动静脉内瘘血流量对维持性血液透析患者心功能的影响

目的探讨动静脉内瘘血流量(AVFB)对维持性血液透析患者心功能的影响。方法选择利用动静脉内瘘行血液透析的慢性肾衰竭患者90例,依据AVFB值大小分为低流量组(AVFB400 ml/min,28例)、中流量组(AVFB在400~600 ml/min,33例)和高流量组(AVFB600 ml/min,29例)。动静脉内瘘吻合术后患者进行1年维持性血液透析,观察期间患者高危事件及内瘘失功能发生情况。采用彩色多普勒超声显像仪,分别在透析前(动静脉内瘘吻合术后1个月)、透析1年后测定心排出量(CO)、心脏指数(CI)和射血分数(EF)。结果三组患者高危事件发生率有统计学差异(P0.05),高流量组患者高危事件发生率显著高于低流量组和中流量组(P0.05)。三组患者内瘘失功能发生率有统计学差异(P0.05),低流量组患者内瘘失功能发生率显著高于中流量组和高流量组(P0.05)。透析后,三组CO、CI和EF的差异有统计学意义(P0.05);高流量组各指标值较低流量组、中流量组显著升高,(P0.05),与透析前比较,中流量组、高流量组CO、CI和EF水平均较透析前升高。结论维持性血液透析患者建立动静脉内瘘时,应注意限制血流量,既要避免因血流量过低引起的内瘘功能丧失,又要防止因血流量过大所致的心力衰竭。     

老年动静脉内瘘与长期置管血液透析患者的生存分析

目的分析老年动静脉内瘘与长期置管血液透析患者生存情况。方法选取老年长期置管维持性血液透析治疗患者109例,按血管通路类型分为动静脉内瘘组和长期置管组;对所有患者均常规进行血生化检查;利用超声心动检查评价左心室功能,每月随访1次,随访时间24~30个月,以患者死亡为观察终点。结果两组患者左心室肥厚发生率、左心室收缩功能异常发生率及左心室舒张功能异常发生率无差别;但动静脉内瘘组患者血红蛋白和血全段甲状旁腺激素(i PTH)水平低于长期置管组(t=2.249,P=0.027;t=-3.085,P=0.003)。Kaplan-Meier生存曲线结果显示,两组患者生存率差异无统计学意义;但长期置管组老年血液透析患者发生左心室收缩功能异常及左心室舒张功能异常的患者生存率高于动静脉内瘘组患者(P=0.044);同时长期置管组发生左心室肥厚的患者生存率低于动静脉内瘘组(P=0.014);多因素COX风险分析显示,血红蛋白、PTH、血钙、收缩压是老年血液透析患者发生死亡事件的危险因素。结论不同血管通路对于老年维持性血液透析患者生存没有影响,对于使用动静脉内瘘的老年维持性血液透析患者,发生左心室功能异常的患者生存率较低。     

上肢高位动静脉内瘘建立在老年血液透析患者的应用

目的 评价各种上肢动静脉内瘘在老年血液透析患者中的应用效果和主要并发症.方法 对46例尿毒症血液透析患者行直接动静脉内瘘,分高位组(前臂上端及肘窝处)26例,腕部标准组20例,比较两组内瘘的血流量、成熟时间、开始应用时间、通畅率及并发症.结果 两组在成熟时间、开始应用时间无显著差异,但内瘘血流量差异显著(P＜0.05).高位组内瘘闭塞2例,标准组内瘘闭塞2例.血栓形成发生率分别为7.69%和6.67%(P＞0.05).结论 高位动静脉内瘘血流量好、通畅率高,为血管条件差的老年患者建立血液透析血管通路的最佳选择.     

