扶他林联合远红外线照射治疗动静脉内瘘早期狭窄的效果观察

自体动静脉内瘘（AV内瘘）是永久性血管通路,是血液透析患者赖以生存的“生命线”.足够的AV内瘘血流量是维持性血液透析患者透析充分的根本保证[1].在临床,血管内膜增生引起的非血栓性内瘘狭窄是引发内瘘失功的重要因素之一[2],患者在未达到足够的血流量情况下进行血液透析,待出现内瘘失功时才开始进行干预,严重影响了透析质量.2012年9月吉林大学白求恩第一医院透析中心对使用自体动静脉内瘘的维持性血液透析患者,采用超声稀释法测定内瘘血流量（Qa）及多普勒超声检测血管狭窄[3],并对其中内瘘早期狭窄的透析患者38例采用双氯芬酸二乙胺乳膏剂（扶他林）联合远红外线照射治疗,取得满意的效果,现报道如下.     

维持性血液透析中不同血管通路使用效果的比较

目的 比较维持性血液透析中不同血管通路的使用效果.方法 选取维持性血液透析患者126例,其中长期颈内静脉导管组38例、股静脉临时导管组46例、动静脉内瘘组42例,比较不同血管通路的使用时限、并发症、透析充分性.结果 股静脉临时组使用时限明显低于长期颈内静脉组与动静脉内瘘组（P＜0.05）;动静脉内瘘组局部/全身感染明显低于其他两组;各组间血栓形成差异有统计学意义（P＜0.05）,股静脉临时组最高,动静脉内瘘组最低;股静脉临时组透析充分性明显优于其他两组.结论 动静脉内瘘组的综合使用情况最优,而对无法行内瘘手术的患者,长期颈内静脉导管留置同样具有良好效果.     

维持性血液透析患者自体动静脉内瘘术后早期失功影响因素的调查研究

目的探讨维持性血液透析患者自体动静脉内瘘术后早期失功影响因素。方法选取我院2016年6月至2018年12月收治的行自体动静脉内瘘术的维持性血液透析患者84例为研究对象,依据动静脉内瘘术状况划分为成功组62例和失功组22例,通过单因素分析、多因素logistic回归分析确定自体动静脉内瘘术后患者早期失功影响因素。结果多因素logistic回归分析显示,性别、年龄、BMI分型、血磷水平、血小板水平、早期转诊、低血压是影响维持性血液透析患者自体动静脉内瘘术后早期失功的独立危险因素(P 0. 05)。结论女性、高龄、肥胖、血磷水平、血小板水平、低血压、未早期转诊是自体动静脉内瘘术后早期失功的危险因素,易加速内瘘失功。     

维持性血液透析患者自体动静脉内瘘低血流量的影响因素分析

目的 探讨维持性血液透析(maintenance hymodialysis,MHD)患者自体动静脉内瘘低血流量的影响因素,为临床早期干预提供依据.方法选择广东省佛山市南海区第二人民医院肾内科2006年6月至2009年12月自体动静脉内瘘MHD患者159例,对其中21例因瘘管低血流量不能改善,导致透析不允分者,进行晕化年龄、性别、原发病、内瘘成熟度、低血压、通路血管血栓、内瘘狭窄等指标,并与133例正常血流量组比较,采用二分类logistic回归分析.结果 159例中21例出现低血流量,发生率13.21%.与止常血流量组比较年龄、体质量指数、原发病、低血压、通路血管血栓、内瘘狭窄、内瘘成熟度和内瘘使用时间,差异均有统计学意义(均P＜0.05).结论体质量指数、糖尿病、通路血管血栓、内瘘使用时间是影响瘘管低血流量非常重要的因素.早期改善患者营养状态,定期临测内瘘情况,可提高自体动静脉内瘘血流量.     

