Multi-center investigation of intial hemodialysis vascular access in end-stage renal disease patients

Objective To investigate vascular access modalities at initiation of hemodialysis for end stage renal disease (ESRD) patients in hospitals of different levels, and to analyze the reasons contributing to the absence of arteriovenous fistula (AVF) during initial hemodialysis. Methods A pre-designed questionnaire was used to collect the information of patients that entered hemodialysis within five years, including basic information and their first vascular access types, and analyze the factors that influence patients' AVF use. Results (1) According to the 203 questionnaires returned from 5 hospitals, central venous catheter (CVC) was chosen by 122 (60.1%) patients, direct arteriovenous puncture by 44 (21.7%) patients, AVF by only 35 (17.2%) patients, and long-term cuffed catheter by 2 (1.0%) patients. For patients in different hospitals, 61.7% of patients in Jiamusi Hospital used direct arteriovenous puncture, while CVC were used most in the other four hospitals. The leading reason contributing to the absence of AVF was patient's refusal [75 cases (44.6%)], among which patients regarding AVF psychologically unacceptable accounted for the most [44 cases (26.2%)]. Following that were 45 cases (26.8%), in which patients were uninformed of AVF and 38 cases (22.6%) caused by time limitation. (3) Logistic regression showed well-educated, female, and urban residential patients were more likely to choose AVF at initiation of hemodialysis. Conclusion The percentage of AVF utility at the start of hemodialysis remains low, with situation varying in different hospitals and regions. Multiple factors are associated with vascular access modalities, among which the influence of doctors cannot be ignored. More efforts should be spared on patient education to improve the dialysis quality of ESRD patients in China.     

上臂人工血管移植透析内瘘的建立及应用

目的 探讨上臂人工血管移植透析内瘘的建立方法及临床应用价值. 方法参考国外文献设计了腋动脉与腋静脉建立上臂U形人工血管移植内瘘,腋动脉与肘窝贵要静脉作上臂直桥式内痿,肱动脉与腋窝腋静脉制作上臂直桥式内瘘,采用3种方法为20例长期血液透析患者建立了上臂人工血管移植透析通路.患者男9例,女11例.年龄37～64岁,平均54岁.透析时间2～15年.结果 20例手术操作均一次成功,术后6～8周用于临床穿刺透析,透析血流量220～300ml/min,血液再循环在正常范围,完全满足长期血液透析治疗的需要.结论 当前臂或上臂由于各种原因不能制作自体动静脉内瘘和前臂血管移植内瘘时,上臂腋窝制作人工血管移植血管内瘘是行之有效的方法.     

三维动态增强MR血管成像观察长期血液透析患者血管通路

目的评价三维动态增强磁共振血管成像（3D-DCE-MRA）观察长期血液透析患者自体动静脉内瘘功能不全的应用价值。方法对11例慢性肾功能不全接受长期血液透析的疑似自体内瘘功能不全患者行3D-DCE-MRA,观察血管通路。结果 11例患者均获得满意的血管图像。4例可见吻合口远端狭窄,其中3例位于流出道吻合处,1例位于距吻合口静脉端2cm处;2例可见尺动脉近段至吻合口段闭塞,桡动脉经掌弓动脉与尺动脉远段形成侧支循环后与头静脉相连;3例可见流出静脉瘤样扩张;2例可见静脉瘤形成。结论 3D-DCE-MRA可清晰显示自体动静脉内瘘及其相关血管,准确评价血管狭窄、闭塞及瘤样扩张。     

Epidemiology of vascular access and complications in patients undergoing maintenance hemodialysis in Tianjin

