指动脉压在诊断透析通路相关缺血综合征的价值

The value of digital blood pressure for the diagnosis of hemodialysis access induced distal ischemia

目的运用光电容积描记法(photoplethysmography,PPG)测量自体动静脉内瘘建立前后手指收缩压,探讨其在透析通路相关缺血综合征(hemodialysis access induced distal ischemia,HAIDI)诊断中的价值。方法 62例终末期肾病患者,完成随访55例。记录患者一般情况;测定双上肢肱动脉、双手拇指、食指及中指动脉收缩压。腕部自体动静脉内瘘术后当天、术后1月及术后3月,行问卷调查,评估肢体缺血情况,复测双手手指动脉压及肱动脉压,并在术后1月及3月短暂阻断内瘘静脉血流后复测手指动脉压。根据是否发生HAIDI,分为HAIDI组与无HAIDI组。结果 HAIDI发生率约16.1%,缺血等级为HAIDI 1级及HAIDI 2a级,术后1月的8例HAIDI患者与术后3月的缺血评分无显著性差异(Z=-0.368,P=0.713)。HAIDI组术后3月的内瘘侧拇指、食指及中指的指肱指数(digital brachial index,DBI)均明显低于无HAIDI组(t=-4.915,P<0.001;t=-4.448,P<0.001;t=-3.681,P=0.001),指动脉压的改变(change in digital pressure,CDP)明显大于无HAIDI组(t=2.522,P=0.015;t=3.316,P=0.002;t=2.187,P=0.033)。术后当天、1月及3月内瘘侧肢体的拇指、食指及中指DBI明显低于对侧肢体(t=-11.057,P<0.001;t=-10.374,P<0.001;t=-8.117,P<0.001;t=-10.803,P<0.001;t=-11.767,P<0.001;t=-9.526,P<0.001;t=-10.684,P<0.001;t=-9.952,P<0.001;t=-8.080,P<0.001)。术后3个时间点拇指、食指及中指的的DBI存在显著性差异(F=11.261,P<0.05;F=6.342,P=0.002;F=6.697,P=0.002)。阻断内瘘血流后,3个手指指动脉压在术后1月和3月均明显上升(t=-14.457,P<0.001;t=-15.679,P<0.001;t=-15.087,P<0.001;t=-12.671,P<0.001;t=-14.087,P<0.001;t=-14.854,P<0.001)。拇指DBI诊断HAIDI受试者工作特征曲线(receiver operating characteristic curve,ROC)下面积最大,当拇指DBI数值取值为0.595时,此时诊断HAIDI的敏感度为0.900,特异度为0.822。结论自体动静脉内瘘建立后内瘘侧肢体指动脉压及DBI明显下降,术后拇指DBI可以用于HAIDI的诊断,CDP可以作为HAIDI发生的预警。

Objective To evaluate digital blood pressure for the diagnosis of hemodialysis access induced distal ischemia （HAIDI） by using photoplethysmography before and after arteriovenous fistula operation. Methods Sixty-two end stage renal disease patients were enrolled in this study, and 55 of them completed the flow-up investigation. Smoking habit, diabetes history and artery calcification evaluated by X-ray on forearm were collected. Before fistula operation, arterial blood pressure of brachial arteries was measured, and the systolic blood pressure at thumb, index and middle fingers of both hands were measured by photoplethysmography. After fistula operation for one day, one month and 3 months, ischemia in distal areas was evaluated by questionnaire, and arterial pressure in fingers and brachial arteries were retested. After the operation for one month and 3 months, digital blood pressure in fingers was measured under the condition that fistula blood flow was temporarily blocked by compression. The patients were then divided in to HAIDI group and non- HAIDI group. Results The prevalence of HAIDI was 16.1%, and the ischemia degree was around HAIDI1 and HAIDI2a. In 8 patients with HAIDI, the ischemia scores after the operation for one month and for 3 months were similar （Z=-0.368, P=0.713）. After the operation for 3 months, the digital brachial index （DBI） of thumb, index and middle fingers in the fistula side were significantly lower in HAIDI group than in non- HAIDI group （t=- 4.915, - 4.448 and - 3.681 respectively; P〈0.001, 0.001 and P=0.001 respectively）; Change in digital pressure （CDP） was significantly greater in HAIDI group than in non- HAIDI group （t=2.522, 3.316 and 2.187 respectively; P=0.015, 0.002 and P=0.033 respectively）. At the operation day, and after the operation for one month and 3 months, DBI of the thumb, index and middle finger were significantly lower in the operation side than in the opposite side （t=-11.057, -10.374 and -8.117 respectively, P〈0.001, 0.001 and 0.001 respectively at the operation day; t=- 10.803, - 11.767 and - 9.526 respectively, P〈0.001, 0.001 and 0.001 respectively after the operation for one month; t=-10.684, -9.952 and -8.080 respectively, P〈0.001, 0.001 and 〈0.001 respectively after the operation for 3 months）. Analysis of variance showed significant differences in DBI among thumb, index and middle fingers （F=11.261, 6.342 and 6.697 respectively, P〈0.05, P=0.002 and 0.002 respectively）. After the operation for one month and 3 months, blood pressure in thumb, index and middle fingers increased significantly when fistula blood flow was temporarily blocked by compression （t=-14.457, -15.679 and -15.087 respectively, P〈0.001, 0.001 and 0.001 respectively after the operation for one month; t=-12.671, -14.087 and -14.854 respectively, P〈0.001, 0.001 and 0.001 respectively after the operation for 3 months）. Using thumb DBI for the diagnosis of HAIDI, the area under the receiver operating characteristic （ROC） curve was the biggest. When the value of the thumb DBI was set at 0.595, the sensitivity for the diagnosis of HAIDI was 0.900 and specificity was 0.822. Conclusion The finger pressure and DBI in fistula limb were significantly decreased after arteriovenous fistula operation. The thumb DBI can be used for the diagnosis of HAIDI, and CDP is an early warning for HAIDI.