García Cortés Ma J, Viedma G, Sánchez Perales M C, Borrego F J, Borrego J, Pérez del Barrio P, Gil Cunquero J M, Liébana A, Pérez Bañasco V
Servicios de Nefrología, Complejo Hospitalario de Jaén.
Nefrologia. 2005;25(3):307-14.
Autologous access is the best vascular access for dialysis also in older patients and it should be mature when patient needs hemodialysis. It is not always possible. Surgeon availability and demographic characteristics of patients (age, diabetes, vascular disease...) are factors that determine primary vascular access.
To analyse outcome and vascular access complications in elderly who start hemodialysis without vascular access.
All patients older than 75 years who initiated hemodialysis without vascular access between January 2000 and June 2002 were included, They were divided en two groups depending on primary vascular access. GI: arterio-venous fistulae. GIIl: Tunnelled cuffed catheter. Epidemiological and analytical data, vascular access complications related, as well as patient and first permanent vascular access survival from their inclusion in dialysis up to December 2002 were analysed and compared in both groups.
32 patients were studied. GI: n = 17 (4 men) and GIIl: n =1 5 (8 men), age: 79.9 +/- 3.8 and 81.7 +/- 4 years respectively (ns). There were no differences in sex and comorbidity (diabetes, ischemic heart disease, peripheral vascular disease and hypertension). It took GI 3 months to get a permanent vascular access suitable for using, while it took GIIl 1.3 months (p < 0.005) The number of temporary untunnelled catheters was higher in GI (3.35 vs 1.87 p < 0.05). Vascular access complications: 70.6% of infections occur in GI (incidence (I) = 48 infections/100 patients-year) while only 29.4% were detected in GII (I = 25 infections/100 patients-year). 70% of central venous thrombosis happen in GI (I: 25 CVT/100 patients-year) vs 30% in GIIl (I = 14.4/100 patients-year) (ns). No significant differences neither in bleeding (66.7% vs 33.3%) nor ischemia (75% vs 25%) were found. Dialysis dose (Kt/V) as well as anaemia degree were similar in both groups. Permanent vascular access survival after 2 years was 45.8% in GI and 24% in GII (ns). Patient survival was similar in GI and GII (72% vs 51% ns).
Elderly who start hemodialysis without vascular access took longer to get a suitable permanent vascular access when arterio-venous fistulae is placed than with a tunnelled cuffed hemodialysis catheter. As a consequence, vascular access complications are larger, infection ones are the most common. In these patients a tunnelled catheter should be inserted at the time a peripheral arterio-venous access is created, in order to avoid temporary untunnelled catheters.
自体血管通路对于老年患者也是透析的最佳血管通路，且应在患者需要血液透析时成熟可用。但这并非总是可行的。外科医生的可及性以及患者的人口统计学特征（年龄、糖尿病、血管疾病等）是决定初始血管通路的因素。
分析开始血液透析时无血管通路的老年患者的结局及血管通路并发症。
纳入2000年1月至2002年6月期间开始血液透析时无血管通路的所有75岁以上患者，根据初始血管通路将他们分为两组。第一组（GI）：动静脉内瘘。第二组（GII）：带隧道涤纶套导管。分析并比较两组的流行病学和分析数据、相关血管通路并发症，以及从纳入透析至2002年12月患者及首次永久性血管通路的存活情况。
研究了32例患者。第一组（GI）：n = 17（4例男性），第二组（GII）：n = 15（8例男性），年龄分别为79.9±3.8岁和81.7±4岁（无显著差异）。性别和合并症（糖尿病、缺血性心脏病、外周血管疾病和高血压）无差异。第一组获得适合使用的永久性血管通路需3个月，而第二组需1.3个月（p < 0.005）。第一组临时非隧道式导管的使用数量更多（3.35对1.87，p < 0.05）。血管通路并发症：70.6%的感染发生在第一组（发生率（I）= 48例感染/100患者年），而第二组仅检测到29.4%（I = 25例感染/100患者年）。70%的中心静脉血栓形成发生在第一组（I：25例中心静脉血栓形成/100患者年），而第二组为30%（I = 14.4/100患者年）（无显著差异）。出血（66.7%对33.3%）和缺血（75%对25%）均未发现显著差异。两组的透析剂量（Kt/V）以及贫血程度相似。两年后永久性血管通路的存活率在第一组为45.8%，在第二组为24%（无显著差异）。第一组和第二组的患者存活率相似（72%对51%，无显著差异）。
开始血液透析时无血管通路的老年患者，放置动静脉内瘘时获得合适的永久性血管通路所需时间比使用带隧道涤纶套血液透析导管更长。因此，血管通路并发症更多，感染是最常见的。在这些患者中，应在建立外周动静脉通路时插入带隧道导管，以避免使用临时非隧道式导管。
