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Liu S, Wang Y, He X, Wang Y, Li X. Factors affecting suboptimal maturation of autogenous arteriovenous fistula in elderly patients with diabetes:A narrative review. Heliyon 2024; 10:e35766. [PMID: 39170451 PMCID: PMC11337043 DOI: 10.1016/j.heliyon.2024.e35766] [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: 03/15/2024] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024] Open
Abstract
Autogenous arteriovenous fistula (AVF) is considered the preferred vascular access choice for individuals undergoing maintenance hemodialysis (MHD) and is widely utilized in China, as reported by the Dialysis Outcomes and Practice Patterns Study. Despite its popularity, the significant incidence of poor AVF maturation often leads to the need for central venous catheter insertion, increasing the risk of complications like superior vena cava stenosis and catheter-related infections, which in turn raises the overall mortality risk. With the prevalence of diabetes rising globally among the elderly and diabetic kidney disease being a leading cause of end-stage renal disease necessitating renal replacement therapy, our retrospective review aims to explore the various factors affecting AVF maturation in this specific patient population. While there have been numerous studies examining AVF complications in MHD patients, including issues like failure, patency loss, stenosis, thrombosis, poor maturation, and other influencing factors, there remains a gap in large-scale clinical studies focusing on the incidence and risk factors for immature AVF specifically in elderly diabetic patients. This paper delves into the pathophysiological mechanisms, diagnostic criteria, and unique considerations surrounding AVF maturation in elderly diabetic patients, distinguishing them from the general population. Our literature review reveals that elderly diabetic patients exhibit a higher risk of AVF immaturity compared to the general population. Additionally, there exists a continuing discourse regarding several aspects related to this group, including the choice of dialysis access, timing of AVF surgery, and surgical site selection. Furthermore, we delve into the management strategies for vascular access within this specific group with the goal of providing evidence-based guidance for the establishment and maintenance of functional vascular access in elderly diabetic patients.
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Affiliation(s)
- Shuangyan Liu
- Graduate School of Hebei Medical University, Shijiazhuang, 050017, Hebei, China
| | - Yaqing Wang
- Graduate School of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Xiaojie He
- Graduate School of Hebei Medical University, Shijiazhuang, 050017, Hebei, China
| | - Yuqing Wang
- Graduate School of Hebei Medical University, Shijiazhuang, 050017, Hebei, China
| | - Xiaodong Li
- Department of Nephrology, Baoding No 1 Central Hospital of Hebei Medical University, Baoding, Hebei, China
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2
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Zhui L, Yuling C, Hansheng W, Xiangjie L. Omentin reduces venous neointimal hyperplasia in arteriovenous fistula through hypoxia-inducible factor-1 alpha inhibition. Microvasc Res 2024; 154:104688. [PMID: 38640999 DOI: 10.1016/j.mvr.2024.104688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/22/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
Arteriovenous fistula (AVF) failure often involves venous neointimal hyperplasia (VNH) driven by elevated hypoxia-inducible factor-1 alpha (HIF-1α) in the venous wall. Omentin, known for its anti-inflammatory and anti-hyperplasia properties, has an uncertain role in early AVF failure. This study investigates omentin's impact on VNH using a chronic renal failure (CRF) rabbit model. The CRF rabbit model of AVF received omentin-expressing adenoviral vector or control β-gal vector to assess omentin's effects on VNH. Human vascular smooth muscle cells (HVSMCs), stimulated with tumor necrosis factor-α (TNF-α), were exposed to recombinant human omentin (Rh-OMT) to study its influence on cell proliferation and migration. The AMP-activated protein kinase (AMPK) inhibitor compound C and the mammalian target of rapamycin (mTOR) activator MHY1485 were employed to explore omentin's mechanisms in VNH reduction through HIF-1α inhibition. Omentin treatment reduced VNH in CRF rabbits, concomitant with HIF-1α down-regulation and the suppression of downstream factors, including vascular endothelial growth factor and matrix metalloproteinases. Rh-OMT inhibited TNF-α-induced HVSMC proliferation and migration by modulating both cell cycle and cell adhesion proteins. Additionally, omentin reduced HIF-1α expression through the AMPK/mTOR pathway activation. Notably, the blockade of AMPK/mTOR signaling reversed omentin-mediated inhibition of VNH, cell proliferation, and migration, both in vivo and in vitro. In conclusion, omentin mitigates VNH post-AVF creation by restraining HIF-1α via AMPK/mTOR signaling. Strategies boosting circulating omentin levels may offer promise in averting AVF failure.
