中国血液净化

中国血液净化 ›› 2018, Vol. 17 ›› Issue (06): 391-396.doi: 10.3969/j.issn.1671-4091.2018.06.008

• 血管通路 • 上一篇    下一篇

自体动静脉内瘘血管超声测量对血液透析尿素清除指数评估的临床价值

赵蕊1,张周沧2,秦燕3,杨洁4,彭彦平5,孔令新6,林越7,刘士英8,尹秀娟9,盖国清10,昶晶晶2,刘伟2,张东亮2   

  1. 北京大学国际医院1超声科2肾内科部透析中心
    3北京老年医院肾内科
    4北京积水潭医院肾内科
    5首都医科大学附属北京康复医院泌尿与代谢病中心
    6北京房山区中医医院肾内科
    7北京王府中西医结合医院血液透析中心
    8北京昌平区中西医结合医院肾内科
    9北京首都国际机场医院血液透析中心
    10北京环生医疗投资有限公司(现在北京大学国际医院进修)
  • 收稿日期:2017-12-08 修回日期:2018-02-06 出版日期:2018-06-12 发布日期:2018-06-20
  • 通讯作者: 张东亮 zdlycy@163.com E-mail:zhangdongliang@pkuih.edu.cn
  • 基金资助:

    北京大学国际医院科研基金重点项目(编号：YN2016ZD05)

The clinical value of ultrasonography measurement for autologous arteriovenous fistula on the estimation of urea clearance index in hemodialysis patients

