Jakes Adam D, Jani Poonam, Allgar Victoria, Lamplugh Archie, Zeidan Ahmed, Bhandari Sunil
Hammersmith Hospital, Imperial College Healthcare NHS Trust, NHS Trust, London, United Kingdom.
King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom.
PLoS One. 2016 Sep 29;11(9):e0163487. doi: 10.1371/journal.pone.0163487. eCollection 2016.
Dialysis in elderly patients (>80-years-old) carries a poor prognosis, but little is known about the most effective vascular access method in this age group. An arteriovenous fistula (AVF) is both time-consuming and initially expensive, requiring surgical insertion. A central venous catheter (CVC) is initially a cheaper alternative, but carries a higher risk of infection. We examined whether vascular access affected 1-year and 2-year mortality in elderly patients commencing haemodialysis.
Initial vascular access, demographic and survival data for elective haemodialysis patients >80-years was collated using regional databases. A cohort of conservatively managed patients was included for comparison. A log-rank test was used to compare survival between groups and a chi-square test was used to compare 1-year and 2-year survival.
167 patients (61% male) were included: CVC (101), AVF (25) and conservative management (41). Mean age (median) of starting haemodialysis (eGFR ≤10mL/min/1.73m2): CVC; 83.4 (2.3) and AVF; 82.3 (1.8). Mean age of conservatively managed patients reaching an eGFR ≤10mL/min/1.73m2 was 85.8 (3.6). Mean (median) survival on dialysis was 2.2 (1.8) years for AVF patients, 2.1 (1.2) for CVC patients, and 1.5 (0.9) for conservatively managed patients (p = 0.107, controlling for age/sex p = 0.519). 1-year and 2-year mortality: AVF (28%/52%); CVC (49%/57%), and conservative management (54%/68%). There was no significant difference between the groups at 1-year (p = 0.108) or 2-years (p = 0.355).
These results suggest that there is no significant survival benefit over a 2-year period when comparing vascular access methods. In comparison to conservative management, survival benefit was marginal. The decision of whether and how (choice of their vascular access method) to dialysis the over 80s is multifaceted and requires a tailored, multidisciplinary approach.
老年患者（80岁以上）进行透析预后较差，但对于该年龄组最有效的血管通路方法知之甚少。动静脉内瘘（AVF）既耗时又成本高昂，需要手术植入。中心静脉导管（CVC）最初是一种较便宜的选择，但感染风险较高。我们研究了血管通路是否会影响开始血液透析的老年患者的1年和2年死亡率。
使用区域数据库整理80岁以上择期血液透析患者的初始血管通路、人口统计学和生存数据。纳入一组保守治疗的患者进行比较。采用对数秩检验比较组间生存率，采用卡方检验比较1年和2年生存率。
纳入167例患者（61%为男性）：CVC组（101例）、AVF组（25例）和保守治疗组（41例）。开始血液透析时的平均年龄（中位数）（估算肾小球滤过率[eGFR]≤10mL/min/1.73m²）：CVC组为83.4（2.3）岁，AVF组为82.3（1.8）岁。达到eGFR≤10mL/min/1.73m²的保守治疗患者的平均年龄为85.8（3.6）岁。AVF组患者透析的平均（中位数）生存期为2.2（1.8）年，CVC组为2.1（1.2）年，保守治疗组为1.5（0.9）年（p = 0.107，校正年龄/性别后p = 0.519）。1年和2年死亡率：AVF组（28%/52%）；CVC组（49%/57%），保守治疗组（54%/68%）。各组在1年（p = 0.108）或2年（p = 0.355）时无显著差异。
这些结果表明，比较血管通路方法时，2年内没有显著的生存获益。与保守治疗相比，生存获益甚微。对于80岁以上患者是否进行透析以及如何进行透析（血管通路方法的选择）的决策是多方面的，需要一种量身定制的多学科方法。
