Chan Micah R, Sanchez Robert J, Young Henry N, Yevzlin Alexander S
Department of Medicine, Section of Nephrology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
Semin Dial. 2007 Nov-Dec;20(6):606-10. doi: 10.1111/j.1525-139X.2007.00370.x.
Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis (HD) patients due to their primary patency and patient survival benefits. Recent scholarship has suggested that the elderly population differs significantly from the general population in terms of inflammatory markers. What is more, recent studies have suggested that the elderly HD population is less likely to have an AVF placed as the initial vascular access compared to a younger cohort. The purpose of this study is to investigate the applicability of current vascular access guidelines to the elderly HD population. We hypothesized that the elderly HD population would derive less patency and survival benefit from AVF placement relative to arteriovenous graft (AVG) than the general population is known to derive. We performed a retrospective analysis using the US Renal Data System (USRDS) Wave II dataset to explore significant predictors of referral for intervention or access failure, and patient survival in the elderly US HD population using Cox regression corrected for race, gender, peripheral vascular disease, diabetes mellitus, and nutritional status. Of the 1471 HD patients with AVF or AVG, 764 patients were >65 years. Elderly diabetics had no significant mortality benefit from the use of AVF compared to AVG [odds ratio (OR) 1.34 (95% CI 0.92-1.95), p = 0.123]. Likewise, elderly nondiabetics had no significant mortality benefit from the use of AVF compared to AVG [OR 1.05 (95% CI 0.81-1.36), p = 0.735]. Elderly diabetics had no difference in odds for intervention referral for AVF compared to AVG [OR 1.49 (95% CI 0.76-2.9), p = 0.24]. Elderly nondiabetics had no difference in odds for intervention referral for AVF compared to AVG [OR 1.48 (95% CI 0.95-2.3), p = 0.08]. We conclude that the potential benefits derived from AVFs compared with AVGs and central venous catheters (CVC) may not apply universally. The recommendations of vascular access choice stipulated by national guidelines may need to be modified for elderly patients.
动静脉内瘘(AVF)因其初始通畅率及对患者生存的益处,被广泛认为是血液透析(HD)患者首选的血管通路。近期学术研究表明,老年人群在炎症标志物方面与普通人群存在显著差异。此外,近期研究显示,相较于年轻人群,老年HD患者作为初始血管通路而进行AVF置入的可能性更低。本研究旨在探讨当前血管通路指南对老年HD人群的适用性。我们假设,相对于动静脉移植物(AVG),老年HD人群通过AVF置入获得的通畅率及生存益处低于普通人群。我们使用美国肾脏数据系统(USRDS)第二波数据集进行回顾性分析,以探索干预转诊或通路失败的显著预测因素,以及使用校正种族、性别、外周血管疾病、糖尿病和营养状况的Cox回归分析美国老年HD人群的患者生存率。在1471例有AVF或AVG的HD患者中,764例患者年龄>65岁。与AVG相比,老年糖尿病患者使用AVF并无显著的死亡率益处[比值比(OR)1.34(95%置信区间0.92 - 1.95),p = 0.123]。同样,与AVG相比,老年非糖尿病患者使用AVF也无显著的死亡率益处[OR 1.05(95%置信区间0.81 - 1.36),p = 0.735]。与AVG相比,老年糖尿病患者因AVF进行干预转诊的几率无差异[OR 1.49(95%置信区间0.76 - 2.9),p = 0.24]。与AVG相比,老年非糖尿病患者因AVF进行干预转诊的几率无差异[OR 1.48(95%置信区间0.95 - 2.3),p = 0.08]。我们得出结论,与AVG和中心静脉导管(CVC)相比,AVF所带来的潜在益处可能并不普遍适用。国家指南规定的血管通路选择建议可能需要针对老年患者进行修改。