- 學位論文
末期腎衰竭病人接受不同類型瘻管之療效及醫療資源使用
The Efficacy and Resources in Utilization Diffident Type Hemodialysis Access in End-Stage Renal Disease Patients
摘要
研究目的： 血管通路的通暢對於血液透析病患而言，不管是生理或心理都極為重要。由於的氣球擴張術的廣泛使用，當瘻管發生阻塞時可藉由氣球擴張術能夠延長透析瘻管使用年限。本研究希望探討樣本醫院不同類型瘻管接受氣球擴張術的現況以找出適當的轉介手術時機，以期能減少無效氣球擴張術所導致的身心不適。 研究方法： 以南部某區域教學醫院洗腎室血液透析病患於2007年1月1日至2014年12月31日期間做電子病歷的回溯性探討，篩選出同樣是在樣本醫院進行透析瘻管手術及氣球擴張術治療的病患，根據不同類型瘻管在人口學、疾病特質、氣球擴張術次數及瘻管重建現況分析。而再以健保資料庫分析樣本醫院與高屏區醫院透析瘻管通路維持處置比較。 研究結果： 此研究群體共有189位病患，合計有249條透析瘻管，有將近70%使用自體血管作為透析瘻管。自體血管(AVF)及人工血管(AVG)的病患在年齡、性別、種族、共病症上並無顯著差異。人工血管(AVG)有較長的原始瘻管暢通維持時間，而氣球擴張術治療後的暢通時間，前四次PTA兩個類型瘻管累計暢通時間差不多(自體血管：1165天，人工血管：1046天)，然而在第6次PTA時出現顯著差異。迴歸分析，人工血管接受PTA的機會相較於自體血管高出4.2倍，人工血管與自體血管在接受PTA治療後重建血管的風險兩者沒有差異，而有高血壓疾病的患者重建瘻管的風險較低。PTA的有無對於死亡並沒有達到顯著的影響，但是有腦血管疾病的患者，死亡風險會高出1.88倍。高屏區醫院使用自體血管為首次透析瘻管的比率為87%，在使用PTA的比率樣本醫院略低高屏區醫院(1.33次/人-年vs.1.61次/人-年)；而一年內透析瘻管的重建率則是樣本醫院比高屏地區來的低(7.14% vs. 10.92%)。 結論與建議 人工血管接受PTA的風險為自體血管的4.2倍。不論是自體血管或人工血管，氣球擴張術能夠延長透析瘻管使用年限，然而維持時間有日漸縮短的趨勢，高血壓有助於延遲瘻管的重建，而腦血管疾病有較高的死亡風險，但仍需大型研究來做進一步的探討。
並列摘要
Abstract Purpose Patency of vascular access for hemodialysis patients was extremely important physically and psychologically. Because of the widespread use of percutaneous transluminal balloon angioplasty (PTA), occlusion arteriovenous fistula might be able to extend the period of function. The study was to discuss current using of PTA in maintained different type arteriovenous fistula patency in order to identify appropriate referrals timing of surgery and reduced the physical and mental discomfort caused by PTA. Method Electronic medical records of sample hospital hemodialysis room were used to survey patient who had received vascular access (AVF or AVG) surgery and follow-up PTA treatment from January 1, 2007 to December 31, 2014. Depending on the type of fistula, demography, underlying disease characteristics, the number of PTA and fistula reconstruction situation were analyzed. The database of National Health Insurance was used to compare sample hospitals and Pingtung district hospital dialysis fistula-maintain result. Result: A total of 189 patients with 249 dialysis fistula were included. In this study, about 70% dialysis fistulas were native vessels. There was no difference in age, gender, race or comorbidities between AVF and AVG groups. AVF had a longer duration of primary patency. Accumulated assist patency time after four PTA treatment were almost the same between two types of fistula (AVF: 1165 days, AVG: 1046 days) but significant difference was occurred in 6th PTA. After regression analysis, AVG had 4.2 times higher opportunity to receive follow-up PTA treatment. Both AVF and AVG was no difference in the risk of fistula reconstruction after PTA. Patients with hypertension had lower risk in fistula reconstruction. Patients with cerebrovascular disease will be higher risk of death (OR: 1.88).The ratio of using AVF as first hemodialysis access in Pingtung district was 87%. The ratio of follow-up PTA was slightly lower in sample hospital which compared with the other Pingtung district hospitals (1.33 times / person-year vs.1.61 times / person-year). The fistula recreation rate was also lower than the other hospitals (7.14% vs. 10.92%). Conclusion The risk of follow-up PTA was much higher in AVG group (4.2 times). PTA could extend the using time both in AVF and AVG groups but shorter maintenance time trend in follow-up PTA was found. Highly blood pressure could delay fistula reconstruction and cerebrovascular diseases had a higher risk of death. These results still need further study to confirm.