Objective To investigate the use of vascular access and complication incidence in patients undergoing maintenance hemodialysis in Tianjin. Methods Patients undergoing maintenance hemodialysis in the third level of first-class hospital in Tianjin were investigated. The investigate method was live interview. Two thousand six hundred and fifty-one cases were available. Basic data, age of dialysis, type of vascular access, age of vascular access and complications were recorded. The differences in clinic data and complications between patients using arteriovenous fistulas (AVF) and central venous catheter (CVC) as vascular access were compared. Results There were 2047 (77.22%) patients using AVF as vascular access, 559 (22.59%) patients using tunnel type central venous catheter, and 5 (0.19%) patients using arteriovenous graft (AVG) for maintenance hemodialysis. Most patients used temporary catheter as the first vascular access [2484(93.70%)]. Compared to AVF, CVC had high incidence of thrombosis and infection in the first four years (P=0.003). Conclusions AVF remains the first choice for maintenance hemodialysis. Most patients use AVF as their vascular access. The second preferred choice is CVC. The management of late chronic kidney disease should be enhanced to avoid the high usage of temporary catheter.     

肘部内瘘与腕部内瘘对维持性血液透析患者左心功能的影响

目的探讨肘部内瘘与腕部内瘘对维持性血液透析患者左心功能的影响。方法选择我院2007年1月至2010年6月维持性血液透析患者39例。血管通路为肘部内瘘者14例,为肘部内瘘组;血管通路为腕部内瘘者25例,为腕部内瘘组。比较2组左心室射血分数（EF）、短轴缩短率（FS）、左心房内径（LAD）、主动脉根部内径（AAo）、左心室舒张末期内径（LVDd）、左心室收缩末期内径（LVDs）、室间隔厚度（IVST）、左心室后壁厚度（LVPWT）、泵控血流量（Qb）及心脏舒张功能减退者比例[E／A（〈1）％]。结果肘部内瘘组LVDd较腕部内瘘组降低[（46．07±6．38）mm比（52．44±7．60）mm3（P〈0．05）,而EF、FS、LAD、AAO、LVDs、IVST、LVPWT、Qb及E／A（〈1）％无差异（P〉0．05）。结论与腕部内瘘相比,肘部内瘘并没有明显影响左心结构,并不成为高输出量性心力衰竭的高危因素。因此,在腕部内瘘不成功的情况下,可选择肘部内瘘作为长期透析的血管通路。     

Ultrasound evaluation and interventional therapy for peripheral vascular access stenosis in dialysis patients

Objective To investigate the patency rate and restenosis after percutaneous transluminal angioplasty (PTA) for the treatment of arteriovenous fistula (AVF) and arteriovenous graft (AVG) stenosis in dialysis patients. Methods The patients who were successfully treated by PTA for the first time in the blood purification center of the 2nd Affiliated Hospital of Nanjing Medical University from January 2016 to June 2017, including 71 cases of AVF in the forearm, 52 cases of AVF in the upper arm and 59 cases of AVG were recorded. The data of different stenosis parts were analyzed before and after treatment and followed up for 12 months. The initial patency rate and assisted-PTA patency rate were observed at 3 months, 6 months, 9 months, and 12 months after ultrasound interventional therapy, and the initial patency time for patients who needed to reintervention among all types of pathways were recorded. Results The initial patency rates at 3 months, 6 months, 9 months and 12 months after ultrasound interventional therapy were 98.59%, 90.14%, 71.93%, 54.93% respectively in forearm AVF, 90.38%, 65.38%, 42.31%, 32.69% respectively in upper arm AVF, 91.53%, 32.20%, 6.78%, 1.69% respectively in AVG, and the PTA-assisted patency rates were 98.59%, 97.18%, 95.77%, 94.37% respectively in forearm AVF, 92.31%, 86.54%, 84.62%, 80.77% respectively in upper arm AVF, 100.00%, 98.31%, 96.61%, 93.22% respectively in AVG, while the initial patency time was (8.99±3.54) months in forearm AVF, (6.33±3.01) months in upper arm AVF, (4.80±1.40) months in AVG respectively. Conclusions Ultrasound can comprehensively evaluate the function of peripheral vascular access, guide PTA treatment, and evaluate treatment outcomes. Ultrasound intervention therapy has best initial patency rate for forearm AVF stenosis. The prognosis of upper arm AVF stenosis PTA is relatively poor due to the easy cephalic stenosis. Although AVG has a short interval of restenosis, it can achieve a better long-term patency rate through regular intervention with ultrasound intervention.     