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MESH Headings
- Animals
- Hyperplasia
- Neointima
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Hypoxia-Inducible Factor 1, alpha Subunit/genetics
- Cytokines/metabolism
- Rabbits
- Humans
- GPI-Linked Proteins/metabolism
- GPI-Linked Proteins/pharmacology
- GPI-Linked Proteins/genetics
- Disease Models, Animal
- Cell Proliferation/drug effects
- Signal Transduction
- Myocytes, Smooth Muscle/pathology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/drug effects
- Lectins/pharmacology
- Lectins/metabolism
- Cell Movement/drug effects
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/drug effects
- AMP-Activated Protein Kinases/metabolism
- Cells, Cultured
- Arteriovenous Shunt, Surgical/adverse effects
- Male
- Kidney Failure, Chronic/pathology
- TOR Serine-Threonine Kinases/metabolism
- Graft Occlusion, Vascular/pathology
- Graft Occlusion, Vascular/prevention & control
- Graft Occlusion, Vascular/metabolism
- Graft Occlusion, Vascular/physiopathology
- Jugular Veins/pathology
- Jugular Veins/metabolism
- Jugular Veins/transplantation
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Affiliation(s)
- Li Zhui
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Chen Yuling
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wang Hansheng
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Li Xiangjie
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Meng L, Ng JJ, Choong AMTL, Dharmaraj RB, Menon R, Wong JCL, Ching S, Wong YF, Kong J, Ho P. Effectiveness of a native vein arteriovenous fistula tracking system. Semin Dial 2024; 37:161-171. [PMID: 37748774 DOI: 10.1111/sdi.13179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/30/2023] [Accepted: 09/10/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE This study aims to evaluate the effectiveness of a tracking program on the functional maturation rate of arteriovenous fistula (AVF). METHODS Two major clinical outcomes (commencement of cannulation and functional maturation) of created AVFs were compared between two cohorts. (i) Cohort 1: historical cohort; (ii) Cohort 2: AVFs created after implementation of the tracking project. Multivariable Cox regression models were used to assess the association between cohort allocation and the two major clinical outcomes. RESULTS Data of 114 and 141 patients were analyzed respectively from Cohorts 1 (historical data) and 2 (with AVF tracking). After adjustment of covariates in the multivariable analysis, the AVFs created in Cohort 2 were more likely to be cannulated earlier (adjusted HR: 2.82; 95% CI: 1.97-4.05; p < 0.001), compared to those in Cohort 1. Similarly, the AVFs of Cohort 2 patients had significantly higher probability of functional maturation (adjusted HR: 1.81; 95% CI: 1.31-2.48; p < 0.001) than fistulas in Cohort 1. Cannulation was commenced for half of the AVFs by 4.1 months post-creation in the historical cohort (Cohort 1), whereas in the post-tracking cohort, 50% of the AVFs were cannulated by 2.3 months after creation (p < 0.001). It took 5.5 and 4.3 months for 50% of the AVFs created in Cohort 1 and Cohort 2 patients to achieve catheter-free functional maturation, respectively (p = 0.06). CONCLUSION An AVF tracking program with maturation target for the access surgeons, together with a standardized tracking, feedback, and clinical strategy adjustment system is able to improve the AVF functional maturation rate.
