终末期肾病患者首次血液透析血管通路情况的分析

Vascular access at the initiation of hemodialysis in end stage renal disease patients

目的了解终末期肾病(end stage renal diease,ESRD)患者首次血液透析时血管通路构成比,为透析前慢性肾脏病(chronic kidney disease,CKD)管理的持续质量改进、计划性的自体动静脉内瘘(autogenous arteriovenous fistula,AVF)通路的建立提供依据。方法采用单中心回顾性研究,纳入2019年1月~2021年12月在江苏大学附属医院进行首次血液透析(hemodialysis,HD)的ESRD患者204例,分为AVF组(n=42)和中心静脉导管(central venous catheter,CVC)组(n=162)。比较2组患者的一般人口学资料、原发病及实验室指标等差异,分析首次透析使用CVC的影响因素。根据原发病情况将患者分为糖尿病肾病(diabetic nephropathy,DN)组(n=82)和非DN组(n=122),分析比较2组患者初次透析原因、血管通路构成比及实验室指标等差异。结果初次透析患者中,AVF与CVC的使用率分别为20.59%与79.41%,AVF组的城镇居民患者占比高于CVC组(χ^(2)=7.380,P=0.007),职工医保占比及透析前eGFR水平高于CVC组(χ^(2)=3.999,P=0.046;Z=-2.017,P=0.044)。Logstic回归分析显示居住地(OR=0.341,95%CI:0.153~0.758,P=0.008)、医保类型(OR=0.488,95%CI:0.239~0.994,P=0.048)及糖尿病肾病(OR=3.076,95%CI:1.525~6.206,P=0.002)是患者首次透析使用CVC的影响因素。初次透析时,DN组患者AVF使用率高于非DN组(χ^(2)=10.369,P=0.001)。DN组血浆白蛋白水平及钙磷乘积均低于非DN组(Z=-2.274,P=0.023;Z=-1.790,P=0.073),血肌酐低于非DN组(Z=-3.524,P<0.001),eGFR高于非DN组(Z=-3.919,P<0.001)。结论江苏大学附属医院近3年初次透析血管通路以CVC为主,居住地及DN为主要影响因素。加强慢性肾脏病管理、提高计划性AVF通路建立的比例仍是目前努力的方向。

Objective To analyze vascular access methods at the initial hemodialysis(HD)in end stage renal disease(ESRD)patients,so as to provide the bases for continuous quality improvement of management before dialysis and for planning autologous arteriovenous fistula(AVF)pathway in chronic kidney disease(CKD)patients.Methods This was a single center retrospective study,involving 204 ESRD patients beginning to have hemodialysis in the Affiliated Hospital of Jiangsu University from January 2019 to December 2021.According to the initial vascular access method,they were divided into autologous arteriovenous fistula(AVF)group(n=42)and central venous catheter(CVC)group(n=162).General demographic data,primary disease and laboratory indexes were compared between the two groups.The influencing factors for the initial use of CVC were analyzed.Based on the primary disease,the patients were further divided into diabetic nephropathy(DN)group(n=82)and non-DN group(n=122);the cause of initiatial hemodialysis,vascular access method and laboratory indexes were compared between the two groups.Results Among the initial hemodialysis patients,the utilization rates of AVF and CVC were 20.59%and 79.41%respectively.The proportion of urban residents was significantly higher in AVF group than in CVC group(78.6%vs.55.6%,x^(2)=7.380,P=0.007).The proportions of workers with medical insurance and patients with better eGFR before dialysis were higher in AVF group than in CVC group(x^(2)=3.999,P=0.046;Z=-2.017,P=0.044).Logistic regression showed that residence area,medical insurance type and DN were the influencing factors for the use of CVC at the beginning of hemodialysis(OR=0.341,0.488 and 3.076 respectively;95%CI:0.153~0.758,0.239~0.994 and 1.525~6.206 respectively;P=0.008,0.048 and 0.002 respectively).At the initial hemodialysis,the use of AVF was significantly higher in DN group than in non-DN group(x^(2)=10.369,P=0.001).In DN group,plasma albumin level and calcium phosphorus product were lower(Z=-2.274,P=0.023;Z=-1.790,P=0.073),serum creatinine was significantly lower(Z=-3.524,P<0.001),and eGFR was significantly higher(Z=-3.919,P<0.001),as compared with those in non-DN group.Conclusion CVC was the main vascular access method at the beginning of hemodialysis in our hemodialysis center in the recent 3 years.Residence place and primary disease were the main influencing factors for the use of CVC.Management of CKD patients and use of AVF for initial hemodialysis must be emphasized in our future practice.