维持性血液透析患者动静脉内瘘失功的影响因素及预测模型构建与验证

夏苑莺; 毕明明; 方晓娟; 徐秀琴; 娄成利; 吴梅

doi:10.16766/j.cnki.issn.1674-4152.004044

维持性血液透析患者动静脉内瘘失功的影响因素及预测模型构建与验证

doi: 10.16766/j.cnki.issn.1674-4152.004044

1.
嘉兴大学附属中医医院血液净化中心，浙江嘉兴 314001
2.
浙江新安国际医院血液净化中心，浙江嘉兴 314001
3.
嘉兴大学附属中医医院肾病科

基金项目:

浙江省中医药科技计划项目 2023ZL174

详细信息

通讯作者:
夏苑莺，E-mail：toby6353@163.com

中图分类号: R459.5
计量
- 文章访问数: 18
- HTML全文浏览量: 16
- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2024-12-08
- 网络出版日期: 2025-09-04

Factors influencing arteriovenous fistula dysfunction in maintenance hemodialysis patients and construction and validation of prediction model

1.
Hemodialysis Center, Jiaxing University Affiliated Hospital of Traditional Chinese Medicine, Jiaxing, Zhejiang 314001, China

摘要

摘要: 目的动静脉内瘘(AVF)失功严重影响血液透析质量，本研究旨在探讨维持性血液透析患者AVF失功的影响因素，并构建预测模型，为血液透析患者AVF失功的评估预测和干预提供参考。方法选取2022年11月—2024年7月嘉兴大学附属中医医院收治的342例维持性血液透析患者为研究对象。根据血液透析患者是否发生AVF失功，分为失功组(55例)和对照组(287例)。收集2组患者的临床资料，包括基本资料、透析和AVF相关资料、实验室指标。进行多因素logistic回归分析筛选危险因素，构建血液透析患者AVF失功的预测模型。另选取88例血液透析患者进行临床外部验证。结果年龄大(OR=1.059)、合并糖尿病(OR=3.622)、合并血瘀证(OR=4.787)、D-D高水平(OR=1.011)、FIB高水平(OR=4.325)均是导致血液透析患者AVF失功的危险因素(P＜0.05)。预测模型：P=e^x/(1+e^x)，X=-19.897+0.058×年龄+1.287×糖尿病+1.566×血瘀证+0.011×D-D+1.465×FIB。临床外部验证显示，该模型预测血液透析患者AVF失功的准确率为90.91%(80/88)，AVF失功预测模型与临床实际结果的一致性较高(Kappa=0.680)。结论年龄大、合并糖尿病、合并血瘀证、D-D高水平和FIB高水平是导致血液透析患者AVF失功的危险因素，由此构建的预测模型准确度较高，对血液透析患者AVF失功的预测评估具有较好的指导意义。
- 维持性血液透析 /
- 动静脉内瘘 /
- 失功 /
- 影响因素 /
- 预测模型
Abstract: Objective The failure of arteriovenous fistula (AVF) seriously affects the quality of hemodialysis. This study aims to explore the influencing factors of AVF failure in maintenance hemodialysis patients and construct a predictive model to provide guidance for the evaluation, prediction, intervention, and prevention of AVF failure in hemodialysis patients. Methods A total of 342 maintenance hemodialysis patients from November 2022 to July 2024 at Jiaxing University Affiliated Hospital of Traditional Chinese Medicine were selected as the research subjects. According to whether hemodialysis patients experience AVF dysfunction, they were divided into a dysfunction group (n=55) and a control group (n=287). Clinical data from two groups of patients were collected, including basic information, dialysis and AVF-related information, and laboratory indicators. Multiple logistic regression analyses was conducted to screen risk factors and construct a predictive model for AVF dysfunction in hemodialysis patients. Another 88 hemodialysis patients were selected for clinical external validation. Results Advanced age (OR=1.059), diabetes (OR=3.622), blood stasis syndrome (OR=4.787), high level of D-D (OR=1.011), high level of FIB (OR=4.325) were risk factors for AVF dysfunction in hemodialysis patients (P < 0.05). Prediction model: P=e^x/(1+e^x), X=-19.897+0.058×age+1.287×diabetes+1.566×blood stasis syndrome+0.011×D-D+1.465×FIB. Clinical external validation showed that the accuracy of the model in predicting AVF failure in hemodialysis patients was 90.91% (80/88), and the consistency between the AVF failure prediction model and clinical actual results was high (Kappa=0.680). Conclusion Advanced age, diabetes, blood stasis syndrome, and high levels of D-D and FIB are risk factors for AVF dysfunction in hemodialysis patients. The prediction model constructed on this basis is highly accurate. It is of guiding significance for evaluating and predicting AVF dysfunction in hemodialysis patients.
- Maintenance hemodialysis /
- Arteriovenous fistula /
- Dysfunction /
- Influencing factor /
- Prediction model