长期导管置管在糖尿病肾病血透患者中的应用

【目的】探讨糖尿病肾病（DN）血透患者血管通路的建立及效果。【方法】对同期在本院做血透的DN肾衰竭血透患者67例，分别采用长期导管（23例）、临时导管（24例）、动静脉内瘘（20例）建立透析血管通路。分别观察每组的使用时间、透析效果及并发症。【结果】三组透析效果相当，长期导管组导管使用时间长于临时导管组及动静脉内瘘组，长期导管组与动静脉内瘘组并发症发生率相比较差异无显著性，均明显低于临时导管组。【结论】长期留置导管对于不能建立理想的内瘘和不能耐受内瘘手术的DN肾衰竭血透患者是一种理想的选择，对于不愿耐受血透穿刺痛苦的患者长期导管可作为首选的血管通路。     

甲状旁腺全切除加前臂移植术后动静脉内瘘早期失功的临床分析

目的回顾性分析甲状旁腺全切除加前臂移植术后动静脉内瘘早期失功的原因及影响因素。方法选择2011年9月～2015年5月在南京医科大学第一附属医院接受甲状旁腺全切除加前臂移植的497例尿毒症继发性甲状旁腺功能亢进患者。其中14例患者在术后24h内发生动静脉内瘘失功。选择同期手术的28例内瘘功能正常的患者(对照组),进行1:2匹配,比较内瘘失功组与对照组的一般情况、手术前后的血压以及生化参数等的变化。结果 14例患者中有2例在术后透析过程中发生内瘘穿刺处血肿,1例患者术中发现甲状腺癌而同时行甲状腺癌根治术,2例术中出现血压明显下降;1例在既往7年中内瘘失功6次,本次在术后12h出现内瘘失功。动静脉内瘘失功组的手术前后收缩压下降值(20.28±17.72)mmHg较对照组的(3.11±17.58)mmHg存在明显差异(t=2.978,P=0.005);收缩压的降低与手术前后血钙水平的降低相关(r=0.385,P=0.012)。回归分析提示手术前后收缩压的下降是术后动静脉内瘘早期失功的危险因素(HR=1.053,95%CI 1.012～1.095,P=0.010)。结论甲状旁腺全切除加前臂移植术后可能发生动静脉内瘘早期失功。手术前后收缩压的下降是术后动静脉内瘘早期失功的危险因素,术后透析过程中血肿的发生也需要密切关注。     

维持性血液透析患者自体动静脉内瘘失功的相关因素分析

目的 探讨维持性血液透析(HD)患者自体动静脉内瘘(AVF)失功的相关因素.方法 回顾性分析AVF行HD的225例患者,透析时间为3～60个月,根据AVF是否失功分成通畅组和失功组,观察两组患者的综合情况(年龄、性别、原发病、血压、高凝倾向)和AVF的各项指标(血栓形成、内瘘狭窄、血流量、压迫时间、穿刺方法、使用时间、血肿)对AVF失功的影响.结果 225例患者中有43例(占19.11%)失功;失功组的平均年龄高于通畅组(P＜0.01);通畅组和失功组在血栓形成、内瘘狭窄、原发病是否为糖尿病肾病、发生血肿、低血压、高凝倾向、穿刺点压迫时间、血流量以及穿刺方法等指标方面差异均有统计学意义(P＜0.05).结论 年龄、血栓形成、内瘘狭窄、糖尿病肾病、压迫时间、内瘘血肿、低血压、低血流量、高凝倾向及纽扣式穿刺法是影响AVF失功的重要因素.     

自体动静脉内瘘失功后的血管通路选择

动静脉内瘘失功是血液透析患者血管通路常见的并发症。一旦动静脉内瘘失功,将面临进一步的血管通路选择问题。目前有8种技术可以解决自体动静脉内瘘失功后的血管通路问题,即经皮腔内血管成形术、静脉内膜增生物剥离/内瘘重建、远离狭窄部位的内瘘重建、重新建立自体内瘘(导管过渡)、移植物内瘘、中心静脉导管、手术切开取栓和内瘘血管搭桥。原则上能修复的内瘘尽最大可能修复,以保护血管资源,提高自体动静脉内瘘使用率。综合考虑,应优先选择手术修复,其次是经皮腔内血管成形术。其他的选择应根据患者的具体情况而定。     

