维持性血液透析患者自体动静脉内瘘瘘口钙化的影响因素分析

The influence factors of calcification at anastomotic orifice of arteriovenous fistula in maintenance hemodialysis patients

目的研究维持性血液透析患者自体动静脉内瘘(AVF)瘘口钙化的影响因素。方法选择安徽省蚌埠医学院第一附属医院肾病科35例以AVF进行透析的尿毒症患者,以彩色多普勒超声观察AVF瘘口处有无钙化,根据瘘口是否钙化将病例分为瘘口钙化组及非钙化组。彩色多普勒超声测量患者瘘口直径、瘘口平均血流速度等血流动力学指标,并计算瘘口血流量。同时收集2组患者血红蛋白、血钙、血磷、总胆固醇、三酰甘油、高密度脂蛋白(HDL)及低密度脂蛋白(LDL)等相关血指标,记录患者年龄、瘘使用时间及平均动脉压等一般情况。对上述指标分别进行单因素分析,对单因素分析有差异性的因素进行多因素非条件logistic回归分析。结果瘘口钙化组患者AVF使用时间、平均动脉压高于非钙化组[(29.4±18.66)月比(16.4±9.62)月,P=0.019;(117.15±5.86)mm Hg比(112.33±7.14)mm Hg,P=0.036],瘘口平均血流速度、钙磷乘积及LDL高于非钙化组[(157.30±9.47)cm/s比(150.38±10.32)cm/s,P=0.048;(59.09±7.77)mg2/dl2比(53.12±8.76)mg2/dl2,,P=0.041;(2.49±0.55)mmol/L比(2.11±0.48)mmol/L,P=0.044];而2组患者年龄[(55.3±9.23)岁比(51.2±7.99)岁]、瘘口直径[(0.43±0.08)cm比(0.43±0.09)cm]、瘘口处血流量[(1439.32±496.87)ml/min比(1370.01±579.47)ml/min]、血红蛋白[(105.25±20.52)g/L比(106.87±16.36)g/L]、血钙[(2.30±0.17)mmol/L比(2.19±0.16)mmol/L]、血磷[(2.07±0.21)mmol/L比(1.97±0.47)mmol/L]、总胆固醇[(3.80±0.85)mmol/L比(3.73±1.15)mmol/L]、三酰甘油[(1.55±0.87)mmol/L比(1.66±2.00)mmol/L]及HDL[(1.02±0.22)mmol/L比(0.96±0.15)mmo/L]等指标差异无统计学意义(P>0.05);多因素非条件logistic回归分析显示AVF使用时间(OR=1.150,P=0.041)、瘘口平均血流速度(OR=1.230,P=0.029)及LDL(OR=174.706,P=0.016)与瘘口钙化相关。结论透析患者随着AVF使用时间延长,瘘口钙化风险增加;瘘口血流速度及LDL水平与瘘口钙化相关,瘘口处长期高血流速度伴高水平LDL可能促进瘘口钙化,增加瘘口远期狭窄风险。

Objective To investigate the influence factors of calcification at the anastomotic orifice of arteriovenous fistula （AVF） in maintenance hemodialysis （MHD） patients. Method A total of 35 uremic patients undergoing hemodialysis with AVF were enrolled in this study. The calcification at anastomotic orifice was examined by color Doppler ultrasonography. We then divided the patients into calcification group and non-calcification group. Diameter of the anastomotic orifice, mean blood flow velocity, the derived blood flow volume, and other hemodynamic parameters were assayed by color Doppler ultrasonography. We also collected the data about hemoglobin, serum calcium, phosphorus, cholesterol, triglyceride, high density lipoprotein （HDL）, low density lipoprotein （LDL）, age, AVF service time, mean arterial pressure, etc. Univariate regression was used to individually analyze these factors, and multivariate non-conditional logistic regression was used to analyze the factors with statistical significance between the two groups. Result Compared to the non-calcification group, the calcification group had longer AVF service time （29.4±18.66 vs. 16.4±9.62 months, P=0.019）, higher mean arterial pressure （117.15±5.86 vs. 112.33±7.14 mmHg, P=0.036）, higher mean blood flow velocity at anastomotic orifice （157.30±9.47 vs. 150.38±10.32 cm/s, P=0.048）, increased Ca-P product （59.09±7.77 vs. 53.12±8.76 mg2/dL2, P=-0.041）, and higher LDL （2.49±0.55 vs. 2.11±0.48 mmol/L, P=- 0.044）, but had insignificant differences in age （55.3±9.23 vs. 51.2±7.99 years, P〉0.05）, diameter of anastomotic orifice （0.43±0.08 vs. 0.43±0.09 cm, P〉0.05）, blood flow volume at anastomotic orifice （1439.32± 496.8 vs. 1370.01±579.47 ml/min, P〉0.05）, hemoglobin （105.25±20.52 vs. 106.87±16.36 g/L, P〉0.05）, serum calcium （2.30±0.17 vs. 2.19±0.16 mmol/L, P〉0.05）, serum phosphorus （2.07±0.21 vs. 1.97±0.47 mmol/L, P〉 0.05）, cholesterol （3.80±0.85 vs. 3.73±1.15 retool/L, P〉0.05）, triglyceride （1.55±0.87 vs. 1.66±2.00 mmol/L, P〉0.05）, and HDL （1.02±0.22 vs. 0.96±0.15 mmo/L,/〉0.05）. Multivariate non-conditional logistic regression revealed that AVF sever time （OR=1.150, P=0.041）, mean blood flow velocity （OR=1.230, P=-0.029）, and LDL （OR=174.706, P=0.016） were the risk factors of calcification at anastomotic orifice. Conclusion The risk of calcification at anastomotic orifice increased with the increase of AVF service time in MHD patients. Higher blood velocity in anastomotic orifice and increased LDL may promote anastomotic calcification and increase the risk of anastomotic stenosis.