【摘要】目的了解蚌埠市维持性血液透析(maintenance hemodialysis，MHD)患者首次及目前血管通路使用情况及影响因素。方法对蚌埠医学院第一、第二附属医院血液透析治疗大于3 个月的患者进行问卷调查。记录患者临床资料、血管通路使用情况、血流量、并发症；分析MHD 患者不同类型血管通路的分布情况；对首次透析使用自体动静脉内瘘(arteriovenous fistula，AVF)组与中心静脉导管(central venous catheter，CVC)组患者的一般情况进行分析，并分析首次透析使用AVF 的影响因素；对MHD 患者AVF 有无并发症进行比较并分析其影响因素。结果本研究纳入198 例MHD 患者，当前患者使用血管通路的比例分别为:AVF88.38%，带隧道带涤纶套导管9.09%，移植物内瘘2.53%；首次透析使用各种血管通路的比例为：AVF29.29%，带隧道带涤纶套导管12.12%，无隧道和涤纶套的透析导管58.59%。首次透析使用AVF 组患者的受教育程度(高中及以上)及职工医保占比高于CVC 组患者(51.7%比39.3%，P= 0.010；82.8%比66.4%，P=0.038)，差异有统计学意义；多因素Logistic 回归分析显示，受教育程度高(OR=3.046, P=0.007)及职工医保(OR=5.128,P=0.005) 的患者首次透析时使用AVF 的比例较高。MHD 患者AVF 有并发症组患者的血钙、血磷、血白蛋白、三酰甘油均高于无并发症组(F=0.180,P＜0.001；F=21.637，P＜0.001；F=0.028,P=0.021；F=0.665,P=0.024)，差异有统计学意义。结论本患者队列中首次血液透析时血管通路以CVC 为主，MHD 阶段血管通路以AVF 为主。文化程度越高，医保条件越好者首次透析使用AVF比例越高。血钙、血磷、白蛋白及三酰甘油水平可能是影响AVF 并发症的危险因素。
【Abstract】Objective To study the first and the present type of vascular access and its influencing factors in maintenance hemodialysis (MHD) patients in Bengbu city. Methods A questionnaire survey was conducted among the patients treated with hemodialysis for more than 3 months in the First and Second Affiliated Hospitals of Bengbu Medical College. Clinical data, the type of vascular access, blood flow and complications were then recorded. The distribution of different vascular access types in MHD patients was analyzed. The general conditions were compared between patients using arteriovenous fistula (AVF) and those using central venous catheter (CVC) at the first hemodialysis to obtain the influencing factors for the application of AVF at the first hemodialysis. The complications associated with AVF and their influencing factors in the MHD patients were also analyzed. Results In the 198 MHD patients enrolled in this study, the present use of AVF, tunnel-cuffed catheter (TCC) and arteriovenous graft for vascular access were 88.38%, 9.09% and 2.53% respectively, and the use of AVF, TCC and non-cuffed catheter for vascular access at the first hemodialysis were 29.29%, 12.21% and 58.59% respectively. Patients using AVF at the first hemodialysis had higher education level (high school or above high school level; 51.7% vs. 39.3%, P=0.010) and higher proportion with“medical insurance for employees”(82.8% vs. 66.4%, P=0.038), as compared with those using CVC at the first hemodialysis. Multivariate logistic regression showed that the proportion of using AVF at the first hemodialysis was higher in patients with higher education level (OR=3.046, P=0.007) and“medical insurance for employees”( OR=5.128,P=0.007). Serum calcium (F=0.180, P=0.000), phosphorus (F=21.637, P=0.000), albumin (F=0.028, P=0.021) and triglyceride (F=0.665, P=0.024) were higher in MHD patients using AVF for vascular access with complications than those without complications. Conclusion In this cohort of patients, CVC for
vascular access was frequently used at the first hemodialysis, and AVF for vascular access was commonly used at the maintenance hemodialysis period. The better the education level and medical insurance the patients had, the more likely AVF for vascular access at the first hemodialysis they accepted. Higher levels of serum calcium, phosphorus, albumin and triglyceride may be the risk factors for complications in patients using AVF for vascular access.
[1] Woo K,Lok CE.New insights into dialysis vascular access:what is the optimal vascular access type and timing of access creation in CKD and dialysis patients?[J].Clin J Am Soc Nephrol,2016,11:1487-1494.
[2] Alencar de Pinho N，Coscas R，Metzger M，et al. Vascular access conversion and patient outcome after hemodialysis initiation with a nonfunctional artriovenous access：a prospective registry-based study[J]．BMC Nephrol，2017，18（1）:74-85.
[3] 杨郁葱，王微，鲁淑敏．中心静脉长期留置导管在维持性血液透析患者中的应用[J]．中国疗养医学，2015，249(4)：419-120．
[4] Combe C, Pisoni RL, Port FK, et al. Dialysis outcomes and practice patterns study: data on the use of central venous catheters in chronic hemodialysis[J]. Nephrologie, 2001, 22(8): 379-384.
[5] Pastan S, Soucie JM, McClellan WM. Vascular access and increased risk of death among hemodialysis patients[ J]. Kidney Int, 2002, 62(2): 620-626.