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Affiliation(s)
- Lingyan Meng
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Jun Jie Ng
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Andrew Mark Tze Liang Choong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Rajesh Babu Dharmaraj
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Raj Menon
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Julian Chi Leung Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Susan Ching
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Yen Feng Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Jaqueline Kong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Pei Ho
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
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Hashmi SA, Hudar SA, Stephen E, Riyami DA, Maawali HA, Abdelhady I, Wahaibi KA, Rizvi S. Factors Affecting the Early Maturation of Arteriovenous Fistulae Created at a Tertiary Centre in Oman. Sultan Qaboos Univ Med J 2024; 24:37-43. [PMID: 38434458 PMCID: PMC10906777 DOI: 10.18295/squmj.9.2023.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 03/05/2024] Open
Abstract
Objectives This study aimed to determine the risk factors associated with the failure of arteriovenous fistulae (AVF) maturation. Methods This retrospective cohort study was conducted from January 2014 to December 2018 in Sultan Qaboos University Hospital, Muscat, Oman. Patients were followed-up 3 months after surgery, and their electronic medical records were accessed for demographic and clinical data. Univariate analysis was used to determine the risk factors associated with early AVF maturation and multivariant analysis was used to determine the predictive factors for AVF failure. Results A total of 269 patients were included. Female gender was a significant factor affecting AVF maturity (P = 0.049), while age (P = 0.626), diabetes (P = 0.954), hypertension (P = 0.378), dyslipidaemia (P = 0.907), coronary artery disease (P = 0.576), cerebrovascular accident (P = 0.864), congestive heart failure (P = 0.685), previous central venous catheterisation (P = 0.05), fistula type (P = 0.863) and fistula site (P = 0.861) did not affect AVF maturation. Binary logistic regression showed that all the risk factors were insignificant. Failure of early AVF maturation affected 11.5% in the cohort. Conclusion This study found that the proportion of early AVF maturation at our hospital is at par with that in the international literature. Failure of AVF maturation was significantly associated with the female gender. These findings can help nephrologists and vascular surgeons prognosticate AVF maturation rates. However, a larger study is needed for definitive conclusions.
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Affiliation(s)
| | | | - Edwin Stephen
- Department of Surgery, Sultan Qaboos University, Muscat, Oman
| | - Dawood Al Riyami
- Department of Internal Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | | | | | | | - Syed Rizvi
- Department of Family Medicine & Public Health, Sultan Qaboos University, Muscat, Oman
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5
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Zhang F, Li J, Yu J, Jiang Y, Xiao H, Yang Y, Liang Y, Liu K, Luo X. Risk factors for arteriovenous fistula dysfunction in hemodialysis patients: a retrospective study. Sci Rep 2023; 13:21325. [PMID: 38044365 PMCID: PMC10694134 DOI: 10.1038/s41598-023-48691-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023] Open
Abstract
Arteriovenous fistula (AVF) is the first choice of vascular access in hemodialysis (HD) patients. However, the correlations between patient factors and the arteriovenous fistula patency remain unclear. Therefore, our study investigates the risk factors associated with AVF dysfunction in HD patients. A total of 233 end-stage renal disease (ESDR) patients who met the study inclusion criteria in the Nephrology Department of Hunan Provincial People's Hospital between December 2020 and June 2022 were included in this study. The baseline demographic, clinical and laboratory parameters were collected at the time of AVF creation and analyzed. Of the 233 ESRD patients, 146 (62.7%) were male and the mean age was 56.11 ± 12.14 (21-82) years. The patients were followed for a median time of 14 months. Kaplan-Meier analysis showed a 6-, 12- and 24-month post-placement survival of 87.1%, 82.8% and 80.7%, respectively. Univariate Cox regression analysis revealed weight (HR, 1.03; P = 0.03) as a predictor for the loss of vascular access functionality. In addition, multivariate Cox regression analysis further demonstrated that sex (HR, 3.41; P = 0.03), weight (HR 1.08; P < 0.01) and phosphorus level (HR: 3.03; P = 0.01) are independent risk factors for AVF dysfunction. AVF dysfunction is highly associated with several risk factors including weight, phosphorus level, and sex. Positive intervention strategies targeting these potential factors, such as weight loss or oral phosphate binders could improve the long-term success of AVF.
