Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
Division of Nephrology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
PLoS One. 2019 Jan 28;14(1):e0211296. doi: 10.1371/journal.pone.0211296. eCollection 2019.
In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.
在一项血液透析（HD）患者事件中，我们旨在研究与从中心静脉导管（CVC）创建动静脉瘘（AVF）相比，在开始 HD 之前创建 AVF 是否与改善 AVF 通畅率相关，并且还比较这些患者之间的患者生存率。2011 年 1 月至 2013 年 12 月，回顾性分析了 524 例首次透析血管通路为 AVF（预 HD 组，n=191）或 CVC 上的 AVF（HD 组，n=333）的新发病例 HD 患者。研究结果定义为 AVF 通畅率和全因死亡率（死亡时间）。在 Kaplan-Meier 生存分析中，两组之间的主要和次要 AVF 通畅率没有显著差异（P=0.812 和 P=0.586），尽管预 HD 组的总生存率显著高于 HD 组（P=0.013）。多因素分析显示，已知的患者因素与原发性（年龄较大和糖尿病[DM]）和继发性（DM 和外周动脉闭塞性疾病）AVF 通畅率降低有关，而使用 CVC 作为初始透析前通路（危险比，1.84；95%置信区间，1.20-2.75；P=0.005）与已知的患者因素（年龄较大、糖尿病和外周动脉闭塞性疾病）一起与生存状况恶化显著相关。HD 组的生存状况较差可能是由于我们研究的回顾性性质造成的选择偏倚所致。因此，与 HD 开始前创建 AVF 相关的较低死亡率并不能完全归因于 CVC 的使用，而是受其他患者水平预后因素的影响。预 HD 组中没有 CVC 相关并发症，而在 HD 组中，10.2%的 CVC 相关并发症。总之，与从 CVC 创建 AVF 的患者相比，在新发病例 HD 患者中，初始 AVF 构建显示出相似的原发性和继发性 AVF 通畅率，但死亡率风险较低。我们还观察到，初始 CVC 使用是与生存状况较差相关的独立危险因素。瘘管优先策略可能是适合 AVF 构建的新发病例 HD 患者的最佳选择。
