Division of Nephrology, University Hospitals Case Medical Center, Cleveland, Ohio, †Section of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia.
Clin J Am Soc Nephrol. 2013 Oct;8(10):1791-7. doi: 10.2215/CJN.03140313. Epub 2013 Jun 6.
The main options for vascular access in hemodialysis patients are arteriovenous fistulas (AVFs), arteriovenous grafts, and tunneled cuffed central venous catheters. AVFs have the lowest complication rate and require the fewest interventions and lowest cost to maintain. There has been a dramatic national increase in prevalent AVFs among patients with ESRD in the United States driven, in part, by the Fistula First Breakthrough Initiative. The Fistula First Breakthrough Initiative has engaged stakeholders in the dialysis community to disseminate best practices and quality improvement activities to increase AVF prevalence in suitable candidates. In the pursuit of maximizing AVF placement and prevalence, less emphasis has been placed on the individual patient context. An AVF may not be the best access choice in a subset of patients, particularly those with poor long-term prognoses or comorbid chronic diseases with a short life expectancy, those patients more likely to die than to have their CKD progress to ESRD requiring dialysis, and those with vascular anatomy not amenable to successful AVF placement. Placement of an AVF in these patients subjects them to uncomfortable and likely unnecessary and/or unsuccessful surgeries at an expense, while doing little to improve their clinical outcome or their individual experience of care. AVF prevalence as a pay-for-performance measure without the appropriate case-mix adjustment may penalize providers for accepting higher-risk patients. Although a functioning AVF that provides reliable hemodialysis remains the gold standard for vascular access for most patients, it may not be the most suitable option for every patient.
血液透析患者血管通路的主要选择包括动静脉瘘（AVF）、动静脉移植物和带隧道的带袖套中心静脉导管。AVF 的并发症发生率最低，需要进行的干预和维护成本也最低。在美国，终末期肾病患者中，AVF 的流行率显著增加，部分原因是“瘘管优先突破倡议”。“瘘管优先突破倡议”让透析社区的利益相关者参与进来，传播最佳实践和质量改进活动，以增加合适患者的 AVF 流行率。在追求最大限度地放置和普及 AVF 的过程中，对个体患者的情况关注较少。在一部分患者中，AVF 可能不是最佳的通路选择，特别是那些长期预后较差或患有合并症、预期寿命较短的患者，这些患者死亡的可能性大于慢性肾脏病进展至需要透析的终末期肾病，并且他们的血管解剖结构不适合成功放置 AVF。在这些患者中放置 AVF 会使他们接受不舒服且可能不必要和/或不成功的手术，而对改善他们的临床结局或他们的个人护理体验几乎没有帮助。如果没有适当的病例组合调整，将 AVF 流行率作为绩效付费措施，可能会因接受高风险患者而惩罚提供者。尽管对于大多数患者来说，有功能的 AVF 提供可靠的血液透析仍然是血管通路的金标准，但它可能不是每个患者的最佳选择。
