末期腎臟病病患之主動脈弓鈣化與自體動靜脈瘻管通暢率的相關研究

Association between Aortic Arch Calcification and Arteriovenous Fistula Patency in End-Stage Renal Disease Patients

葉玉雄(Yit-Sheung Yap)

指導教授 ： 莊萬龍

高雄醫學大學/醫學院/臨床醫學研究所博士班/博士(2019年)

摘要

研究背景: 主動脈弓鈣化盛行於末期腎臟病病患，它被認為是這特別族群的一個重要心血管疾病的危險因子。這兩研究的主旨為探討自體動靜脈瘻管初始通暢率下降及一年內重覆失能的相關因子，尤其是瞭解主動脈弓鈣化對瘻管通暢度的影響。
研究材料與方法：接受首次自體動靜脈瘻管手術的受試者之數據資料及胸部Ｘ光將會被參閱。胸部Ｘ光上之主動脈弓鈣化會被區分為四個程級（程級0-3）。接著第一部份研究是使用Cox比例風險回歸統計分析主動脈弓鈣化程級及其他臨床因子與瘻管初始通暢率的相關性；而第二部份之研究則是使用邏輯迴歸來統計分析主動脈弓鈣化程級及其他臨床因子與一年內瘻管重覆失能的相關性。
結果:　
第一部份之研究：這研究共包含了286位受試者（163位男性，平均年齡62.5 ± 13.1歲），而這群末期腎臟病病患的主動脈弓鈣化之盛行率為79.1%。高程級主動脈弓鈣化（程級2及3）多發生於老年及多合併症之女性，以及與低血壓、高校正血清鈣及低完整副甲狀腺素值相關。在多變項Cox比例風險回歸分析中，主動脈弓鈣化程級2（風險比值（95%信賴區間）：1.80 (1.15–2.84)；p = 0.011）和程級3（3.03 (1.88–4.91)；p < 0.001）以及高完整副甲狀腺素值（p = 0.047）與瘻管初始通暢率下降相關。在分組分析當中，即只納入瘻管手術只由一位術者且有進行血管超音波的受試者，結果顯示僅有主動脈弓鈣化程級3（2.41 (1.45–4.00); p = 0.001）以及高完整副甲狀腺素（p = 0.025）值與瘻管通暢率下降有關。
第二部份之研究：這研究則納入了284位受試者（158位男性，平均年齡61.7 ± 13.1歲）。結果顯示高程級主動脈弓鈣化的受試者為年紀較大的、有較多的糖尿病及心血管疾病、有較低的舒張壓以及有較高的校正血清鈣和較低的完整副甲狀腺素值。在多變項邏輯迴歸分析中，高程級主動脈弓鈣化（勝算比(95%信賴區間): 2.98 (1.43-6.23); p = 0.004）、低平均校正血清鈣及白蛋白值與一年內瘻管重覆失能有關.
結論：在末期腎臟病族群，高程級主動脈弓鈣化及較高完整副甲狀腺素值能預測自體動靜脈瘻管之初始通暢率下降；而高程級主動脈弓鈣化、較低的平均校正血清鈣及白蛋白值則能預測自體動靜脈瘻管一年內重覆失能。因此，在瘻管手術前，可考慮常規安排胸部Ｘ光來當作風險評估工具來檢測這群病患族群。

關鍵字

主動脈弓鈣化 ； 自體動靜脈瘻管 ； 初始通暢率下降 ； 重覆自體動靜脈瘻管失能 ； 末期腎臟病

並列摘要

Background: Aortic arch calcification (AAC) is prevalent in patients with end-stage renal disease (ESRD), and it is recognized as an important cardiovascular risk factor in these specific populations. The aims of these two studies were to define the associated factors of primary patency loss of arteriovenous fistula (AVF) and repeated AVF failure within 1-year, especially the impact of AAC on patency of AVF.
Materials and Methods: The data and chest radiography of study subjects who had an initial AVF placed were reviewed. The extent of AAC which identified on chest radiography was divided into four grades (0–3). In part 1 research, the relationship among AAC grade, other clinical factors and primary patency of AVF was then analyzed by Cox proportional hazard analysis; while in part 2 research, the association between AAC grade, other clinical variables, and repeated failure of AVF within 1-year was then analyzed by binary logistic regression analysis.
Results:
Part 1 Research: This study included 286 subjects (163 males, mean age 62.5 ± 13.1 years), and the prevalence of AAC in this ESRD population was 79.1%. Higher AAC grades (grade 2 and 3) were associated with older female patients with more comorbidities, lower blood pressure, higher correct calcium and lower intact parathyroid hormone level. In multivariate Cox proportional hazard analysis, the presence of AAC grade 2 (hazard ratio (95% confidence interval): 1.80 (1.15–2.84); p = 0.011) and grade 3 (3.03 (1.88–4.91); p < 0.001), and higher level of intact-parathyroid hormone (p = 0.047) were associated with primary patency loss of AVF. In subgroup analysis, which included AVF placed by a surgeon assisted with preoperative vascular mapping, only AAC grade 3 (2.41 (1.45–4.00); p = 0.001), and higher intact-parathyroid hormone (p = 0.025) level were associated with AVF patency loss.
Part 2 Research: This study included 284 subjects (158 males, mean age 61.7 ± 13.1 years). Study subjects with higher AAC grade were older, had more frequently diabetes mellitus and cardiovascular disease, had lower diastolic blood pressure, and had higher corrected calcium and lower intact parathyroid hormone levels. In multivariate analysis, the presence of higher AAC grade (odds ratio (95% confidence interval): 2.98 (1.43-6.23); p = 0.004), lower mean corrected calcium (p = 0.017), and mean serum albumin level (p = 0.008) were correlated with repeated AVF failure within 1-year.
Conclusion: In ESRD populations, higher AAC grade and intact-parathyroid hormone level predicted primary patency loss of AVF, while higher AAC grade, lower mean corrected calcium and mean serum albumin level predicted repeated AVF failure within 1 year. Hence, routine chest radiography as a risk factor assessment tool may be considered in these populations for AVF creation.

並列關鍵字

aortic arch calcification ； arteriovenous fistula ； primary patency loss ； repeated arteriovenous fistula failure ； end-stage renal disease

參考文獻

1. Report USRDS. United States Renal Data System (USRDS). Available at: https://wwwusrdsorg/2017/view/Defaultaspx. Accessed March 1, 2018.

2. Wu MS, Wu IW, Shih CP, Hsu KH. Establishing a Platform for Battling End-stage Renal Disease and Continuing Quality Improvement in Dialysis Therapy in Taiwan–Taiwan Renal Registry Data System (TWRDS). Acta Nephrologica. 2011; 25(3): 148-153.

3. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG. Vascular access and all-cause mortality: A propensity score analysis. J Am Soc Nephrol. 2004; 15(2): 477-486.

4. Lilly MP, Lynch JR, Wish JB, Huff ED, Chen SC, Armistead NC, McClellan WM. Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure. Am J Kidney Dis. 2012; 59(4): 541-549.

5. Usta E, Elkrinawi R, Salehi-Gilani S, Adili S, Sonnentag T, Alscher M, Artunc F, Franke U. Risk factors predicting the successful function and use of autogenous arteriovenous fistulae for hemodialysis. The Thoracic and cardiovascular surgeon. 2013; 61(5): 438-444.