HTML全文

图 1 血液透析患者AVF失功预测模型的ROC曲线

Figure 1. ROC curve of the prediction model for AVF dysfunction in hemodialysis patients

下载: 全尺寸图片幻灯片

图 2 血液透析患者AVF失功预测模型的校准曲线

Figure 2. Calibration curve of the prediction model for AVF dysfunction in hemodialysis patients

下载: 全尺寸图片幻灯片

图 3 血液透析患者AVF失功预测模型的列线图

Figure 3. Nomogram of the prediction model for AVF dysfunction in hemodialysis patients

下载: 全尺寸图片幻灯片

图 4 血液透析患者AVF失功预测模型临床外部验证的ROC曲线

Figure 4. ROC curve of clinical external validation of the prediction model for AVF dysfunction in hemodialysis patients

下载: 全尺寸图片幻灯片

表 1 2组维持性血液透析患者临床资料比较(x ±s)

Table 1. Comparison of clinical data between the two groups of maintenance hemodialysis patients (x ±s)

项目	失功组(n=55)	对照组(n=287)	统计量	P值
性别[例(%)]			0.004^a	0.947
男性	38(69.09)	197(68.64)
女性	17(30.91)	90(31.36)
年龄(x ±s，岁)	64.24±10.37	58.72±10.77	3.502^b	0.001
BMI(x ±s)	22.54±3.65	22.76±4.35	0.348^b	0.728
透析龄(x ±s，月)	43.93±8.48	41.70±8.19	1.839^b	0.067
吸烟[例(%)]			1.412^a	0.235
是	8(14.55)	62(21.60)
否	47(85.45)	225(78.40)
糖尿病[例(%)]			9.929^a	0.002
是	32(58.18)	102(35.54)
否	23(41.82)	185(64.46)
优势侧手臂AVF[例(%)]			0.001^a	0.993
是	13(23.64)	68(23.69)
否	42(76.36)	219(76.31)
AVF同侧中心静脉导管史[例(%)]			0.712^a	0.399
是	7(12.73)	26(9.06)
否	48(87.27)	261(90.94)
血瘀证[例(%)]			11.753^a	0.001
是	35(63.64)	111(38.68)
否	20(36.36)	176(61.32)
CRP(x ±s，mg/L)	4.74±1.22	4.70±1.55	0.181^b	0.857
PLT(x ±s，×10⁹/L)	176.24±44.51	175.26±48.95	0.138^b	0.890
LDL-C(x ±s，mmol/L)	2.04±0.87	2.00±0.75	0.363^b	0.717
HDL-C(x ±s，mmol/L)	1.63±0.40	1.68±0.52	0.676^b	0.500
TC(x ±s，mmol/L)	3.84±1.24	3.99±1.23	0.827^b	0.409
TG(x ±s，mmol/L)	1.27±0.32	1.18±0.39	1.610^b	0.108
血磷(x ±s，mmol/L)	1.68±0.61	1.67±0.54	0.097^b	0.923
血钙(x ±s，mmol/L)	2.33±0.55	2.24±0.48	1.243^b	0.215
PTH(x ±s，pmol/L)	194.33±38.82	188.75±33.64	1.098^b	0.273
ALB(x ±s，g/L)	39.99±3.44	40.45±3.32	0.940^b	0.348
Scr(x ±s，μmol/L)	412.73±85.26	396.47±76.19	1.422^b	0.156
BUN(x ±s，mmol/L)	36.27±9.55	34.14±8.25	1.709^b	0.088
PT(x ±s，s)	10.97±0.72	11.04±0.76	0.710^b	0.478
APTT(x ±s，s)	28.45±2.38	28.51±3.58	0.117^b	0.907
D-D(x ±s，ng/mL)	872.68±187.97	676.36±113.68	10.389^b	＜0.001
FIB(x ±s，g/L)	4.35±0.86	3.46±0.83	7.243^b	＜0.001
注：^a为χ²值，^b为t值。

