Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla.
Division of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md; Division of Vascular Surgery, Massachusetts General Hospital, Boston, Mass.
J Vasc Surg. 2019 Feb;69(2):517-525.e1. doi: 10.1016/j.jvs.2018.05.219.
The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.
A retrospective analysis was performed of all patients ≥75 years old in the prospectively maintained United States Renal Database System who had an AVF or AVG placed for hemodialysis (HD) access between January 2007 and December 2011. Outcomes were mortality, conduit patency, maturation, time to catheter-free dialysis, and infection. A χ test, Student t-test, Kaplan-Meier analysis, and multivariable Cox regression analysis were employed.
Of the 124,421 patients studied, there were 19,173 (15%) AVF initiates, 4480 (4%) AVG initiates, 29,872 (24%) AVF converts, 10,712 (9%) AVG converts, and 59,824 (48%) patients who persisted on HD catheters. Compared with AVF initiates, relative mortality was significantly higher for AVG initiates (adjusted hazard ratio [aHR], 1.24; P < .001), AVF converts (aHR, 1.36; P < .001), AVG converts (aHR, 1.62; P < .001), and catheter-persistent patients (aHR, 2.23; P < .001). Primary patency (aHR, 1.21; P < .001) and primary assisted patency (aHR, 1.31; P < .001) were higher for AVF. Secondary patency was higher for AVGs within the first 4 months (aHR, 1.12; P < .001) but higher for AVFs beyond that time point (aHR, 1.25; P < .001). Maturation rate and median time to maturation were 80% vs 84% (P < .001) and 46 vs 26 days (P < .001) for AVF vs AVG.
Pre-emptive AVF remains the best mode of HD in elderly patients who can tolerate surgery. Patients who cannot tolerate pre-emptive surgery or have to initiate HD on an urgent basis with a catheter should convert to AVF when it is feasible if life expectancy is >4 months. If life expectancy is <4 months, surgical risk and quality of life should be considered in making the decision to persistently dialyze through HD catheter or to convert to AVG.
本研究旨在对比美国老年人群中经大样本基于人群队列研究的动静脉瘘（AVF）和动静脉移植物（AVG）的治疗结局。
回顾性分析 2007 年 1 月至 2011 年 12 月期间美国前瞻性维持的肾脏数据库系统中所有年龄≥75 岁并接受用于血液透析（HD）通路的 AVF 或 AVG 置入的患者。结局包括死亡率、导管通畅性、成熟度、无导管透析时间和感染。采用 χ 检验、学生 t 检验、Kaplan-Meier 分析和多变量 Cox 回归分析。
在研究的 124421 例患者中，有 19173 例（15%）为 AVF 初始患者，4480 例（4%）为 AVG 初始患者，29872 例（24%）为 AVF 转换患者，10712 例（9%）为 AVG 转换患者，59824 例（48%）患者持续使用 HD 导管。与 AVF 初始患者相比，AVG 初始患者（校正风险比[aHR]，1.24；P<0.001）、AVF 转换患者（aHR，1.36；P<0.001）、AVG 转换患者（aHR，1.62；P<0.001）和导管持续患者（aHR，2.23；P<0.001）的相对死亡率显著更高。AVF 的主要通畅率（aHR，1.21；P<0.001）和主要辅助通畅率（aHR，1.31；P<0.001）更高。AVG 在最初 4 个月内的次要通畅率更高（aHR，1.12；P<0.001），但在此时间点后 AVF 的次要通畅率更高（aHR，1.25；P<0.001）。AVF 的成熟率和中位成熟时间分别为 80%和 46 天（均 P<0.001），而 AVG 分别为 84%和 26 天（均 P<0.001）。
对于能够耐受手术的老年患者，预防性 AVF 仍然是 HD 的最佳模式。如果预期寿命>4 个月，无法耐受预防性手术或必须紧急开始 HD 治疗且需要使用导管的患者，如果可行，应转为 AVF。如果预期寿命<4 个月，则应考虑手术风险和生活质量来决定是否持续通过 HD 导管透析或转为 AVG。