专项预见性干预减少老年透析患者动静脉内瘘并发症观察

目的观察专项预见性干预减少老年透析患者动静脉内瘘相关并发症。方法选择2017年1月至2018年6月在我院血液透析科首次接受维持性血液透析治疗的老年患者85例,随机分为预见性干预组(43例)及对照组(42例),预见性干预组另行专项护理干预,内容包括进行健康教育、指导围术期功能锻炼、采用弹力包扎预防出血、预防假性动脉瘤形成、预防内瘘血栓形成。结果接受维持性血液透析治疗1年后,预见性干预组的内瘘闭塞、动脉瘤样扩张、血栓形成及并发症总例数均明显低于对照组(P<0.01,P<0.05)。结论专项预见性干预可以明确减少老年透析患者动静脉内瘘相关并发症。     

前臂近端自体动静脉内瘘在老年血液透析病人中的应用

目的探讨老年血液透析病人在前臂近端建立自体动静脉内瘘的优劣性及临床转归。方法选取在我院进行首次自体动静脉内瘘建立的老年病人,分为近端组(桡动脉起始段与正中静脉或头静脉吻合)和远端组(桡动脉与头静脉吻合),观察2组病人内瘘术后的手术并发症以及内瘘血流量、成熟情况及预后等。结果所有内瘘手术术后即刻成功率为100%。术后6~8周进行内瘘超声评估,近端组和远端组的血流量分别为(1328.5±234.4)mL/min和(1125.6±198.1)mL/min(P<0.05),首次穿刺时间分别为(56±15)d和(62±13)d(P=0.03),首次穿刺成功率分别为87.8%和78.9%(P<0.05)。2组术后总体并发症发生率差异无统计学意义(P>0.05);所有手术6个月的总体通畅率为92.41%,1年的总体通畅率为81.01%。2组病人1年的内瘘存活率差异无统计学意义(85.2%比74.1%,P=0.32),但在第2年时,近端组的存活率为74.3%,明显高于远端组的48.3%(P<0.05);同时近端组由于血栓形成而导致的内瘘闭塞率及再次手术干预次数也低于远端组(P<0.05)。结论前臂近端自体动静脉内瘘具有成熟快、流量充足、通畅率高等优点,对于前臂远端血管条件不佳、需建立内瘘的老年人,尤其是高龄病人可以优先考虑。     

鼻烟窝动静脉内瘘对中青年及老年尿毒症血液透析患者的疗效对比

目的 通过比较老年及非老年患者建立鼻烟窝自体动静脉内瘘应用于尿毒症血液透析的临床疗效,来探讨老年患者建立鼻烟窝动静脉内瘘的临床特点.方法 根据患者就诊及随访情况,记录患者的基本病情,建立鼻烟窝动静脉内瘘的时间,血管的情况,内瘘成熟所需时间,内瘘第一次穿刺时间,透析时的初始血流量,内瘘用于透析的时间,内瘘的畅通情况,发生的并发症等.结果 两组患者的基本病情,建立鼻烟窝动静脉内瘘的平均吻合口内径,内瘘成熟时间,透析时的初始血流量,内瘘用于透析的时间以及分别在1个月、1年、2年及3年的畅通率,并发症发生情况均无显著差异(P＞0.05).结论 老年患者建立鼻烟窝自体动静脉内瘘用于尿毒症血液透析安全有效.     

改良鼻烟窝动静脉内瘘对血液透析患者心功能的影响

目的探讨改良鼻烟窝动静脉内瘘（AVF）对血液透析患者心功能的影响。方法选取我院采用动静脉内瘘进行维持性血液透析患者60例，根据手术部位不同将患者分为两组：A组30例，行前臂桡动脉与头静脉端侧吻合术；B组30例，行改良鼻烟窝处桡动脉末端与头静脉端侧吻合术。彩色多普勒超声显像观察患者AVF术前、术后1个月、术后半年的心输出量（CO）、心脏指数（CI）、射血分数（EF）和短轴缩短率（FS），同时测定不同时期内瘘吻合口直径（AVFD）、内瘘血流量（AVFB）值。结果术后1个月及术后半年心输出量、心脏指数较术前明显增高（P〈0．01），射血分数、短轴缩短率变化不明显；AVFB、AVFD与心输出量差值（△CO）、心脏指数差值（△CI）呈直线正相关（r=0．499，P〈0．01）。A组AVFB、△CO、△CI明显大于B组（P〈0．05）。结论AVF对血液透析患者的心功能有一定影响。改良鼻烟窝AVF与前臂AVF比较，其血流量相对较小，对患者心功能的影响较小。     

