Chan Micah R, Young Henry N, Becker Yolanda T, Yevzlin Alexander S
Section of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53713, USA.
Semin Dial. 2008 May-Jun;21(3):274-9. doi: 10.1111/j.1525-139X.2008.00434.x. Epub 2008 Apr 6.
Arteriovenous fistulae (AVF) are widely regarded as the preferred vascular access in hemodialysis patients due to their primary patency and patient survival benefits. While the obesity paradox has been associated with improved cardiovascular morbidity and all-cause mortality in dialysis patients, its long-term vascular access outcomes are less clear. Recent literature has suggested that obese patients may have increased early and late fistula failure. The purpose of this study was to explore the relationships between obesity and vascular access outcomes. We performed a retrospective cohort analysis using the USRDS DMMS Wave 2 data set. All incident dialysis patients as of January 1, 1996, over the age of 18, receiving only hemodialysis as mode of renal replacement therapy were eligible for inclusion. Among other variables, data collected for the DMMS Wave 2 included: type and location of vascular access, AVF maturity, vascular access revision, and failure. Logistic regression analyses were used to examine the relationships between obesity and vascular access outcomes, adjusting for important covariates. In all, 1486 hemodialysis patients were included. Using body mass index (BMI) <30 kg/m(2) as reference, obesity did not emerge as a factor in predicting vascular access revisions or failures. An increased risk of AVF failure to mature was found only in the highest BMI quartile (>or=35 kg/m(2)) (aOR 3.66 [95% CI 1.27-10.55], p = 0.017). Peripheral vascular disease was independently associated with an increased risk of AVF failure (aOR 2.78 [95% CI 1.01-7.63], p = 0.047) and arteriovenous graft (AVG) failure (aOR 1.65 [95% CI 1.03-2.64], p = 0.036). Obesity was not associated with increased AVF or AVG revision rates or failure and only associated with poorer AVF maturity at highest BMI quartile. We conclude that obesity should not preclude placement of AVF as vascular access of choice, except in the very obese where assessment should be individually based.
动静脉内瘘（AVF）因其初始通畅率和对患者生存有益，被广泛认为是血液透析患者首选的血管通路。虽然肥胖悖论与透析患者心血管疾病发病率降低和全因死亡率降低有关，但其对长期血管通路结局的影响尚不清楚。最近的文献表明，肥胖患者早期和晚期内瘘失败的风险可能增加。本研究的目的是探讨肥胖与血管通路结局之间的关系。我们使用美国肾脏数据系统（USRDS）透析模式和血管通路研究（DMMS）第二波数据集进行了一项回顾性队列分析。所有在1996年1月1日及以后年满18岁、仅接受血液透析作为肾脏替代治疗方式的新透析患者均符合纳入标准。在其他变量中，DMMS第二波收集的数据包括：血管通路的类型和位置、动静脉内瘘成熟度、血管通路修复和失败情况。采用逻辑回归分析来检验肥胖与血管通路结局之间的关系，并对重要的协变量进行校正。总共纳入了1486例血液透析患者。以体重指数（BMI）<30 kg/m²为参照，肥胖并未成为预测血管通路修复或失败的因素。仅在BMI最高四分位数（≥35 kg/m²）的患者中发现动静脉内瘘成熟失败的风险增加（调整后比值比[aOR]为3.66[95%置信区间（CI）为1.27 - 10.55]，p = 0.017）。外周血管疾病与动静脉内瘘失败风险增加（aOR为2.78[95%CI为1.01 - 7.63]，p = 0.047）和动静脉移植物（AVG）失败风险增加（aOR为1.65[95%CI为1.03 - 2.64]，p = 0.036）独立相关。肥胖与动静脉内瘘或动静脉移植物修复率或失败率增加无关，仅在BMI最高四分位数时与较差的动静脉内瘘成熟度相关。我们得出结论，肥胖不应妨碍将动静脉内瘘作为首选血管通路，除非是极度肥胖患者，对此应进行个体化评估。