下载: 导出CSV

表 2 变量赋值情况

Table 2. Variable assignments

变量	赋值方法
年龄	连续变量，以实际值赋值
糖尿病	是=1，否=0
血瘀证	是=1，否=0
D-D	连续变量，以实际值赋值
FIB	连续变量，以实际值赋值
AVF失功	是=1，否=0

下载: 导出CSV

表 3 AVF失功影响因素的多因素logistic回归分析

Table 3. Multivariate logistic regression analysis of the influencing factors of AVF dysfunction

变量	B	SE	Wald χ²	OR值	95% CI	P值
年龄	0.058	0.019	9.352	1.059	1.021~1.099	0.002
糖尿病	1.287	0.582	4.890	3.622	1.158~11.333	0.028
血瘀证	1.566	0.506	9.578	4.787	1.776~12.907	0.002
D-D	0.011	0.002	40.576	1.011	1.008~1.014	＜0.001
FIB	1.465	0.278	27.666	4.325	2.506~7.465	＜0.001

下载: 导出CSV

表 4 预测模型与临床实际结果的一致性分析(例)

Table 4. Consistency analysis between the prediction model and actual clinical results (cases)

预测模型	临床实际		合计
预测模型	失功	正常	合计
失功	11	6	17
正常	2	69	71
合计	13	75	88

下载: 导出CSV

参考文献(20)

