维持性血液透析病人自体动静脉内瘘失功影响因素的系统评价

Influencing factors of failure of native arteriovenous fistulas in patients with maintenance hemodialysis:a system review

[目的]系统评价维持性血液透析病人自体动静脉内瘘失功的影响因素。[方法]计算机检索the Cochrane Library、PubMed、EMbase、Ovid、Web of Science、CINAHL、中国生物医学文献数据库(CBM)、中国知网全文数据库(CNKI)、中文科技期刊数据库(VIP)和万方数据库中关于维持性血液透析病人自体动静脉内瘘失功影响因素的队列研究,检索时间为数据库从建库到2019年6月30日。由2名评价者独立筛查文献、提取数据、评价纳入文献的方法学质量后,采用RevMan 5.3软件行Meta分析。[结果]共纳入32篇文献。Meta分析结果显示,维持性血液透析病人自体动静脉内瘘失功的影响因素归纳为4大类。(1)个人因素:高龄[RR=1.30,95%CI(1.10,1.53),P=0.002]、女性[RR=1.19,95%CI(1.11,1.28),P<0.00001]、吸烟[RR=1.39,95%CI(1.07,1.81),P=0.01]、肥胖[RR=2.09,95%CI(1.10,3.97),P=0.03];(2)临床因素:糖尿病史[RR=1.23,95%CI(1.20,1.26),P<0.00001]、高血压史[RR=1.08,95%CI(1.05,1.12),P<0.00001]、冠状动脉疾病史[RR=1.17,95%CI(1.14,1.20),P<0.00001]、脑血管疾病史[RR=1.15,95%CI(1.09,1.22),P<0.00001]、桡动脉钙化[RR=1.53,95%CI(1.28,1.83),P<0.00001]、C-反应蛋白[RR=1.12,95%CI(1.01,1.25),P=0.03]、周围血管疾病史[RR=1.24,95%CI(1.00,1.55),P=0.05];(3)透析相关因素:同侧导管置入史[RR=1.38,95%CI(0.76,2.51),P=0.28]、内瘘位置[RR=0.88,95%CI(0.65,1.19),P=0.41]、透析上肢[RR=0.91,95%CI(0.79,1.05),P=0.20];(4)药物因素:他汀类药[RR=0.68,95%CI(0.51,0.91),P=0.009]、抗凝药[RR=1.03,95%CI(0.87,1.23),P=0.69]。[结论]现有证据表明,高龄、女性、吸烟、肥胖、糖尿病史、高血压史、冠状动脉疾病史、脑血管疾病史、C-反应蛋白、桡动脉钙化是维持性血液透析病人自体动静脉内瘘失功的危险因素,服用他汀类药物可降低其失功率,但周围血管疾病史、同侧导管置入史、透析肢体、内瘘位置和服用抗凝药物对其影响不大。

Objective:To systematically evaluate the influencing factors of failure(AVF)of native arteriovenous fistulas(AVF)in patients with maintenance hemodialysis(MHD).Methods:Cohort study on influencing factors of failure of native arteriovenous fistulas in patients with maintenance hemodialysis were retrieved from PubMed,EMbase,the Cochrane Library,Web of Science,Ovid,CINAHL,China National Knowledge Infrastructure,WanFang Database,VIP and China Biology Medicine.The retrieval time was from the databases establishment to March 2019.Screening of literatures,extraction of data and evaluation of methodological quality of included studies were implemented by two reviewers independently.And Meta-analyses of extracted data was carried out using RevMan 5.3 software.Results:A total of 32 literatures were included.The influencing factors were classified into four categories through Meta-analysis results.(1)Personal factors:advanced age[RR=1.30,95%CI(1.10,1.53),P=0.002],female[RR=1.19,95%CI(1.11,1.28),P<0.00001],smoking[RR=1.39,95%CI(1.07,1.81),P=0.01],obesity[RR=2.09,95%CI(1.10,3.97),P=0.03];(2)Clinical factors:diabetes[RR=1.23,95%CI(1.20,1.26),P<0.00001],hypertension[RR=1.08,95%CI(1.05,1.12),P<0.00001],coronary artery disease[RR=1.17,95%CI(1.14,1.20),P<0.00001],cerebrovascular disease[RR=1.15,95%CI(1.09,1.22),P<0.00001],calcification of radial artery[RR=1.53,95%CI(1.28,1.83),P<0.00001],CRP[RR=1.12,95%CI(1.01,1.25),P=0.03],peripheral vascular disease[RR=1.24,95%CI(1.00,1.55),P=0.05];(3)Dialysis related factors:history of ipsilateral catheterization[RR=1.38,95%CI(0.76,2.51),P=0.28],fistula location[RR=0.88,95%CI(0.65,1.19),P=0.41],dialysis upper limbs[RR=0.91,95%CI(0.79,1.05),P=0.20];(4)Drug factors:Statin[RR=0.68,95%CI(0.51,0.91),P=0.009],anticoagulants[RR=1.03,95%CI(0.87,1.23),P=0.69].Conclusions:Current evidence shows that the elderly,women,smoking,obesity,diabetes,history of hypertension,coronary artery disease,cerebrovascular disease,CRP and calcification of radial artery are risk factors of failure of AVF in patients with MHD.Taking Statins can reduce its failure rate,but peripheral vascular disease,history of ipsilateral catheterization,fistula location,dialysis upper limbs and taking anticoagulants has nothing to do with failure of AVF in patients with MHD.