Drew David A, Lok Charmaine E
aDivision of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA bDivision of Nephrology, Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada.
Curr Opin Nephrol Hypertens. 2014 May;23(3):314-20. doi: 10.1097/01.mnh.0000444815.49755.d9.
Achieving functioning vascular access in hemodialysis patients remains challenging. Current guidelines recommend creating arteriovenous fistulas (AVFs) as the initial form of vascular access and are primarily based on outdated, observational data. Determining the optimal access for each individual patient is, therefore, of great interest.
Multiple recent studies suggest that certain subgroups of patients may benefit from alternative forms of vascular access. In particular, the elderly and patients with limited life-expectancy may be less likely to benefit from an AVF first approach. These patients may be more likely to die before benefiting from an AVF and are more likely to experience primary failure of an AVF. If these factors are considered, arteriovenous grafts, and in some cases central venous catheters, become a valid alternative form of vascular access. Patients may also have strong opinions about each type of vascular access, leading to a preference for alternative forms of access.
A patient-centered approach to the choice of dialysis access that incorporates a balance between recent evidence from the literature and patient preferences may be preferred to the current fistula first focus in vascular access choice.
在血液透析患者中实现有效的血管通路仍然具有挑战性。当前指南推荐将动静脉内瘘（AVF）作为血管通路的初始形式，且主要基于过时的观察性数据。因此，确定适合每个患者的最佳通路备受关注。
近期多项研究表明，某些亚组患者可能从其他形式的血管通路中获益。特别是老年人和预期寿命有限的患者，可能不太可能从优先选择AVF的方法中获益。这些患者在从AVF中获益之前可能更容易死亡，并更有可能经历AVF的原发性失败。如果考虑这些因素，动静脉移植物，在某些情况下还有中心静脉导管，就成为一种有效的替代血管通路形式。患者对每种血管通路也可能有强烈的看法，从而导致对替代通路形式的偏好。
与目前在血管通路选择中首先关注内瘘的做法相比，以患者为中心的透析通路选择方法，即在文献中的最新证据和患者偏好之间取得平衡，可能更受青睐。
