自体动静脉内瘘血栓形成的危险因素分析

Analysis of Risk Factors for Autogenous Arterio-venous Fistulas Thrombosis in Chronic Hemodialysis Patients

目的通过监测长期血液透析患者的自体动静脉内瘘(autogenous arterio-venous fistulas,AVF)血流量以及相关临床指标,探讨引起AVF血栓的危险因素。方法选取在首都医科大学附属北京友谊医院透析中心进行维持性血液透析患者56例,使用TransonicHD02血液透析监护仪(超声稀释技术)检测AVF血流量和心输出量。收集血压、血脂、血红蛋白、钙磷、透析充分性(KT/v)等临床指标以及抗凝治疗情况进行相关分析。随访6个月,以发生内瘘血栓为终点事件,分析发生内瘘血栓的危险因素。结果19.6%患者随访过程中发生AVF功能不良。患者分为AVF血栓组和非血栓组。2组患者的性别、年龄、体质量指数均匹配。分析2组的临床资料,发现其血压、血红蛋白浓度、血小板、凝血时间、胆固醇、三酰甘油等指标差异无统计学意义。而AVF流量在血栓组明显下降(P=0.001)。发生内瘘血栓患者的KT/v较非血栓患者减小(P=0.038)。按照内瘘流量500 mL/min作为阈值分为2组,发现当内瘘流量小于500 mL/min时,半年内内瘘的累计通畅率是65.2%,其发生血栓的风险是内瘘流量较大组的4.5倍。结论AVF透析患者内瘘血流量越低,AVF发生血栓的可能性越大。AVF的血流量减于500 mL/min是发生近期血栓的强预测因素。及时纠正狭窄有利于提高终末期肾病(end stage renal disease,ESRD)患者透析质量。

Objective Autogenous arterio-venous fistulas（AVF） are regarded as the optimal vascular access for chronic hemodialysis（CHD） patients. This study was conducted to investigate the association of clinical indexes and vascular access thrombosis in chronic hemodialysis patients. Methods Fifty-six CHD patients with AVF were followed up for over 6 months. Vascular access blood flow was measured by the ultrasound dilution technique. Their clinical indexes were collected. Thrombotic events were recorded during follow-up. Results A total of 11 thrombotic events in 56 accesses were documented throughout this study duration. Patients were divided into two groups： thrombotic group and non-thrombotic group. They were comparable in age, gender, and weight index. It was found that the access blood flow was much more decreased in the thrombotic group than in nonthrombotic patients at the beginning of this study〔（337.3±236.9）mL/min vs （748.5±386.7）mL/min; P=0.001〕. However, there was no statistically significant difference in the blood pressure, hemoglobin concentration, blood plaque, clotting time and blood lipids. The dialysis adequacy（KT/v） was reduced in the thrombotic group compared to the other group（1.3±0.3 vs 1.5±0.3, P=0.038）. The AVF cumulative survival rate was about 65.2%, when their access flow was less than 500 mL/min. There was a 4.5 fold increase in the relative risk of thrombosis for patients with an access blood flow less than 500 mL/min compared to those with more than 500 ml/min. Conclusion In CHD patients with AVF, the less access blood flow was, the more possible the vascular access thrombosis. When vascular access blood flow was blow 500 mL/min, it was a strong predictive factor for thrombosis. It was necessary to correct the reduced flow to improve the dialysis adequacy.