新建立自体动静脉内瘘首次穿刺时间对内瘘预后影响的系统评价和Meta分析

Influence of the first cannulation time for newly established arteriovenous fistula on vascular access failure: a systematic review and meta-analysis

目的系统评价新建立的自体动静脉内瘘(arteriovenous Fistula,AVF)首次穿刺使用时间对AVF远期预后的影响。方法计算机检索Pub Med、Med Line、the Cochran Library(2017年第6期)、CNKI等数据库,查找有关新建立的AVF术后首次穿刺使用时间对其预后影响的队列研究,检索时限均从建库到2017年6月1日。由2位研究员按照纳入与排除标准独立筛选文献、提取资料并交叉核对和评价质量后,采用Stata 12.0软件进行Meta分析。结果系统评价共纳入9个研究,合计5045例AVF,AVF术后首次穿刺时间是影响内瘘预后的危险因素之一。Mete分析纳入4个研究,共计2450例AVF,根据术后第1次穿刺时间比较初始通畅率的变化:14天内穿刺和14天后穿刺比较,随访3个月(RR=2.124,P=0.030)、12个月(RR=2.172,P<0.001)、18个月(RR=2.276,P=0.003)、24个月(RR=2.087,P=0.008)、36个月(RR=2.093,P=0.337)以上差异均有统计学意义;30天内穿刺和30天后穿刺比较,在24个月(RR=2.952,P<0.001)和36个月(RR=2.336,P<0.001)差异有统计学意义,其余早期随访时间点无统计学差异;14天内穿刺和15-30天穿刺比较,在24个月(RR=1.146,P=0.442)差异有统计学意义,其余早期随访时间点无统计学差异;15~30天内穿刺与30天后穿刺比较,在3个月(RR=2.893,P=0.030)、24个月(RR=2.834,P<0.001)和36个月(RR=2.232,P<0.001)时有统计学意义,其余早期随访时间点无统计学差异。结论新建立的AVF术后首次穿刺使用时间是影响其远期预后的重要危险因素之一。应避免AVF术后14天内首次穿刺使用,有紧急透析指征可通过物理和超声检查充分评估AVF已成熟情况下,可在AVF术后14天以后进行首次穿刺使用。AVF最佳成熟时间可能至少30天。

Objective To systematically review the influence of the first cannulation time for newly established arteriovenous fistula（AVF） on vascular access failure. Methods Databases including Pub Med, Medline, the Cochrane Library（Issue 6, 2017） and CNKI were searched up to June 2017 to collect cohort studies about the influence of first cannulation time for newly established arteriovenous fistula on vascular access failure. According to the inclusion and exclusion criteria, the related cohort studies were screened, data were extracted and cross-checked, and quality of included studies was independently evaluated by two reviewers. Meta-analysis was then conducted using Stata 12.0 software. Results A total of 9 studies involving 5,045 AVFs were included to the systematic review, showing that the first cannulation time for newly established arteriovenous fistula is associated with fistula failure. Four studies involving 2,450 AVFs were finally included in our meta-analysis. When the primary patency rates were compared between patients with the first cannulation time within 14 days and those more than 14 days, the differences were statistically significant after 3 months（RR=2.124, P=0.030）, after 12 months（RR=2.172, P〈0.001）, after 18 months（RR=2.276, P=0.003）, and after 24 months（RR=2.087, P=0.008）, but without significance after 36 months（RR=2.093, P=0.337）. When the primary patency rates were compared between patients with the first cannulation time within 30 days and those more than 30 days, the differences were statistically significant after 24 months（RR=2.952, P〈0.001）and after 36 months（RR=2.336, P〈0.001）, but without significance at other time points of follow-up. When the primary patency rates were compared between patients with the first cannulation time within 14 days and those within 15~30 days, the difference was statistically significant after 24 months（RR=1.146, P=0.442）,but without significance at other time points of follow-up. When the primary patency rates were compared between patients with the first cannulation time within 15~30 days and those more than 30 days, the differences were statistically significant after 3 months（RR=2.893, P=0.030）, 24 months（RR=2.834, P〈0.001） and 36 months（RR=2.232, P〈0.001）, but without significance at other time points of follow-up. Conclusions The first cannulation time of the newly established AVF was an important risk factor for long-term patency. Cannulation of AVF within 14 days should be avoided. Cannulation between 2 and 4 weeks was performed only at emergency condition, and the maturation degree of the fistula must be evaluated by physical and ultrasound examinations before cannulation. Maturation of AVF was completed after 30 days.