Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.
Nephrol Dial Transplant. 2018 Jul 1;33(7):1244-1250. doi: 10.1093/ndt/gfx380.
The modality by which haemodialysis (HD) is delivered [arteriovenous fistula (AVF), arteriovenous graft (AVG) or central venous catheter (CVC)] varies widely and is influenced by clinical evidence, patient factors and the prevailing service configuration. The aim of this study was to determine the outcome and impact of access strategy on patient outcome by mapping out the HD journey in a cohort of incident patients.
A 2-year cohort of consecutive incident HD patients from the point of referral for first dialysis access to completion of the first 365 days of HD was prospectively reviewed. Data were sought on access type; radiological, surgical and other access-related activity; bacteraemic events; admission rates and cumulative financial cost.
A total of 144 patients started RRT for the first time with HD over the 2-year period. All were followed up to 1 year after starting HD, generating a total of 47 753 observed HD days. Activity prior to starting HD for the full cohort was found to average 0.92 arteriovenous (AV) access creation procedures, 0.40 CVC insertions, 0.14 interventional radiology procedures and 0.41 ultrasound examinations per patient. The small number of patients who started on an AVG had a tendency towards higher pre-HD surgical and imaging activity than those who started on an AVF or CVC. Activity after starting HD varied greatly with the access type used at the start of HD, with AVF patients experiencing less hospitalization, procedure and imaging activity and financial costs compared with those who start HD with a CVC. Patients who started on an AVG had a tendency towards lower surgical activity rates and financial costs than those who started on a CVC.
Providing, maintaining and dealing with the complications of HD vascular access places a significant burden of activity that is shared across nephrology, surgery and imaging services. A well-functioning AVF is associated with the lowest burden, whereas a failed AVF or CVC access is associated with the highest burden. Patient journeys are shaped by the vascular access that they use and we suggest that the contemporary pursuit of HD access should focus on delivering personalized access solutions.
血液透析（HD）的实施方式（动静脉瘘（AVF）、动静脉移植物（AVG）或中心静脉导管（CVC））差异很大，受到临床证据、患者因素和当前服务配置的影响。本研究的目的是通过描绘队列中首次透析通路的 HD 之旅，确定通路策略对患者结局的影响和结果。
前瞻性回顾了在开始 HD 治疗的第 1 年中，每例新接受 HD 治疗的患者的 2 年队列。我们寻求了通路类型、放射学、手术和其他与通路相关的活动、菌血症事件、入院率和累积财务成本的数据。
在 2 年期间，共有 144 名患者首次开始接受 RRT 治疗，其中所有患者均在开始 HD 治疗后 1 年进行了随访，共观察到 47753 个 HD 日。全队列在开始 HD 治疗之前的活动平均为每位患者 0.92 次动静脉（AV）通路建立手术、0.40 次 CVC 插入、0.14 次介入放射学程序和 0.41 次超声检查。少数开始使用 AVG 的患者的术前手术和影像学活动比开始使用 AVF 或 CVC 的患者更倾向于更高。在开始 HD 治疗后，使用的通路类型存在很大差异，与开始使用 CVC 的患者相比，AVF 患者的住院、手术和影像学活动以及财务成本更少。与开始使用 CVC 的患者相比，开始使用 AVG 的患者的手术活动率和财务成本较低。
提供、维护和处理 HD 血管通路的并发症会带来大量的活动负担，这些负担由肾脏病学、外科和影像学服务共同承担。功能良好的 AVF 相关的负担最低，而功能失败的 AVF 或 CVC 通路相关的负担最高。患者的治疗过程取决于他们使用的血管通路，我们建议，当代 HD 通路的追求应侧重于提供个性化的通路解决方案。
