糖尿病患者和非糖尿病患者自体动静脉瘘和人工移植物血液透析通路的结果。
Outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in diabetic and nondiabetic patients.
机构信息
Division of Vascular Surgery, University of South Florida, Tampa, Fla; Division of Vascular Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
Division of Vascular Surgery, Johns Hopkins Medical Institutions, Baltimore, Md.
出版信息
J Vasc Surg. 2020 Dec;72(6):2088-2096. doi: 10.1016/j.jvs.2020.02.035. Epub 2020 Apr 8.
BACKGROUND
This study evaluated the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population-based cohort of patients.
METHODS
A retrospective cohort study was conducted of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). The χ test, Student t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection, and mortality.
RESULTS
The study of 381,622 patients comprised 303,307 (79.5%) autogenous fistulas and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for diabetics compared to nondiabetics who received autogenous fistulas (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.83-0.88; P < .001) and prosthetic grafts (aHR, 0.88; 95% CI, 0.83-0.93; P < .001). Comparing diabetics vs nondiabetics, primary patency at 5 years was 19.4% vs 23.5% (P < .001) for autogenous fistulas and 9.1% vs 11.2% (P < .001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2% vs 38.7% (P < .001) for autogenous fistulas and 17.2% vs 19.2% (P = .015) for prosthetic grafts. Secondary patency at 5 years was 44.8% vs 48.6% (P < .001) for autogenous fistulas and 34.1% vs 36.8% (P = .002) for prosthetic grafts. There was 5% decrease in primary patency (aHR, 0.95; 95% CI, 0.94-0.96; P < .001) for diabetics compared to nondiabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted, and secondary patency for prosthetic grafts in comparing diabetic to nondiabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR, 0.99; 95% CI, 0.92-1.08; P = .90). There was a 19% increase in patient mortality for diabetic relative to nondiabetic autogenous fistula recipients (aHR, 1.19; 95% CI, 1.17-1.20; P < .001) and 12% increase for prosthetic graft recipients (aHR, 1.12; 95% CI, 1.10-1.15; P < .001).
CONCLUSIONS
In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and primary fistula patency. In contrast, there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision.
背景
本研究评估了糖尿病对美国肾脏数据系统（2007-2014 年）中接受血液透析的自体瘘和人工移植物患者结局的影响。
方法
对美国肾脏数据系统中所有开始血液透析的患者进行回顾性队列研究。采用卡方检验、学生 t 检验、Kaplan-Meier 分析、对数秩检验、多变量逻辑和 Cox 回归分析评估成熟度、干预、通畅性、感染和死亡率。
结果
这项包含 381622 名患者的研究包括 303307 例（79.5%）自体瘘和 78315 例（20.5%）人工移植物，分别在 231134 例（60.6%）糖尿病患者和 150488 例（39.4%）非糖尿病患者中进行。与非糖尿病患者相比，糖尿病患者的自体瘘成熟度降低（调整后的危险比[aHR]，0.86；95%置信区间[CI]，0.83-0.88；P<0.001）和人工移植物（aHR，0.88；95%CI，0.83-0.93；P<0.001）。与非糖尿病患者相比，糖尿病患者自体瘘 5 年原发通畅率为 19.4%，而非糖尿病患者为 23.5%（P<0.001）；人工移植物为 9.1%，而非糖尿病患者为 11.2%（P<0.001）。自体瘘 5 年原发辅助通畅率为 35.2%，而非糖尿病患者为 38.7%（P<0.001）；人工移植物为 17.2%，而非糖尿病患者为 19.2%（P=0.015）。自体瘘 5 年继发性通畅率为 44.8%，而非糖尿病患者为 48.6%（P<0.001）；人工移植物为 34.1%，而非糖尿病患者为 36.8%（P=0.002）。与非糖尿病患者相比，糖尿病患者的原发性通畅率降低 5%（aHR，0.95；95%CI，0.94-0.96；P<0.001）。与糖尿病患者相比，自体瘘和人工移植物的原发性辅助通畅率和继发性通畅率均无差异。两组严重人工移植物感染率也无显著差异（aHR，0.99；95%CI，0.92-1.08；P=0.90）。与非糖尿病自体瘘患者相比，糖尿病患者的患者死亡率增加了 19%（aHR，1.19；95%CI，1.17-1.20；P<0.001），而人工移植物患者的死亡率增加了 12%（aHR，1.12；95%CI，1.10-1.15；P<0.001）。
结论
在这项基于人群的血液透析患者队列中，糖尿病与患者生存、通路成熟和原发性瘘管通畅率下降有关。相反，糖尿病与人工移植物通畅率和严重人工移植物感染之间没有关联，需要切除。
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