不同动静脉瘘穿刺方式对血液透析患者透析充分性的影响

干雁群; 郑志波

doi:10.16766/j.cnki.issn.1674-4152.003030

不同动静脉瘘穿刺方式对血液透析患者透析充分性的影响

doi: 10.16766/j.cnki.issn.1674-4152.003030

干雁群^,,
郑志波

浙江医院血液净化中心, 浙江杭州 310013

基金项目:

浙江省医药卫生科技计划项目 2022RC093

详细信息

通讯作者:
干雁群, E-mail: yanqun198212@126.com

中图分类号: R459.5
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- 文章访问数: 254
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- 被引次数: 0
出版历程
- 收稿日期: 2022-09-01
- 网络出版日期: 2023-08-26

Effect of different arteriovenous fistula puncture methods on the dialysis adequacy of hemodialysis patients

GAN Yanqun^,,
ZHENG Zhibo

Blood Purification Center, Zhejiang Hospital, Hangzhou, Zhejiang 310013, China

摘要

摘要: 目的动静脉穿刺针插入技术可显著影响透析效果，本文旨在探究不同穿刺方式对透析充分性的影响差异以供临床实践参考。方法以2020年1月—2021年10月至浙江医院血液净化中心进行透析的217例患者为研究对象，进行区域、绳梯和扣眼3种不同穿刺方式，采集患者临床信息，通过透析开始后6个月内的平均尿素清除指数(Kt/V)和尿素下降率(urea reduction ratio, URR)比较透析的充分性差异，通过logistic回归分析探究相关的影响因素。结果患者透析龄为(55.6±2.8)个月，动静脉内瘘使用时间为(45.3±1.6)个月。穿刺技术中区域穿刺法116例(53.5%)，绳梯穿刺70例(32.2%)，扣眼穿刺31例(14.3%)。Kt/V、URR值与动静脉瘘位置间存在显著关联，肱动脉-头静脉内瘘组患者的Kt/V及URR值更优于桡动脉-头静脉内瘘组患者(P值分别为0.002、0.028)。穿刺针沿顺行方向使得Kt/V增加了0.892倍(95% CI：0.851~0.963，P=0.033)，而穿刺方法、动脉针旋转、动静脉瘘位置和动静脉针是否位于同一血管节段对Kt/V、URR值即透析充分性无显著影响(均P>0.05)。结论血液透析患者动静脉瘘穿刺方式中穿刺针方向与血流方向一致时可增加血液透析的充分性，不同穿刺方式、插入后动脉针旋转及动静脉穿刺针位于同一血管节段均不会对透析充分性产生显著影响。
- 血液透析 /
- 穿刺 /
- 动静脉瘘 /
- 尿素清除指数 /
- 尿素下降率
Abstract: Objective Arteriovenous puncture technique can significantly affect the adequacy of dialysis. This study aims to explore the differences in the impact of different puncture methods on dialysis adequacy for clinical practice reference. Methods A total of 217 patients who underwent hemodialysis at the Blood Purification Center, Zhejiang Hospital from January 2020 to October 2021 were selected as the research objects. Regional, rope ladder, and buttonhole puncture methods were used, and patient clinical information was collected. The adequacy of dialysis was compared by the average urea clearance index (Kt/V) and urea reduction rate (URR) within 6 months after dialysis. Logistic regression analysis was used to explore the related influencing factors. Results The average age of the patients was (55.6±2.8) months, and the average use time of the arteriovenous fistula was (45.3±1.6) months. Among the puncture techniques, 116 cases (53.5%) used regional puncture, 70 cases (32.2%) used rope ladder puncture, and 31 cases (14.3%) used buttonhole puncture. There was a significant correlation between Kt/V, URR values and the location of the arteriovenous fistula. Patients with brachial artery-cephalic vein fistula had better Kt/V and URR values than those with radial artery- cephalic vein fistula (P=0.002, 0.028). Puncture needle direction along the blood flow direction increased Kt/V by 0.892 times (95% CI: 0.851-0.963, P=0.033), while puncture method, arterial needle rotation, whether the arterial and venous needles were in the same vascular segment had no significant effect on Kt/V, URR values, and dialysis adequacy (all P>0.05). Conclusion When the direction of the puncture needle is consistent with the blood flow direction in arteriovenous fistula puncture, it can increase the adequacy of hemodialysis. Different puncture methods, arterial needle rotation after insertion, and whether the arterial and venous needles are in the same vascular segment do not have a significant effect on dialysis adequacy.
- Hemodialysis /
- Puncture /
- Arteriovenous fistula /
- Urea clearance index /
- Urea reduction rate

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表 1 糖尿病和高血压患者中穿刺方式相关变量比较

Table 1. Comparison of puncture mode related variables between diabetic patients and hypertensive patients

