Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study
Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study
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DOI：
10.1681/asn.2004090748
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发表时间：
2005-05-01
影响因子：
13.6
通讯作者：
Coresh, J
中科院分区：
文献类型：
--
作者：
Astor, BC;Eustace, JA;Coresh, J
动静脉瘘（AVF）比动静脉移植物（AVG）和中心静脉导管（CVC）有优势，但AVF是否与更好的生存率独立相关尚不清楚。最近的研究表明，这种生存效益没有包括早期获得经验或考虑到随着时间的推移获得类型的变化，也没有包括一些重要混杂因素的数据。本文报道了616名ESRD患者在开始血液透析后3年的生存率，这些患者被纳入了健康结局选择研究（CHOICE）。共使用1084个通道（AVF 185个，AVG 296个，CVC 603个），共1381人年。开始时，409例（66%）患者使用CVC， 122例（20%）使用AVG， 85例（14%）使用AVF。6个月后，34%的患者使用CVC， 40%的患者使用AVG， 26%的患者使用AVF。AVF的年死亡率为11.7%，AVG为14.2%，CVC为16.1%。与AVF相比，CVC的校正相对危险度（RH）为1.5(95%可信区间1.0 ~ 2.2)，AVG的校正相对危险度（RH）为1.2（0.8 ~ 1.8）。与AVF相比，男性（n = 334; RH = 2.0; P = 0.01）比女性（n = 282; RH = 1.0; P = 0.92）与CVC相关的风险增加更强。这些结果有力地支持了现有的临床实践指南，并建议应尽量减少静脉导管的使用，以减少进入并发症的频率，提高患者的生存率，特别是男性血液透析患者。
Arteriovenous fistulae (AVF) have advantages over arteriovenous grafts (AVG) and central venous catheters (CVC), but whether AVF are associated independently with better survival is unclear. Recent studies showing such a survival benefit did not include early access experience or account for changes in access type over time and did not include data on some important confounders. Reported here are survival rates stratified by the type of access in use up to 3 yr after initiation of hemodialysis among 616 incident patients who were enrolled in the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. A total of 1084 accesses (185 AVF, 296 AVG, 603 CVC) were used for a total of 1381 person-years. At initiation, 409 (66%) patients were using a CVC, 122 (20%) were using an AVG, and 85 (14%) were using an AVF. After 6 mo, 34% were using a CVC, 40% were using an AVG, and 26% were using an AVF. Annual mortality rates were 11.7% for AVF, 14.2% for AVG, and 16.1% for CVC. Adjusted relative hazards (RH) of death compared with AVF were 1.5 (95% confidence interval, 1.0 to 2.2) for CVC and 1.2 (0.8 to 1.8) for AVG. The increased hazards associated with CVC, as compared with AVF, were stronger in men (n = 334; RH = 2.0; P = 0.01) than women (n = 282; RH = 1.0 for CVC; P = 0.92). These results strongly support existing clinical practice guidelines and suggest that the use of venous catheters should be minimized to reduce the frequency of access complications and to improve patient survival, especially among male hemodialysis patients.