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Affiliation(s)
- Fan Zhang
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Jiali Li
- Department of Nephrology, Changsha central hospital, Changsha, China
| | - Jie Yu
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yang Jiang
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Hailang Xiao
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yiya Yang
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yumei Liang
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Kanghan Liu
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Xun Luo
- Department of Nephrology and Laboratory of Kidney Disease, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China.
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6
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Yan Q, Davies MG. Obesity drives secondary procedures to achieve access maturation in end-stage renal disease. J Vasc Surg 2023; 78:1531-1540.e4. [PMID: 37597592 DOI: 10.1016/j.jvs.2023.08.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Establishing long-term arteriovenous access is an important component in the long-term care of a patient with end-stage renal disease. The increasing frequency of obesity is reported to impact the access management of end-stage renal disease patients. This study aims to evaluate the outcomes of arteriovenous fistulae (AVF) in obese and nonobese patients. METHODS A retrospective review of all patients over ten years with primary autogenous AVF (radiocephalic, brachiocephalic, and brachial-basilic) was undertaken at a single center. Patients were subcategorized by body mass index into nonobese, class I, II, and III obesity. Outcomes of maturation (successful progression to hemodialysis), reintervention, functional dialysis (continuous hemodialysis for 3 consecutive months), and patency were examined. RESULTS From January 1999 to December 2019, 2311 patients (67% female; mean age, 61 ± 15 years) underwent primary AVF placement (12% radiocephalic, 53% brachiocephalic, and 35% brachial basilic). Forty-one percent were nonobese, 29% had class I obesity, 19% had class II obesity, and 11% had class III obesity. The majority of patients were diabetic and Hispanic. The 30-day major adverse cardiovascular event rate was elevated in class II (0.20%) and class III (0.50%) obesity compared with class I obesity (0.15%) and nonobese (0.05%). The 30-day morbidity rate was higher in all classes of obesity (0.5% vs0.3% vs 0.2% vs 0.05% for class III vs class II vs class I obesity and nonobese, respectively). Early thrombosis was significantly increased in class II (9%) and class III obesity (12%) compared with class I obesity (5%) and nonobese (3%). There was a two-fold increase in procedures to effect maturation in class II (51%) and class III (74%) obesity compared with class I obesity (22%) and nonobese (34%). Secondary patency at 3 years was significantly lower in class III (62 ± 4%) and class II (79 ± 3%) compared with class I obesity (87 ± 2%) and nonobese (93 ± 4%). All classes of obesity required significantly more secondary Interventions per year compared with nonobese (3.9 vs 3.1 vs 2.5 vs 1.4 secondary interventions per year for class III vs class II vs class I obesity and nonobese, respectively). CONCLUSIONS Advancing obesity class is associated with an increased number of procedures to achieve AVF maturation and is associated with poorer patency and functionality as the category of obesity advances.
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Affiliation(s)
- Qi Yan
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Long School of Medicine, San Antonio, TX
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX.
