Barriers to optimal vascular access for hemodialysis
Barriers to optimal vascular access for hemodialysis
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DOI：
10.1111/sdi.12922
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发表时间：
2020-10-08
影响因子：
1.6
通讯作者：
Brown, Robert S.
中科院分区：
文献类型：
--
作者：
Brown, Robert S.
血管通路是血液透析（HD）的致命弱点。动静脉瘘（AVF）被认为是HD的最佳入路，而不是移植物或中心静脉导管（CVC），导致“瘘优先”倡议主导质量评估。然而，这一举措产生了意外后果，增加了不太理想的导管的比例，导致“瘘管第一，导管最后”。但是，随着终末期肾病（ESKD）人群随着年龄的增长而扩大，病情加重的患者，对适当访问的个体评估将范式改变为KDOQI的“患者第一：ESKD生命计划”，以实现“正确的访问，在正确的患者中，在正确的时间，出于正确的原因”。然而，这样的目标已被证明是难以捉摸的，因为目前不存在最佳的血管通路。因此，ESKD护理提供者试图提供“正确的访问”必须权衡的障碍，以实现最佳的访问，以适应他们的每一个HD患者。这些障碍是基于与三种血管通路中的每一种以及每名ESKD患者的人口统计学特征、身体因素、生活质量和成本考虑相关的缺点。本文将描述这些障碍，以便临床医生为开始或接受HD的ESKD患者提供最佳的血管通路。
Vascular access is the Achilles heel for hemodialysis (HD). An arteriovenous fistula (AVF), considered the optimal access for HD, rather than a graft or central venous catheter (CVC) caused the "Fistula First" initiative to dominate quality assessment. However, this initiative had the unintended consequence of increasing the proportion of less desirable catheters, leading to "Fistula First, Catheter Last". But as the end-stage kidney disease (ESKD) population expanded with aging, sicker patients, individual assessment of the appropriate access changed the paradigm to KDOQI's "Patient First: ESKD Life-Plan" to attain the "right access, in the right patient, at the right time, for the right reasons". However, such a goal has proved elusive because the optimal vascular access does not currently exist. Thus, ESKD care providers attempting to offer the "right access" must weigh the barriers to achieving the most optimal access to suit each of their HD patients. The barriers are based on shortcomings related specifically to each of the three vascular accesses and to characteristics of each ESKD patient's demographics, physical factors, quality of life, and cost considerations. This article will describe these barriers so that clinicians caring for ESKD patients initiating or receiving HD provide the most optimal vascular access for that specific patient.