本文由小咖机器人翻译整理

期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.0535

摘要内容如下：

重要性

血液透析需要可靠的血管通路进入患者的血液循环，例如自体动静脉瘘或非自体动静脉移植物形式的动静脉通路。这篇综述阐述了与血液透析动静脉通路的构建和维护相关的关键问题。

观察

所有肾衰竭患者都应为肾脏替代治疗和透析通路制定个性化策略（称为患者生命计划、通路需求或计划），包括通路失败的应急计划。当患者的估计肾小球滤过率逐渐下降至15至20 mL/min时，或者当患者的腹膜透析、肾移植或当前血管通路失败时，应转诊至血液透析通路。慢性肾脏病患者应限制或避免可能使未来动静脉通路复杂化的血管操作，如肘前静脉穿刺或外周插入中心静脉导管。自体动静脉瘘需要3至6个月才能成熟，而标准动静脉移植物可在建立后2至4周使用，“早期插管”移植物可在建立后24至72小时内使用。动静脉通路血流相关并发症的主要病理损害是动静脉通路内的内膜增生，可导致狭窄、成熟失败（6个月时33%-62%）或通畅性差（2年时60%-63%）和透析不理想。非流动并发症，例如与通路相关的手缺血（“盗血综合征”；1%-8%的患者）和动静脉通路感染需要及时识别和治疗。出血风险高的动静脉通路是外科急症。

结论和相关性

血液透析血管通路的动静脉通路的选择、建立和维护对于肾衰竭患者至关重要。全科医生在保护当前和未来的动静脉通路中发挥着重要作用。识别动静脉通路并发症，如感染、盗血综合征和高输出量心力衰竭；及时转诊以促进动静脉通路的建立和动静脉通路并发症的治疗。

英文原文如下：

Abstracts

Importance  Hemodialysis requires reliable vascular access to the patient's blood circulation, such as an arteriovenous access in the form of an autogenous arteriovenous fistula or nonautogenous arteriovenous graft. This Review addresses key issues associated with the construction and maintenance of hemodialysis arteriovenous access.

Observations  All patients with kidney failure should have an individualized strategy (known as Patient Life-Plan, Access Needs, or PLAN) for kidney replacement therapy and dialysis access, including contingency plans for access failure. Patients should be referred for hemodialysis access when their estimated glomerular filtration rate progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing. Patients with chronic kidney disease should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters. Autogenous arteriovenous fistulas require 3 to 6 months to mature, whereas standard arteriovenous grafts can be used 2 to 4 weeks after being established, and "early-cannulation" grafts can be used within 24 to 72 hours of creation. The prime pathologic lesion of flow-related complications of arteriovenous access is intimal hyperplasia within the arteriovenous access that can lead to stenosis, maturation failure (33%-62% at 6 months), or poor patency (60%-63% at 2 years) and suboptimal dialysis. Nonflow complications such as access-related hand ischemia ("steal syndrome"; 1%-8% of patients) and arteriovenous access infection require timely identification and treatment. An arteriovenous access at high risk of hemorrhaging is a surgical emergency.

Conclusions and Relevance  The selection, creation, and maintenance of arteriovenous access for hemodialysis vascular access is critical for patients with kidney failure. Generalist clinicians play an important role in protecting current and future arteriovenous access; identifying arteriovenous access complications such as infection, steal syndrome, and high-output cardiac failure; and making timely referrals to facilitate arteriovenous access creation and treatment of arteriovenous access complications.

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