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Alexandra N, Christos A, Miltos LK, George GS. A meta-analysis of vascular access outcomes in hemodialysis patients aged 75 years or older. J Vasc Access 2024; 25:843-848. [PMID: 36447351 DOI: 10.1177/11297298221139059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Several existing guidelines advocate the access creation without any specific recommendations for those patients over 75 years of age. The aim of this meta-analysis is to compare the outcomes of different vascular access procedures in the sub-group of elderly ESRD patients ⩾75 years of age. METHODS A literature search was performed using the MEDLINE and SCOPUS electronic databases. The analysis focused on studies with subgroups of elderly patients ⩾75 years of age with different vascular access procedures, and compared the failure rates of autologous versus prosthetic vascular access. Articles comparing patency rates of distal (forearm) versus proximal upper arm AVFs were also investigated. RESULTS Twelve relevant studies were identified and included in the meta-analysis. The pooled results revealed a statistically significant unassisted (primary) failure rate at 24 months in favor of autologous AVFs [odds ratio (OR): 0.56, 95% CI: 0.38-0.83, p = 0.003]. A secondary analysis revealed significantly higher 12 months unassisted (primary) and secondary failure rates of forearm AVFs compared with proximal upper arm AVFs (OR: 2.14, 95% CI: 1.53-2.97, p < 0.00001 and OR: 1.76, 95% CI: 1.12-2.78, p < 0.01 respectively). CONCLUSION An increased risk of failure of prosthetic vascular access procedures was found compared with autologous AVFs in patients ⩾75 years of age. Elderly patients ⩾75 years should not be excluded from creation of an autologous access, with proximal upper arm AVFs having better patency rates.
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Affiliation(s)
- Ntemka Alexandra
- Democritus University Medical School, Alexandroupolis, Greece
- Nephrology Department, Papageorgiou General Hospital, Thessaloniki, Greece
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Yan T, Gameiro J, Grilo J, Filipe R, Rocha E. Hemodialysis vascular access in elderly patients: A comprehensive review. J Vasc Access 2024; 25:27-39. [PMID: 35546530 DOI: 10.1177/11297298221097233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.
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Affiliation(s)
- Teófilo Yan
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - João Grilo
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Rui Filipe
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Ernesto Rocha
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
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Li J, Lu H, Xie Z, Li Q, Shi H. Outcomes of arteriovenous graft vs. fistula for haemodialysis access in the elderly: A systematic review and meta‑analysis. Exp Ther Med 2023; 26:399. [PMID: 37522056 PMCID: PMC10375446 DOI: 10.3892/etm.2023.12098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/14/2023] [Indexed: 08/01/2023] Open
Abstract
The impact of the type of vascular access on the outcomes in the elderly haemodialysis patients is still unclear. The goal of the present study was to compare survival outcomes in elderly haemodialysis patients who received either arteriovenous graft (AVG) or arteriovenous fistula (AVF). A systematic literature search was performed in EMBASE, Cochrane, MEDLINE, ScienceDirect and Google Scholar databases for papers published from January 1954 until January 2022. Risk of bias in the selected publications was assessed by Newcastle Ottawa scale or Cochrane risk of bias tool depending on the study design. Meta-analysis was carried out using the random-effects model. Data were reported as pooled odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI). A total of 12 studies were included in the analysis. The majority of the studies had poor quality. Elderly patients receiving AVG had significantly worse survival rate compared with patients that received AVF for the haemodialysis access, with a pooled HR of 1.38 (95% CI, 1.24-1.53; I2=79.9%). Pooled HR for access survival was 1.60 (95% CI, 1.54-1.66; I2=0%). Pooled OR for primary patency rate, maturation failure and infections were 1.81 (95% CI, 0.73-4.49; I2=79.2%), 0.33 (95% CI, 0.12-0.91; I2=70.4%) and 9.74 (95% CI, 2.60-36.49; I2=52.4%), respectively. These results suggested that in elderly patients undergoing haemodialysis, AVG was associated with reduced overall survival and access survival, and higher infection rate, compared with AVF. Notably, AVG was also associated with a lower risk of maturation failure, presenting a potential advantage in specific patient populations (study registration: PROSPERO, no. CRD42022313199).
