血管通路置管医嘱与血液透析患者结局：一项纵向研究。

Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study.

机构信息

Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.

出版信息

Am J Nephrol. 2017;46(4):268-275. doi: 10.1159/000481313. Epub 2017 Sep 21.

DOI:10.1159/000481313

PMID:28930719

Abstract

BACKGROUND

Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement.

METHODS

All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age.

RESULTS

In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments.

CONCLUSIONS

HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.

摘要

背景

在进行血液透析（HD）的患者中，动静脉通路（AVA）被标记为动静脉瘘（AVF）或移植物（AVG）的“永久性”，以及隧道式中心静脉导管（TCVC）的“临时性”。根据放置或使用的顺序，永久性血管通路的耐用性和结果很少受到关注。本研究根据放置顺序分析了基于 TCVC 和 AVA 的 HD 结果之间的纵向转换。

方法

本研究纳入了 2012 年至 2013 年期间在 12 个门诊学术透析单位通过 TCVC 开始接受慢性 HD 的所有 391 例患者。在平均（SD）2.8（0.9）年的时间内记录了 HD 血管通路的时间分布，并按 TCVC 提供和 AVA 提供（AVF 或 AVG）HD 的顺序进行分组。根据通路放置顺序和类型，调整年龄后，评估原发性 AVA 失败和累积通路存活率。

结果

共有 92.3%（361/391）的患者接受了 497 次 AVA 置管手术。分析最初的 3 次手术，随着每次 fistula 放置，原发性 AVF 失败率增加（p = 0.008）。在 82.9%（324/391）成功转换为 AVA 的 TCVC 患者中，有 30.9%的患者重新使用 TCVC，其次是 58.0%的患者转换为另一个 AVA。使用 TCVC 的每位患者每年血管通路转换率为 2.02（0.09）个 HD 期，使用 AVA 的转换率为 0.54（0.03）个 HD 期。与第二个通路相比，第一个通路的累积通路生存率分别为 701.0（370.0）和 426.5（275.0）天。排除从未转换为 AVF 或 AVG 的患者，169 名（52.2%）患者随后从 TCVC 转换为永久性通路，并通过 AVA 接受≥80%的治疗。