动静脉内瘘部位对老年血液透析患者预后的影响

目的评价不同动静脉内瘘部位对老年尿毒症血液透析患者预后的影响。方法 80例老年肾衰竭尿毒症患者,经显微外科技术确定动静脉内瘘位置,根据建立部位不同分为4组:上肢前臂内瘘组15例、腕部内瘘组20例、鼻烟窝内瘘组22例、上臂肱动脉内瘘组23例,比较不同时间4组疗效与预后。结果 4组内瘘血流量比较上臂肱动脉内瘘组血流量水平明显高于其他3组(P<0.05);腕部内瘘组、上肢前臂内瘘组、鼻烟窝内瘘组的1年通畅率、2年通畅率、3年通畅率显著高于上臂肱动脉内瘘组(P<0.05);腕部内瘘组、上肢前臂内瘘组、鼻烟窝内瘘组的3年内并发充血性心力衰竭、血栓、假性动脉瘤发生率明显低于上臂肱动脉内瘘组(P<0.05)。结论血管条件良好老年尿毒症血液透析患者选择鼻烟窝内瘘作为首选部位,血管条件普遍较差者可选择上臂肱动脉内瘘。     

老年血液透析患者自体动静脉内瘘失功原因分析

目的 探讨老年血液透析患者自体动静脉内瘘失功原因,以寻求有效的预防措施.方法 选择维持性血液透析治疗且发生内瘘狭窄或闭塞的老年透析患者30例,回顾性分析患者自体动静脉内瘘失功的原因.结果 动静脉内瘘失功原因有低血压14例（46.7％）、维护不当4例（13.3％）、穿刺处出血/血肿3例（10.0％）和慢性失功9例（30.0％）.结论 低血压、维护不当、穿刺处出血/血肿和慢性失功是导致老年血液透析患者自体动静脉内瘘失功的原因.     

彩色多普勒超声对长期血液透析老年患者动静脉内瘘并发症的监测作用

目的 探讨彩色多普勒超声检测老年人长期血液透析动静脉内瘘并发症的临床应用价值.方法 36例血液透析老年患者,其中27例采用自体动静脉瘘,9例因自身血管条件限制,不能建立理想的血管通路,采用人工血管移植建立动静脉瘘,应用彩色多普勒超声检测动静脉内瘘的功能及其并发症的发生情况.结果 36例老年血液透析患者中,26例(72....     

Effect of Blood Pump Flow and Arteriovenous Fistula Blood Flow on the Blood Pressure and Cardiac Function in Patients Undergoing Maintenance Hemodialysis

The effect of blood pump flow rate on the cardiac functions of hemodialysis patients with arteriovenous fistula (AVF) is largely unknown. This study aimed to investigate if blood pump flow rate (Qb) and AVF access flow rate (Qa) can affect the cardiac function of Chinese hemodialysis patients. A total of 72 patients undergoing AVF hemodialysis were included from March 2010 to June 2014 and dichotomized into the high‐ and low‐flow groups using the medians of Qb (220 mL/min) and Qa (1000 mL/min) as the cutoffs. The cardiac function parameters were measured by ultrasound dilution technique within the first (t + 30) and the last (t ? 30) 30 min of dialysis. At t + 30, Qb‐high group had significantly higher systolic blood pressure (SBP) and mean arterial pressure (MAP) than Qb‐low group. At t ? 30, Qb‐high group had higher SBP, diastolic blood pressure (DBP), and MAP than Qb‐low group. Qa‐high group had higher SBP, MAP, cardiac output (CO), cardiac index (CI), central blood volume (CBV), and lower peripheral resistance than Qa‐low group. Multiple linear regression showed that at t ? 30, Qb was positively correlated with SBP and MAP. Qa was positively correlated with CO, CI, CBV, and PR but negatively correlated with heart rate. Although Qb > 220 mL/min and Qa >1000 mL/min would elevate some parameters, the means of SBP, DBP, MAP remain within the normal range, indicating that appropriate increase in blood pump flow rate has little effect on the cardiac function of hemodialysis patients.     

Early Failure of Dialysis Access among the Elderly in the Era of Fistula First

Background and objectives

Recent evidence indicates that fistula maturation and patency may be compromised in the elderly dialysis population compared with younger patients. The objective of this study was to characterize the short-term outcomes of arteriovenous fistulas and arteriovenous grafts for hemodialysis access in the Medicare population.