  • Received:2017-12-08 Revised:2018-02-06 Online:2018-06-12 Published:2018-06-20

PDF

639

摘要： 【摘要】目的探讨超声测量自体动静脉内瘘(arteriovenous fistula, AVF)血管对AVF 成熟及血液透析(hemodialysis,HD)治疗充分性的评价作用。方法对8 个HD 中心符合条件的患者进行横断面研究，超声测量前臂AVF 血管，包括AVF 侧上肢肱动脉末段(a1)、桡动脉(a2)和尺动脉起始段(a3)、AVF 吻合口上桡动脉(a4)、AVF 流出道静脉穿刺引血段(a5)等血管的内径(diameter，D)、收缩峰流速(systolic peak flow velocity，SPV)、舒张末流速(end-diastolic flow velocity，EDV)、血流量(blood flow volume，BFV)，选取其中稳定HD 测算单次尿素溶质清除指数Kt/V，以Da5≥0.5cm 且BFVa5＞500ml/min 为AVF 成熟，Kt/V≥1.2 为HD 治疗达标，对AVF 成熟和Kt/V 达标进行Logistic 回归分析，用受试者工作特征曲线(receiver operating characteristic curve，ROC)根据Logistic 回归公式评估Kt/V 达标情况；根
据AVF 成熟和Kt/V 达标情况，分为双达标组(组1)、AVF 成熟但Kt/V 不达标组(组2)、AVF 不成熟但Kt/V 达标组(组3)，对各组间各参数进行对比分析。结果8 家HD 中心入组患者324 例，AVF 成熟223 例(68.83%)，HD 治疗达标310 例(95.68%)，AVF 成熟的相关参数为Da2(相关系数为5.779，OR 为0.003，P=0.003)，Kt/V 达标的相关参数为体质量(相关系数为-0.057，OR 为1.059，P=0.000)、有无糖尿病(相关系数为0.983，OR 为0.374，P=0.035)、和Da5(相关系数为6.137，OR 为0.002，P=0.000)，Logistic 公式估算值对Kt/V 进行ROC 计算得到的曲线下面积=0.849(P=0.000，95% CI 0.784～0.914)；组1 有209 例(64.5%)、组2 有14 例(4.3%)、组3 有101 例(31.2%)，组2 与另两组比糖尿病比例(78.6%对组1 的40.2%，χ2=15.234，P=0.000；对组2 的35.6%，χ2=84.236，P=0.000)、身高[(173.64±8.35)cm 对组1 的(167.37±7.86)cm，P=0.003，95% CI: 2.15～10.39；对组3 的(166.10 ± 6.89)cm，P=0.001，95% CI: 3.29～11.80]、体质量[(85.04±22.19)Kg 对组1 的(66.63±10.72)Kg，P=0.000，95% CI: -24.88～11.93；对组3 的(65.31±12.37)Kg，P=0.000，95% CI: -26.41～13.03]更大、Kt/V[(1.04±0.13)对组1 的(1.31±0.28)，P=0.000，95% CI:0.12～0.42；对组3 的(1.29±0.27)cm，P=0.001，95% CI: 0.101～0.406]更小，组3 的Da1～Da4 [Da1 为(0.54±0.11)cm 对(0.61±0.13)cm，P=0.000，95% CI: -0.063～0.072；Da2 为(0.41 ± 0.10)cm 对(0.48 ± 0.13)cm，P=0.000，95% CI: - 0.062～0.016；Da3 为(0.41 ± 0.09)cm 对(0.46±0.11)cm，P=0.000，95% CI: - 0.071～- 0.021；Da4 为(0.31±0.08)cm 对(0.35±0.10)cm，P =0.001，95% CI: - 0.062～- 0.016]、SPVa1[(112.01 ± 48.70)cm/s 对(129.45 ± 48.12)cm/s，P=0.003，95% CI: -28.780～-6.097]和EDVa1[(55.34±31.20)cm/s 对(69.08±43.19)cm/s，P=0.004，95% CI: -23.050～-4.415]明显小于组1，而Da5[(0.46±0.15)cm 对组1 的(0.75±0.31)cm，P=0.000，95% CI: -0.349～- 0.221；对组2 的(0.63 ± 0.26)cm，P=0.037，95% CI: - 0.311～- 0.010] 和BFVa5[(587.67 ±413.08)ml/min 对组1 的(2039.28±1550.72)ml/min，P=0.000，95% CI: -1762.72～1140.502；对组2 的(1695.37±401.58)ml/min，P=0.003，95% CI: -1839.843～-375.571]明显小于另两组。结论超声测量血管可以反映AVF 成熟情况，Da2 是AVF 成熟与否的独立影响因素，包含Da5、体质量和患DM 情况的回归公式可以估测单次HD的Kt/V 水平，AVF 成熟与Kt/V 达标存在不匹配。

