Study On Photoplethysmography In The Diagnosis Of Hemodialysis Access-induced Distal Ischemia

Hemodialysis access is a lifeline for patients with end-stage renal disease,Hemodialysis access-induced distal ischemia(HAIDI)is a rare but serious complication of arteriovenous fistula.With the increase of patients with end-stage renal disease,incidence of HAIDI has been showed ascendant trend.HAIDI can be classified as acute(within 1 day),subacute(?1 month)and chronic(> 1month),based on the time of onset after access creation.Now,diagnosis of HAIDI is predominantly based on clinical manifestation,and abstents objective and effective methods.The principle of photoplethysmography(PPG)is the use of photoelectric technology in real-time monitoring of the blood volume in living tissue,indirectly reflect the acra blood supply situation.PPG has a advantage of simple,noninvasive,economy,and strong repeatability,etc,whose measurement indicators include basal digital pressure(BDP),change in digital pressure with access compression(CDP),digital to contralateral brachial index(DBI).If PPG can be used widely in clinical,which will have an important significance to the diagnosis of HAIDI.So far,PPG in the applications of HAIDI has not been reported in national.Objective:Taking the PPG test in patients with end-stage renal disease,to discuss the value of the application of PPG for the diagnosis of HAIDI.In different arteriovenous fistula,to study HAIDI morbidity,and to investigate the differences of the time of onset in HAIDI.Methods:Patients who were referred to our nephrology department for arteriovenous fistula creation with end-to-side anastomosis between June 2016 and december2016 were included in the study.The clinical data,which included general infor-mation,such as gender,age,smoking,length of dialysis treatment,blood pressure,di-abetes mellitus,coronary artery disease,and hyperlipemia,and test indicators,such as hemoglobin,blood creatinine,albumin,blood calcium,blood phosphorus,and par-athyroid hormone,were collected.In addition,patients were asked to take PPG test in peroperative(0-48h),1 day(12 to 24 h)after operation,1 month after operation,3 month after operative,and to respond to hand ischemia questionnaire in 1 and 3 month after operation.The purpose of study is to investigate theincidence of the HAIDI,And to assess the value of PPG in the diagnosis of HAIDI.The SPSS 19.0 statistical software for statistical data was processed.Results :1.A total of 69 cases were included into research in peroperative,and 3 cases during the follow-up period were removed.Ultimately,a total of 66 cases were included into research,male 39 cases,femal 27 cases,the average age of 55.42 ± 14.93 years old.During the period of observation,a total of 15 cases was clearly diagnosed as HAIDI,and classified as HAIDI group,the rest of 51 cases were classified as the control group.In 15(21.7%)cases with HAIDI,the ischemic syndrome in 5 patients had relieved in 3 month after operation.In the HAIDI group,7 cases(46.7%)were radialcephalic autogenous arteriovenous fistula(AVF),3 cases(20%)were brachial artery-based AVF,5 cases(33.3%)were arteriovenous graft(AVG).Patients with HAIDI accounted for 75%,35.7% and 75% respectively in the brachial artery-based AVF,AVG and radialcephalic AVF.The average time in radialcephalic AVF significantly more than the brachial artery-based AVF and AVG(1.19 VS 0.83 VS0.33 month).2.BDP and DBI in HAIDI group were significantly lower than the control group in each time after operation(P < 0.001).BDP and DBI significantly increased by manual AVF compression between the two groups in 1 and 3 month after operative(P< 0.01).CDP in HAIDI group was significantly higher than the control group in 1month after operation(59.60 ± 25.52 VS 44.26 ± 19.74,P=0.018).3.BDP and DBI in each time after operation were significantly lower than preoperation between the two groups(P < 0.01),In HAIDI group,DBI decreased from0.91 to 0.51,and recovered slightly to 0.59 in 3 month after operative.However,DBI decreased from 0.95 to 0.71 in the control group,and recovered slightly to 0.83 in 3month after operative.A drop of DBI in HAIDI group was significantly greater than the control group.4.The result of ROC curve suggested that the diagnostic accuracy of BDP and DBI was above CDP,The discriminatory thresholds of HAIDI were 94 mm-Hg(sensitivity,66.7%;specificity,93.6%)for BDP,0.6(sensitivity,80%;specificity,83%)for DBI,65mmHg(sensitivity,53.3%;specificity,91.5%)for CDP.Conclusion:1.The morbidity of HAIDI was associated with the type of vascular access,brachial artery-based AVF was the highest,the second was AVG,radialcephalicAVF was the lowest.The brachial artery-based AVF and AVG were often suba-cute,However,the radialcephalic AVF was often associated with chronic HAIDI.2.BDP and DBI in HAIDI group were significantly lower than the control group in each time after operation.And CDP in HAIDI group were significantly higher than the control group,which prompted that PPG can be applied to assist in diagnosis of HAIDI.3.BDP and DBI changed over time between the groups,which prompted that PPG can be as a monitoring tool for a HAIDI patient in early phase.4.The diagnostic accuracy of BDP and DBI was above CDP,The discriminatory thresholds of HAIDI were 94 mm Hg(sensitivity,66.7%;specificity,93.6%)for BDP,0.6(sensitivity,80%;specificity,83%)for DBI,65mmHg(sensitivity,53.3%;specificity,91.5%)for CDP.