Alencar de Pinho Natalia, Coscas Raphael, Metzger Marie, Labeeuw Michel, Ayav Carole, Jacquelinet Christian, Massy Ziad A, Stengel Bénédicte
Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France.
Division of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France.
PLoS One. 2017 Jul 27;12(7):e0181254. doi: 10.1371/journal.pone.0181254. eCollection 2017.
Determinants of nonfunctional arteriovenous (AV) access, including timing of AV access creation, have not been sufficiently described. We studied 29 945 patients who had predialysis AV access placement and were included in the French REIN registry from 2005 through 2013. AV access was considered nonfunctional when dialysis began with a catheter. We estimated crude and adjusted odds ratio (OR) with 95% confidence intervals (CI) of nonfunctional versus functional AV access associated with case-mix, facility characteristics, and timing of AV access creation. Analyses were stratified by dialysis start condition (planned or as an emergency) and comorbidity profile. Overall, 18% patients had nonfunctional AV access at hemodialysis initiation. In the group with planned dialysis start, female gender (OR 1.43, 95% CI 1.32-1.56), diabetes (OR 1.28, 95% CI 1.15-1.44), and a higher number of cardiovascular comorbidities (OR 1.27, 95% CI 1.09-1.49, and 1.31, 1.05-1.64, for 3 and >3 cardiovascular comorbidities versus none, respectively) were independent predictors of nonfunctional AV access. A higher percentage of AV access creation at the region level was associated with a lower rate of nonfunctional AV access (OR 0.98, 95% CI 0.98-0.99 per 1% increase). The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with fewer than 2 cardiovascular comorbidities and 6 months in patients with diabetes or 2 or more such comorbidities. In conclusion, both patient characteristics and clinical practices may play a role in successful AV access use at hemodialysis initiation. Adjusting the timing of AV access creation to patients' comorbidity profiles may improve functional AV access rates.
包括动静脉（AV）通路建立时机在内的无功能AV通路的决定因素尚未得到充分描述。我们研究了29945例在透析前进行AV通路置入且纳入2005年至2013年法国REIN登记处的患者。当开始透析时使用导管时，AV通路被认为是无功能的。我们估计了与病例组合、机构特征以及AV通路建立时机相关的无功能与有功能AV通路的粗比值比（OR）和调整后比值比（OR）以及95%置信区间（CI）。分析按透析开始条件（计划内或急诊）和合并症情况进行分层。总体而言，18%的患者在开始血液透析时有无功能的AV通路。在计划开始透析的组中，女性（OR 1.43，95%CI 1.32 - 1.56）、糖尿病（OR 1.28，95%CI 1.15 - 1.44）以及更多的心血管合并症（3种和>3种心血管合并症与无合并症相比，OR分别为1.27，95%CI 1.09 - 1.49和1.31，1.05 - 1.64）是无功能AV通路的独立预测因素。地区层面较高比例的AV通路建立与较低的无功能AV通路发生率相关（每增加1%，OR 0.98，95%CI 0.98 - 0.99）。在无糖尿病且心血管合并症少于2种的患者中，从通路建立到开始血液透析的时间增加至3个月时，无功能AV通路的几率降低；在患有糖尿病或有2种或更多此类合并症的患者中，该时间增加至6个月时，无功能AV通路的几率降低。总之，患者特征和临床实践在血液透析开始时成功使用AV通路方面可能都起作用。根据患者的合并症情况调整AV通路建立的时机可能会提高有功能的AV通路使用率。