血液灌流在维持性血液透析并发难治性高血压治疗中的临床疗效观察

目的观察血液灌流（hemoperfusion,HP）对维持性血液透析（hemodiaIysis,HD）患者并发难治性高血压的治疗作用并探讨其可能的致病机制。方法将58例符合难治性高血压的维持性HD患者随机分为治疗组30例及对照组28例,治疗组在HD基础上进行HP治疗,每2周1次,每次2．5h,持续12周,对照组仅行HD治疗。观察两组治疗前、后血压变化,降压药使用种类以及血浆肾素活性（plasmareninactivity,PRA）、血管紧张素（angiotensin,Ang）Ⅱ、醛固酮（aldosterone,Ald）、内皮素（endothelin,ET）、全段甲状旁腺素（intactparathyroidhormone,i-PTH）等物质的水平。结果维持性HD并发难治性高血压患者体内存在较高水平的PRA、AngⅡ、Ald、ET、i-PTH,12周后治疗组PRA、AngⅡ、Aid、ET、i-PTH较治疗前以及对照组明显下降,差异有统计学意义（P〈0．05）,而对照组治疗前、后各项指标无明显变化（P〉0．05）,治疗组血压下降,使用降压药种类减少,与治疗前及对照组比较,差异有统计学意义（P〈0．05）,而对照组治疗前、后血压无明显变化（P〉0．05）。结论HP对维持性HD伴难治性高血压患者有显著的治疗作用。这与HP有效的清除尿毒症患者体内PRA、AngⅡ、Ald、ET、i-PTH等中、大分子物质有关。     

长期维持性血液透析患者并发的肺动脉高压

目的 研究长期维持性血液透析(MHD)患者肺动脉高压(PHT)的特征及相关因素.方法 参照2010年美国心脏超声协会右心检测指南,肺动脉收缩压(PASP)＞35 mm Hg诊为PHT.超声心动图和脉搏波传导速度(baPWV)于透析后次日集中检测.自体动静脉内瘘(AVF)流量采用超声稀释法检测.收集及评估患者的透析相关信息,取血检测血常规、钙、磷、甲状旁腺激素(iPTH)、肝肾功能等指标.结果 我院透析中心进行MHD 6个月以上,采用自体AVF并除外其他疾病引起并发PHT者,共111例,其中男性45例,女性66例,平均年龄( 57.32±12.49)岁,平均透析龄为(70.51±44.98)个月.28例诊为PHT,占25.23％,平均PASP为(45.68±10.83) mm Hg.PHT组的左室舒张功能不全明显较非PHT组常见(53.60％比6.02％,P＜0.01).PHT组左室射血分数(EF)值(62.06％±14.90％比69.72％±8.60％)、左室内径缩短分数(36.46％±10.04％比40.20％±7.86％)均低于非PHT组(均P＜0.01).EF＜50％者在PHT组和非PHT组分别占21.43％和3.61％.但PHT组和非PHT组在年龄、性别、透析龄、身高、体质量指数(BMl)、透析间期平均每日体质量增长、透析前血压、血红蛋白、血白蛋白、前白蛋白、血钙、血磷、iPTH、标准化蛋白分解率(nPCR)、Kt/V、baPWV以及AVF流量等差异均无统计学意义.结论 PHT是维持性血液透析常见的并发症,其发生与左室收缩和舒张功能下降密切相关;与钙磷代谢、AVF流量、血红蛋白、透析充分性及营养状态等无明显相关性.     