维持性血液透析患者内瘘情况分析

目的 分析血液透析患者的内瘘使用情况以及内瘘失功常见原因及其处理.方法 采集436例患者病史和体格检查,动静脉内瘘手术方法分别为非惯用手前臂桡动脉和头静脉侧侧吻合,结扎远心端头静脉,形成改良端侧吻合,少数为惯用手前臂桡动脉和头静脉侧侧吻合,观察内瘘一般情况,统计患者开始透析时间,内瘘手术时间,开始使用时间,内瘘失功时间,目前内瘘使用情况.结果 436例患者完成统计,其中男性245例,女性191例,内瘘失功76例,138例患者肾移植术后自然堵塞.结论 自体内瘘是维持性血液透析患者的主要血管通路,内瘘失功的主要原因是内瘘血栓形成和内瘘狭窄,糖尿病、低血压、高超滤量是易患因素,正确的穿刺和透析结束后绑带绑扎时间和方法亦很重要.     

影响自体动静脉内瘘早期功能失功的相关因素及护理干预对策

目的:探讨影响自体动静脉内瘘(AVF)早期功能失功的相关因素及护理干预对策。方法:将2011年1月~2012年12月接受AVF术的血液透析患者215例列为对照组,给予常规护理,分析导致失败的相关因素,将2013年1月~2014年12月行AVF术的血液透析患者230例列为观察组,在常规护理的基础上,根据对照组失败的相关因素基础上制定相应的护理措施进行干预,比较两组AVF早期失功率。结果:观察组AVF失功率明显低于对照组(P0.05),对照组年龄55岁、体重指数(BMI)24.0 kg/m2、低血压状态、导管留置时间30 d伴有糖尿病、感染性疾病失功率明显高于年龄≤55岁、BMI≤24.0 kg/m2、非低血压状态、导管留置时间≤30、非糖尿病、无感染性疾病患者(P0.05);年龄、BMI、低血压状态、导管留置时间、伴有糖尿病、感染性疾病是影响AVF失功的关键因素(P0.05)。结论:AVF失功年龄、BMI、低血压、导管留置时间、糖尿病及感染有关,根据影响因素制定相关护理干预措施可有效预防AVF失功。     

Right ventricular diastolic function in dialysis patients could be affected by vascular access

Tricuspid annular plane excursion (TAPSE) measurement in echocardiography is a measure of heart diastolic distensibility: a low TAPSE indicates reduced ventricular distensibility leading to diastolic dysfunction. It is a good prognostic index for cardiac mortality risk in congestive heart failure patients, adding significant prognostic information to the NYHA clinical classification. Our study was designed to evaluate the effect of a single hemodialysis (HD) session on diastolic function and TAPSE, focusing on the effects of vascular access typology. Twenty chronically uremic patients (age 51 ± 10 years, dialytic age 24 ± 8 months), without overt heart disease, underwent conventional two-dimensional and Doppler echocardiography immediately before starting and 15 min after ending a mid-week HD session. Ten patients had distal radiocephalic arterovenous fistula (AVF), and 10 had permanent central venous catheters (CVC). The amount of fluid removed by HD was 2,706 ± 1,047 g/session. HD led to a reduction in TAPSE, left ventricle end-diastole volume, left ventricle end-systole volume, right ventricle end-diastole diameter, peak early transmitral flow velocity, and the ratio of early to late Doppler velocities of diastolic mitral flow. AVF patients showed greater right ventricle diameters versus CVC patients, while TAPSE appeared higher in the latter. Only the AVF patient group showed TAPSE values <15 mm. Our data confirm the effects of terminal uremia on right ventricle function (chamber dilation, impaired diastolic function), showing that these abnormalities are more frequent in AVF patients as opposed to CVC patients. It is reasonable to explain these clinical features as the effect of preload increase operated by AVF.     

