【摘要】目的探讨隧道式带涤纶套股静脉导管代替临时中心静脉导管作为临时过渡血管通路在老年糖尿病血液透析患者中应用的可行性。方法本文为回顾性队列研究，选择2017 年1 月～2020 年1月在厦门大学附属第一医院肾内科住院并行血液透析治疗资料完整的老年糖尿病透析患者作为研究对象，其中在该期间置入隧道式带涤纶套股静脉导管(简称股静脉半永久导管组)患者共38 例，并选择同期置入中心静脉临时导管(包括股静脉、颈内静脉等中心静脉临时导管，简称临时导管组)的老年糖尿病透析患者共61 例作为对照组。所选取的2 组患者的自体动静脉内瘘手术均在置管2 周内完成，对2 组患者在自体动静脉内瘘使用前的透析充分性、导管通畅率、通路导管并发症发生率、导管留置时间及卫生经济学指标等5 个方面进行1～3 个月观察比较。结果①在透析充分性上，分别对2 组患者透析后的Kt/V 值进行比较，结果提示股静脉半永久导管组在透析充分性方面优于临时导管组[(1.39±0.05)比(1.25±0.04), t= 21.750，P=0.001]；②在导管通畅率方面，股静脉半永久导管组导管通畅率明显高于临时导管组(94.7%比80.3%，χ2=4.004 P= 0.045)；③在透析导管并发症发生率方面上，主要以导管感染及血栓栓塞最为常见，其中股静脉半永久导管导管组发生导管感染需要住院拔管1 例，导管相关并发症发生率为2.6%；临时导管组发生导管感染需要住院拔管5 例、血栓堵管需要住院拔管4 例，并发症发生率为16.4%，2 组导管相关并发症发生率差异具有统计学意义(2.6%比16.4%，χ2=4.690，P=0.037)；④在透析导管留置时间上，股静脉半永久导管组留置时间明显长于临时导管组[(74.0±8.2)d 比(51.7±9.9)d，t=11.630，P=0.001]。⑤在卫生经济学指标方面，2 组患者在内瘘使用前实际产生的总住院费用无明显差异[(15636.3±2148.7)元比(14634.1±4208.1)元，t=-2.027，P=0.177]，但在总住院时间方面，股静脉半永久导管组实际住院时间要少于临时导管组[(8.3±2.7)d 比(10.4±5.1)d，t=1.360，P=0.045)]。结论
在老年糖尿病肾病透析患者中，特别是血管条件差、内瘘成熟缓慢的患者，隧道式带涤纶套股静脉导管作为血液透析临时过渡血管通路，不仅留置时间更长，导管相关并发症发生率低，住院时间短，未显著增加住院费用，并且在透析充分性及导管通畅率方面优于中心静脉临时导管，可替代中心静脉临时导管作为首选过渡通路。

【Abstract】Objective To assess the clinical efficacy of a tunneled cuffed catheter in femoral vein as a transitional blood access pathway for hemodialysis in elderly dialysis patients with diabetes. Methods This was a retrospective and cohort study. A total of 99 elderly dialysis patients with diabetes undergoing the establishment of a transitional blood access pathway for hemodialysis in the First Affiliated Hospital of Xiamen University during the period from January 2017 to January 2020 were enrolled in this study. Thirty-eight of the 99 patients used the tunneled cuffed catheter in femoral vein as the semi-permanent blood access pathway (femoral vein group), and 61 patients used various temporary central venous catheters via femoral vein or internal jugular vein (temporary catheter group). Autologous arteriovenous fistula (AVF) surgery was performed within 2 weeks after the catheterization in all patients in the two groups. Dialysis adequacy, catheter patency rate, catheter- related complications, duration of catheter indwelling, and medical expenses before the use of AVF were recorded and compared between the two groups. Results ①The post- dialysis Kt/v values were 1.39±0.05 and 1.25±0.04 (t=21.750, P=0.001) in the femoral vein group and the temporary catheter group respectively, suggesting that the femoral vein group had better dialysis adequacy than the temporary catheter
group. ②The catheter patency rates were 94.7% and 80.3% (χ2=4.004, P=0.045) in the femoral vein group and the temporary catheter group respectively, suggesting that the femoral vein group had higher catheter patency rate than the temporary catheter group. ③The rates of catheter complications were 2.6% and 16.4% (χ2=4.690, P=0.037) in the femoral vein group and the temporary catheter group respectively, significantly lower in the femoral vein group than in the temporary catheter group. In femoral vein group, one case had catheterrelated infection and required hospitalization to remove the catheter; in contrast in temporary catheter group, 5 cases had catheter-related infection and 4 cases had catheter occlusion and thrombosis, they required hospitalization to remove the catheters. ④The periods of catheter indwelling were 74.0±8.2 days and 51.7±9.9 days (t=11.630, P=0.001) in the femoral vein group and the temporary catheter group respectively, significantly longer in the femoral vein group than in the temporary catheter group. ⑤The medical expenses before the use of AVF for blood access was similar between the two groups (15636.3 ± 2148.7 vs. 14634.1 ± 4208.1 yuan, t=-2.027, P=0.177). However, the hospitalization days were shorter in the femoral vein group than in the temporary catheter group (8.3±2.7 vs. 10.4±5.1 day, t=1.360, P=0.045). Conclusion Tunneled cuffed catheter in femoral vein as a temporary transitional vascular access pathway was advisable for elderly dialysis patients with diabetes, especially for those with poor vascular conditions and slow maturation of the autologous AVF. This method had the advantages of longer catheter indwelling time, better dialysis adequacy, higher catheter patency rate, lower rate of catheter-related complications and shorter hospitalization period than the method of central venous temporary catheter, without extra medical expenses. Therefore, tunneled cuffed catheter in femoral vein is a better method to replace the central venous temporary catheter used as the transitional vascular access for hemodialysis.