光电容积描记法在血液透析通路相关肢端缺血征诊断中的应用研究

发布时间：2018-06-04 10:24

本文选题：动静脉内瘘 + 血液透析通路相关肢端缺血征　；参考：《南昌大学》2017年硕士论文

【摘要】：血液透析通路是终末期肾脏病患者的生命线,血液透析通路相关肢端缺血征(hemodialysis access-induced distal ischemia,HAIDI)是动静脉内瘘少见但严重的并发症。随着终末期肾脏病患者的增加,HAIDI的发病率也曾呈上升的趋势。基于距离动静脉内瘘建立时间的长短,HAIDI可分为急性(1天内)、亚急性(≤1个月)和慢性(1个月)。目前HAIDI的诊断主要依靠临床表现,缺乏客观及有效的诊断方法。光电容积描记法(photoplethysmography,PPG)是利用光电技术在活体组织中实时监测血容量的原理,间接反映肢端供血情况,具有简易、无创、经济、可重复性强等优点,其测量指标包括基础指压(basal digital pressure,BDP)、压闭内瘘后指压变化(change in digital pressure with access compression,CDP)及指肱指数(digital to contralateral brachial index,DBI),如果能在临床推广使用,对HAIDI的诊断将具有重要意义。目前,国内尚无PPG在HAIDI诊断中应用的报道。目的:通过对动静脉内瘘端侧吻合术的终末期肾脏病患者行PPG检查,探讨PPG在HAIDI诊断中应用的价值,并对不同动静脉内瘘术式在HAIDI发病率及发病时间中的差异进行研究。方法:前瞻性对2016年6月至2016年12月期间,于我院术侧上肢首次行动静脉内瘘的终末期肾脏病患者进行研究。术前收集其临床资料,主要包括性别、年龄、吸烟史、透析龄、血压情况、糖尿病、冠心病及高脂血症等一般资料,血红蛋白、血肌酐、血白蛋白、血钙、血磷及血甲状旁腺激素等检验指标,并于术前(0-48h)、术后1天(12-24h)、术后1月及术后3月对双侧上肢行PPG检查,术后1月及3月行肢体缺血问卷调查,了解该人群HAIDI的发生率及评价PPG在HAIDI诊断中应用的价值。统计学采用SPSS19.0统计软件进行数据处理。结果:1、术前共纳入研究69例患者,剔除3例,最终纳入研究66例,其中男性37例,女性29例,平均年龄55.42士14.93岁。观察期间明确诊断为HAIDI者共15例,为HAIDI组,其余51例为非HAIDI组。15例(21.7%)HAIDI患者中,5例术后3月缺血症状有所缓解。HAIDI组中前臂桡动脉自体动静脉脉内瘘(autogenous arteriovenous fistula,AVF)7例(46.7%),肘部肱动脉AVF3例(20%),前臂人工血管内瘘(arteriovenous graft,AVG)5例(33.3%)。在肱动脉AVF、前臂AVG及桡动脉AVF中HAIDI患者分别占75%、35.7%及14.6%。桡动脉AVF出现HAIDI的平均时间明显长于肱动脉AVF及前臂AVG(1.19 VS 0.83 VS 0.33月)。2、HAIDI组术后各时刻BDP及DBI均明显低于非HAIDI组(P0.001),术后1月及术后3月压闭内瘘后BDP与DBI在两组间均出现明显增高(P0.01)。术后1月HAIDI组CDP高于非HAIDI组(59.60士25.52 VS 44.26士19.74,P=0.018)。3、两组中术后各时刻BDP及DBI均明显低于术前(P0.001),HAIDI组DBI从0.91下降至0.51,术后3月小幅回升至0.59,非HAIDI组DBI0.95下降至0.71,术后3月小幅回升至0.83,且HAIDI组下降幅度较非HAIDI组大。4、ROC曲线结果提示BDP及DBI的诊断准确性较CDP高。诊断HAIDI各指标的临界值为:BDP94mmHg(灵敏度66.7%,特异度93.6%)、DBI0.6(灵敏度80%,特异度83%)及CDP65mmHg(灵敏度53.3%,特异度91.5%)。结论:1、HAIDI的发病率与血管通路类型相关,肱动脉AVF前臂AVG桡动脉AVF,前臂AVG及肱动脉AVF常为亚急性HAIDI,桡动脉AVF常表现为慢性。2、HAIDI组中术后各时刻DBI及BDP较非HAIDI组明显更低,且HAIDI组CDP较非HAIDI组高,提示PPG可应用于HAIDI的诊断中。3、HAIDI组与非HAIDI组术后BDP及DBI随时间的变化规律提示PPG可作为早期HAIDI患者的监测工具。4、BDP及DBI的诊断准确性较CDP高,诊断HAIDI各指标的临界值为:BDP94mmHg(灵敏度66.7%,特异度93.6%)、DBI0.6(灵敏度80%,特异度83%)及CDP65mmHg(灵敏度53.3%,特异度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%).
【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692.5

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