不同动静脉内瘘重建手术方式比较

目的 探讨终末期肾脏病血液透析患者动静脉内瘘失功后3种重建自体血管通路手术的优缺点,为临床选择做参考.方法 针对终末期肾脏病维持性3种液透析动静脉内瘘失功患者(241例),根据其自身血管条件、原有内瘘情况、血管彩超等检查结果,施行以下3种之其中一种重建自体血管通路的手术:原有内瘘近心端重新吻合血管(92例)、使用取栓管球囊行经皮血管成形术(包括内瘘取栓术和血管扩张术,87例),另选血管建立动静脉内瘘(62例).随访2年,比较3种手术方式的成功率、通畅率、平均血流量、并发症发生率等情况.结果 3种手术方式的手术成功率分别为93.5％、94.2％、96.8％,2年通畅率分别为80.4％、82.7％、80.6％,2年平均内瘘血流量分别为(250±24) ml/min、(240±21)ml/min、(230±16)ml/min,均无统计学差异.3组患者均无充血性心力衰竭、窃血综合征等严重并发症发生.结论 针对动静脉内瘘失功的血液透析患者,应依据血管条件选择手术方式来重建血管通路.经皮血管成形术(包括内瘘取栓术和血管扩张术)作为一种微创有效的手术方式,能最大限度地保留患者的血管资源,可予临床推广.     

北京市单中心初始血液透析动-静脉内瘘使用情况及相关因素分析

目的调查维持性血液透析（maintenance hemodialysis,MHD）患者初始透析动一静脉内瘘使用情况,并分析其相关因素,为提高初始透析动一静脉内瘘使用率提供参考依据。方法选择2012年1～3月北京市海淀医院接受维持性血液透析患者86例,采用问卷调查方式记录患者一般情况（如年龄、性别、婚姻状况、文化程度、职业、家庭收入）;患者疾病相关情况[如原发病、透析时间、肾科专科随访时间、在预计进入透析前半年行建立透析通路告知（以下称“预先通路告知”）、告知透析医院级别、居住地与最近医院距离、居住地与透析医院距离];对上述指标进行量化后Logistic回归分析。结果北京市海淀区单中心初始血液透析动一静脉内瘘使用率约为30．2％（26／86）,肾科专科随访1年以上（OR值4．825,P=0．02）、预先通路告知（0R值22．15,P=0．006）是主要影响因素。结论早期肾科专科随访、预先通路告知是影响维持性血液透析患者首次透析动一静脉内瘘使用的重要因素,慢性肾脏病患者早期肾科专科就诊、告知患者选择合适时机建立动一静脉内瘘可以提高初始血液透析动一静脉内瘘使用率。     

经皮腔内血管成形术在血液透析患者失功或未成熟动静脉内瘘中的应用

<正>自体动静脉内瘘是临床对需长期血液透析的慢性肾衰竭患者建立动静脉通路的常用方式,然而目前动静脉内瘘失功及未成熟的发生率仍较高,其中桡动脉—头静脉内瘘失功及未成熟发生率高达25%~33%~([1])。近年研究~([2-3])强调多数失功或未成熟的动静脉内瘘可通过经皮穿刺技术重塑再通。本研究旨在评估对需长期血液透析的动静脉内瘘患者进行经皮腔内     

HD02型血透监测仪对血液透析患者内瘘的监测

目的评价应用超声稀释法的HD02型血透监测仪对血液透析患者内瘘监测的效能。方法使用HD02型血透监测仪对90例长期维持性血液透析（MHD）患者在透析期间进行内瘘再循环、流量及心输出量等监测。分析影响内瘘流量的相关因素。结果4例患者出现再循环。占4．44％。且均大于5％（非尿素稀释法异常标准）。21例患者内瘘血流量〈500mL／min，占23．33％：3例〉2000ml／min，占3．33％。影响内瘘流量的Logistic回归分析显示，年龄、性别、透析时间、内瘘使用时间、平均动脉压均与内瘘流量下降无相关；低心输出量和糖尿病与内瘘流量下降相关。33例患者心输出量〈4L／min，占36．67％，提示部分患者在透析期间处于低心输出量状态。其中低心输出量的8例患者接受心脏彩色多普勒超声检查。均发现有不同程度的室间隔肥厚、瓣膜区钙化和反流、左室舒张功能不全等心血管功能和形态学改变。结论超声稀释法是一项操作简便、非侵入及实用的内瘘监测方法。自体动静脉内瘘在有足够血流情况下．再循环率低。低心输出量和糖尿病与内瘘流量下降相关。     