关键词: 动静脉内瘘, 超声检查, 血液透析, 尿素清除指数, 血流量

Abstract: 【Abstract】Objectives To study the measurement of arteriovenous fistula (AVF) by ultrasonography for the estimation of AVF maturation and hemodialysis (HD) adequacy. Methods HD patients with forearm AVF in the 8 HD centers were enrolled into this cross-sectional study. AVFs were measured by ultrasonography to obtain the parameters of diameter (D), systolic peak flow velocity (SPV), end-diastolic flow velocity (EDV) and blood flow volume (BFV) at the sites of end segment of brachial artery (a1), beginning segments of radial artery (a2) and ulnar artery (a3), upper segment of radial artery before anastomotic stoma (a4) and segment of cephalic vein near the blood access suite (a5). Urea clearance index (Kt/V) was measured in one stable HD session in the middle of a week. An AVF with D-a5 ≥0.5cm and BFV-a5＞500ml/min was regarded as a maturated AVF. The adequacy of HD was identified as Kt/V ≥1.2. Logistic regression was done to analyze the parameters affecting maturation of AVF and the rate of compliance with the target Kt/V value. Receiver operating characteristic curve (ROC) was performed to estimate the rate of compliance with the target Kt/V value based on the formula from logistic regression analyses. Patients were then divided into 3 groups according to maturation of AVF and compliance with the target Kt/V value, group one with maturated AVF and compliance with the target Kt/V value, group 2 with maturated AVF and without compliance with the target Kt/V value, and group 3 without maturated AVF but with compliance with the target Kt/V value. The parameters were compared among the three groups. Results A total of 324 patients were enrolled in this study, including 223 patients (68.83%) with maturated AVFs and 310 patients (95.68%) with Kt/V compliant with the target level. The independent correlation parameter for AVF maturation was D-a2 (RR=5.779, OR=0.003, P=0.003). The independent correlation parameters for Kt/V compliant with the target level were body weight (RR=-0.057, OR=1.059, P=0.000), diabetes (RR=0.983, OR=0.374, P=0.035) and D-a5 (RR=6.137, OR=0.002, P=0.000). The area under the curve to estimate the rate of compliance with target Kt/V value based on the formula from logistic regression was 0.849 (P=0.000, 95% CI 0.784～0.914). There were 209 patients (64.5%) in group one, 14 patients (4.3%) in group 2 and 101 patients (31.2%) in group 3. Compared to the other two groups, patients in group 2 had more diabetes patients (78.6% vs. 40.2%, χ2=15.234, P=0.000, compared to group one; 78.6% vs. 35.6%, χ2=84.236, P=0.000, compared to group 3), higher height [(173.64±8.35)cm vs. (167.37±7.86)cm, P=0.003, 95% CI 2.15～10.39, compared to group one; (173.64±8.35)cm vs. (166.10±6.89)cm, P=0.001, 95% CI 3.29～11.80, compared to group 3), heavier weight [(85.04±22.19)kg vs. (66.63±10.72)kg, P=0.000, 95% CI -24.88～11.93, compared to group one; (85.04±22.19)kg vs. (65.31±12.37)kg, P=0.000, 95% CI - 26.41～13.03, compared to group 3), and lower Kt/V [(1.04±0.13) vs. (1.31±0.28), P=0.000, 95% CI 0.12～0.42, compare to group one; (1.04±0.13) vs. (1.29±0.27), P=0.001, 95% CI 0.101～0.406, compared to group 3]. Compared to group one, patients in group 3 had less values of D-a1, D-s2, D-a3 and D-a4 [(0.54± 0.11)cm vs. (0.61±0.13)cm, P=0.000, 95% CI -0.063～0.072 for D-a1; (0.41±0.10)cm vs. (0.48±0.13)cm, P=0.000, 95% CI -0.062～0.016 for D-a2; (0.41±0.09)cm vs. (0.46±0.11)cm, P=0.000, 95% CI -0.071～-0.021 for D- a3; (0.31 ± 0.08)cm vs. (0.35 ± 0.10)cm, P=0.001, 95% CI - 0.062～- 0.016 for D- a4], lower SPV- a1 [(112.01 ± 48.70)cm/s vs. (129.45±48.12)cm/s, P=0.003, 95% CI -28.78~6.097) and lower EDV- a1 (55.34±31.20)cm/s vs. (69.08±43.19)cm/s, P=0.004, 95% CI -23.050～-4.415]. Compared to groups one and 2, patients in group 3 had less value of D-a5 [(0.46±0.15)cm vs. (0.75±0.31)cm, P=0.000, 95% CI -0.349～-0.221, compared to group one; 0.46 ± 0.15cm vs. (0.63 ± 0.26)cm, P=0.037, 95% CI - 0.311～- 0.010, compared to groups 2] and less BFV- a5 [(587.67±413.08)ml/min vs. (2,039.28±1,550.72)ml/min, P=0.000, 95% CI - 1, 762.72~1,140.502, compared to group one; 587.67±413.08ml/min vs. 1,695.37±401.58ml/min, P=0.003, 95% CI -1,839.843～-375.571, compared to group 2]. Conclusion Maturation of AVF can be assessed by ultrasonography measurement. The value of D-a2 is an independent factor for AVF maturation. Logistic formula including D- a5, body weight and diabetes can be used to estimate Kt/V in a HD ssession. There exists unmatched situation between AVF maturation and compliance with target Kt/V value.

Key words: arteriovenous fistula, ultrasonography, hemodialysis, urea clearance index, blood volume