【摘要】 目的:探讨两种动静脉内瘘（AVF）穿刺策略对血液透析患者血液流变学与内皮功能的长期影响。方法:回顾性纳入2021年1月至2023年8月接受维持性血液透析（MHD）且使用AVF穿刺的121例患者，按穿刺策略分为扣眼法（BHC）组（n=62）与绳梯法（RLC）组（n=59）。于基线、6个月、12个月采集血液样本，检测血液流变学[低剪切率全血黏度(WBV₁₀)、高剪切率全血黏度(WBV₂₀₀)]、内皮功能指标[内皮素-1（ET-1）、一氧化氮（NO）]及血红蛋白（Hb）水平，并分析上述指标变化趋势与内瘘通畅率的相关性。采用多因素Logistic回归分析内瘘通畅不良的独立危险因素，通过多重中介分析探讨穿刺策略影响内瘘通畅性的潜在机制。结果:重复测量分析显示，RLC组随访期间WBV₁₀、WBV₂₀₀和ET-1水平显著下降，NO水平显著上升，组别×时间交互作用具有统计学意义（P<0.05）,BHC组各指标无明显变化。两组Hb水平随时间整体升高，但组别效应及组别×时间交互作用均无统计学差异（P>0.05）。相关性分析显示，基线WBV₁₀与WBV₂₀₀呈正相关（P<0.01）,基线ET-1与NO呈轻度负相关（P<0.05）,基线WBV₁₀、WBV₂₀₀与ET-1呈正相关，与NO呈负相关（P<0.05）。Kaplan-Meier分析显示，RLC组12个月内瘘初级通畅率高于BHC组（89.83%vs 74.19%,P<0.05）。多因素Logistic回归分析显示，WBV₁₀、WBV₂₀₀和ET-1升高为内瘘通畅不良独立危险因素，NO升高为保护因素，RLC组内瘘通畅不良风险显著低于BHC组（P<0.05）。多重中介分析表明，RLC通过降低WBV₁₀、WBV₂₀₀、ET-1水平及提高NO水平，对减少内瘘通畅不良事件发挥显著间接保护作用[总间接效应=-0.912,95%CI:（-1.428,-0.502）,P<0.01];直接效应无统计学差异（c′=-0.144,P=0.298）。结论:RLC穿刺策略可通过调节血液流变学、改善内皮功能，优化内瘘血流动力学环境，显著提升内瘘长期通畅率，为MHD患者AVF穿刺的优选方案。更多还原

【Abstract】 Objective:To evaluate the long-term effects of two arteriovenous fistula（AVF） cannulation strategies on hemorheology and endothelial function in hemodialysis patients.Method:A retrospective cohort of 140 patients who underwent hemodialysis with AVF cannulation from January 2021 to August 2023 was included.Patients were assigned to the buttonhole cannulation（BHC） group（n=62） or the rope-ladder cannulation（RLC） group（n=59）.Blood samples were collected at baseline,6 months,and 12 months to measure hemorheological parameters[whole blood viscosity at low shear rate(WBV₁₀) and high shear rate(WBV₂₀₀)],endothelial function markers[endothelin-1（ET-1） and nitric oxide（NO）],and hemoglobin（Hb） levels.Trends over time and their association with AVF patency were analyzed.Multivariable logistic regression analysis was used to identify independent risk factors for AVF dysfunction,and multiple mediation analysis was performed to explore potential mechanisms by which puncture trategy affects AVF patency.Results:Repeated measures analysis showed significant decreases in WBV₁₀,WBV₂₀₀ and ET-1 and an increase in NO in the RLC group,with a significant group X time interaction（P<0.05）.In the BHC group,these parameters showed no significant changes.Hb levels increased over time overall,but neither group effect nor group X time interaction reached statistical significance（P>0.05）.Correlation analysis revealed that baseline WBV₁₀ and WBV₂₀₀ were positively correlated（P<0.01）,ET-1 and NO showed a mild negative correlation（P<0.05）,and baseline WBV₁₀ and WBV₂₀₀ were positively correlated with ET-1 and negatively correlated with NO（P<0.05）.Kaplan-Meier analysis indicated that the 12-month primary AVF patency rate was higher in the RLC group than in the BHC group（89.83% vs.74.19%,P<0.05）.Multivariate analysis identified elevated WBV₁₀,WBV₂₀₀,and ET-1 as independent risk factors for AVF dysfunction,whereas higher NO was protective.The RLC group had a significantly lower risk of AVF dysfunction compared with the BHC group（P<0.05）,Multiple mediation analysis showed that RLC significantly reduced AVF dysfunction indirectly by decreasing WBV₁₀, WBV₂₀₀,ET-1,and increasing NO（total indirect effect=-0,912,95% CI:-1.428,-0.502,P<0.01）,while the direct effect was not statistically significant（c’=0.144,P=0.298）.Conclusion:RLC cannulation can optimize AVF hemodynamics and improve endothelial function,thereby significantly enhancing long-term AVF patency,and is a preferred option for AVF cannulation in MHD patients.更多还原