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Anderson L, Kraiss LW, Sarfati MR, Hales JB, Brooke BS. Predictors of Arteriovenous Fistula Maturation among Patients with Severe Obesity. Ann Vasc Surg 2023; 97:82-88. [PMID: 37385338 DOI: 10.1016/j.avsg.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND There is an increasing prevalence of obesity among patients who develop end-stage renal disease and require dialysis. While referrals for arteriovenous fistulas (AVFs) among patients with class 2-3 obesity (i.e., body mass index [BMI] ≥ 35) are increasing, it is unclear what type of autogenous access is most likely to mature in this patient population. This study was designed to evaluate factors that impact maturation of AVF among patients with class ≥2 obesity. METHODS We retrospectively reviewed AVFs created at a single center from 2016 to 2019 for patients who had undergone dialysis within the same healthcare system. Ultrasound studies were used to evaluate factors that defined functional maturation, including diameter, depth, and volume flow rates through the fistula. Logistic regression models were used to evaluate the risk-adjusted association between class ≥2 obesity and functional maturation. RESULTS A total of 202 AVFs [radiocephalic (24%), brachiocephalic (43%), and transposed brachiobasilic (33%)] were created during the study period, of which 53 (26%) patients had a BMI >35. Functional maturation was significantly lower among patients with class ≥2 obesity undergoing brachiocephalic (58% obese versus 82% normal-overweight; P = 0.017), but not radiocephalic or brachiobasilic AVFs. This was primarily a result of excessive AVF depth in severely obese patients (9.6 ± 4.0 mm obese versus 6.0 ± 2.7 mm normal-overweight; P < 0.001), whereas there was no significant difference found in average volume flow or AVF diameter between groups. In risk-adjusted models, a BMI ≥35 was associated with a significantly lower likelihood of achieving AVF functional maturation (odds ratio: 0.38; 95% confidence interval: 0.18-0.78; P = 0.009) after controlling for age, sex, socioeconomic status, and fistula type. CONCLUSIONS Patients with a BMI >35 are less likely to mature AVFs after creation. This principally affects brachiocephalic AVFs and occurs because of increased fistula depth as opposed to diameter or volume flow parameters. These data can help guide decision-making when planning AVF placement in severely obese patients.
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Affiliation(s)
- Laura Anderson
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Larry W Kraiss
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Mark R Sarfati
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Julie B Hales
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT.
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The Effect of Obesity on Outcomes After Arteriovenous Fistulae Creation: A Systematic Review. Ann Vasc Surg 2023; 92:304-312. [PMID: 36812981 DOI: 10.1016/j.avsg.2023.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Establishing reliable vascular access is critical for hemodialysis in end-stage renal disease (ESRD). In recent years, the global health burden of ESRD has grown, matched by a rise in prevalence of obesity. Currently, more and more arteriovenous fistulae (AVFs) are being created for obese patients with ESRD. This is a growing concern as creating arteriovenous (AV) access in obese ESRD patients can be more challenging and may be associated with poorer outcomes. METHODS We performed a literature search with multiple electronic databases. We included studies that compared outcomes after autogenous upper extremity AVF creation between obese and nonobese patients. The relevant outcomes were postoperative complications, outcomes related to maturation, outcomes related to patency, and outcomes related to reintervention. RESULTS We included 13 studies with a total of 305,037 patients. We found a significant association between obesity and poorer early and late AVF maturation. Obesity was also strongly associated with lower primary patency rates and a higher need for reintervention. CONCLUSIONS This systematic review found that higher body mass index and obesity are associated with poorer AVF maturation outcomes, poorer primary patency, and higher reintervention rates.
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Choudhury D, Yalamanchili HB, Hasan A. Dialysis of the Obese Patient: Meeting Needs for a Growing Epidemic. Semin Nephrol 2021; 41:371-379. [PMID: 34715966 DOI: 10.1016/j.semnephrol.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Increasing population obesity and associated metabolic consequences has led to increased number of obese patients with chronic kidney disease and end-stage renal disease. While obesity is associated with increased cardiovascular morbidity and mortality, obese dialysis patients present a seeming paradox for survival benefit, given other acute intervening illnesses for those on dialysis with loss of lean body mass overtime. Challenges remain in providing adequate renal replacement options and therapy for this growing segment of obese patients on dialysis which are discussed in this article.
