Division of Nephrology, University Hospital East, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
Division of Nephrology, University Hospital East, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
Kidney Int. 2019 May;95(5):1053-1063. doi: 10.1016/j.kint.2018.11.046. Epub 2019 Mar 4.
Worldwide, hemodialysis remains the prevalent dialysis modality for more than 2 million patients who require well-functioning vascular access for this procedure. Creation of an arteriovenous fistula for long-term hemodialysis was the first innovation since the Scribner shunt and was followed by the development of an arteriovenous graft and catheter. Bioengineered vessels were developed during the last century, but this field has been energized by recent technology relating to the creation of human vessels. Novel endovascular techniques for creating an arteriovenous fistula may resolve some of the logistical issues involved in obtaining a timely arteriovenous fistula. Treatment of access stenosis, infection, and thrombosis has remained suboptimal, and innovative technologies are evolving. Many new approaches are now targeting the biological and mechanical aspects of vascular access, such as creation and maturation of arterial and venous anastomoses, development of a biological conduit for outflow, and negotiating the problems of central vein stenosis. Importantly, processes of access care that have long focused on arteriovenous fistulas are now recognizing the new paradigm, providing a complementary niche to arteriovenous grafts and dialysis catheters in the algorithm for individualized access placement. Cumulatively, to the credit of the multidisciplinary team approach, the long overdue focus on the very existential issue of vascular access for hemodialysis is being approached with newfound evidence-based enthusiasm as the vexing challenges related to regulations and reimbursement in hemodialysis persist. Patient choice and experience, often missed and ignored in the challenging management of an end-stage organ failure, need to stay central as we focus on patient-centered care of vascular access.
在全球范围内，血液透析仍然是 200 多万名需要功能良好的血管通路进行该程序的患者中流行的透析方式。动静脉瘘管的建立是自 Scribner 分流器以来的第一项创新，随后开发了动静脉移植物和导管。在上个世纪，生物工程血管得到了发展，但最近与人类血管创建相关的技术使这一领域充满了活力。新型的血管内技术可能会解决获得及时动静脉瘘管所涉及的一些后勤问题。动静脉通路狭窄、感染和血栓形成的治疗效果仍不理想，创新技术正在不断发展。许多新方法现在针对血管通路的生物学和机械方面，例如动脉和静脉吻合口的创建和成熟、用于流出的生物导管的开发以及解决中心静脉狭窄的问题。重要的是，长期以来一直专注于动静脉瘘管的通路护理过程现在正在认识到新的范例，为动静脉移植物和透析导管在个体化通路放置的算法中提供了互补的利基。总的来说，多学科团队方法的功劳在于，长期以来一直存在的血液透析血管通路的存在问题终于得到了关注，人们对这一问题充满了新的基于证据的热情，因为血液透析相关的监管和报销方面的令人困扰的挑战仍然存在。在终末期器官衰竭的挑战性管理中经常被忽视的患者选择和体验，需要作为我们关注以患者为中心的血管通路护理的核心。
