超声稀释法及彩色多普勒超声监测的血液透析患者动静脉内瘘血流量与动静脉内瘘丧失功能的相关性  

Association of access blood flow with patency loss of arteriovenous fistula in maintenance hemodialysis patients:ultrasound dilution versus color Doppler ultrasound

作　　者：郑茜子[1] 段秀芳 王晋伟[1] 刘瑶[1] 孟利 尹彦琪 金其庄[1] Zheng Xizi;Duan Xiufang;Wang Jinwei;Liu Yao;Meng Li;Yin Yanqi;Jin Qizhuang(Renal Division,Peking University First Hospital,Peking University Institute of Nephrology,Key Laboratory of Renal Disease,Ministry of Health of China,Key Laboratory of CKD Prevention and Treatment,Ministry of Education of China,Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases,Chinese Academy of Medical Sciences,Beijing 100034,China)

机构地区：[1]北京大学第一医院肾内科、北京大学肾脏疾病研究所、卫生部肾脏疾病重点实验室慢性肾脏病防治教育部重点实验室(北京大学)、中国医学科学院免疫介导肾病诊治创新单元,北京100034

出　　处：《中华肾脏病杂志》2022年第12期1025-1031,共7页Chinese Journal of Nephrology

基　　金：北京市科技新星计划(2021051);北京大学第一医院科研种子基金(2019SF28、2020SF16);中国医学科学院医学与健康科技创新工程项目(2019-I2M-5-046)。

摘　　要：目的探讨应用超声稀释法及彩色多普勒超声监测的动静脉内瘘(arteriovenous fistula,AVF)血流量与AVF丧失功能(失功)的关系。方法采用双向队列研究方法,选取2018年1月1日至2020年7月31日在北京大学第一医院使用AVF进行维持性血液透析的成年患者为研究对象。采用超声稀释法和彩色多普勒超声(测量肱动脉及头静脉)检测AVF血流量,依据基线超声稀释法测量的AVF血流量(Qa)将患者分为低Qa组(<500 ml/min)、正常Qa组(500~1500 ml/min)和高Qa组(>1500 ml/min)。收集患者临床资料和实验室检查结果并进行组间比较。入选者入组后第1年每3个月进行1次Qa监测,随访终点事件定义为AVF失功或患者死亡,随访截止日期为2022年7月31日。采用线性回归分析评价Qa变化趋势,Fine-Gray竞争风险模型估算AVF失功的累积发生率,Cox比例风险回归模型评价基线Qa、肱动脉及头静脉血流量以及Qa变化趋势与AVF失功的相关关系。结果共163例维持性血液透析患者入选该研究,年龄(57.0±13.7)岁,男性110例(67.5%),中位随访时间45(22,53)个月,其中44例(27.0%)患者发生AVF失功,29例(17.8%)患者死亡。基线Qa、肱动脉或头静脉血流量<500 ml/min以及Qa呈下降趋势患者的AVF失功累积发生率高于基线正常和高血流量及Qa呈上升趋势患者(Gray′s检验,均P<0.05)。经校正年龄、性别、内瘘龄、是否合并糖尿病及血管狭窄病史等因素后,多因素Cox回归分析结果显示,基线Qa<500 ml/min(HR=3.508,95%CI 1.382~8.905,P=0.008)、基线肱动脉血流量<500 ml/min(HR=2.413,95%CI 1.058~5.503,P=0.036)及Qa呈下降趋势(HR=2.498,95%CI 1.241~5.027,P=0.010)与AVF失功风险增加独立相关。结论基线AVF低血流量及血流量呈下降趋势的患者发生AVF失功的风险显著增加,肱动脉可作为彩色多普勒超声监测AVF血流量的优先选择部位。Objective To explore the association of access blood flow measured by ultrasound dilution and color Doppler ultrasound with patency loss of arteriovenous fistula(AVF).Methods This was a bidirectional cohort study.The adult patients who underwent maintenance hemodialysis(MHD)with AVF in Peking University First Hospital from January 1,2018 to July 31,2020 were enrolled.AVF blood flow was measured by ultrasonic dilution method(Qa),and color Doppler ultrasound in cephalic vein and brachial artery.Patients were divided into low Qa(<500 ml/min),normal Qa(500⁃1500 ml/min)and high Qa(>1500 ml/min)groups according to baseline AVF blood flow measured by ultrasonic dilution method.Qa was monitored every 3 months within the first year.The endpoint events of follow⁃up were defined as AVF patency loss or death.The deadline of the follow⁃up was July 31,2022.Linear regression analysis was used to assess the change trend of Qa.Fine and Gray competitive risk model was used to evaluate the cumulative incidence of AVF patency loss.The Cox proportional hazards regression model was used to evaluate the association between access AVF blood flow and patency loss.Results A total of 163 patients were enrolled,with age of(57.0±13.7)years old and 110 males(67.5%).The median follow⁃up time was 45(22,53)months.Forty⁃four patients(27.0%)had AVF failure,and 29 patients(17.8%)died.The cumulative incidence rates of AVF patency loss in patients with low Qa,low blood flow of brachial artery and cephalic vein(<500 ml/min),and in those with a downward trend of Qa were higher than those in patients with normal or high blood flow,and in those with a upward trend of Qa(Gray′s test,all P<0.05).After adjusted for age,sex,age of fistula,diabetes and vascular stenosis,multivariable Cox regression analysis results showed that baseline Qa<500 ml/min(HR=3.508,95%CI 1.382-8.905,P=0.008),baseline brachial artery flow<500 ml/min(HR=2.413,95%CI 1.058-5.503,P=0.036)and a downward trend of Qa(HR=2.498,95%CI 1.241-5.027,P=0.010)were independently associa

关 键 词：肾透析 动静脉瘘 超声检查 通路流量 

分 类 号：R692.5[医药卫生—泌尿科学] R445.1[医药卫生—外科学]