Vascular Access Choice in Incident Hemodialysis Patients: A Decision Analysis
Vascular Access Choice in Incident Hemodialysis Patients: A Decision Analysis
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DOI：
10.1681/asn.2013111236
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发表时间：
2015-01-01
影响因子：
13.6
通讯作者：
Weiner, Daniel E.
中科院分区：
文献类型：
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作者：
Drew, David A.;Lok, Charmaine E.;Weiner, Daniel E.
血液透析血管通路建议首先促进动静脉（AV）瘘；然而，这可能不是所有血液透析患者的最佳方法，因为成功放置瘘管的可能性、手术相关和后续费用以及患者的生存会改变最佳通路选择。我们进行了一项决策分析，评估了 AV 瘘、AV 移植和中心静脉导管 (CVC) 策略，适用于开始使用 CVC 进行血液透析的患者，这种情况发生在超过 70% 的美国透析患者中。构建决策树模型来反映血液透析开始后的进展。患者被分为三种血管通路选择之一：维持 CVC、尝试瘘管或尝试移植。我们明确地对每种通路类型的主要和次要通畅概率进行了建模，成功率根据年龄、性别和糖尿病进行了修改。使用预先存在的队列数据（包括年龄、性别和糖尿病术语）纳入特定死亡率。费用根据 2010 年 USRDS 报告和 Medicare 的手术费用确定。研究发现，就大多数患者特征组合的死亡率和费用而言，AV 瘘尝试策略优于 AV 移植物和 CVC，尤其是没有糖尿病的年轻男性。无论接入类型如何，患有糖尿病的女性和患有糖尿病的老年男性都有相似的结果。总体而言，在老年患者中，尤其是患有糖尿病的女性中，动静脉瘘尝试策略的优势大大减弱，反映出动静脉瘘成功率较低和预期寿命较低的影响。这些结果表明，可以通过考虑患者个体特征来优化血管通路相关的结果。
Hemodialysis vascular access recommendations promote arteriovenous (AV) fistulas first; however, it may not be the best approach for all hemodialysis patients, because likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival modify the optimal access choice. We performed a decision analysis evaluating AV fistula, AV graft, and central venous catheter (CVC) strategies for patients initiating hemodialysis with a CVC, a scenario occurring in over 70% of United States dialysis patients. A decision tree model was constructed to reflect progression from hemodialysis initiation. Patients were classified into one of three vascular access choices: maintain CVC, attempt fistula, or attempt graft. We explicitly modeled probabilities of primary and secondary patency for each access type, with success modified by age, sex, and diabetes. Access-specific mortality was incorporated using preexisting cohort data, including terms for age, sex, and diabetes. Costs were ascertained from the 2010 USRDS report and Medicare for procedure costs. An AV fistula attempt strategy was found to be superior to AV grafts and CVCs in regard to mortality and cost for the majority of patient characteristic combinations, especially younger men without diabetes. Women with diabetes and elderly men with diabetes had similar outcomes, regardless of access type. Overall, the advantages of an AV fistula attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the effect of lower AV fistula success rates and lower life expectancy. These results suggest that vascular access-related outcomes may be optimized by considering individual patient characteristics.