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Affiliation(s)
- Jia Li
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Hua Lu
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Zhen Xie
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Qingchao Li
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Hongguang Shi
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
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Kim H, Park HS, Ban TH, Yang SB, Kwon YJ. Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database. Hemodial Int 2023. [PMID: 36943638 DOI: 10.1111/hdi.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/12/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years. METHODS In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared. RESULTS Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001). CONCLUSION Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Seung Boo Yang
- Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Hajibandeh S, Burton H, Gleed P, Hajibandeh S, Wilmink T. Impact of arteriovenous fistulas versus arteriovenous grafts on vascular access performance in haemodialysis patients: A systematic review and meta-analysis. Vascular 2021; 30:1021-1033. [PMID: 34461784 DOI: 10.1177/17085381211041473] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Controversy exists regarding the best-performing vascular access type for patients undergoing haemodialysis. We aimed to compare outcomes of starting dialysis on arteriovenous fistulas (AVFs) versus arteriovenous grafts (AVGs) in haemodialysis patients. METHODS We conducted a systematic search of multiple electronic information sources and bibliographic reference lists. The following outcome parameters were evaluated at 1, 2 and 5 years: primary failure, defined as access never used for dialysis; primary patency, defined as intervention-free access survival; primary-assisted patency, defined as uninterrupted access survival with interventions; and secondary patency, defined as cumulative access survival. RESULTS We identified 15 comparative studies reporting a total of 118,434 patients who initiated haemodialysis with AVF (n = 95,143) or AVG (n = 23,291). Our analysis demonstrated that AVF was associated with significantly higher primary failure rate (OR: 2.05, p = .0005) but significantly higher rate of primary patency at 1 year (OR: 1.91, p < .00001), at 2 years (OR: 2.52, p < .00001) and at 5 years (OR: 2.59, p < .00001); and primary-assisted patency at 1 year (OR: 1.71, p < .00001), at 2 years (OR: 2.13, p < .00001) and 5 years (OR: 2.79, p < .00001). There was no significant difference in secondary patency at 1 year (OR: 1.08, p < .00001) but AVF had better secondary patency at 2 years (OR: 1.26, p < .00001) and 5 years (OR: 1.60, p < .00001) than AVG. CONCLUSIONS The meta-analysis of best available comparative evidence (Level 2) demonstrated that AVFs may be associated with significantly higher primary failure rate but higher primary patency, primary-assisted patency and secondary patency at 1, 2 and 5 years compared to AVGs. However, the available evidence is subject to significant selection bias and confounding by indication.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, Hereford County Hospital, 8947Wye Valley NHS Trust, Hereford, UK
| | - Hannah Burton
- Department of Vascular Surgery, 159028Royal Devon and Exeter Hospital, Exeter, UK
| | - Philippa Gleed
- Department of Vascular Surgery, 159028Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Teun Wilmink
- Department of Vascular Surgery, 159028Royal Devon and Exeter Hospital, Exeter, UK
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da Rocha LF, Pippi B, Joaquim AR, de Andrade SF, Fuentefria AM. 8-hydroxyquinoline-5-(N-4-chlorophenyl) sulfonamide and fluconazole combination as a preventive strategy for Candida biofilm in haemodialysis devices. J Med Microbiol 2021; 70. [PMID: 34259620 DOI: 10.1099/jmm.0.001377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction. The presence of Candida biofilms in medical devices is a concerning and important clinical issue for haemodialysis patients who require constant use of prosthetic fistulae and catheters.Hypothesis/Gap Statement. This prolonged use increases the risk of candidaemia due to biofilm formation. PH151 and clioquinol are 8-hydroxyquinoline derivatives that have been studied by our group and showed interesting anti-Candida activity.Aim. This study evaluated the biofilm formation capacity of Candida species on polytetrafluoroethylene (PTFE) and polyurethane (PUR) and investigated the synergistic effects between the compounds PH151 and clioquinol and fluconazole, amphotericin B and caspofungin against biofilm cells removed from those materials. Further, the synergistic combination was evaluated in terms of preventing biofilm formation on PTFE and PUR discs.Methodology. Susceptibility testing was performed for planktonic and biofilm cells using the broth microdilution method. The checkerboard method and the time-kill assay were used to evaluate the interactions between antifungal agents. Antibiofilm activity on PTFE and PUR materials was assessed to quantify the prevention of biofilm formation.Results. Candida albicans, Candida glabrata and Candida tropicalis showed ability to form biofilms on both materials. By contrast, Candida parapsilosis did not demonstrate this ability. Synergistic interaction was observed when PH151 was combined with fluconazole in 77.8 % of isolates and this treatment was shown to be concentration- and time-dependent. On the other hand, indifferent interactions were predominantly observed with the other combinations. A reduction in biofilm formation on PUR material of more than 50 % was observed when using PH151 combined with fluconazole.Conclusion. PH151 demonstrated potential as a local treatment for use in a combination therapy approach against Candida biofilm formation on haemodialysis devices.