[6] Ravani P，Palmer SC，Oliver MJ，et al．Associations between hemodialysis access type and clinical outcomes:a systematic review[J].J Am Soc Nephrol，2013，24(3)：465-743.
[7] Malas MB，Canner JK，Hicks CW，et al．Trends in incident hemodialysis access andmortality[J]．JAMA Surg，2015，150(5)：441-448．
[8] Polkinghorne KR, McDonald SP, Atkins RC, et al. Vascular access and all-cause mortality: a propensity score analysis[ J]. J Am Soc Nephrol, 2004, 15(2): 477-486.
[9] Huber TS, Carter JW, Carter RL, et al. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review[ J]. J Vasc Surg, 2003, 38(5): 1005-1011.
[10] Vascular Access Work Group. Clinical practice guidelines for vascular access[J]. Am J Kidney Dis, 2006, 48(Suppl 1): S248-273.
[11] Kukita K, Ohira S, Amano I, et al. 2011 update Japanese society for dialysis therapy guidelines of vascular access construction and repair for chronic hemodialysis[ J]. Ther Apher Dial, 2015, 19(Suppl 1): 1-39.
[12] Tordoir J, Canaud B, Haage P, et al. EBPG on vascular access[ J]. Nephrol Dial Transplant, 2007, 22 (Suppl 2): ii88-117.
[13] 中国医院协会血液净化中心管理分会血液净化通路学组. 中国血液透析用血管通路专家共识(第1版)[ J]. 中国血液净化, 2014, 13(8): 549-558.
[14] Inker LA，Astor BC，Fox CH，et al.KODOQI US commentary on the 2012 KODOQI clinical practice guideline for the evaluation and management of CKD [J].Am J Kidney Dis，2014，63(5) ，713-735.
[15] 王梦迪，张凌，刘鹏，等．终末期肾脏病患者初次血液透析血管通路应用的多中心调查[J]．中华肾脏病杂志，2016，32(6):418-424.
[16] O,Shaughnessy MM，Montez-Rath ME，Zheng Y，et al.Differences in initial hemodialysis vascular access use among glomerulonephritis subtypes in the United States[J]. Am J Kidney Dis，2016，67(4) ，638-647.
[17] Thwaites SE, Robless PA.Thwa Outcomes of initial hemodialysis access surgery in an Asian population[J].J Vasc Access,2012,13(4):409-414.
[18] 马祖等，陈玲，杨正林，等．维持性血液透析患者动静脉内瘘血栓形成影响因素分析．中国血液净化，2009，8( 10): 544-546．
[19] Yilmaz H, Bozkurt A, Cakmak M, et al. Relationship between late arteriovenous fistula (AVF) stenosis and neutrophil-lymphocyte ratio (NLR) in chronic hemodialysis patients.[J]. Renal Failure, 2014, 36(9):1390-1394.
[20] Lazich I, Chang A, Watson S, et al. Morphometric and histological parameters in veins of diabetic patients undergoing brachiocephalic fistula placement.[J]. Hemodialysis International, 2015, 19(4):490-498.
[21] 崔天蕾, 张任重, 刘芳,等. 糖尿病对终末期肾脏病患者动静脉内瘘早期失功的影响[J]. 四川大学学报(医学版), 2012, 43(3):438-441.
[22] 陈彤, 班遵浦. 糖尿病与自体动静脉内瘘后期失功的相关性分析[J]. 中国中西医结合肾病杂志, 2012, 13(3):238-240.
［23］ 张良红，林少容，李勇飞 . 维持性血液透析患者脂代谢紊乱与 心脑血管事件的关系研究 ［J］． 实用心脑肺血管病杂志，2014， 22 ( 4) : 68-69.
[24] Danis Ｒ，Ozmen S，Akin D，et al．Thmmbophilias and arterlovenous fistula dysfunction in maintenance hemodialysis．Journal of Thrombosis and ThromlMysis，2009，27( 3) : 307-315．
[25] Yang H，Curinga G，Giachelli CM. Elevated extracellular calcium levels induce smooth muscle cell matrix mineralization in vitro[J]. Kidney Int，2004，66:2293-2299.
[26] Lomashvili KA，Cobbs S，Hennigar ＲA，et al． Phosphate-induced vascular calcification: role of pyrophosphate and osteopontin［J］． J Am Soc Nephrol，2004，15( 6) : 1392-1401．
[27] London GM, Guérin AP, Marchais SJ, et al. Arterial media calcification in end-stage renal disease: impact on allcause and cardiovascular mortality[J]. Nephrol Dial Transplant,2003,18:1731-1740.
[28] Oh J, Wunsch R, Turzer M, et al. Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure[J]. Circulation,2002,2,106:100-105.
［29］ ＲOCA - TEY Ｒ， PAEZ Ｒ， ＲIVAS A， et al. Prevalence and functional effect of arteriovenous fistula calcifications，evaluated by spiral CT in chronic haemodialysis patients ［J］． Nefrologia，2009， 29 ( 3) : 214-221.
