Альманах клинической медицины. 2017; 45: 526-534
Сосудистый доступ у пациентов на хроническом гемодиализе в Московской области: состояние и перспективы
https://doi.org/10.18786/2072-0505-2017-45-7-526-534Аннотация
Актуальность. Ежегодно во всем мире отмечается рост количества больных хронической болезнью почек (ХБП). Для пациентов на хроническом гемодиализе (ГД) наличие стабильно функционирующей артериовенозной фистулы (АВФ) – одно из основных условий хорошей выживаемости. Имеющиеся клинические рекомендации по формированию и обслуживанию сосудистого доступа для ГД, как правило, не дают четкого ответа на ряд важных вопросов. Мы обобщили и проанализировали имеющийся у нас опыт по формированию и обслуживанию сосудистого доступа. Цель – проанализировать результаты формирования и обслуживания сосудистого доступа в большой популяции пациентов на хроническом ГД в Московской области. Материал и методы. Мы проанализировали результаты 3837 операций (1862 больных) по формированию и реконструкции сосудистого доступа для хронического ГД, выполненных в 2012–2016 гг. Результаты. Инциденс ХБП стадии 5д вырос на протяжении последних трех лет с 239 до 391. На данный момент под наблюдением состоят 2204 пациента, которые получают лечение в 38 амбулаторных центрах. Почти половину операций – 43,5% (1668 из 3837) – составили формирования АВФ, при этом только треть – 33% (1266 из 3837) – de novo, а 10,5% (403 из 3837) пришлись на долю операций по формированию новой АВФ у пациентов на ГД после тромбоза имеющейся АВФ. Операций по реконструкции АВФ выполнено 15,4% (590 из 3837), разобщению АВФ после успешной трансплантации почки – 4% (154 из 3837), формированию АВФ при помощи сосудистого протеза – 3,2% (121 из 3837), тромбэктомий из протеза проведено 3% (115 из 3837), имплантаций перманентного центрального венозного катетера (ЦВК) – 14,6% (559 из 3837), операций временного ЦВК – 13,6% (520 из 3837). Больше половины пациентов – 54,4% (1012 из 1862) – имели функциональную АВФ, 2,2% (41 из 1862) – сосудистый протез на момент начала ГД, через год – 73,8% (1152 из 1561 пациентов) и 5,3% (83 из 1561 пациентов) соответственно. Вид сосудистого доступа на момент начала ГД сильно зависел от причины ХБП. 60,4% (192 из 318) больных с поликистозом почек и 65,1% (181 из 278) с системными или онкологическими процессами начали ГД через ЦВК. Выживаемость больных, начавших ГД через АВФ, через ЦВК с последующей конверсией на АВФ и начавших и продолживших ГД только через ЦВК составила через год 87,5% (95% доверительный интервал (ДИ) 83,5–90,6), 79,6% (95% ДИ 72,3–82,5) и 66,4% (95% ДИ 57–74,2) соответственно; через пять лет – 61% (95% ДИ 51,8–71,9), 53,9% (95% ДИ 42,5–67), 31,6% (95% ДИ 21,4–41,4) соответственно. Первичная и вторичная проходимость АВФ через год составили 77,2% (95% ДИ 71,7–81,8) и 87% (95% ДИ 83,7–89,7) соответственно, через пять лет – 34,1% (95% ДИ 27,8–40,5) и 60,9% (95% ДИ 56,4–65,1) соответственно. Заключение. Для выявления факторов риска осложнений сосудистого доступа и оптимизации подходов к его формированию и реконструкции требуется более детальный анализ. Эффективным способом достижения этой цели представляется создание локального регистра больных ХБП.
Список литературы
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2. European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2015. 2017. Доступно на: https://www.era-edta-reg.org/files/annualreports/pdf/AnnRep2015.pdf.
3. United States Renal Data System. 2016 USRDS annual data report. Vol. 2 – Endstage Renal Disease (ESRD) in the United States: 1. Incidence, Prevalence, Patient Characteristics, and Treatment Modalities 2016. Доступно на: https://www.usrds. org/2016/view/Default.aspx.
4. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). Annual Data Report 2016. 2016. Доступно на: http://www.anzdata.org.au/v1/report_2016.html.
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8. Neild GH. Life expectancy with chronic kidney disease: an educational review. Pediatr Nephrol. 2017;32(2):243–8. doi: 10.1007/ s00467-016-3383-8.
9. Arhuidese IJ, Obeid T, Hicks C, Qazi U, Botchey I, Zarkowsky DS, Reifsnyder T, Malas MB. Vascular access modifies the protective effect of obesity on survival in hemodialysis patients. Surgery. 2015;158(6):1628–34. doi: 10.1016/j. surg.2015.04.036.
10. Malas MB, Canner JK, Hicks CW, Arhuidese IJ, Zarkowsky DS, Qazi U, Schneider EB, Black JH 3rd, Segev DL, Freischlag JA. Trends in incident hemodialysis access and mortality. JAMA Surg. 2015;150(5):441–8. doi: 10.1001/ jamasurg.2014.3484.
11. Zhang JC, Al-Jaishi AA, Na Y, de Sa E, Moist LM. Association between vascular access type and patient mortality among elderly patients on hemodialysis in Canada. Hemodial Int. 2014;18(3):616–24. doi: 10.1111/hdi.12151.
12. Xue H, Ix JH, Wang W, Brunelli SM, Lazarus M, Hakim R, Lacson E Jr. Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications. Am J Kidney Dis. 2013;61(1):123–30. doi: 10.1053/j. ajkd.2012.09.006.
13. Woo K, Lok CE. New insights into dialysis vascular access: what is the optimal vascular access type and timing of access creation in CKD and dialysis patients? Clin J Am Soc Nephrol. 2016;11(8):1487–94. doi: 10.2215/ CJN.02190216.
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16. Ravani P, Quinn RR, Oliver MJ, Karsanji DJ, James MT, MacRae JM, Palmer SC, Strippoli GF. Preemptive correction of arteriovenous access stenosis: a systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis. 2016;67(3):446–60. doi: 10.1053/j. ajkd.2015.11.013.
17. Zulkarnaev A, Vatazin A, Yankovoy A, Fominikh N, Kardanahishvili Z. Preventive surgery for hemodialysis vascular access saving. J Vasc Access. 2017;18(Suppl 2):S21. doi: 10.5301/jva.5000726.
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19. Brown RS, Patibandla BK, Goldfarb-Rumyantzev AS. The survival benefit of "Fistula First, Catheter Last" in hemodialysis is primarily due to patient factors. J Am Soc Nephrol. 2017;28(2):645–52. doi: 10.1681/ ASN.2016010019.
20. Sequeira A, Naljayan M, Vachharajani TJ. Vascular access guidelines: summary, rationale, and controversies. Tech Vasc Interv Radiol. 2017;20(1):2–8. doi: 10.1053/j.tvir.2016.11.001.
21. Jindal K, Chan CT, Deziel C, Hirsch D, Soroka SD, Tonelli M, Culleton BF; Canadian Society of Nephrology Committee for Clinical Practice Guidelines. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol. 2006;17(3 Suppl 1):S1–27. doi: 10.1681/ASN.2005121372.
22. Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, Kanno Y, Satou T, Sakai S, Sugimoto T, Takemoto Y, Haruguchi H, Minakuchi J, Miyata A, Murotani N, Hirakata H, Tomo T, Akizawa T; Vascular Access Construction and Repair for Chronic Hemodialysis Guideline Working Group, Japanese Society for Dialysis Therapy. 2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis. Ther Apher Dial. 2015;19 Suppl 1:1–39. doi: 10.1111/1744-9987.12296.
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24. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Clinical Practice Guidelines and Clinical Practice Recommendations (2006 Update). Clinical Practice Guidelines For Vascular Access. 2006. Доступно на: http://kidneyfoundation. cachefly.net/professionals/KDOQI/guideline_
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26. Oliver MJ, Quinn RR, Garg AX, Kim SJ, Wald R, Paterson JM. Likelihood of starting dialysis after incident fistula creation. Clin J Am Soc Nephrol. 2012;7(3):466–71. doi: 10.2215/ CJN.08920811.