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Affiliation(s)
- Letícia Fernandes da Rocha
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratório de Micologia Aplicada, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Bruna Pippi
- Laboratório de Micologia Aplicada, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Angélica Rocha Joaquim
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Saulo Fernandes de Andrade
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Microbiologia Agrícola e do Ambiente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre Meneghello Fuentefria
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Microbiologia Agrícola e do Ambiente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Weaver ML, Holscher CM, Sorber RA, Lum YW, Reifsnyder T. Redo Hemodialysis Access in Elderly Patients has Acceptable Outcomes With Similar Patency of Arteriovenous Fistulas as Compared to Grafts. Ann Vasc Surg 2021; 76:128-133. [PMID: 34004325 DOI: 10.1016/j.avsg.2021.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Selecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients. METHODS All patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression. RESULTS Overall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47). CONCLUSIONS These results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
| | - Courtenay M Holscher
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca A Sorber
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ying Wei Lum
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Reifsnyder
- Division of Vascular Surgery, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD
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Lee SYD, Xiang J, Kshirsagar AV, Steffick D, Saran R, Wang V. Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study. ACTA ACUST UNITED AC 2020; 1:763-771. [PMID: 34355198 DOI: 10.34067/kid.0002722020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Because functioning permanent vascular access (arteriovenous fistula [AVF] or arteriovenous graft [AVG]) is crucial for optimizing patient outcomes for those on hemodialysis, the supply of physicians placing vascular access is key. We investigated whether area-level demographic and healthcare market attributes were associated with the distribution and supply of AVF/AVG access physicians in the United States. Methods A nationwide registry of physicians placing AVFs/AVGs in 2015 was created using data from the United States Renal Data System and the American Physician Association's Physician Masterfile. We linked the registry information to the Area Health Resource File to assess the supply of AVF/AVG access physicians and their professional attributes by hospital referral region (HRR). Bivariate analysis and Poisson regression were performed to examine the relationship between AVF/AVG access physician supply and demographic, socioeconomic, and health resource conditions of HRRs. The setting included all 50 states. The main outcome was supply of AVF/AVG access physicians, defined as the number of physicians performing AVF and/or AVG placement per 1000 prevalent patients with ESKD. Results The majority of vascular access physicians were aged 45-64 (average age, 51.6), male (91%), trained in the United States (76%), and registered in a surgical specialty (74%). The supply of physicians varied substantially across HRRs. The supply was higher in HRRs with a higher percentage white population (β=0.44; SEM=0.14; P=0.002), lower unemployment rates (β=-10.74; SEM=3.41; P=0.002), and greater supply of primary care physicians (β=0.18; SEM=0.05; P=0.001) and nephrologists (β=15.89; SEM=1.22; P<0.001). Conclusions Geographic variation was observed in the supply of vascular access physicians. Higher supply of such specialist physicians in socially and economically advantaged areas may explain disparities in vascular access and outcomes in the United States and should be the subject of further study and improvement.
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Affiliation(s)
- Shoou-Yih D Lee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Jie Xiang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Abhijit V Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Diane Steffick
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
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Jeong S, Kwon H, Chang JW, Kim MJ, Ganbold K, Han Y, Kwon TW, Cho YP. Effects of patient age on patency of chronic hemodialysis vascular access. BMC Nephrol 2019; 20:422. [PMID: 31752721 PMCID: PMC6873763 DOI: 10.1186/s12882-019-1604-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/29/2019] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population. METHODS The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (< 65 years), and 206 patients (31.6%) were in the elderly group (≥ 65 years). Study outcomes were defined as primary or secondary VA patency. RESULTS Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P < 0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P < 0.01); secondary patency, however, was similar between groups (P = 0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P < 0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P < 0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P = 0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency. CONCLUSIONS Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.
