Division of Vascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Vascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Division of Vascular Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada.
J Vasc Surg. 2018 May;67(5):1491-1500. doi: 10.1016/j.jvs.2017.08.080. Epub 2017 Dec 8.
Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65-79 years, >80 years) to determine whether protocols should be modified to account for advanced age.
All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan-Meier survival and Cox hazards models were used to compare access patency and risk factors for failure.
There were 941 autogenous arteriovenous accesses (median follow-up, 23 months; range, 0-89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss.
Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.
目前肾脏病预后质量倡议指南在确定自体动静脉血液透析通路的位置时并未考虑年龄因素，而在老年患者中最佳的初始构型仍存在争议。我们比较了几个年龄组（<65 岁、65-79 岁、>80 岁）的通畅率、成熟度、生存率和并发症，以确定是否需要修改方案以考虑高龄因素。
我们从两个教学医院前瞻性维护的数据库中回顾性分析了 2007 年至 2013 年间在任一侧手臂首次进行自体动静脉通路创建的所有患者；使用 Kaplan-Meier 生存和 Cox 风险模型比较了通路通畅率和失败的危险因素。
共纳入 941 例自体动静脉通路（中位随访时间 23 个月；范围 0-89 个月）；152 例（15.3%）在>80 岁的患者中建立，397 例（42.2%）在 65-79 岁的患者中建立，392 例（41.8%）在<65 岁的患者中建立。>80 岁、65-79 岁和<65 岁的患者 12 个月时的原发通畅率分别为 40%±4%、38%±3%和 51%±3%，36 个月时分别为 12%±5%、13%±3%和 27%±3%（P<0.001）。原发辅助通畅率在 12 个月时分别为 72%±4%、70%±2%和 78%±2%，36 个月时分别为 52%±5%、52%±3%和 67%±3%（P<0.001）。继发性通畅率在 12 个月时分别为 72%±4%、71%±2%和 79%±2%，36 个月时分别为 54%±5%、55%±3%和 72%±3%（P<0.001）。桡动脉通路在老年患者中的通畅率最低；在>80 岁、65-79 岁和<65 岁的患者中，12 个月时分别为 65%±7%、67%±4%和 77%±3%，36 个月时分别为 41%±8%、51%±5%和 68%±4%（P=0.019）。这些患者的继发性头臂动脉通路通畅率在 12 个月时分别为 78%±5%、80%±3%和 82%±3%，36 个月时分别为 68%±7%、66%±5%和 77%±4%（P=0.206）。65-79 岁和>80 岁的两个年龄组的头臂动脉继发性通畅率均优于桡动脉（P=0.048 和 P=0.015）；然而，<65 岁的患者中，在配置和继发性通畅率之间没有差异。12 个月和 24 个月时桡动脉通路成熟失败率在<65 岁患者中分别为 25%±3%和 29%±4%，在 65-79 岁患者中分别为 32%±3%和 39%±4%，在>80 岁患者中分别为 40%±7%和 48%±8%（P=0.006）。12 个月和 24 个月时头臂动脉通路成熟失败率在<65 岁患者中分别为 17%±3%和 20%±3%，在 65-79 岁患者中分别为 21%±3%和 25%±4%，在>80 岁患者中分别为 18%±5%和 21%±5%（P=0.740）。多变量分析显示，冠心病、女性、同侧或双侧导管史、桡动脉构型和年龄>65 岁与继发性通畅率丧失相关。
65-79 岁和>80 岁的患者与<65 岁的患者相比，原发性、原发性辅助性和继发性通畅率和成熟度较低。在按构型分层时，桡动脉通路在 65-79 岁和>80 岁的患者中与头臂动脉通路相比，其通畅率和成熟度较低，是继发性通畅率丧失的独立预测因素。