Design, setting, participants, & measurements

This was a retrospective cohort study performed using Medicare Part A and B claims data from 2006 through 2011. The study population included 16,464 dialysis-dependent patients age ≥66 years undergoing arteriovenous fistula and arteriovenous graft creation. The primary outcome measure was incidence of repeat fistula/graft creation and tunneled catheter placements in the 12 months after arteriovenous fistula and graft creation.

Results

In the 12 months postindex fistula/graft, the mortality in the fistula group was 28.2% versus 29.9% in the graft group (P=0.03). A repeat fistula/graft creation was required in 26.9% of patients in the fistula group and 16.7% in the graft group (P<0.001). There was no significant difference in the proportion of patients who required a tunneled hemodialysis catheter in the 12 months after an index fistula creation (fistula 28.4% versus graft 27.3%, P=0.19). In the index fistula group, 44.4% of patients required a repeat fistula/graft creation and/or a tunneled catheter, compared with 33.7% in the graft group (P<0.001). At 365 days after the index fistula/graft, the repeat fistula/graft/catheter-free survival was 39.7% in the fistula group versus 46.0% in the graft group (P<0.001). Index fistula was associated with a higher risk of loss of repeat fistula/graft/catheter-free survival with an odds ratio of 1.19 (95% confidence interval, 1.13 to 1.24).

Conclusions

Fistulas were associated with a somewhat lower mortality than grafts in the first 12 months after creation. However, the incidence of repeat fistula/graft creation and tunneled catheter placement is substantially higher in the first 12 months after fistula creation compared with grafts. One-year repeat fistula/graft/catheter-free survival is lower after fistula creation than grafts.     

Cardiac effects of persistent hemodialysis arteriovenous access in recipients of renal allograft

In hemodialysis patients, large arteriovenous (AV) fistulas for vascular access may cause ventricular hypertrophy and high-output cardiac failure. The long-term cardiac consequences of functional AV fistulas in renal transplant patients are unclear. A precise knowledge of these consequences is important to decide if and when such fistulas should be closed in successfully transplanted patients. In this retrospective study including 61 stable renal transplant patients with adequate renal function (serum creatinine <2.0 mg/100 ml), echocardiography was performed in 39 patients with a functional AV fistula (group 1) and in 22 whose fistulas had been closed, for esthetic reasons, within 2 months postoperatively (group 2). The volume flow of the fistulas, measured in 22 randomly selected individuals of group 1, was 900 +/- 350 ml/min (range 500-1,600). Patients of group 1 were older (40 +/- 12 vs. 33 +/- 12 years, p < 0.05), had longer duration of the fistula (62 +/- 31 vs. 36 +/- 30 months, p < 0.05), higher body mass index (24 +/- 4 vs. 22 +/- 3 kg/m2, p < 0.05), systolic (154 +/- 24 vs. 138 +/- 18 mm Hg, p < 0.05) and diastolic (96 +/- 12 vs. 89 +/- 11 mm Hg, p < 0.05) blood pressure and increased left ventricular (LV) end-diastolic dimension (53 +/- 5 vs. 49 +/- 5 mm, p < 0.01). LV mass, cardiac index, ejection fraction and the proportion of patients with LV hypertrophy were comparable in the two groups. LV end-diastolic dimension was positively and independently influenced only by the presence of the AV fistula (p < 0.01) after adjusting for age, duration of the fistula, body mass index, systolic and diastolic blood pressure and the nature of the antihypertensive drugs used. In conclusion, the persistence of large, high-flow AV fistulas for prolonged periods of time had little impact on cardiac morphology and function of stable renal transplant patients with adequate renal function. The data do not support routine closure of these fistulas in all renal transplant patients.     

Cardiac failure and upper extremity arteriovenous dialysis fistulas. Case reports and a review of the literature.

