肾脏替代治疗血管通路位置与并发症的Meta分析

Vascular access and complications in renal replacement therapy: a Meta-analysis

目的评价肾脏替代治疗时不同导管置管部位的选择与置管并发症发生率及患者治疗效果之间是否存在相关性。方法检索Pub Med、Medline、Embase、Cochrane图书馆、中国学术期刊全文数据库、万方、维普数据库,按照文献纳入及排除标准筛选1998年4月—2018年4月所发表的符合研究要求的文献,用Rev Man 5.3软件进行Meta分析,对计数资料计算其比值比(odds ratio,OR)及其95%置信区间(confidence interval,CI),计量资料计算其加权均数差(weighted mean difference,WMD)及95%CI,评估导管相关感染及机械性并发症、患者临床治疗结局等指标。结果检索到符合纳入标准文献9篇,其中随机对照临床试验2篇,观察性研究7篇,共纳入肾脏替代治疗患者5 220例次。Meta分析结果显示:肾脏替代治疗患者中,股静脉置管与非股静脉置管(包括颈内静脉及锁骨下静脉)相比,血液透析导管相关性血流感染及细菌定植的发生率差异无统计学意义(P≥0.05)。在置管相关机械性并发症中,误穿动脉、置管相关深静脉血栓、导管功能障碍(导管流量不足)及导管意外脱落事件的发生率,股静脉与非股静脉置管相比差异无统计学意义(P≥0.05)。股静脉置管患者导管穿刺局部血肿、出血、渗血的发生率低于非股静脉置管患者[OR=0.44,95%CI(0.23,0.82),P=0.009],血液透析导管留置时间短于非股静脉置管患者[WMD=–1.40 d,95%CI(–2.17,–0.62)d,P=0.000 4];不同置管部位的血流量及滤器凝血事件发生率、患者重症监护病房死亡率之间差异无统计学意义(P≥0.05)。结论肾脏替代治疗患者采用不同置管部位时,股静脉置管部位局部血肿、出血、渗血事件发生率低于非股静脉置管;股静脉置管留置时间短于非股静脉置管,但置管相关感染事件的发生率及患者临床治疗结局并无差异。

Objective To compare dialysis catheter function and complications according to catheter site in patients undergoing hemopurification. Methods Literatures were searched from Pub Med, Medline, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang Data, and VIP Database according to the inclusion and exclusion criteria. Publication years of these literatures ranged from April 1998 to April 2018. Meta-analysis was performed with Rev Man 5.3 software. The odds ratio（OR） and 95% confidence intervals（CI） were calculated for uncontinuous outcomes, and the weighted mean difference（WMD） and 95%CI were calculated for continuous outcomes.The incidence of catheter related infection, other complications and patients outcome were compared between different sites for dialysis vascular access. Results A total of 9 articles were included, including 2 randomized controlled trials and7 observational clinical studies, and 5 220 adult patients undergoing renal replacement therapy. Meta-analysis showed that there was no significant difference in incidences of catheter colonization or catheter-related bloodstream infection, as well as arterial puncture, local thrombosis, catheter dysfunction and spontaneous catheter withdrawal, between femoral and non-femoral（jugular or subclavian） catheterization（P≥0.05）. Whereas the incidence of bleeding and local hematoma was lower in femoral catheterization [OR=0.44, 95%CI（0.23, 0.82）, P=0.009], and the duration of catheters was shorter in femoral catheterization [WMD=–1.40 d, 95%CI（–2.17, –0.62） d, P=0.000 4]. The blood flow rate, filters clotting incidence and patients intensive case unit mortality were similar in different catheterization. Conclusions In patients undergoing renal replacement therapy, the bleeding and local hematoma incidence is lower in femoral catheterization but the duration of catheters is shorter. Nevertheless the patients have similar clinical outcome. This result may provide reference for clinical decision-making.