Allon Michael
Division of Nephrology, Birmingham, AL 35233, USA.
Clin J Am Soc Nephrol. 2007 Jul;2(4):786-800. doi: 10.2215/CJN.00860207. Epub 2007 May 30.
Optimizing vascular access outcomes remains an ongoing challenge for clinical nephrologists. All other things being equal, fistulas are preferred over grafts, and grafts are preferred over catheters. Mature fistulas have better longevity and require fewer interventions, as compared with mature grafts. The major hurdle to increasing fistula use is the high rate of failure to mature of newly created fistulas. There is a desperate need for enhanced understanding of the mechanisms of failure to mature and the optimal type and timing of interventions to promote maturity. Grafts are prone to frequent stenosis and thrombosis. Surveillance for graft stenosis with preemptive angioplasty may reduce graft thrombosis, but recent randomized clinical trials have questioned the efficacy of this approach. Graft stenosis results from aggressive neointimal hyperplasia, and pharmacologic approaches to slowing this process are being investigated in clinical trials. Catheters are prone to frequent thrombosis and infection. The optimal management of catheter-related bacteremia is a subject of ongoing debate. Prophylaxis of catheter-related bacteremia continues to generate important clinical research. Close collaboration among nephrologists, surgeons, radiologists, and the dialysis staff is required to optimize vascular access outcomes and can be expedited by having a dedicated access coordinator to streamline the process. The goal of this review is to provide an update on the current status of vascular access management.
优化血管通路的效果对临床肾脏病学家来说仍然是一项持续存在的挑战。在其他条件相同的情况下，动静脉内瘘优于移植血管，移植血管优于导管。与成熟的移植血管相比，成熟的动静脉内瘘使用寿命更长，所需的干预措施更少。增加动静脉内瘘使用的主要障碍是新建立的动静脉内瘘成熟失败率很高。迫切需要加强对成熟失败机制以及促进成熟的最佳干预类型和时机的了解。移植血管容易出现频繁的狭窄和血栓形成。通过预防性血管成形术监测移植血管狭窄可能会减少移植血管血栓形成，但最近的随机临床试验对这种方法的疗效提出了质疑。移植血管狭窄是由侵袭性内膜增生引起的，目前正在临床试验中研究减缓这一过程的药物治疗方法。导管容易出现频繁的血栓形成和感染。导管相关菌血症的最佳管理是一个仍在争论的话题。导管相关菌血症的预防仍然是重要的临床研究课题。肾脏病学家、外科医生、放射科医生和透析工作人员之间需要密切合作，以优化血管通路的效果，并且可以通过设立专门的通路协调员来简化流程，从而加快这一进程。本综述的目的是提供血管通路管理现状的最新信息。
