Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates
Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates
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DOI：
10.1001/jamasurg.2021.4527
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发表时间：
2021-09-22
期刊：
影响因子：
16.9
通讯作者：
Feldman, Harold, I
中科院分区：
文献类型：
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作者：
Huber, Thomas S.;Berceli, Scott A.;Feldman, Harold, I
重要性国家倡议强调使用自体动静脉内瘘（AVF）进行血液透析，但其声称的好处已受到质疑。目的在血液透析内瘘成熟（HFM）研究中检查AVF的可用性，长期功能通畅性和补救程序，以促进成熟，管理并发症或维持通畅性。和参与者HFM研究是一项多中心（n = 7）前瞻性国立卫生研究院国立糖尿病、消化和肾脏疾病研究所队列研究，旨在确定与AVF成熟相关的因素。共招募了602名参与者（透析，肾衰竭：380例;透析前，慢性肾脏疾病[CKD]：222例），确定AVF成熟535例（肾衰竭，353;干预所有关于AVF管理的临床决策都被推迟到各个中心，但在6周内不鼓励进行补救干预。主要结果和措施在本病例系列分析中，主要结果是无辅助成熟。使用Kaplan-Meier分析总结了功能性通畅率、无干预率和参与者生存率。结果大多数参与者（n = 535）为男性（372 [69.5%]）和糖尿病患者（311 [58.1%]）;平均（SD）年龄为54.6（13.6）岁。几乎三分之二的AVF（535例中的342例[64%]）发生在上臂。肾衰竭与CKD参与者的AVF成熟率在3个月时分别为29%与10%，6个月时分别为67%与38%，12个月时分别为76%与58%。几名患有肾衰竭（133 [37.7%]）和CKD（63 [34.6%]）的参与者接受了干预措施，以促进成熟或在成熟前管理并发症。从建立入路到成熟的中位时间为115天（四分位距[IQR]，86-171天），但因初始适应症而异（CKD，170天; IQR，113-269天;肾衰竭，105天; IQR，81-137天）。AVF成熟1年时的功能通畅率为87%（95% CI，83.2%-90.2%），2年时为75%（95% CI，69.7%-79.7%），成熟前接受干预的患者无显著差异。几乎一半（188 [47.5%]）的AVF成熟有进一步的干预，以保持通畅或治疗并发症。结论和相关性-这项研究的结果表明，AVF仍然是一个公认的血液透析通路的选择，虽然它的成熟和继续使用需要适度的干预措施，以保持通畅和治疗相关的并发症。
IMPORTANCE National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned.OBJECTIVE To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study.DESIGN, SETTING, AND PARTICIPANTS The HFM Studywas a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants.INTERVENTIONS All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation.MAIN OUTCOMES AND MEASURES In this case series analysis, the primary outcomewas unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis.RESULTS Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87%(95% CI, 83.2%-90.2%) and at 2 years, 75%(95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications.CONCLUSIONS AND RELEVANCE The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.