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Affiliation(s)
- Devasmita Choudhury
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA; Department of Medicine, Division of Nephrology, Virginia Tech Carilion School of Medicine, Roanoke, VA; Department of Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlottesville, VA.
| | - Hima Bindu Yalamanchili
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA; Department of Medicine, Division of Nephrology, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Alia Hasan
- Department of Medicine, Division of Nephrology, Salem Veterans Affairs Health System, Salem, VA
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Arteriovenous Fistula Formation with Adjuvant Endovascular Maturation. J Vasc Surg 2021; 75:641-650.e2. [PMID: 34506894 DOI: 10.1016/j.jvs.2021.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 08/16/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The clinical utility of the native arteriovenous fistula (AVF) is limited by a prolonged time to maturation, low overall maturation rate, and subsequent abandonment. Endovascular intervention is increasingly accepted as first line therapy to treat AVF stenosis. The objective of this study was to evaluate AVF formation outcomes when early endovascular intervention was selectively performed to bring about timely AVF maturation. METHODS A retrospective study (February 2014- February 2020) was performed on 82 AVF consecutive patients (mean age 62.5±13.5 (17-83); 58 male (70.7%)) with end-stage renal failure who had Vascular Access (VA) construction at a single institution. Four year AVF patency, vascular diameters, haemodialysis parameters, re-intervention rate, and mortality were analysed. RESULTS Radiocephalic AVF was the most common fistula constructed (71 patients; 88.6%). Post formation evaluation (46.2+/-56.0 days (5-343)) revealed 33 (40.2%) immature AVFs. Subsequently, 19 patients underwent endovascular procedures consisting of angioplasty/stenting of the juxta-anastomosis, cannulation and/or outflow segments to bring about timely maturation of the AVF. Hence 93.9% of AVFs had reached functional patency (maturation) by 6 months post formation, with a mean time to maturation of 67.8 +/- 65.9 (5-320) days. After reaching maturation, Primary Access Functional Patency was 82 +/- 4.3 % at 6 months, 58+/- 5.5% at 12 months and 34 +/- 6.8% at 48 months. Primary Assisted Access Functional Patency was 95 +/- 2.4% at 6 months, 90 +/-3.3 % at 12 months and 83 % +/- 4.7 % at 48 months. 121 endovascular interventions were performed to maintain patency, equating to an endovascular reintervention rate of .37 procedures/patient year. Mean arterial, venous and brachial flow rates did not change significantly after maturation with a mean fistula (primary assisted functional patency) survival time of 5.9 +/- 0.26 (5.33- 6.36) years from maturation. Only 12 thromboses occurred after the first post formation follow up review, which were all salvaged using endovascular techniques leading to 100% Total secondary functional patency at 4 years. 5 year estimated all-cause mortality was 45.6 +/-12.7%. CONCLUSION Arteriovenous fistula maturation rate and time to maturation can be improved when early endovascular intervention is selectively performed post formation. This allows for near universal maturation where, once matured, the use of ongoing endovascular re-intervention allows for a low re-intervention rate and long term patency providing for reliable long term renal vascular access.
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11
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Ghosh NK, Bhattacharjee HK, Prajapati O, Krishna A, Kumar A, Mahajan S, Bansal VK. Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients. J Vasc Access 2021; 23:508-514. [PMID: 33719712 DOI: 10.1177/11297298211001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients. MATERIAL AND METHODS This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent t-test, chi-square test, logistic regression analysis and multivariate analysis were used. The p-value of <0.05 was considered significant. RESULTS A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome (p < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure (p = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001). CONCLUSION In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.
