中国血液净化 ›› 2015, Vol. 14 ›› Issue (01): 33-36.doi: 10.3969/j.issn.1671-4091.2015.01.009

• 临床研究 • 上一篇    下一篇

终末期慢性肾脏病儿童血液透析用动静脉内瘘回顾性研究

梁颖1,孙宁2,王辉1,沈颖1   

  1. 1. 首都医科大学附属北京儿童医院肾脏内科
    2. 首都医科大学附属北京儿童医院泌尿外科
  • 收稿日期:2014-07-08 修回日期:2014-09-25 出版日期:2015-01-12 发布日期:2015-01-12
  • 通讯作者: 沈颖 shenying@bch.com.cn E-mail:shenying@bch.com.cn

Retrospective study of arteriovenous fistula used in pediatric patients with end- stage renal disease

Ying LIANG,Ning SUN,Hui WANG,Ying SHEN   

  • Received:2014-07-08 Revised:2014-09-25 Online:2015-01-12 Published:2015-01-12
  • Contact: Ying SHEN E-mail:shenying@bch.com.cn

摘要: 目的总结目前儿童维持性透析用动静脉内瘘临床情况,为进一步研究提供基线数据。方法选择2007 年6 月~2014 年4 月在首都医科大学附属北京儿童医院肾科行自体动静脉内瘘成形术的慢性肾脏病维持性血液透析患儿62 例,回顾性采集患儿相关临床资料并进行统计分析。结果①男性41 例,女性21 例,患儿手术时平均年龄13 岁5 月18 天(年龄区间为5 岁8 月~16 岁2 月),5~9 岁为9 例(14.52%),10~13 岁为33 例(53.23%),14~17 岁为20 例(32.25%)。籍贯南方为4.8%,北方为95.2%。原发病构成比前两位:慢性肾小球肾炎占29.03%,肾脏畸形及发育不良占27.4%。②从患儿确诊慢性肾脏病到行动静脉内瘘成形术平均时间为30.8 天。③麻醉方式:全麻42 例(67.7%),基础麻醉加臂丛麻醉17例(27.4%),余不详。④侧别选择:左侧为58 例(93.55%),选择右侧为4 例(6.45%)。手术均为前臂动静脉端侧吻合,选用经典桡动脉-头静脉吻合者55 例(88.7%),桡动脉-非头静脉吻合者7 例(11.3%)。⑤术中吻合口内径:2mm 者为22 例(35.5%),2.5mm 者为3 例(4.8%),3mm 者为31 例(50%),4mm 者为3 例(4.8%),不详者为3 例(4.8%)。⑥以术后1 周可于动静脉内瘘成形术处触及血管震颤、闻及血管杂音作为内瘘成形手术成功的判断指标,首次动静脉内瘘成形术成功者为50 例(80.65%),失败者为12 例(19.35%),其中2mm 组手术成功18 例/22 例(81.8%),>2mm 组成功32 例/37 例(86.5%),2 组成功率无显著性差异(P>0.05)。2 次手术成功率为87.5%。⑦术后可触及明显震颤者为52 例(83.9%),轻微者为3 例(4.8%),未触及者为7 例(11.3%);可闻及明显血管杂音者为53 例(85.5%),轻微者为2 例(3.2%),未闻及者为7 例(11.3%)。⑧术后急性并发症:血栓为6 例(9.7%),渗血为5 例(8.0%), 肿胀、疼痛4 例(6.5%),血肿1 例 (1.6)%,手指麻木1 例(1.6%)。首次透析动静脉内瘘使用率为1.6%(1 例)。结论从确诊慢性肾脏病到行动静脉内瘘成形术时间过短,低于指南提出的6~12 个月,准备和教育时间不足。手术优先选择左侧前臂桡动脉头静脉端侧吻合,成功率达80.65%,吻合口内径2mm 组和>2 mm 组的手术成功率比较无显著性差异。最常见的急性并发症为渗血和血栓。

关键词: 终末期慢性肾脏病, 儿童维持性血液透析, 血管通路, 自体动静脉内瘘

Abstract: Objectives To obtain baseline data for further research we summarized the use of arteriovenous fistula for blood access in pediatric maintenance hemodialysis patients. Methods We retrospectively reviewed the clinical data of 62 pediatric patients with autologous arteriovenous fistula for maintenance hemodialysis
during the period from June 2007 to April 2014 in the Department of Nephrology, Beijing Children’s Hospital. Results ①in the 62 cases, 41 were males and 21 were females with the age of 5~9 years old in 9 cases, 9~13 years old in 33 cases, and 13~17 years old in 20 cases. The average age at surgery was 13 years and 5 months (5y8m to 16y2m). The primarily resident place was southern China in 4.8% cases and northern China in 95.2% cases. The primary disease was chronic glomerulonephritis in 29.03% cases, and kidney abnormality or dysplasia in 27.40% cases. ②The average interval from diagnosis of chronic renal disease to arteriovenous fistula surgery was 30.8 days. ③ Anesthesia modalities: general anesthesia in 42 cases, and brachial plexus block in 17 cases. ④Side selection: left side in 58 cases, and right side in 4 cases. All patients were subjected to forearm arteriovenous fistula surgery, in which radio- cephalic end- to- lateral anastomosis was performed in 55 cases and radio-noncephalic anatomosis in 7 cases. ⑤Inner diameter of the fistula at surgery: 2mm in 22 cases (35.5%), 2.5mm in 3 cases (4.8%), 3mm in 31 cases (50%), 4mm in 3 cases (4.8%), and size unknown in 3 cases. ⑥The presence of tremor and vascular bruit at the operation site after surgery for one week was regarded as surgery success. Fistula was established in 50 cases (80.65%), and was failed to establish
in 12 cases (19.35%). The success rate to establish a fistula was 81.8% (18/22) in patients with fistula in-ner diameter of 2mm, and was 86.5% (32/37) in those with the diameter of >2mm, without significant difference between the two groups. The success rate of the second surgery was 87.5%. ⑦The tremor at the operation site after the surgery was relatively strong in 52 case (83.9%), weak in 3 cases (4.8%), and none in 7 cases (11.3%). The vascular bruit was relatively intense in 53 cases (85.5%), slight in 2 cases (3.2%), and none in 7 cases (11.3%). ⑧Complications immediately after surgery: thrombosis in 6 cases (9.7%), errhysis in 5 cases (8.0%), swollen and pain in 4 cases (6.5%), hemorrhage in one case (1.6%), and finger numbness in one case (1.6%). ⑨Arteriovenous fistula was used at the first hemodialysis session in only one case (1.6%). Conclusion The time interval from diagnosis of chronic renal disease to fistula surgery was 30.8 day, much shorter than 6~12 months suggested by the vascular access guideline in 2006 NKF-KDOQI. We preferred to make ratio- cephlic end- to- lateral anastomosis in left wrist. Success rate of the operation was 80.65% (50 cases), which was unrelated to the inner diameter of fistula orifice. The most common acute complications in this series of patients were thrombosis and errhysis.

Key words: end-stage renal disease, pediatric maintenance hemodialysis, vascular access, arteriovenousfistula