Arbor Research Collaborative for Health, Ann Arbor, MI, USA.
Am J Kidney Dis. 2010 Dec;56(6):1032-42. doi: 10.1053/j.ajkd.2010.08.010. Epub 2010 Oct 20.
Recognizing that autologous arteriovenous fistula use was associated with improved outcomes in hemodialysis patients, the 1997 Dialysis Outcomes Quality Initiative (DOQI) vascular access practice guidelines from the National Kidney Foundation stressed fistulas as the optimal means of dialysis vascular access. In the United States, this emphasis has continued with the Fistula First Breakthrough Initiative. Much of the data supporting fistulas for dialysis access are derived from longitudinal cohorts, including the Dialysis Outcomes and Practice Patterns Study (DOPPS), dialysis provider databases, and other sources. This article reviews major findings from these data sources, focusing on specific practices and characteristics associated with greater arteriovenous fistula use in dialysis facilities worldwide. Important and often overlooked characteristics that are discussed in detail include specific preferences of dialysis staff regarding access type and the emphasis placed on fistula primacy and the number of fistulas created during surgical training. For example, in the DOPPS, the risk of initial fistula failure was 34% lower when fistulas were placed by surgeons who had created at least 25 fistulas during training (P = 0.002). It is imperative that dialysis clinicians advocate actively for specific dialysis access types on behalf of individual patients. Vascular surgery teaching programs must supervise adequate numbers of fistula procedures for every trainee.
认识到自体动静脉瘘的使用与血液透析患者的改善结果相关，1997 年国家肾脏基金会的透析结果和质量倡议 (DOQI) 血管通路实践指南强调瘘管是透析血管通路的最佳方式。在美国，这种强调一直伴随着瘘管优先突破倡议。支持瘘管用于透析的大部分数据来自于纵向队列研究，包括透析结果和实践模式研究 (DOPPS)、透析提供者数据库和其他来源。本文回顾了这些数据源的主要发现，重点关注与世界各地透析机构中更多使用动静脉瘘相关的具体实践和特征。讨论了一些重要且经常被忽视的特征，包括透析工作人员对通路类型的具体偏好，以及对瘘管首要性和手术培训期间创建的瘘管数量的重视。例如，在 DOPPS 中，当培训期间至少创建了 25 个瘘管的外科医生进行瘘管放置时，初始瘘管失败的风险降低了 34%（P=0.002）。透析临床医生代表个别患者积极倡导特定的透析通路类型是至关重要的。血管外科学教学计划必须为每个学员监督足够数量的瘘管手术。