27. Hod T, Patibandla BK, Vin Y, Brown RS, Goldfarb-Rumyantzev AS. Arteriovenous fistula placement in the elderly: when is the optimal time? J Am Soc Nephrol. 2015;26(2):448–56. doi: 10.1681/ASN.2013070740.
28. Martínez-Gallardo R, Ferreira-Morong F, García-Pino G, Cerezo-Arias I, Hernández-Gallego R, Caravaca F. Congestive heart failure in patients with advanced chronic kidney disease: association with pre-emptive vascular access placement. Nefrologia. 2012;32(2): 206–12. doi: 10.3265/Nefrologia.pre2011.
29. Wilmink T, Hollingworth L, Stevenson T, Powers S. Is early cannulation of an arteriovenous fistula associated with early failure of the fistula? J Vasc Access. 2017;18(Suppl 1):92–7. doi: 10.5301/jva.5000674.
30. Al Shakarchi J, Inston N. Timing of cannulation of arteriovenous grafts: are we too cautious? Clin Kidney J. 2015;8(3):290–2. doi: 10.1093/ ckj/sfu146.
31. Alencar de Pinho N, Coscas R, Metzger M, Labeeuw M, Ayav C, Jacquelinet C, Massy ZA, Stengel B; French REIN registry. Vascular access conversion and patient outcome after hemodialysis initiation with a nonfunctional arteriovenous access: a prospective registry-based study. BMC Nephrol. 2017;18(1):74. doi: 10.1186/s12882-017-0492-y.
32. Allon M, Daugirdas J, Depner TA, Greene T, Ornt D, Schwab SJ. Effect of change in vascular access on patient mortality in hemodialysis patients. Am J Kidney Dis. 2006;47(3):469–77. doi: 10.1053/j.ajkd.2005.11.023.
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Almanac of Clinical Medicine. 2017; 45: 526-534
Vascular access in patients on chronic hemodialysis in the Moscow Region: current state and outlook
https://doi.org/10.18786/2072-0505-2017-45-7-526-534Abstract
Background: The prevalence of chronic kidney disease (CKD) is annually growing worldwide. Stable functioning arteriovenous fistula (AVF) is one of the main prerequisites of survival for patients on chronic hemodialysis (HD). As a rule, available clinical guidelines for creation and maintenance of HD vascular access do not give a clear answer to some important questions. We have summarized and analyzed our experience of the creation and maintenance of the vascular access. Aim: To analyze the results of the creation and maintenance of vascular access in a large population of patients on chronic HD (in the Moscow Region). Materials and methods: We analyzed the results of 3837 surgeries for creation and reconstruction of the vascular access in 1862 patients, performed from 2012 to 2016. Results: The CKD stage 5D incidence has increased from 239 to 391 over the last three years. Currently, 2204 patients are followed up and receiving treatment in 38 outpatient centers. Almost one half of all interventions, 43.5% (1668/3837), has been performed to create AVF. Only one third, i.e. 33% (1266/3837) of them was de novo operations, whereas 10.5% (403/3837) were done to create a new AVF in HD patients after thrombosis of the existing AVF. 15.4% (590/3837) of the interventions were performed for AVF reconstruction, 4% (154/3837) for AVF closure after successful kidney transplantation, 3.2% (121/3837) for creation of AVF with vascular graft, 3% (115/3837) for thrombectomy from the graft, 14.6% (559/3837) to implant a permanent central venous catheter (CVC), and 13.6% (520/3837) for placement of a temporary CVC. 54.4% (1012/1862) of the patients had their functional AVF, 2.2% (41/1862) had a vascular graft at the beginning of HD, and one year later, there were 73.8% (1152/1561) and 5.3% (83/1561) of such patients, respectively. The type of vascular access at the start of HD strongly depended on the cause of CKD. 60.4% (192/318) of patients with polycystic kidney disease and 65.1% (181/278) with systemic disease or cancer started HD with the CVC. Oneyear survival of patients who started HD with AVF, who started HD with CVC and switched to AVF, and those who initiated and continued HD with CVC only, was 87.5% (95% confidence interval [CI] 83.5– 90.6), 79.6% [95% CI 72.3–82.5], and 66.4% (95% CI 57–74.2), respectively. The 5-year survival in these groups was 61% (95% CI 51.8–71.9), 53.9% (95% CI 42.5–67), and 31.6% (95% CI 21.4–41.4), respectively. At one year, primary and secondary AVF patency amounted to 77.2% (95% CI 71.7–81.8) and 87% (95% CI 83.7–89.7), respectively, at 5 years 34.1% (95% CI 27.8–40.5) and 60.9% (95% CI 56.4– 65.1), respectively. Conclusion: A more detailed analysis is necessary to identify risk factors for complications of the vascular access and to optimize approaches to its creation and reconstruction. An effective way to achieve this goal is to establish a local registry of CKD patients.