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Affiliation(s)
- Seonjeong Jeong
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyunwook Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jai Won Chang
- Division of Nephrology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Khaliun Ganbold
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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10
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Viecelli AK, Lok CE. Hemodialysis vascular access in the elderly-getting it right. Kidney Int 2019; 95:38-49. [PMID: 30606427 DOI: 10.1016/j.kint.2018.09.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/21/2018] [Accepted: 09/11/2018] [Indexed: 01/01/2023]
Abstract
Choosing the optimal hemodialysis vascular access for the elderly patient is best achieved by a patient-centered coordinated multidisciplinary team approach that aligns the patient's end-stage kidney disease Life-Plan, i.e., the individual treatment approach (supportive care, time-limited or long-term kidney replacement therapy, or combination thereof) and selection of dialysis modality (peritoneal dialysis versus hemodialysis) with the most suitable dialysis access. Finding the right balance between the patient's preferences, the likelihood of access function and survival, and potential complications in the context of available resources and limited patient survival can be extremely challenging. The framework for choosing the most appropriate vascular access for the elderly presented in this review considers the individual end-stage kidney disease Life-Plan, the patient life expectancy, the likelihood of access function and survival, the timing of dialysis relative to access placement, prior access history, and patient preference. This complex decision-making process should be dynamic in order to accommodate patients' changing needs and life and health circumstances. Effective and timely communication between the patient, their caregivers, and treating team is key to delivering truly patient-centered care. Delivering this care also requires overcoming the limitations of the currently available evidence that is predominantly based on observational data with its inherent risks of bias. While challenging, future randomized controlled studies exploring the risks, benefits, costs, and timing of placement of available access types in the elderly are required to help us "get it right" for our patients.
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Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Charmaine E Lok
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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11
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Miyamoto M, Kurita N, Suemitsu K, Murakami M. Fistula and Survival Outcomes after Fistula Creation among Predialysis Chronic Kidney Disease Stage 5 Patients. Am J Nephrol 2017; 45:356-364. [PMID: 28301835 DOI: 10.1159/000466707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most guidelines recommend the creation of arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) stage 4. However, an increasing number of studies suggest that early AVF creation leads to high rates of AVF failure and death before dialysis commencement. Only the Japanese guideline recommends AVF creation at CKD stage 5; however, no data are available regarding access-related outcomes at this stage. METHOD This was a multicenter cohort study involving Japanese CKD stage 5 patients who underwent preemptive AVF creation from 2009 to 2013. The primary outcome was unnecessary AVF creation, defined as death before requiring dialysis or AVF failure before dialysis commencement. The secondary outcome was dialysis commencement. The associations with candidate predictors and the outcomes were examined. RESULTS A total of 303 patients were registered. Four cases of death before dialysis and 13 cases of AVF failure before dialysis commencement were observed. A total of 283 patients who advanced to dialysis were found to have functional AVFs. The cumulative incidences of unnecessary AVF creation and dialysis commencement at 1 year were 4.8 and 89.3%, respectively. Competing risk regression analyses showed that age ≥75 years (subhazard ratio [SHR] 3.12, 95% CI 1.20-8.09) and female gender (SHR 3.31, 95% CI 1.20-9.09) were associated with unnecessary AVF creation. CONCLUSIONS A low incidence of unnecessary AVF creation was revealed among Japanese patients who received AVF at CKD stage 5. These results may help clarify the natural history of unnecessary AVF creation for other countries reformatting their guidelines regarding late vascular access creation.
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Affiliation(s)
- Masahito Miyamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Woo K, Lok CE. New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients? Clin J Am Soc Nephrol 2016; 11:1487-1494. [PMID: 27401524 PMCID: PMC4974877 DOI: 10.2215/cjn.02190216] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts.
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Affiliation(s)
- Karen Woo
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California; and
| | - Charmaine E. Lok
- Division of Nephrology, University Health Network–Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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