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Affiliation(s)
- Nalini Kanta Ghosh
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | | | - Omprakash Prajapati
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Asuri Krishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mahajan
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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12
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Sadasivan K, Kunjuraman U, Murali B, Yadev I, Kochunarayanan A. Factors Affecting the Patency of Radiocephalic Arteriovenous Fistulas Based on Clinico-Radiological Parameters. Cureus 2021; 13:e13678. [PMID: 33824829 PMCID: PMC8018724 DOI: 10.7759/cureus.13678] [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] [Indexed: 11/05/2022] Open
Abstract
Arteriovenous fistulas are an important means of vascular access for long-term haemodialysis in patients with end-stage renal disease (ESRD). We evaluated the outcome of radiocephalic arteriovenous fistulas (RCAVFs) in 55 patients operated upon in our hospital in southern India. We studied the outcome of RCAVF surgery with the demographic factors, duration of diabetes, the diameter of the radial artery and cephalic vein, and any signs of atherosclerosis in the radial artery. We found that a small cephalic vein size of ≤ 2 mm, a negative cephalic vein tap test, a thickened, non-compressible, calcified radial artery on palpation, and evidence of atherosclerosis on radiological investigations were associated with a significant chance of RCAVF failure. A clinico-radiological grading of atherosclerosis for peripheral arteries is also proposed. Any patient presenting to the microsurgeon with a small cephalic vein size, a negative cephalic vein tap test, a thickened, non-compressible, calcified vessel on palpation, and tram-track calcification or whole vessel calcification or severely atherosclerotic vessel on radiological evaluation must be approached with caution regarding RCAVF creation and must be prepared for an arteriovenous fistula (AVF) creation at a higher level.
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Affiliation(s)
- Kalesh Sadasivan
- Plastic and Reconstructive Surgery, Government Medical College Thiruvananthapuram, Thiruvananthapuram, IND
| | - Usha Kunjuraman
- Radiology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, IND
| | - Biju Murali
- Plastic and Reconstructive Surgery, Government Medical College Thiruvananthapuram, Thiruvananthapuram, IND
| | - Induprabha Yadev
- General Surgery, Government Medical College Thiruvananthapuram, Thiruvananthapuram, IND
| | - Ajayakumar Kochunarayanan
- Plastic and Reconstructive Surgery, Government Medical College Thiruvananthapuram, Thiruvananthapuram, IND
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13
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Lee J, Lee S, Chang JW, Kim SW, Song JK. Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:121-126. [PMID: 32551292 PMCID: PMC7287223 DOI: 10.5090/kjtcs.2020.53.3.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/14/2019] [Accepted: 12/24/2019] [Indexed: 11/16/2022]
Abstract
Background The aim of this study was to analyze the clinical outcomes of autogenous brachiocephalic arteriovenous fistulas and to investigate the factors associated with 1-year patency after initiation of hemodialysis. Methods We retrospectively reviewed the medical records of 41 patients who underwent surgery to create an autogenous brachiocephalic arteriovenous fistula between January 2015 and December 2017, received hemodialysis at the same hospital for longer than 1 year, and were monitored for their vascular access status. Intraoperative flow was measured using transit-time ultrasonography. Results The 1-year primary and secondary patency rates were 61% (n=25) and 87.8% (n=36), respectively. The functional group (subjects who required no intervention to maintain patency within the first year after hemodialysis initiation) displayed a significantly higher median intraoperative flow rate (450 mL/min) than the non-functional group (subjects who required intervention at least once regardless of 1-year patency) (275 mL/min) (p=0.038). Based on a receiver operating characteristic curve analysis, all patients were additionally subdivided into a high-flow group (>240 mL/min) and a low-flow group (≤240 mL/min). The high-flow group included a significantly greater number of functional brachiocephalic arteriovenous fistulas than the low-flow group (74.2% vs. 20%, respectively; p=0.007). Conclusion Transit-time flow, as measured with intraoperative transit-time ultrasonography, was associated with patency without the need for intervention at 1 year after initiation of hemodialysis.
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Affiliation(s)
- Jonggeun Lee
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Seogjae Lee
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jee Won Chang
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Su Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jung-Kook Song
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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14
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Raulli SJ, Sather K, Dicken QG, Farber A, Kalish JA, Eslami MH, Zhang Y, Cheng TW, Levin SR, Siracuse JJ. Higher body mass index is associated with reinterventions and lower maturation rates after upper extremity arteriovenous access creation. J Vasc Surg 2020; 73:1007-1015. [PMID: 32442609 DOI: 10.1016/j.jvs.2020.04.510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/17/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation. METHODS A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-39.9 kg/m2), and morbidly obese (>40 kg/m2). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated. RESULTS A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P = .041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P < .001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P = .002), obese (OR, 2.12; 95% CI, 1.19-3.47; P = .009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P < .001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P = .02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival. CONCLUSIONS Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.
