EpidStat Institute, Ann Arbor, MI, USA.
Humacyte Incorporated, Morrisville, NC, USA; Department of Surgery, Duke University, Durham, NC, USA.
Eur J Vasc Endovasc Surg. 2017 Oct;54(4):513-522. doi: 10.1016/j.ejvs.2017.06.024. Epub 2017 Aug 23.
Arteriovenous fistulae are the currently recommended gold standard vascular access modality for haemodialysis because of their prolonged patency, improved durability, and low risk of infection for those that mature. However, notable disadvantages are observed in terms of protracted maturation time, associated high rates of catheter use, and substantial abandonment rates. The aim of this study was to quantitatively summarize the outcomes of fistula patency, infection, maturation, and abandonment published in the scientific literature.
This was a systematic review and meta-analyses of studies evaluating fistula outcomes. Literature searches were conducted in multiple databases to identify observational and interventional studies of mean fistula patency rates at 1 year, infection risk, maturation time, and abandonment. Digitisation software was used to simulate individual patient level data from Kaplan-Meier survival plots.
Over 8000 studies were reviewed, and from these, 318 studies were included comprising 62,712 accesses. For fistulas the primary unassisted, primary assisted, and secondary patency rates at one year were 64%, 73% and 79% respectively, however not all fistulas reported as patent could be confirmed as being clinically useful for dialysis (i.e. functional patency). For fistulas that were reported as mature, mean time to maturation was 3.5 months, however only 26% of created fistulas were reported as mature at 6 months and 21% of fistulas were abandoned without use. Overall risk of infection in fistula patients was 4.1% and the overall rate per 100 access days was 0.018.
Reported fistula patency rates may overstate their potential clinical utility when time to maturation, maturation rate, abandonment and infection are considered. Protracted maturation times, abandonment and infection all have a significant impact on evaluating the clinical utility of fistula creation. A rigorous and consistent set of outcomes definitions for hemodialysis access are necessary to clarify factors contributing to fistula success and the clinical consequence of fistula failure.
动静脉瘘是目前推荐的血液透析血管通路的金标准，因为它们具有较长的通畅时间、改善的耐用性，以及成熟后感染风险低。然而，在成熟时间长、导管使用率高和大量废弃率方面存在显著的缺点。本研究的目的是定量总结瘘管通畅、感染、成熟和废弃方面的研究结果，这些结果发表在科学文献中。
这是一项系统评价和荟萃分析，评估瘘管结果的研究。在多个数据库中进行了文献检索，以确定 1 年时瘘管通畅率、感染风险、成熟时间和废弃率的观察性和干预性研究。数字化软件用于从 Kaplan-Meier 生存图模拟个体患者水平数据。
共审查了 8000 多项研究，从中纳入了 318 项研究，共涉及 62712 例通路。对于瘘管，一年时的原发性未辅助、原发性辅助和继发性通畅率分别为 64%、73%和 79%，但并非所有报告为通畅的瘘管都能被证实对透析具有临床用途（即功能性通畅）。对于报告为成熟的瘘管，平均成熟时间为 3.5 个月，但只有 26%的创建瘘管在 6 个月时报告为成熟，21%的瘘管未使用而被废弃。瘘管患者的总体感染风险为 4.1%，每 100 个通路日的感染率为 0.018。
当考虑成熟时间、成熟率、废弃和感染时，报告的瘘管通畅率可能夸大了其潜在的临床用途。成熟时间长、废弃和感染都会对评估瘘管创建的临床实用性产生重大影响。需要一套严格和一致的血液透析通路结局定义，以明确瘘管成功的因素以及瘘管失败的临床后果。
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