jul;15(7):1936-42. doi: 10.1097/01.asn.0000131524.52012.f8.
The creation of fistulas or grafts before starting dialysis is recommended, but whether it reduces major adverse events is largely unknown. The objective of this study was to determine if early access creation was associated with a reduced risk of hospitalization from sepsis and mortality. Fistulas or grafts created at least 4 mo before starting hemodialysis were defined as Early creations (n = 1240), and accesses created between 4 mo and 1 mo before starting hemodialysis were defined as Just Prior creations (n = 997). Accesses created within 1 mo of starting dialysis or after were defined as Late creations (reference group, n = 3687). Hemodialysis catheter use was defined as insertion, removal, or manipulation of a catheter before the occurrence of sepsis. Eighty percent of accesses were fistulas. Early access creation was associated with a relative risk (RR) of sepsis of 0.57 (95% CI, 0.41 to 0.79) compared with Late access creation. Catheter use increased the risk of sepsis by 1.41 (95% CI, 1.14 to 1.81). The risk of sepsis with Early creation decreased to 0.48 (95% CI, 0.35 to 0.65) if catheter use was not adjusted. Early access creation was associated with lower mortality (RR 0.76; 95% CI 0.58 to 1.00), but this association became nonsignificant if catheter use and sepsis were adjusted. Catheter use and sepsis independently increased mortality. This study demonstrates that fistula creation at least 4 mo before starting chronic hemodialysis is associated the lowest risk of sepsis and death, primarily by reducing the use of hemodialysis catheters.
建议在开始透析前建立动静脉内瘘或移植物，但它是否能减少主要不良事件在很大程度上尚不清楚。本研究的目的是确定早期建立血管通路是否与败血症住院风险和死亡率降低相关。在开始血液透析前至少4个月建立的动静脉内瘘或移植物被定义为早期建立组（n = 1240），在开始血液透析前4个月至1个月之间建立的血管通路被定义为即将开始透析前建立组（n = 997）。在开始透析后1个月内或之后建立的血管通路被定义为晚期建立组（参照组，n = 3687）。血液透析导管的使用被定义为在败血症发生前对导管的插入、拔除或操作。80%的血管通路为动静脉内瘘。与晚期建立血管通路相比，早期建立血管通路的败血症相对风险（RR）为0.57（95%CI，0.41至0.79）。使用导管使败血症风险增加1.41（95%CI，1.14至1.81）。如果不调整导管使用情况，早期建立血管通路的败血症风险降至0.48（95%CI，0.35至0.65）。早期建立血管通路与较低的死亡率相关（RR 0.76；95%CI 0.58至1.00），但如果调整导管使用和败血症情况，这种相关性变得不显著。导管使用和败血症独立增加死亡率。本研究表明，在开始慢性血液透析前至少4个月建立动静脉内瘘与败血症和死亡风险最低相关，主要是通过减少血液透析导管的使用。