活血化瘀中药外用对维持性血液透析患者动静脉内瘘功能影响的Meta分析

目的 系统评价活血化瘀中药外用对维持性血液透析患者动静脉内瘘(Arteriovenous Fistula,AVF)功能的影响。方法 计算机检索CNKI、万方数据知识服务平台、维普中文科技期刊数据库、中国生物医学文献数据库、PubMed、Cochrane Library、EMBase、Web of Science数据库,由两名研究者单独筛选文献、提取资料。采用RevMan 5.3软件进行Meta分析,采用Cochrane偏倚风险评估工具对纳入文献进行质量评价。结果 共纳入26篇随机对照试验,共2039例MHD患者。Meta分析结果显示,观察组皮下血肿治疗有效率〔相对危险度(RR)=1.25,95%CI(1.19,1.32),P＜0.00001〕、血管硬结改善率〔相对危险度(RR)=1.44,95%CI(1.18,1.75),P=0.0003〕、血管杂音增强率〔相对危险度(RR)=1.55,95%CI(1.31,1.83),P＜0.00001〕高于对照组,差异有统计学意义。观察组血管硬结发生率〔相对危险度(RR)=0.11,95%CI(0.06,0.22),P＜0.00001〕、血管狭窄发生率〔相对危险度(RR)=0.32,95%CI(0.20,0.49),P＜0.00001〕、内瘘闭塞发生率〔相对危险度(RR)=0.15,95%CI(0.07,0.33),P＜0.00001〕、假性假性动脉瘤发生率〔相对危险度(RR)=0.51,95%CI(0.35,0.75),P=0.0006〕均低于对照组,差异有统计学意义。结论 基于目前证据,对于AVF的维护,联用活血化瘀中药能更好地治疗内瘘穿刺后皮下血肿、软化血管硬结、增强血管杂音,且能预防血管硬结、血管狭窄、内瘘闭塞、假性假性动脉瘤并发症的发生。     

Impact of a hemodialysis session on cardiac function in patients with chronic renal failure

AIM: To determine the impact of hemodialysis (HD) session on cardiac function in patients with chronic renal failure. MATERIAL AND METHODS: Thirty patients (17 male, 13 female, mean age 49 +/- 11 years) on bicarbonate HD were studied. M-mode echocardiography was performed and ejection fraction (EF) was estimated. Transmitral flow was assessed by Doppler echocardiography. Peak velocity of early (E) and late (A) filling, E/A ratio, isovolumic relaxation time (IVRT) and early deceleration time (DT) were estimated. All the estimations were made one hour before and immediately after HD by one investigator. Flow propagation velocity of early diastolic flow was assessed by color M-mode Doppler echocardiography. RESULTS: A significant decrease of the ejection fraction (delta EF) was observed only in patients with intradialytic hypotension. Hemodialysis resulted in a decrease of early flow velocity from 99.2 +/- 23.8 to 80.6 + 26.0 cm/s (p = 0.0000) and E/A ratio from 1.23 +/- 0.57 to 0.98 +/- 0.43 (p = 0.006). IVRT and DT showed no significant difference. There was a significant positive correlation between the amount of ultrafiltration and deltaE (r = 0.46; p = 0.01), there was no correlation between the amount of ultrafiltration and delta Vp (r = -0.01; p = 0.9). CONCLUSION: The results show that a hemodialysis session influences cardiac function in patients with chronic renal failure. Early diastolic filling considerably decreased in correlation with ultrafiltration. A significant decrease in an ejection fraction was detected only in patients with intradialytic hypotension. Ultrafiltration had no impact on flow propagation velocity of early diastolic flow of the left ventricle assessed by color M-mode Doppler echocardiography.     

扣眼穿刺法与绳梯穿刺法对动静脉内瘘功能影响的Meta分析

目的分析扣眼穿刺法与绳梯穿刺法对维持性血液透析(maintenance hemodialysis,MHD)患者自体动静脉内瘘(arteriovenous fistula,AVF)的影响,选取适合AVF患者的最佳穿刺方法,更好地保护内瘘。方法通过计算机检索PubMed、Cochrane Library、Elsevier、Wiley、中国知网、中国生物医学文献、维普和万方等国内外数据库中扣眼穿刺法与绳梯穿刺法对MHD患者影响的相关研究,由2位评价者独立进行文献筛选、资料提取、质量评价并进行交叉核对,采用RevMan 5.3软件进行Meta分析。结果最终纳入9个研究,共757例患者。Meta分析结果显示:在MHD患者中,扣眼组的感染发生率随着时间的增加而大幅上升,随访时间≤6个月时,虽然2组间差异无统计学意义(P=0.080),但扣眼组的感染发生率是绳梯组的3.42倍[RR=3.42,95%CI:(0.86~13.69)],随访时间>6个月时,扣眼组的感染发生率增至绳梯组的14.43倍(RR=14.43,95%CI:3.50~59.55),2组间的差异具有统计学意义(RR=8.33,95%CI:3.17~21.88,P=0.000);绳梯组血管狭窄或阻塞发生率低于扣眼组(RR=4.64,95%CI:2.01~10.72,P=0.000);2组患者血肿(RR=0.70,95%CI:0.42~1.16,P=0.170)和血栓(RR=0.83,95%CI:0.43~1.58,P=0.570)发生率的差异无统计学意义。结论在常规AVF患者穿刺时,绳梯法比扣眼法有助于降低远期并发症,更利于保护内瘘血管功能以延长AVF使用寿命。我们需要更多研究来帮助制定改进扣眼穿刺技术的策略,而不是禁用此技术。作为绳梯穿刺法的有益补充,应使扣眼穿刺法发挥其优势作用,更好地服务于AVF患者。     

