Hayes Wesley N, Tennankore Karthik, Battistella Marisa, Chan Christopher T
Division of Nephrology, Hospital for Sick Children, Toronto, Canada.
Hemodial Int. 2014 Apr;18(2):481-7. doi: 10.1111/hdi.12140. Epub 2014 Jan 27.
Frequent hemodialysis is associated with increased vascular access adverse events. We hypothesized that bacteremia would be more frequent in patients with central venous catheter (CVC) than arteriovenous fistula or arteriovenous graft (AVF/AVG) in nocturnal home hemodialysis (NHHD). We reviewed blood culture reports and concurrent clinical data for a cohort of one hundred eighty-seven NHHD patients between January 1, 2006 and June 30, 2012. The primary outcome was time to first bacteremia, technique failure, or death after commencing NHHD. Types of bacteremia and clinical consequences were analyzed. Analyses were adjusted for a priori defined confounders. One hundred eighty-seven patients were included with a total follow up of six hundred five patient years. Initial vascular access was AVF in seventy-eight (42%) patients, AVG in eleven (6%) patients, and CVC in ninety-eight (52%) patients. A total of 79.3% of patients with a CVC reached the composite endpoint of bacteremia, technique failure, or death in the study period; 44.5% of patients with an AVF or AVG reached this composite endpoint. Adjusted time to first bacteremia, technique failure, or death was significantly shorter in patients with initial CVC access (hazard ratio 2.42, 95% confidence interval 1.50-3.90, p < 0.001). Risk factors for bacteremia were comorbid status quantified by the Charlson Comorbidity Index (p < 0.001) and diabetes (p < 0.001). Coagulase negative staphylococcus was the commonest organism cultured accounting for 51.4% bacteremias. The second commonest organism was staphylococcus aureus (20.3% bacteremias). Patients undergoing NHHD with a CVC have a shorter duration to first infection, technique failure, or death than those with permanent vascular access.
频繁进行血液透析与血管通路不良事件的增加有关。我们推测，在夜间家庭血液透析（NHHD）中，中心静脉导管（CVC）患者发生菌血症的频率会高于动静脉内瘘或动静脉移植物（AVF/AVG）患者。我们回顾了2006年1月1日至2012年6月30日期间187例NHHD患者的血培养报告及同期临床数据。主要结局是开始NHHD后首次发生菌血症、技术失败或死亡的时间。分析了菌血症的类型及临床后果。分析针对预先定义的混杂因素进行了校正。纳入了187例患者，总随访时间为605患者年。初始血管通路为AVF的患者有78例（42%），为AVG的患者有11例（6%），为CVC的患者有98例（52%）。在研究期间，共有79.3%的CVC患者达到了菌血症、技术失败或死亡的复合终点；44.5%的AVF或AVG患者达到了该复合终点。初始采用CVC通路的患者首次发生菌血症、技术失败或死亡的校正时间显著更短（风险比2.42，95%置信区间1.50 - 3.90，p < 0.001）。菌血症的危险因素包括用Charlson合并症指数量化的共病状态（p < 0.001）和糖尿病（p < 0.001）。凝固酶阴性葡萄球菌是培养出的最常见病原体，占菌血症的51.4%。第二常见的病原体是金黄色葡萄球菌（占菌血症的20.3%）。与采用永久性血管通路的患者相比，接受NHHD且使用CVC的患者首次感染、技术失败或死亡的持续时间更短。
