基于超声稀释法的血管通路监测在动静脉内瘘维护中的临床应用

The clinical application of ultrasound dilution technology for vascular access flow detection among maintenance hemodialysis patients

目的探讨基于超声稀释法(ultrasound Dilution,UD)的血管通路监测在维持性血液透析(maintenance Hemodialysis,MHD)患者血管通路维护中的临床应用价值。方法回顾性分析2015年1月~2016年2月于华西医院血液透析中心使用动静脉内瘘(arteriovenous Fistula,AVF)并利用HD02血液透析监测仪行UD评估血管通路的MHD患者213例。记录AVF患者首次采用UD监测的实际血流量、内瘘流量(access flow,Qa)、心输出量(cardiac output,CO)、内瘘流量与心输出量的比例(Qa/CO)、心脏指数(cardiac index,CI)。评估基于UD方法在AVF低血流量相关因素分析、AVF狭窄诊断和处理等方面的应用。结果 (1)组间比较结果提示,与Qa≥500ml/min的患者比较,Qa<500ml/min的患者AVF血栓的发生率较高(38.235%比11.173%;c2=15.983;P<0.001)、血管狭窄的比例较高(20.588%比1.676%;c2=22.840;P<0.001);(2)采用多元logistic逐步回归对基于UD方法测量的低血流量危险因素进行分析,结果提示,血管狭窄与AVF流量不足独立相关[OR=14.192,95%CI 3.410~59.056,P<0.001]。(3)针对AVF狭窄进行干预后使用UD复测内瘘实际流量及Qa,结果显示流量均较前升高。(4)UD测量AVF高流量的患者间隔>1年后复查左心室大小及左室射血分数无明显差异(t=-0.424,P=0.681;t=0.497,P=0.631)。结论 AVF血栓及血管狭窄是Qa的影响因素,其中血管狭窄与AVF低血流量独立相关。使用UD可有效地动态评估AVF狭窄治疗干预前后的Qa变化。基于UD的血管通路监测有助于及时发现血管通路障碍,在MHD患者血管通路维护中具有临床应用价值,下一步拟前瞻性队列研究进一步验证本研究结果。

Objective The primary purpose of this study is to explore the clinical value of ultrasound di-lution （UD） technology for vascular access flow detection among patients undergoing maintenance hemodialy-sis （MHD） by conducting a single-center retrospective study. Methods We retrospectively studied the clinical characteristic data and detection results from Transonic HD02 hemodialysis monitor, collected from a cohort of 213 patients undergoing MHD longer than six months in our hemodialysis center. UD was applied to detect the blood flow, access flow （Qa）, cardiac output （CO）, Qa/CO, cardiac index （CI） in MHD patients with arte-riovenous fistula （AVF）. Results ①Comparative results from two independent samples grouped by access flow （Qa〈500 ml/min vs. Qa≥500ml/min） indicated that significantly higher prevalence of fistula thrombus and vascular stenosis could be found in patients with Qa〈500 ml/min when compared to those with Qa≥500ml/min （38.235%vs. 11.173%;c2=15.983;P〈0.001 and 20.588%vs. 1.676%;c2=22.840;P〈0.001, re-spectively）,②Results from multivariate logistic regression analysis indicated that vascular stenosis was a sig-nificant risk factor for Qa insufficiency （OR=14.192, 95% CI 3.410~59.056, P〈0.001）, while the associa-tions of Qa insufficiency with age, diabetes mellitus and time of AVF use were insignificant;③Both actual flow in fistula and Qa were significantly improved after the intervention towards AVF stenosis;④For patients with Qa≥500ml/min, no significant differences were found between baseline results and the figures one year later concerning left ventricular volume and left ventricular ejection fraction （t=-0.424, P=0.681;t=0.497, P=0.631）. Conclusion For patients with AVF, AVF thrombus and vascular stenosis were associated with lower AVF flow, and notably vascular stenosis acted as an independent risk factor. It is of great clinical value to de-tect Qa based on UD technology among MHD patients to maintain vascular access, especially for effectively recognizing access dysfunction. A multi-center prospective cohort study based on a larger scale is on our schedule to further validate the findings from this study.