维持性血液透析患者动静脉内瘘侧上肢功能障碍及其影响因素的研究

A study on dysfunction of the upper limbs with arteriovenous fistula and its influence factors in maintenance hemodialysis patients

目的评估维持性血液透析(maintenance hemodialysis,MHD)患者动静脉内瘘侧上肢功能,分析动静脉内瘘对肢体功能的影响和相关影响因素。方法选择中国康复研究中心北京博爱医院规律血液透析超过3个月的MHD患者67例,评估其上肢功能:双手握力、指捏力、腕关节活动度和简易上肢功能评分。结果①握力:MHD患者内瘘侧握力与非内瘘侧相比偏低[(24.22±12.54)比(26.05±11.01)N,t=-2.075,P=0.042];多元线性回归分析结果显示,年龄、白蛋白、内瘘侧被动背伸异常为内瘘侧握力水平下降的独立危险因素(β分别为-0.364、0.408、-0.231,P值分别为0.002、0.001、0.044),动静脉内瘘是利手握力的独立危险因素(β=-0.345,P=0.006)。②指捏力:内瘘侧指捏力与非内瘘侧相比无明显差异[拇指-食指:(6.24±3.78)比(6.19±2.13)N,t=0.104,P=0.918;拇指-中指:(4.69±1.70)比(4.83±1.57)N,t=-0.820,P=0.417;拇指-无名指:(2.97±1.35)比(3.10±0.99)N,t=-0.808,P=0.423]。③腕关节活动度:内瘘侧的被动掌曲活动度异常的比例较非内瘘侧高(38.6%比19.3%,x^2=5.160,P=0.023)。④简易上肢功能评分:评分异常者在内瘘组和非内瘘组所占比例无统计学差异(6%比9%,x^2=0.437,P=0.509),内瘘侧肢体与非内瘘侧肢体相比粗大动作评分(49比47,Z=-1.371,P=0.170)、精细动作评分(49比48,Z=-1.126,P=0.260)和总分(96比96,Z=-1.285,P=0.199)无统计学差异。结论MHD患者内瘘侧肢体与非内瘘侧肢体相比存在握力下降和被动掌曲功能异常,需要引起临床医师的高度关注,尽早开展内瘘侧手部的抓握运动及腕关节的掌曲、背伸、旋转活动,以期提高患者的生活质量和工作能力。

Objective To evaluate the function of upper limbs with arteriovenous fistula(AVF)and its related factors in patients with maintenance hemodialysis(MHD).Methods A total of 67 MHD patients with regular hemodialysis for more than 3 months in Beijing Boai Hospital of China Rehabilitation Research Center were enrolled to evaluate the upper limb functions,including grip strength,pinch force,wrist motion and simple test for evaluating hand function(STEF).Results①Grip strength:Grip strength of the upper limbs with AVF was lower than that of the upper limbs without AVF(24.22±12.54 vs.26.05±11.01 N,t=-2.075,P=0.042).Multivariate linear regression analysis showed that age,albumin and abnormal passive dorsal extension of the upper limbs with AVF were the independent risk factors for grip strength of the upper limbs with AVF(standardization coefficientβ=-0.364,0.408 and-0.231 respectively;P=0.002,0.001 and 0.044 respectively).AVF was an independent risk factor for grip strength of dominant hand(standardization coefficientβ=-0.345;P=0.006).②Pinch force:Pinch force of the upper limbs with AVF had no significant difference with that of the upper limbs without AVF(thumb-forefinger:6.24±3.78 vs.6.19±2.13 N,t=0.104,P=0.918;thumb-middle finger:4.69±1.70 vs.4.83±1.57 N,t=-0.820,P=0.417;thumb-ring finger:2.97±1.35 vs.3.10±0.99 N,t=-0.808,P=0.423).③Wrist motion:The proportion of abnormal passive palmar curvature on the AVF side was higher than that on the non-AVF side(38.6%vs.19.3%,x^2=5.160,P=0.023).④STEF:There were no significant differences in the proportion of abnormal scoring(6%vs.9%,x^2=0.437,P=0.509),gross motor score(49 vs.47,Z=-1.371,P=0.170),fine motor score(49 vs.48,Z=-1.126,P=0.260)and total score(96 vs.96,Z=-1.285,P=0.199)between the upper limbs with AVF and those without AVF.Conclusion Compared with non-AVF limbs,the upper limbs with AVF have lower grip strength and abnormal passive palmar curvature in MHD patients.These dysfunctions have to be concerned by clinicians.Early intervention for the dysfunctions of grasp movement,and palmar curvature,dorsal extension and rotation of wrist joint on the AVF side should be carried out in order to improve quality of life and movement ability of MHD patients.