Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
JAMA. 2024 Apr 16;331(15):1307-1317. doi: 10.1001/jama.2024.0535.
Hemodialysis requires reliable vascular access to the patient's blood circulation, such as an arteriovenous access in the form of an autogenous arteriovenous fistula or nonautogenous arteriovenous graft. This Review addresses key issues associated with the construction and maintenance of hemodialysis arteriovenous access.
All patients with kidney failure should have an individualized strategy (known as Patient Life-Plan, Access Needs, or PLAN) for kidney replacement therapy and dialysis access, including contingency plans for access failure. Patients should be referred for hemodialysis access when their estimated glomerular filtration rate progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing. Patients with chronic kidney disease should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters. Autogenous arteriovenous fistulas require 3 to 6 months to mature, whereas standard arteriovenous grafts can be used 2 to 4 weeks after being established, and "early-cannulation" grafts can be used within 24 to 72 hours of creation. The prime pathologic lesion of flow-related complications of arteriovenous access is intimal hyperplasia within the arteriovenous access that can lead to stenosis, maturation failure (33%-62% at 6 months), or poor patency (60%-63% at 2 years) and suboptimal dialysis. Nonflow complications such as access-related hand ischemia ("steal syndrome"; 1%-8% of patients) and arteriovenous access infection require timely identification and treatment. An arteriovenous access at high risk of hemorrhaging is a surgical emergency.
The selection, creation, and maintenance of arteriovenous access for hemodialysis vascular access is critical for patients with kidney failure. Generalist clinicians play an important role in protecting current and future arteriovenous access; identifying arteriovenous access complications such as infection, steal syndrome, and high-output cardiac failure; and making timely referrals to facilitate arteriovenous access creation and treatment of arteriovenous access complications.
血液透析需要可靠的血管通路进入患者的血液循环，例如自体动静脉瘘或非自体动静脉移植物形式的动静脉通路。本综述讨论了与血液透析动静脉通路的构建和维护相关的关键问题。
所有肾衰竭患者都应制定个体化的肾脏替代治疗和透析通路策略（称为患者生命计划、通路需求或 PLAN），包括通路失败的应急计划。当估计肾小球滤过率逐渐下降至 15 至 20ml/min 时，或当腹膜透析、肾移植或当前血管通路失败时，患者应接受血液透析通路的转介。患有慢性肾脏病的患者应限制或避免可能使未来动静脉通路复杂化的血管操作，例如肘前静脉穿刺或外周中央导管插入。自体动静脉瘘需要 3 至 6 个月才能成熟，而标准动静脉移植物在建立后 2 至 4 周即可使用，“早期插管”移植物可在创建后 24 至 72 小时内使用。动静脉通路血流相关并发症的主要病理病变是动静脉通路内的内膜增生，可导致狭窄、成熟失败（6 个月时为 33%-62%）或通畅性差（2 年内为 60%-63%）和透析效果不佳。非血流并发症，如与通路相关的手部缺血（“窃血综合征”；1%-8%的患者）和动静脉通路感染，需要及时识别和治疗。有出血高风险的动静脉通路是一种手术急症。
血液透析血管通路的动静脉通路的选择、创建和维护对肾衰竭患者至关重要。全科医生在保护当前和未来的动静脉通路方面发挥着重要作用；识别感染、窃血综合征和高输出性心力衰竭等动静脉通路并发症；并及时转介以促进动静脉通路的创建和治疗动静脉通路并发症。
