Dept of Internal Medicine and Clinical Nutrition, Institution of Medicine, University of Gothenburg, Gothenburg, Sweden.
Department of Nephrology, Skaraborg hospital, 541 85, Skovde, Sweden.
BMC Nephrol. 2021 Jan 18;22(1):30. doi: 10.1186/s12882-020-02209-6.
Patients in maintenance hemodialysis (HD) need a patent vascular access for optimal treatment. The recommended first choice is a native arteriovenous fistula (AVF). Complications of AVF are frequent and include thrombosis, stenosis and infections leading to worsening of dialysis efficacy. Some known risk factors are age, gender and the presence of diabetes mellitus. The aim was to investigate if further risk variables are associated with dysfunctional AVF.
This retrospective observational study included 153 chronic HD patients (Cases) referred to a total of 473 radiological investigations due to clinically suspected complications of their native AVF. Another group of chronic HD patients (n = 52) who had a native AVF but were without history of previous complications for at least 2 years were controls. Statistical analyses included ANOVA, logistic regression, parametric and non-parametric methods such as Student's T-test and Mann-Whitney test.
Among Cases, at least one significant stenosis (> 50% of the lumen) was detected in 348 occasions. Subsequent PTA was performed in 248 (71%). Median erythropoiesis-stimulating agent (ESA) weekly doses were higher in Cases than in Controls (8000 vs 5000 IU, p < 0.001). Cases received higher doses of intravenous iron/week than the Controls before the investigation (median 50 mg vs 25 mg, p = 0.004) and low molecular weight heparin (LMWH, p = 0.028). Compared to Controls, Cases had a lower level of parathyroid hormone (median 25 vs 20 ρmol/L, p = 0.009). In patients with diabetes mellitus, HbA1c was higher among Cases than Controls (50 vs 38 mmol/mol, p < 0.001). Multiple regression analysis revealed significant associations between Cases and female gender, prescription of doxazocin, and doses of ESA and LMWH. There was no difference between the groups regarding hemoglobin, CRP or ferritin.
In conclusion, the present study indicated that the factors associated with AVF problems were high doses of ESA, iron administration, and tendency of thromboembolism (indicated by high LMWH doses); the use of doxazocin prescription, however, requires further investigation.
维持性血液透析（HD）患者需要通畅的血管通路以获得最佳治疗效果。首选的血管通路是自体动静脉瘘（AVF）。AVF 常出现血栓、狭窄和感染等并发症，导致透析效果恶化。已知的一些危险因素包括年龄、性别和糖尿病。本研究旨在探讨是否存在其他与 AVF 功能障碍相关的危险因素。
这是一项回顾性观察性研究，纳入了 153 名因怀疑自体 AVF 并发症而接受了总计 473 次影像学检查的慢性 HD 患者（病例组）。另一组慢性 HD 患者（n=52）为自体 AVF 且至少 2 年无既往并发症史的患者作为对照组。统计分析包括方差分析、逻辑回归、参数和非参数方法，如学生 t 检验和曼-惠特尼检验。
在病例组中，348 次检查中至少发现一处显著狭窄（>50%管腔狭窄）。随后，248 次（71%）进行了经皮腔内血管成形术（PTA）。病例组每周红细胞生成刺激剂（ESA）剂量中位数高于对照组（8000 vs 5000IU，p<0.001）。在进行检查之前，病例组每周静脉铁/周剂量和低分子肝素（LMWH）剂量中位数均高于对照组（50 vs 25mg，p=0.004 和 p=0.028）。与对照组相比，病例组甲状旁腺激素水平较低（中位数 25 vs 20 ρmol/L，p=0.009）。在糖尿病患者中，病例组的糖化血红蛋白（HbA1c）高于对照组（50 vs 38mmol/mol，p<0.001）。多元回归分析显示，病例组与女性、多沙唑嗪处方和 ESA 及 LMWH 剂量之间存在显著关联。两组间血红蛋白、C 反应蛋白或铁蛋白无差异。
综上所述，本研究表明，与 AVF 问题相关的因素是大剂量 ESA、铁剂的使用和血栓栓塞倾向（LMWH 剂量较高提示）；多沙唑嗪的使用需要进一步研究。
