Department of Public Health and Clinical Medicine, Umea University, SE 90187, Umea, Sweden.
BMC Nephrol. 2020 Dec 21;21(1):544. doi: 10.1186/s12882-020-02195-9.
An arteriovenous fistula (AVF) is the first choice when considering access for haemodialysis (HD). When a forearm AVF fails an upper arm AVF is a frequent subsequent dialysis access option. The latter may cause cardiac strain. NT-pro-B-type natriuretic peptide (NT-NT-proBNP) is a marker used to estimate volume overload and cardiac strain. This case report shows the benefit of using longitudinal individual follow-up of pre-dialysis NT-proBNP in clinical practice to detect changes in cardiac condition that may be due to high-output AVF.
An 18 years old patient performed HD via an upper arm AVF before he was admitted to our unit. NT-proBNP was above the upper detection level of 70,000 ng/L. Echocardiography revealed a left-ventricular cardiac insufficiency. Interdialytic weight gain (IDWG) was above 5%. He was instructed to lower fluid intake and IDWG towards 2%. Four months later NT-proBNP surpassed 70,000 ng/L again. Flow in the brachial artery was at 3034 ml/min. Reconstructive surgery of the AVF did not reduce flow and NT-proBNP in the long run. Clinically, he worsened to NYHA class III-IV. It was decided to close the upper arm AVF and to replace it with a lower arm AVF leading to a reduced artery flow of 1344 mL/min. The clinical condition successively recovered and NT-proBNP decreased to 7000 ng/L.
Pre-dialysis NT-proBNP should be considered as a suitable routine marker for cardiac strain such as caused by high-output AVF besides variables such as IDWG. Brachial artery flow besides AVF flow measurement is helpful.
动静脉瘘（AVF）是血液透析（HD）首选的通路。当下肢 AVF 出现故障时，上肢 AVF 是常用的后续透析通路选择。后者可能会导致心脏负担。氨基末端 B 型利钠肽前体（NT-proBNP）是一种用于估计容量超负荷和心脏负担的标志物。本病例报告展示了在临床实践中使用 NT-proBNP 的纵向个体化随访来检测因高流量 AVF 引起的心脏状况变化的益处。
一名 18 岁患者在转入我院前通过上肢 AVF 进行 HD，NT-proBNP 高于 70000ng/L 的检测上限。超声心动图显示左心室心脏功能不全。透析间期体重增加（IDWG）超过 5%。他被指示减少液体摄入和 IDWG 至 2%。四个月后，NT-proBNP 再次超过 70000ng/L。肱动脉血流为 3034ml/min。AVF 的重建手术并不能从长远上降低血流和 NT-proBNP。临床上，他的病情恶化到 NYHA Ⅲ-Ⅳ级。决定关闭上肢 AVF，并更换为下臂 AVF，从而导致动脉血流减少至 1344ml/min。临床状况逐渐恢复，NT-proBNP 降低至 7000ng/L。
除了 IDWG 等变量外，透析前 NT-proBNP 应被视为高流量 AVF 引起的心脏负担等的合适常规标志物。肱动脉血流测量有助于评估 AVF 血流。