血液透析常用血管通路的选择与维护

血管通路是血液透析患者的生命线,及时建立和维护血管通路功能十分重要。老年人及糖尿病肾病的增多增加了建立内瘘的难度,各个专科技术和治疗手段的拓展影响了血管通路的建立,以及患者透析时间延长导致血管耗竭都使得血管通路医生面临巨大挑战。本文提出了目前的一些有关临床问题,强调保护好血管资源,正确选择血管通路;并进一步介绍维护内瘘通畅和实时介入干预技术,同时强调了分享带涤纶套隧道导管的应用与管理经验,也强调多学科合作,发展介入肾脏病学。     

Vascular access and patient outcomes in hemodialysis: questions answered in recent literature

Hemodialysis is not possible without access to the vascular system to provide an adequate and reliable source of blood flow through the hemodialyzer. Since maintenance hemodialysis therapy became a reality in the latter half of the twentieth century, no vascular access has exceeded the success and reliability of arteriovenous fistulae (AVF). They have the lowest infection and thrombosis rates, have the longest patency rates, and are associated with the best morbidity and mortality outcomes of any access modality. In the United States, the majority of patients starting hemodialysis do not have a primary AVF, which may explain why vascular access complications represent almost 20% of the total spending for hemodialysis. In addition, as much as 50% of hospitalization costs for end-stage renal disease are related to access issues. Every effort must be directed in the U.S. as well as elsewhere to promote the use of AVF whenever possible. In some European countries, more than 90% of patients have AVF as their hemodialysis access when nephrologists perform placement of vascular access. Already, some programs in the U.S. have recognized the need for trained nephrologists to provide these services. U.S. interventional nephrologists should be given the opportunity to learn AVF placement procedures to emulate their European counterparts, and thus improve U.S. dialysis outcomes.     

Femoral vein transposition is a durable hemodialysis access for patients who have exhausted upper extremity options

ObjectiveAccess surgeons often encounter patients with end-stage renal disease who have exhausted all upper extremity hemodialysis access options. Although the lower extremity is often the next alternative, prosthetic lower extremity access can be prone to infectious complications and historically has poor patency. We describe our contemporary experience with an autogenous femoral vein transposition (FVT) arteriovenous fistula.MethodsAll FVTs performed at an academic medical center from 2006 to 2018 were analyzed. FVTs were placed after upper extremity access was deemed no longer possible by the treating surgeon. Patient demographics, comorbidities, and access history were described, and perioperative and short-term outcomes, including maturation, were analyzed.ResultsTwenty-one patients treated with FVT were identified. The mean age was 55.3 ± 11.1 years; 23.8% were female, and 71.4% were African American. The median body mass index was 27.1 kg/m² (range, 17-46 kg/m²). Comorbidities included hypertension (100%), diabetes (61.9%), coronary artery disease (57.1%), congestive heart failure (47.6%), and obesity (38.1%). Twenty patients had at least one prior arm access, whereas 13 patients (61.9%) had more than three prior arm accesses. Seventeen patients (81%) had central venous stenosis or occlusion confirmed on preoperative imaging. The mean operative time was 250 minutes (range, 144-406 minutes), and estimated blood loss was 140.5 mL. Preanastomotic tapering was performed in 20 (95.2%) patients. Four (19%) patients returned to the operating room within 30 days. Thirty-day postoperative cardiac and wound complications occurred in 9.5% and 19% of patients, respectively. Distal arterial ischemia requiring revascularization occurred in one (4.8%) patient at 7 months. There were no access-related infections that resulted in fistula ligation. There was no mortality at 30 days. Successful fistula maturation rate at 6 months was 88.9%. At 1 year, primary and secondary patency rates were 65.9%, and 94.7%, respectively.ConclusionsAlthough autogenous FVT performed in patients without upper extremity options has a significant wound complication rate, it is associated with an outstanding maturation rate and excellent patency rates at 1 year. This access should be readily considered in hemodialysis patients without upper extremity access options.     

