不同血管通路类型对老年维持性血液透析患者生存的影响

Effects of different types of vascular access on survival of elderly patientson maintenance hemodialysis

目的探讨老年维持性血液透析(maintenance hemodialysis,MHD)患者生存的影响因素及不同血管通路类型间的差异。方法前瞻性队列研究设计,纳入2017年1月1日至2019年12月31日在海南省人民医院MHD且大于60岁的患者121例。根据血管通路类型分为2组:自体动静脉内瘘(arteriovenous fistula,AVF)和带隧道涤纶套导管组(tunneled cuffed catheter,TCC)。主要观察终点为2组患者3年间病死率。结果(1)121例患者平均年龄(71.6±7.7)岁,糖尿病肾病54例(44.6%),男性77例(63.6%),AVF组74例(61.2%),TCC组47例(38.8%)。(2)AVF组病死率40.5%(30/74)低于TCC组44.7%(21/47),差异无统计学意义(P>0.05);2组死亡原因构成比差异无统计学意义(P>0.05),AVF组第一位死亡原因是心血管事件和感染,TCC组是感染。(3)3年追踪期间AVF组累积生存率高于TCC组,差异无统计学意义(P>0.05)。(4)单因素分析显示:白蛋白和性别是影响患者全因死亡的重要因素(P<0.05)。(5)多因素COX回归分析,校正原发病、白蛋白、性别、年龄后维持性血管通路类型对全因死亡无影响(P>0.05);白蛋白水平升高是全因死亡的保护因素(P<0.05)。结论本中心血管通路类型不直接影响老年MHD患者的生存率。因此,可以结合患者的个人意愿,制定个体化血管通路,通过纠正营养不良,提高白蛋白水平,可提高患者生存率。

Objective To explore the influencing factors of survival in elderly patients on maintenance hemodialysis(MHD)and examine the differences between different vascular access types.Methods A prospective cohort study was conducted for 121 elderly patients on MHD from January 1,2017 to December 31,2019.According to the specific type of vascular access,it was divided into 2 groups of arteriovenous fistula(AVF)and tunneled cuffed catheter(TCC).The major observation endpoint was death during 3-years follow-ups.Results They had an average age(71.6±7.7)years.There were 54 diabetic nephropathy(44.6%),77 males(63.6%),74 AVF(61.2%)and 47 TCC(38.8%).The mortality rate of AVF group was lower than that of TCC group(40.5%,30/74 vs 44.7%,21/47).There was no statistical difference(P>0.05).No significant inter-group difference existed in cause of death ratio(P>0.05).Top 1 cause of death was cardiovascular events and infection in AVF group and infection in TCC group.The cumulative survival rate was higher in AVF group than that in TCC group during 3-year follow-ups.There was no significant difference(P>0.05).Single-factor analysis indicated that gender and albumin were important influencing factors of all-cause death(P<0.05).Multivariate COX regression analysis revealed that,after correcting for primary disease,albumin,gender and age,vascular access was not an independent risk factor for all-cause death(P>0.05).Albumin was an independent protective factor for all-cause death in elderly MHD patients(P<0.05).Conclusion Vascular access type has no direct impact upon survival in elderly MHD patients.Therefore individualized vascular path may be established according to personal wishes of patients.By correcting malnutrition and improving albumin level,the survival rate of patients can be improved.