Nine patients with high-output cardiac failure from arteriovenous forearm dialysis fistulas are reviewed, and six new cases are presented. Decreases in cardiac output with temporary fistula occlusion ranged from 0.3 to 11.0 liters/min (mean, 2.9 liters/min); fistula flow rates varied from 0.6 to 2.9 liter/min (mean, 1.5 liters/min). Surgical correction of high-flow fistulas resulted in notable improvement of cardiac failure in 13 of 14 patients. Although cardiac failure in individuals who are receiving long-term dialysis treatment is usually caused by intrinsic cardiac disease, volume overload, or anemia, forearm fistulas with large flow rates may be an important contributing factor. Correction of these large flow rates may be an important contributing factor. Correction of these large flow rates by banding or closure can substantially improve cardiac function in selected patients.     

Clinical effect of high inhalation flow from a fluticasone diskhaler in chronic asthma]

The optimal inhalation flow of dry powder formula fluticasone dipropionate (DFP) is not known. This study investigated the clinical effects of inhaling a flow of DFP. A randomized cross-over trial was applied to 13 patients with chronic persistent asthma. After a 2-week run-in period using the current dose of beclomethasone from a metered dose inhaler (BDP-run), BDP was replaced with an equipotent amount of DFP. The patients entered either an 8-week run with high-flow (> 100 L/min) inhalation followed by a 4-week run with medium-flow (70 L/min) (HM group) or a medium-flow run followed by a high-flow run (MH group). The peak inhaling flow from DFP was measured daily. The mean of the inhalation flow in the high-flow run (111.4 +/- 3.6 (SE) L/min) was significantly higher than that (77.3 +/- 0.6 L/min) in the medium-flow run. In both groups, morning and evening peak expiratory flows (PEFs) increased in the first week of change from BDP to DFP, peaking in the first 8-week run, then maintained this level until the end of the following 4-week run. When PEFs in the last week of the 3 runs were compared, those during the DFP-run of either flow were significantly larger than those during the BDP-run, but the PEFs during the high-flow and medium-flow runs were not significantly different. The asthma symptoms also improved with a change from BDP to DFP, but the symptoms did not change with a change in the inhalation flow rate. An inhaled flow of up to 111 L/min is acceptable in terms of clinical efficacy for the use of DFP.     

心脏干预治疗在老年急性心肌梗死病人中的疗效及对炎症因子和心室重构的影响

目的探讨心脏干预治疗在老年急性心肌梗死病人中的临床疗效及对炎症因子、心室重构的影响。方法选择2018年3月至2019年3月老年急性心肌梗死病人88例作为对象,分为对照组(n=44)和观察组(n=44)。对照组给予介入治疗,观察组在对照组基础上联合心脏干预治疗,治疗4周后对病人效果进行评估,比较2组心功能水平、炎症因子水平、心室重构及心血管并发症发生率。结果观察组治疗后4周LVEF水平高于对照组,左心室舒张末内径(LVEDD)、左心室收缩末内径(LVESD)、BNP、细胞可溶性凋亡相关因子(s-FAS)、IL-6及hs-CRP水平均低于对照组(P<0.05);观察组治疗后4周总体心血管并发症发生率低于对照组(P<0.05)。结论心脏干预治疗能提高老年急性心肌梗死病人心功能水平,改善心室重构,降低炎症因子水平及介入治疗并发症发生率,值得推广应用。     

Matrix‐Metalloproteinase‐2 Predicts Arteriovenous Fistula Failure in Hemodialysis Patients

In hemodialysis patients the principal cause of arteriovenous fistula dysfunction is stenosis. Matrix‐metalloproteinase‐2 is implicated in the pathophysiological mechanism of stenosis development. Our study tried to assess the clinical impact of this protease on arteriovenous fistula survival. Seventy‐nine prevalent dialysis patients with functional arteriovenous fistulas were included in the study. The presence of stenosis and the serum levels of matrix‐metalloproteinase‐2 were determined at the beginning of the study. The patency of the arteriovenous fistulas was followed‐ up for two years. In multivariate regression; matrix‐metalloproteinase‐2 was a significant predictor of vascular access loss (HR = 1.104, 95%CI 1.033–1.179, P = 0.003). Patients with a level of matrix‐metalloproteinase‐2 lower than 50 ng/mL had a better survival of the arteriovenous fistulas. Matrix‐metalloproteinase‐2 was an even stronger predictor of fistula failure in the stenosis group (HR = 1.076, 95%CI 1.027–1.127, P = 0.002). In our study matrix‐metalloproteinase‐2 has a predictive value for arteriovenous fistula failure.