Effect of cryotherapy on pain management at the puncture site of arteriovenous fistula among children undergoing hemodialysis

ObjectiveTo evaluate the effectiveness of cryotherapy in managing the pain at the puncture site of Arterio-Venous Fistula (AVF) among children undergoing maintenance hemodialysis (HD).MethodsA one-group pre-post quasi-experiment was performed in two HD centers affiliated with Cairo University. The experiment involved 40 children with AVF undergoing HD. Before puncturing, cryotherapy was applied using 2 cm–3 cm pieces of frozen distilled water in a plastic bag. Pain was assessed subjectively and objectively in two dialysis sessions before and after cryotherapy. A part from a physiological assessment of vital signs, pain was assessed using the Wong–Baker Faces Pain and the Observed Pain Behavior rating scales. All research ethics were applied.ResultsHD had a median duration of four years, while cryotherapy had a median application time of 8.8 min. The Wong–Baker Faces Pain score and almost all observed pain behaviors significantly decreased after cryotherapy. Significant improvements were observed in respiratory rate before and after needle puncture and in oxygen saturation after needle puncture. A lower skin dryness was observed after cryotherapy (12.5%) than before cryotherapy (52.5%; p < 0.001).ConclusionsCryotherapy can effectively reduce the venipuncture pain among children with AVF undergoing maintenance HD. However, the confounding effects of distraction and the non-randomized design used must be both considered when interpreting the findings. This study recommends the use of cryotherapy in managing needle puncture pain. Further research must adopt a randomized trial design with a placebo to support further the benefits of this procedure.     

不同血液透析模式对透析中低血压的影响

目的 比较低温+超滤曲线HD、钠曲线+超滤曲线HD、低温+钠曲线HD、低温+钠曲线+超滤曲线HD、常规HD+上机前口服米多君与常规HD在透析过程中低血压发生的情况.方法 对经常出现血液透析相关性低血压的20例维持性血透患者,依次实施常规HD、低温+超滤曲线HD、钠曲线+超滤曲线HD、低温+钠曲线HD、低温+钠曲线+超滤曲线HD、常规HD+上机前口服米多君,每人每种方式实施四周的治疗剂量,观察比较6种模式透析低血压的发生情况.结果 低温+超滤曲线组、钠曲线+超滤曲线组、低温+钠曲线组低血压的发生率低于常规组(P＜0.05),低温+超滤曲线+钠曲线组、上机前口服米多君组低血压的发生率显著低于常规(P＜0.01),低温+超滤曲线组、钠曲线组+超滤曲线、低温+钠曲线组,之间比较低血压的发生率无差异(P＞0.05),低温+超滤曲线+钠曲线组与上机前口服米多君组低血压的发生率无差异(P＞0.05),低温+超滤曲线组、钠曲线组+超滤曲线、低温+钠曲线组与低温+超滤曲线+钠曲线组、常规透析+上机前口服米多君组之间低血压的发生率经统计学处理均有显著差异(P＜0.01).结论 在体重增长、超滤率大致相等情况下,低温+超滤曲线+钠曲线组与常规HD+上机前口服米多君组低血压的发生率在统计学无意义(P＜0.01),提示这两种透析模式预防透析相关性低血压的效果最佳,可以根据患者的经济及对透析模式的耐受情况具体选择.