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19. Brown RS, Patibandla BK, Goldfarb-Rumyantzev AS. The survival benefit of "Fistula First, Catheter Last" in hemodialysis is primarily due to patient factors. J Am Soc Nephrol. 2017;28(2):645–52. doi: 10.1681/ ASN.2016010019.
20. Sequeira A, Naljayan M, Vachharajani TJ. Vascular access guidelines: summary, rationale, and controversies. Tech Vasc Interv Radiol. 2017;20(1):2–8. doi: 10.1053/j.tvir.2016.11.001.
21. Jindal K, Chan CT, Deziel C, Hirsch D, Soroka SD, Tonelli M, Culleton BF; Canadian Society of Nephrology Committee for Clinical Practice Guidelines. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol. 2006;17(3 Suppl 1):S1–27. doi: 10.1681/ASN.2005121372.
22. Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, Kanno Y, Satou T, Sakai S, Sugimoto T, Takemoto Y, Haruguchi H, Minakuchi J, Miyata A, Murotani N, Hirakata H, Tomo T, Akizawa T; Vascular Access Construction and Repair for Chronic Hemodialysis Guideline Working Group, Japanese Society for Dialysis Therapy. 2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis. Ther Apher Dial. 2015;19 Suppl 1:1–39. doi: 10.1111/1744-9987.12296.
23. Tordoir J, Canaud B, Haage P, Konner K, Basci A, Fouque D, Kooman J, Martin-Malo A, Pedrini L, Pizzarelli F, Tattersall J, Vennegoor M, Wanner C, ter Wee P, Vanholder R. EBPG on Vascular Access. Nephrol Dial Transplant. 2007;22 Suppl 2:ii88–117. doi: 10.1093/ndt/gfm021.
24. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Clinical Practice Guidelines and Clinical Practice Recommendations (2006 Update). Clinical Practice Guidelines For Vascular Access. 2006. Dostupno na: http://kidneyfoundation. cachefly.net/professionals/KDOQI/guideline_
25. upHD_PD_VA/index.htm.
26. Oliver MJ, Quinn RR, Garg AX, Kim SJ, Wald R, Paterson JM. Likelihood of starting dialysis after incident fistula creation. Clin J Am Soc Nephrol. 2012;7(3):466–71. doi: 10.2215/ CJN.08920811.
27. Hod T, Patibandla BK, Vin Y, Brown RS, Goldfarb-Rumyantzev AS. Arteriovenous fistula placement in the elderly: when is the optimal time? J Am Soc Nephrol. 2015;26(2):448–56. doi: 10.1681/ASN.2013070740.
28. Martínez-Gallardo R, Ferreira-Morong F, García-Pino G, Cerezo-Arias I, Hernández-Gallego R, Caravaca F. Congestive heart failure in patients with advanced chronic kidney disease: association with pre-emptive vascular access placement. Nefrologia. 2012;32(2): 206–12. doi: 10.3265/Nefrologia.pre2011.
29. Wilmink T, Hollingworth L, Stevenson T, Powers S. Is early cannulation of an arteriovenous fistula associated with early failure of the fistula? J Vasc Access. 2017;18(Suppl 1):92–7. doi: 10.5301/jva.5000674.
30. Al Shakarchi J, Inston N. Timing of cannulation of arteriovenous grafts: are we too cautious? Clin Kidney J. 2015;8(3):290–2. doi: 10.1093/ ckj/sfu146.
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