Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama.
Clin J Am Soc Nephrol. 2019 Jun 7;14(6):954-961. doi: 10.2215/CJN.00490119. Epub 2019 Apr 11.
This commentary critically examines key assumptions and recommendations in the 2006 Kidney Disease Outcomes Quality Initiative vascular access guidelines, and argues that several are not relevant to the contemporary United States hemodialysis population. First, the guidelines prefer arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs), on the basis of their superior secondary survival and lower frequency of interventions and infections. However, intent-to-treat analyses that incorporate the higher primary failure of AVFs, demonstrate equivalent secondary survival of both access types. Moreover, the lower rate of AVF versus AVG infections is counterbalanced by the higher rate of catheter-related bloodstream infections before AVF maturation. In addition, AVFs with assisted maturation (interventions before successful AVF use), which account for about 50% of new AVFs, are associated with inferior secondary patency compared with AVGs without intervention before successful use. Second, the guidelines posit lower access management costs for AVFs than AVGs. However, in patients who undergo AVF or AVG placement after starting dialysis with a central venous catheter (CVC), the overall cost of access management is actually higher in patients receiving an AVF. Third, the guidelines prefer forearm over upper arm AVFs. However, published data demonstrate superior maturation of upper arm versus forearm AVFs, likely explaining the progressive increase in upper arm AVFs in the United States. Fourth, AVFs are thought to fail primarily because of aggressive juxta-anastomotic stenosis. However, recent evidence suggests that many AVFs mature despite neointimal hyperplasia, and that suboptimal arterial vasodilation may be an equally important contributor to AVF nonmaturation. Finally, CVC use is believed to result in excess mortality in patients on hemodialysis. However, recent data suggest that CVC use is simply a surrogate marker of sicker patients who are more likely to die, rather than being a mediator of mortality.
这篇评论批判性地审视了 2006 年肾脏病预后质量倡议血管通路指南中的关键假设和建议，并认为其中有几个与当代美国血液透析人群无关。首先，该指南基于动静脉瘘（AVF）的次级生存更好且干预和感染频率更低，因此优先选择 AVF 而非动静脉移植物（AVG）。然而，纳入 AVF 更高原发性失败的意向性治疗分析表明，两种通路类型的次级生存相当。此外，AVF 比 AVG 感染率低的情况被 AVF 成熟前导管相关血流感染率高所抵消。此外，辅助成熟的 AVF（在成功使用 AVF 前进行干预）占新 AVF 的约 50%，与在成功使用前没有干预的 AVG 相比，次级通畅率较差。其次，该指南认为 AVF 的血管通路管理成本低于 AVG。然而，在开始血液透析后使用中心静脉导管（CVC）进行 AVF 或 AVG 置管的患者中，接受 AVF 的患者的总体血管通路管理成本实际上更高。第三，该指南偏好前臂而非上臂 AVF。然而，已发表的数据表明，上臂 AVF 的成熟度优于前臂 AVF，这可能解释了美国上臂 AVF 逐渐增加的原因。第四，AVF 被认为主要因吻合口旁狭窄而失败。然而，最近的证据表明，尽管有新生内膜增生，许多 AVF 仍能成熟，并且动脉血管舒张不佳可能同样是 AVF 不成熟的重要原因。最后，人们认为 CVC 的使用会导致血液透析患者的死亡率过高。然而，最近的数据表明，CVC 的使用只是代表更可能死亡的病情更严重的患者的替代标志物，而不是死亡率的中介因素。