Abstract：

Objective Low -temperature + UF curves HD, sodium curve + UF curves HD, low -temperature + sodium curve HD, low - temperature + sodium curve HD + UF curves HD, HD + oral administration of midodrine before dialysis' and conventional HD were comprised to observe hypotension occurrence during hemodialysis. Methods Twenty patients were selected who occurred related hypotension frequently. They were treated with the following proposals: conventional HD, low -temperature + UF curves HD, sodium ctuve+UF curves HD, low - temperature + sodium curve HD, low - temperature + sodium curve + UF curves HD, conventional HD + oral administration of midodrine before dialysis. Each patient's treatments lasted four weeks under each dialysis mode. The incidence of hypotension were observed and compared among six dialysis modes. Results The incidence of hypotension in low - temperature + UF curves, sodium curve + UF curves, low - temperature + sodium curve groups were lower than that of ( P ＜ 0. 05), the incidence of hypotension in lowtemperature + sodium curve + UF curves, oral administration of midodrine before dialysis groups were significant lower than that of conventional group (P＜0.01) . The incidences of hypotension among low- temperature + UF curves HD group, sodium curve + UF curves group and low - temperature + sodium curve group were no difference ( P ＞ 0. 05) . The incidences of hypotension between low - temperature + sodium curve + UF curves group and oral administration of midodrine group were no difference ( P ＞ 0. 05) . There was significant difference by statistical treatment on incidences of hypotension between low - temperature + UF curves group, sodium curve + UF curves group, low- temperature + sodium curve group and low- temperature + sodium curve + UF curves group, conventional HD + oral administration of midodrine before dialysis group (P＜0.01). Conclusions The incidences of hypotension in low - temperature + sodium curve + UF curves group and conventional HD + oral administration of midodrine before dialysis group were no statistical significance ( P＜0. 01). It hints that the effect of preventing dialysis - related hypotension is the best under two modes. The patients can choose these modes according to their economy and endurance.     

影响动静脉内瘘成熟的因素探讨

目的了解内瘘手术后存活情况以及影响内瘘成熟的因素。方法前瞻性研究390例患者内瘘手术动静脉直径和动脉开窗长度、动脉增厚、原发病等因素对内瘘成熟的影响以及并发症情况。结果390例患者共计413例次动静脉内瘘吻合手术,其中370次初次瘘,再次瘘43例次。手术共有43例次（10.4%）内瘘失败。包括术后未成熟的共34例次,另外有8例次是在使用一定时间（6～12个月）后失功能。其中22例是经彩色多普勒证实为血栓形成。内瘘失败与年龄、性别、动静脉内径、以及吻合部位和术后是否抗凝无关,与糖尿病和动脉增厚,动脉吻合口大小有关。糖尿病（OR=2.72,95%CI：1.18-6.28,P=0.019）及吻合口大小（OR=0.12,95%CI：0.02-0.62,P=0.011）是内瘘失败的独立危险因素。结论动静脉内瘘失败的发生率为10.4%。血栓形成是内瘘失败的主要原因。动静脉内瘘失败的主要危险因素是内瘘吻合口直径及糖尿病。     

