本文選題：動靜脈內瘺 + 血液透析通路相關肢端缺血征��； 參考：《南昌大學》2017年碩士論文

【摘要】：血液透析通路是終末期腎臟病患者的生命線,血液透析通路相關肢端缺血征(hemodialysis access-induced distal ischemia,HAIDI)是動靜脈內瘺少見但嚴重的并發(fā)癥。隨著終末期腎臟病患者的增加,HAIDI的發(fā)病率也曾呈上升的趨勢�；诰嚯x動靜脈內瘺建立時間的長短,HAIDI可分為急性(1天內)、亞急性(≤1個月)和慢性(1個月)。目前HAIDI的診斷主要依靠臨床表現(xiàn),缺乏客觀及有效的診斷方法。光電容積描記法(photoplethysmography,PPG)是利用光電技術在活體組織中實時監(jiān)測血容量的原理,間接反映肢端供血情況,具有簡易、無創(chuàng)、經濟、可重復性強等優(yōu)點,其測量指標包括基礎指壓(basal digital pressure,BDP)、壓閉內瘺后指壓變化(change in digital pressure with access compression,CDP)及指肱指數(digital to contralateral brachial index,DBI),如果能在臨床推廣使用,對HAIDI的診斷將具有重要意義。目前,國內尚無PPG在HAIDI診斷中應用的報道。目的:通過對動靜脈內瘺端側吻合術的終末期腎臟病患者行PPG檢查,探討PPG在HAIDI診斷中應用的價值,并對不同動靜脈內瘺術式在HAIDI發(fā)病率及發(fā)病時間中的差異進行研究。方法:前瞻性對2016年6月至2016年12月期間,于我院術側上肢首次行動靜脈內瘺的終末期腎臟病患者進行研究。術前收集其臨床資料,主要包括性別、年齡、吸煙史、透析齡、血壓情況、糖尿病、冠心病及高脂血癥等一般資料,血紅蛋白、血肌酐、血白蛋白、血鈣、血磷及血甲狀旁腺激素等檢驗指標,并于術前(0-48h)、術后1天(12-24h)、術后1月及術后3月對雙側上肢行PPG檢查,術后1月及3月行肢體缺血問卷調查,了解該人群HAIDI的發(fā)生率及評價PPG在HAIDI診斷中應用的價值。統(tǒng)計學采用SPSS19.0統(tǒng)計軟件進行數據處理。結果:1、術前共納入研究69例患者,剔除3例,最終納入研究66例,其中男性37例,女性29例,平均年齡55.42士14.93歲。觀察期間明確診斷為HAIDI者共15例,為HAIDI組,其余51例為非HAIDI組。15例(21.7%)HAIDI患者中,5例術后3月缺血癥狀有所緩解。HAIDI組中前臂橈動脈自體動靜脈脈內瘺(autogenous arteriovenous fistula,AVF)7例(46.7%),肘部肱動脈AVF3例(20%),前臂人工血管內瘺(arteriovenous graft,AVG)5例(33.3%)。在肱動脈AVF、前臂AVG及橈動脈AVF中HAIDI患者分別占75%、35.7%及14.6%。橈動脈AVF出現(xiàn)HAIDI的平均時間明顯長于肱動脈AVF及前臂AVG(1.19 VS 0.83 VS 0.33月)。2、HAIDI組術后各時刻BDP及DBI均明顯低于非HAIDI組(P0.001),術后1月及術后3月壓閉內瘺后BDP與DBI在兩組間均出現(xiàn)明顯增高(P0.01)。術后1月HAIDI組CDP高于非HAIDI組(59.60士25.52 VS 44.26士19.74,P=0.018)。3、兩組中術后各時刻BDP及DBI均明顯低于術前(P0.001),HAIDI組DBI從0.91下降至0.51,術后3月小幅回升至0.59,非HAIDI組DBI0.95下降至0.71,術后3月小幅回升至0.83,且HAIDI組下降幅度較非HAIDI組大。4、ROC曲線結果提示BDP及DBI的診斷準確性較CDP高。診斷HAIDI各指標的臨界值為:BDP94mmHg(靈敏度66.7%,特異度93.6%)、DBI0.6(靈敏度80%,特異度83%)及CDP65mmHg(靈敏度53.3%,特異度91.5%)。結論:1、HAIDI的發(fā)病率與血管通路類型相關,肱動脈AVF前臂AVG橈動脈AVF,前臂AVG及肱動脈AVF常為亞急性HAIDI,橈動脈AVF常表現(xiàn)為慢性。2、HAIDI組中術后各時刻DBI及BDP較非HAIDI組明顯更低,且HAIDI組CDP較非HAIDI組高,提示PPG可應用于HAIDI的診斷中。3、HAIDI組與非HAIDI組術后BDP及DBI隨時間的變化規(guī)律提示PPG可作為早期HAIDI患者的監(jiān)測工具。4、BDP及DBI的診斷準確性較CDP高,診斷HAIDI各指標的臨界值為:BDP94mmHg(靈敏度66.7%,特異度93.6%)、DBI0.6(靈敏度80%,特異度83%)及CDP65mmHg(靈敏度53.3%,特異度91.5%)。
[Abstract]:Hemodialysis access is the lifeline of end-stage renal disease patients. Hemodialysis hemodialysis access-induced distal ischemia (HAIDI) is a rare but serious complication of arteriovenous fistula. With the increase of end-stage renal disease, the incidence of HAIDI is also rising. Based on distance arteriovenous HAIDI can be divided into acute (1 days), subacute (less than 1 months) and chronic (1 months). At present, the diagnosis of HAIDI mainly relies on clinical manifestations and lacks objective and effective diagnostic methods. Photoplethysmography (PPG) is the principle of real-time monitoring of blood volume in living tissues by photoelectric technology. It has the advantages of simple, noninvasive, economical, and repeatable, and its measurement indexes include the base pressure (basal digital pressure, BDP), the change of the finger pressure after the closed internal fistula (change in digital pressure with access compression, CDP) and the finger brachial index. In clinical application, the diagnosis of HAIDI will be of great significance. At present, there are no reports of the application of PPG in the diagnosis of HAIDI. Objective: To explore the value of the application of PPG in the diagnosis of HAIDI through the PPG examination of end-stage renal disease patients with end-side anastomosis of arteriovenous fistula, and the incidence of different arteriovenous fistula in HAIDI and the