[1]	GEDNEY N. Arteriovenous fistula or dialysis catheter: a patient's perspective[J]. Kidney360, 2022, 3(6): 1109-1110.
[2]	OZEN N, AYDIN A, SAYILAN S, et al. Relationship between arteriovenous fistula cannulation practices and dialysis adequacy: a prospective, multicenter study[J]. J Ren Care, 2022, 48(1): 41-48.
[3]	LU W, DANG X, LIU C, et al. Factors associated with dialysis initiation in patients with predialysis arteriovenous fistula[J]. Blood Purif, 2024, 53(3): 210-218.
[4]	VAZQUEZ R I, DUQUE J C, TABBARA M, et al. Intimal hyperplasia and arteriovenous fistula failure: looking beyond size differences[J]. Kidney360, 2021, 2(8): 1360-1372.
[5]	熊清玓, 徐媖, 黄玲, 等. 慢性肾衰中医证型与动静脉内瘘相关性分析研究[J]. 中国实用医药, 2023, 18(6): 15-20. XIONG Q D, XU Y, HUANG L, et al. Study on effect of arteriovenous fistuloplasty on chronic renal failure patients with different traditional Chinese medicine syndromes[J]. China Practical Medicine, 2023, 18(6): 15-20.
[6]	VENKATNARAYANAN R, DOGRA P M, BAVDEKAR R, et al. Primary failure of autogenous arteriovenous fistula: critical analysis[J]. Indian J Nephrol, 2020, 30(6): 382-390.
[7]	SAMRA G, RAI V, AGRAWAL D K. Innate and adaptive immune cells associate with arteriovenous fistula maturation and failure[J]. Can J Physiol Pharmacol, 2022, 100(8): 716-727.
[8]	中国康复医学会肾脏病康复专业委员会, 中关村肾病血液净化联盟肾康复专业委员会, 中国医师协会康复医师分会肾康复治疗专业委员会. 我国成人血液透析患者康复治疗的专家共识[J]. 中国血液净化, 2021, 20(11): 721-727. Renal Rehabilitation Committee of China Association Rehabilitation Medicine, Renal Rehabilitation Committee of Zhongguancun Nephrology & Blood Purification Innovation Alliance, Renal Rehabilitation Committee of Rehabilitation Physician Branch of China Medical Doctor Association. Expert consensus on rehabilitation treatment of adult hemodialysis patients in China[J]. Chinese Journal of Blood Purification, 2021, 20(11): 721-727.
[9]	Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease[J]. Kidney Int, 2024, 105(4): 117-314.
[10]	世界中医药学会联合会. 国际血瘀证诊断指南[J]. 世界中医药, 2022, 17(1): 31-36. World Federation of Chinese Medicine Societies. Diagnostic guidelines for blood-stasis syndrome[J]. World Chinese Medicine, 2022, 17(1): 31-36.
[11]	SEE Y P, CHO Y, PASCOE E M, et al. Predictors of arteriovenous fistula failure: a post hoc analysis of the FAVOURED study[J]. Kidney360, 2020, 1(11): 1259-1269.
[12]	HAN M, ZHAO Q, ZHAO J, et al. Risk prediction models for autogenous arteriovenous fistula failure in maintenance hemodialysis patients: a systematic review and meta-analysis[J]. World J Surg, 2024, 48(10): 2526-2542.
[13]	YAP Y S, CHI W C, LIN C H, et al. Association of early failure of arteriovenous fistula with mortality in hemodialysis patients[J]. Sci Rep, 2021, 11(1): 5699-5702.
[14]	HUDSON R, PASCOE E M, SEE Y P, et al. A comparison of arteriovenous fistula failure between Malaysian and Australian and New Zealand participants enrolled in the FAVOURED trial[J]. J Vasc Access, 2024, 25(1): 193-202.
[15]	干雁群, 郑志波. 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[J]. 中华全科医学, 2023, 21(6): 981-984. doi: 10.16766/j.cnki.issn.1674-4152.003030 GAN Y Q, ZHENG Z B. Effect of different arteriovenous fistula puncture methods on the dialysis adequacy of hemodialysis patients[J]. Chinese Journal of General Practice, 2023, 21(6): 981-984. doi: 10.16766/j.cnki.issn.1674-4152.003030
[16]	姚志, 孙鲁英, 赵宗江, 等. 维持性血液透析患者自体动静脉内瘘失功的影响因素、风险预测及中医证候分布[J]. 现代中西医结合杂志, 2022, 31(15): 2058-2063. YAO Z, SUN L Y, ZHAO Z J, et al. Influencing factors, risk prediction and TCM syndrome distribution of autologous arteriovenous fistula dysfunction in maintenance hemodialysis patients[J]. Modern Journal of Integrated Traditional Chinese and Western Medicine, 2022, 31(15): 2058-2063.
[17]	曾冬梅, 吴鹏, 黄琳, 等. 益气温阳活血化瘀法对慢性肾衰竭患者自体动静脉内瘘的影响[J]. 中国医学创新, 2024, 21(16): 62-66. ZENG D M, WU P, HUANG L, et al. The effect of Yiqi Wenyang Huoxue Huayu method on autologous arteriovenous fistula in chronic renal failure patients[J]. Medical Innovation of China, 2024, 21(16): 62-66.
[18]	翁雪莹, 吴慧敏, 陈宇珊, 等. 基于随机生存森林的动静脉内瘘晚期失功预后因素研究[J]. 中国实用内科杂志, 2024, 44(3): 235-242. WENG X Y, WU H M, CHEN Y S, et al. Research on the prognostic factors of arteriovenous fistula late failure based on the random survival forest[J]. Chinese Journal of Practical Internal Medicine, 2024, 44(3): 235-242.
[19]	李莉, 薛莲, 伍梦寒. 糖尿病肾病患者凝血功能血浆血红蛋白和D-D水平及其与血液透析动静脉内瘘血栓形成的关系研究[J]. 河北医学, 2023, 29(1): 107-112. LI L, XUE L, WU M H. Coagulation plasma haemoglobin and D-D Levels in patients with diabetic nnephropathy and the relationship with haemodialysis arteriovenous fistula thrombosis[J]. Hebei Medicine, 2023, 29(1): 107-112.
[20]	申鹏, 李宏, 郭珏, 等. 血液透析患者自体动静脉内瘘血栓预防的最佳证据总结[J]. 中华护理杂志, 2022, 57(13): 1634-1640. SHEN P, LI H, GUO J, et al. Evidence summary for thrombosis prevention of autogenous arteriovenous fistula in maintenance hemodialysis patients[J]. Chinese Journal of Nursing, 2022, 57(13): 1634-1640.