维持性血液透析患者动静脉内瘘侧上肢功能障碍及其影响因素的研究

目的评估维持性血液透析(maintenance hemodialysis,MHD)患者动静脉内瘘侧上肢功能,分析动静脉内瘘对肢体功能的影响和相关影响因素。方法选择中国康复研究中心北京博爱医院规律血液透析超过3个月的MHD患者67例,评估其上肢功能:双手握力、指捏力、腕关节活动度和简易上肢功能评分。结果①握力:MHD患者内瘘侧握力与非内瘘侧相比偏低[(24.22±12.54)比(26.05±11.01)N,t=-2.075,P=0.042];多元线性回归分析结果显示,年龄、白蛋白、内瘘侧被动背伸异常为内瘘侧握力水平下降的独立危险因素(β分别为-0.364、0.408、-0.231,P值分别为0.002、0.001、0.044),动静脉内瘘是利手握力的独立危险因素(β=-0.345,P=0.006)。②指捏力:内瘘侧指捏力与非内瘘侧相比无明显差异[拇指-食指:(6.24±3.78)比(6.19±2.13)N,t=0.104,P=0.918;拇指-中指:(4.69±1.70)比(4.83±1.57)N,t=-0.820,P=0.417;拇指-无名指:(2.97±1.35)比(3.10±0.99)N,t=-0.808,P=0.423]。③腕关节活动度:内瘘侧的被动掌曲活动度异常的比例较非内瘘侧高(38.6%比19.3%,x^2=5.160,P=0.023)。④简易上肢功能评分:评分异常者在内瘘组和非内瘘组所占比例无统计学差异(6%比9%,x^2=0.437,P=0.509),内瘘侧肢体与非内瘘侧肢体相比粗大动作评分(49比47,Z=-1.371,P=0.170)、精细动作评分(49比48,Z=-1.126,P=0.260)和总分(96比96,Z=-1.285,P=0.199)无统计学差异。结论MHD患者内瘘侧肢体与非内瘘侧肢体相比存在握力下降和被动掌曲功能异常,需要引起临床医师的高度关注,尽早开展内瘘侧手部的抓握运动及腕关节的掌曲、背伸、旋转活动,以期提高患者的生活质量和工作能力。     

左心室重量指数和主动脉弓钙化评分是维持性血液透析患者预后的独立预测因素

目的分析维持性血液透析(maintenance hemodialysis,MHD)患者发生全因死亡、心血管(cardiovascular,CV)死亡和非致死性心血管事件(CV events,CVE)的预测因素,比较血液透析(hemodialysis,HD)和在线血液透析滤过(hemodiafiltration,HDF)对相关因素以及长期预后的影响。方法入组333名MHD患者,随访50±15月,观察全因死亡,CV死亡和CVE发生。在入组基线时,记录人口学资料,测量临床指标。根据入组后的治疗模式,将患者分为HD组(n=268)和HDF组(n=65)。在第6个月末,测量临床和实验室指标。使用COX模型分析基线时全因死亡,心血管死亡和CVE的预测因素。分别使用t检验和Kaplan-Meier生存分析比较组间第6个月末相关因素以及长期预后差异。结果年龄(RR=1.041,P<0.001)、女性(RR=0.615,P=0.020)、左心室重量指数(left ventricula rmass index,LVMI)(RR=1.011,P=0.006)、主动脉弓钙化评分(aortic arch calcification score,AoACS)(RR=1.277,P<0.001),血红蛋白(hemoglobin,Hb)<100g/L(RR=2.609,P<0.001),铁蛋白>500ng/ml(RR=1.637,P=0.037)是发生全因死亡的独立预测因素。C反应蛋白(C-reactive protein,CRP)(RR=1.093,P<0.001)、LVMI(RR=1.030,P<0.001)、AoACS(RR=1.652,P<0.001)和Hb<100g/L(RR=2.144,P=0.016)是发生CV死亡的预测因素。心血管疾病(cardiovascular disease,CVD)病史(RR=3.408,P<0.001),LVMI(RR=1.028,P<0.001)和AoACS(RR=1.329,P=0.003)是发生非致死性CVE的预测因素。第6个月末,HDF组患者体质量指数(body mass index,BMI)(t=-2.494,P=0.013)、体质量(t=-2.252,P=0.023)、总胆固醇(t=-1.992,P=0.047)和Hb(t=-2.175,P=0.030)水平较高,CRP(t=6.432,P<0.001)、LVMI(t=2.420,P=0.017)和AoACS(t=2.337,P=0.020)水平较低。HDF组患者全因死亡(x2=9.610,P=0.002)、CV死亡(x2=4.533,P=0.033)和CVE(x2=4.598,P=0.032)等长期预后更好。结论年龄、性别、LVMI、AoACS、Hb和铁蛋白是MHD患者全因死亡的独立预测因素,CRP、LVMI、AoACS和Hb是CV死亡的独立预测因素。CVD病史、AoACS和LVMI是非致死性CVE的预测因素。HDF能改善MHD患者BMI、体质量、总胆固醇、Hb、CRP、LVMI、AoACS,以及全因死亡、心血管死亡和CVE等长期预后。