incidence of different arteriovenous fistula. The differences in the time of the onset were studied. Methods: a prospective study of end-stage renal diseases in the upper limb of our hospital from June 2016 to December 2016 was conducted. The clinical data were collected before operation, including sex, age, smoking history, age of dialysis, blood pressure, diabetes, coronary heart disease and hyperlipidemia. General data, hemoglobin, blood creatinine, serum albumin, blood calcium, blood phosphorus and parathyroid hormone, and before operation (0-48h), 1 days after operation (12-24h), January and March after operation, PPG examination of bilateral upper limbs, January and March postoperatively to investigate the incidence of HAIDI and evaluate the incidence of HAIDI in this population and the evaluation of PPG in the diagnosis of HAIDI SPSS19.0 statistical software was used for data processing. Results: 1, 69 patients were included in the study before operation, 3 cases were eliminated, and 66 cases were included in the study, including 37 men and 29 women, with an average age of 55.42 and 14.93 years. The observation period was clearly diagnosed as 15 cases, group HAIDI, and the rest 51 cases were non HAIDI.15 cases (21.7%. Among the patients with HAIDI, 5 cases of ischemic symptoms in March were relieved in the.HAIDI group, 7 cases (autogenous arteriovenous fistula, AVF) in the forearm artery (46.7%), AVF3 cases of the brachial artery in the elbow (20%), 5 cases of artificial vascular fistula (arteriovenous graft, AVG) in the forearm (33.3%), and AVF in the brachial artery and the radial artery. The average time of HAIDI of the radial artery AVF in 75%, 35.7% and 14.6%. was longer than that of the brachial artery AVF and the AVG of the forearm (1.19 VS 0.83 VS 0.33 months). The BDP and DBI in each time of group HAIDI were significantly lower than that of the non HAIDI group. After the operation in January and after the operation, the two groups were significantly increased after the closure of the internal fistula in January and after the operation. Group CDP was higher than that of non HAIDI group (59.60, 25.52 VS 44.26, 19.74, P=0.018).3. The BDP and DBI in all the two groups were significantly lower than before operation (P0.001), DBI from 0.91 to 0.51 in HAIDI group, 0.59 in March, 0.71 in non HAIDI group, and 0.83 in March after operation. The curve results showed that the diagnostic accuracy of BDP and DBI was higher than that of CDP. The critical values of the diagnostic HAIDI were BDP94mmHg (sensitivity 66.7%, specificity 93.6%), DBI0.6 (sensitivity 80%, specificity 83%) and CDP65mmHg (sensitivity 53.3%, specificity 91.5%). Conclusion: 1, HAIDI is associated with the type of vascular pathway, and the AVG radial artery of the humeral artery AVF forearm is AVF, The AVG of the forearm and the AVF of the brachial artery are often subacute HAIDI, and the AVF of the radial artery often appears as a chronic.2. In group HAIDI, DBI and BDP are lower than those in the non HAIDI group at all times, and HAIDI CDP is higher than that of non HAIDI groups. The diagnostic accuracy of.4, BDP and DBI in AIDI patients was higher than that of CDP. The critical value of the diagnostic HAIDI indexes was BDP94mmHg (sensitivity 66.7%, specificity 93.6%), DBI0.6 (sensitivity 80%, specificity 83%) and CDP65mmHg (sensitivity 53.3%, specificity 91.5%).
【學位授予單位】：南昌大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R692.5

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本文編號：1977018