维持性血液透析患者透析通路相关缺血综合征发病率及相关因素

目的 调查维持性血液透析患者透析通路相关缺血综合征及窃血现象发病率,对缺血综合征发生的危险因素进行分析.方法 采用横断面研究,选取2012年1至3月在北京市海淀医院以头静脉-桡动脉端侧吻合自体动静脉内瘘为通路行维持性血液透析者71例,询问并检查患者是否存在内瘘侧肢端发凉、发绀等缺血症状;应用彩色多普勒超声观察动静脉内瘘吻合口桡动脉近心端、远心端是否存在反向血流,测量内瘘吻合口、桡动脉、肱动脉内径及血流量;记录入组患者性别、高血压、糖尿病、吸烟和动脉硬化等,对上述指标进行量化后行logistic回归分析.结果 透析通路相关缺血综合征发病率为19.7％（14/71）.彩色多普勒超声显示,桡动脉远端血流方向及频谱方向均为反向者42例（59.2％）.多元回归分析显示,内瘘口径大小、肱动脉血流量、女性、糖尿病、动脉硬化不是缺血综合征的危险因素（均P＞0.05）.结论 动静脉内瘘后,缺血综合征发生率不低,目前尚不能通过控制内瘘口径大小等方法预防其发生.     

血液透析动-静脉造瘘术后并发症的处理

目的 总结血液透析（血透）患者动静脉造瘘手术后并发症的处理经验。方法 收集我院120例患者,造瘘手术144例次,其中行内瘘134例次,人工血管瘘10例次。结果 术后扩要并发症：（1）血栓形成,AVF：17%、AVG：60%。内瘘血栓形成多发生于6周以内,治疗以重建新瘘道为主,或改建人工血管瘘;人工血管瘘血栓以取栓治疗为主,同时尽可能修复静脉流出道。（2）感染,AVG感染率为10%,行引流行移植物切除手术。（3）充血性心功能衰竭：3.5%,超滤、强心治疗。（4）窃血：1.4%,行血管成型和旁路架桥手术治疗。结论 积极预防和正确处理造瘘术后并发症可延长瘘道的通畅时间。     

糖尿病与非糖尿病维持性血液透析患者血管钙化的对比研究

目的探讨糖尿病维持性血液透析（MHD）患者血管钙化的影响因素。方法选择我院MHD患者90例,其中糖尿病组21例、非糖尿病组69例。检测2组透析前、后血压、心率、相关血生化指标以及全段甲状旁腺素（iPTH）、1,84-PTH、25一羟一维生素功,比较2组血管钙化情况,探讨糖尿病组患者血管钙化的相关因素。结果与非糖尿病组相比,糖尿病组透析前血肌酐较低,三酰甘油较高,高密度脂蛋白胆固醇较低（P〈0．05）。糖尿病组iPTH达标率高于非糖尿病组,而钙磷乘积低于后者（P〈0．05）。糖尿病组钙化发生率和钙化积分高于非糖尿病组（P〈0．05）。对糖尿病MHD患者,血管钙化积分与糖尿病病程、慢性肾脏病（CKD）病程、透析时间、iPTH、碱性磷酸酶呈正相关（r值分别为0．491、0499、0．652、0．727和0．564,P值均〈0．05）。结论与非糖尿病患者相比,患有糖尿病的MHD患者有较高的血管钙化发生率及较重的血管钙化程度;其中糖尿病病程、CKD病程、透析时间、iPTH、ALP可能参与糖尿病患者血管钙化的发生和发展。