Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Clin J Am Soc Nephrol. 2010 Dec;5(12):2348-54. doi: 10.2215/CJN.06050710. Epub 2010 Oct 28.
The Fistula First Initiative has strongly encouraged nephrologists, vascular access surgeons, and dialysis units in the United States to make valiant efforts to increase fistula use in the hemodialysis population. Unfortunately, the rigid "fistula first" recommendations are not based on solid, current, evidence-based data and may be harmful to some hemodialysis patients by subjecting them to prolonged catheter dependence with its attendant risks of bacteremia and central vein stenosis. Once they are successfully cannulated for dialysis, fistulas last longer than grafts and require fewer interventions to maintain long-term patency for dialysis. However, fistulas have a much higher primary failure rate than grafts, require more interventions to achieve maturation, and entail longer catheter dependence, thereby leading to more catheter-related complications. Given the tradeoffs between fistulas and grafts, there is equipoise about their relative merits in patients with moderate to high risk of fistula nonmaturation. The time is right for definitive, large, multicenter randomized clinical trials to compare fistulas and grafts in various subsets of chronic kidney disease patients. Until the results of such clinical trials are known, the optimal vascular access for a given patients should be determined by the nephrologist and access surgeon by taking into account (1) whether dialysis has been initiated, (2) the patient's life expectancy, (3) whether the patient has had a previous failed vascular access, and (4) the likelihood of fistula nonmaturation. Careful clinical judgment should optimize vascular access outcomes and minimize prolonged catheter dependence among hemodialysis patients.
瘘管优先倡议强烈鼓励美国的肾病学家、血管通路外科医生和透析单位做出巨大努力，增加血液透析患者中瘘管的使用。不幸的是，这种僵化的“瘘管优先”建议并非基于可靠的、当前的、基于证据的数据，可能会对某些血液透析患者造成伤害，使他们长期依赖导管，从而带来菌血症和中心静脉狭窄的风险。一旦他们成功地进行了透析导管插入，瘘管的使用寿命比移植物长，并且需要更少的干预来维持长期通畅，以进行透析。然而，瘘管的初次失败率远高于移植物，需要更多的干预来实现成熟，并需要更长时间的导管依赖，从而导致更多与导管相关的并发症。鉴于瘘管和移植物之间的权衡，在中高危瘘管不成熟患者中，它们的相对优点存在争议。现在是时候进行明确的、大型的、多中心随机临床试验，以比较不同慢性肾脏病患者亚组中的瘘管和移植物了。在这些临床试验的结果出来之前，理想的血管通路应该由肾病学家和血管通路外科医生根据以下因素来确定：（1）是否已经开始透析，（2）患者的预期寿命，（3）患者是否有过失败的血管通路，以及（4）瘘管不成熟的可能性。仔细的临床判断应该优化血管通路的结果，并最大限度地减少血液透析患者中长时间依赖导管。