变量	存在糖尿病		统计量	P值	存在高血压		统计量	P值
变量	是(n=59)	否(n=158)	统计量	P值	是(n=111)	否(n=106)	统计量	P值
穿刺方式[例(%)]			0.492^a	0.782			1.484^a	0.476
区域穿刺	31(52.5)	85(53.8)			56(50.5)	60(56.6)
绳梯穿刺	18(30.5)	52(32.9)			40(36.0)	30(28.3)
扣眼穿刺	10(17.0)	21(13.3)			15(13.5)	16(15.1)
穿刺针方向[例(%)]			0.166^a	0.684			0.001^a	0.977
顺行	30(50.8)	66(41.8)			49(44.1)	47(44.3)
逆行	29(49.2)	92(58.2)			62(55.9)	59(55.6)
穿刺针旋转[例(%)]			0.166^a	0.684			0.087^a	0.768
是	38(64.4)	97(61.4)			68(61.3)	67(63.2)
否	21(35.6)	61(38.6)			43(38.7)	39(36.8)
动静脉瘘位置[例(%)]			1.693^a	0.429			6.782^a	0.034
桡动脉-头静脉内瘘	37(62.7)	113(71.5)			68(61.3)	82(77.4)
肱动脉-头静脉内瘘	21(35.6)	42(26.6)			40(36.0)	23(21.7)
鼻烟窝内瘘	1(1.7)	3(1.9)			3(2.7)	1(0.9)
动静脉管位于同一血管内[例(%)]			2.849^a	0.091			3.749^a	0.053
是	5(8.5)	28(17.7)			22(19.8)	11(10.4)
否	54(91.5)	130(82.3)			89(80.2)	95(89.6)
Kt/V(x±s)	1.64±0.29	1.62±0.34	0.041^b	0.968	1.60±0.28	1.64±0.32	-0.944^b	0.372
URR(x±s，%)	73.36±8.02	74.02±7.79	-0.385^b	0.709	73.46±7.88	72.98±8.02	0.860^b	0.412
注：^a为χ²值, ^b为t值。

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表 2 不同穿刺技术Kt/V及URR值比较情况

Table 2. Comparison of Kt/V and URR values of different puncture techniques

变量	例数(%)	Kt/V(x±s)	统计量	P值	URR值(x±s，%)	统计量	P值
穿刺方式			1.120^a	0.886		1.800^a	0.167
区域穿刺	116(53.5)	1.60±0.30			73.33±7.88
绳梯穿刺	70(32.2)	1.61±0.31			74.25±7.15
扣眼穿刺	31(14.3)	1.63±0.32			71.16±7.06
穿刺针方向			0.451^b	0.652		0.665^b	0.507
顺行	96(44.2)	1.64±0.33			74.36±7.96
逆行	121(55.8)	1.62±0.32			73.69±6.88
穿刺针旋转			0.237^b	0.813		0.450^b	0.653
是	135(62.2)	1.62±0.29			72.88±7.36
否	82(37.8)	1.63±0.32			73.36±8.02
动静脉瘘位置			0.430^a	0.002		3.650^a	0.028
桡动脉-头静脉内瘘	150(69.1)	1.53±0.32			71.96±6.96
肱动脉-头静脉内瘘	63(29.0)	1.68±0.21			74.38±7.90
鼻烟窝内瘘	4(1.9)	1.74±0.37			78.36±8.99
动静脉管位于同一血管内			0.827^b	0.409		1.363^b	0.174
是	33(15.2)	1.60±0.32			74.25±8.06
否	184(84.8)	1.65±0.32			72.36±7.20
注：^a为F值，^b为t值。

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表 3 影响Kt/V及URR值相关因素回归分析

Table 3. Regression analysis of related factors affecting Kt/V and URR values

变量	Kt/V						URR值(%)
变量	β	SE	Waldχ²	P值	OR值	95% CI	β	SE	Waldχ²	P值	OR值	95% CI
穿刺方式	0.120	1.103	0.012	0.913	1.127	0.130~3.564	-2.285	1.348	2.874	0.090	0.102	0.007~2.708
穿刺针方向	0.114	0.126	0.017	0.033	0.892	0.851~0.963	-0.988	1.398	0.499	0.480	0.372	0.024~1.061
穿刺针旋转	1.718	1.065	2.604	0.107	5.573	0.692~9.654	0.921	1.642	0.315	0.575	2.512	0.101~4.263
动静脉瘘位置	-0.215	1.154	0.035	0.852	0.807	0.084~1.656	1.437	1.511	0.585	0.958	4.208	0.019~7.058
动静脉管位置	1.125	0.143	0.024	0.055	3.080	0.014~5.592	-0.381	1.578	2.461	0.085	0.814	0.036~1.689

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