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Affiliation(s)
- Stephen J Raulli
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Kristiana Sather
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Quinten G Dicken
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yixin Zhang
- Department of Biostatistics, Boston University, School of Public Health, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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15
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Arya S, Melanson TA, George EL, Rothenberg KA, Kurella Tamura M, Patzer RE, Hockenberry JM. Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population. J Am Soc Nephrol 2020; 31:625-636. [PMID: 31941721 DOI: 10.1681/asn.2019030274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 11/18/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC). METHODS To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013. RESULTS At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft. CONCLUSIONS Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.
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Affiliation(s)
- Shipra Arya
- Division of Vascular Surgery and .,Division of Vascular Surgery, Surgical Services Line and
| | - Taylor A Melanson
- Division of Transplant, Department of Surgery, Emory School of Medicine
| | | | - Kara A Rothenberg
- Division of Vascular Surgery and.,Department of Surgery, University of California, San Francisco East Bay, Oakland, California
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Healthcare System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Rachel E Patzer
- Department of Surgery, Emory School of Medicine.,Department of Epidemiology, Rollins School of Public Health, and
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
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16
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Benedetto U, Caputo M, Zakkar M, Davies A, Gibbison B, Bryan A, Angelini GD. The effect of obesity on survival in patients undergoing coronary artery bypass graft surgery who receive a radial artery. Eur J Cardiothorac Surg 2019; 51:376-381. [PMID: 28186261 DOI: 10.1093/ejcts/ezw323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Umberto Benedetto
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alan Davies
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Ben Gibbison
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alan Bryan
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
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17
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Hossain S, Sharma A, Dubois L, DeRose G, Duncan A, Power AH. Preoperative point-of-care ultrasound and its impact on arteriovenous fistula maturation outcomes. J Vasc Surg 2018; 68:1157-1165. [DOI: 10.1016/j.jvs.2018.01.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/22/2018] [Indexed: 10/16/2022]
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18
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Schwann TA, Ramia PS, Habib JR, Engoren MC, Bonnell MR, Habib RH. Effectiveness of radial artery–based multiarterial coronary artery bypass grafting: Role of body habitus. J Thorac Cardiovasc Surg 2018; 156:43-51.e2. [DOI: 10.1016/j.jtcvs.2018.02.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/09/2018] [Accepted: 02/04/2018] [Indexed: 01/08/2023]
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19
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Schwann TA, Gaudino M, Baldawi M, Tranbaugh R, Schwann AN, Habib RH. Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy. J Card Surg 2018; 33:205-212. [PMID: 29370589 DOI: 10.1111/jocs.13517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.
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Affiliation(s)
- Thomas A Schwann
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | | - Mustafa Baldawi
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | | | | - Robert H Habib
- Society of Thoracic Surgeons Research Center, Chicago, Illinois
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20
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Arteriovenous Fistulae for Haemodialysis: A Systematic Review and Meta-analysis of Efficacy and Safety Outcomes. Eur J Vasc Endovasc Surg 2017; 54:513-522. [PMID: 28843984 DOI: 10.1016/j.ejvs.2017.06.024] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/27/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Arteriovenous fistulae are the currently recommended gold standard vascular access modality for haemodialysis because of their prolonged patency, improved durability, and low risk of infection for those that mature. However, notable disadvantages are observed in terms of protracted maturation time, associated high rates of catheter use, and substantial abandonment rates. The aim of this study was to quantitatively summarize the outcomes of fistula patency, infection, maturation, and abandonment published in the scientific literature. METHODS This was a systematic review and meta-analyses of studies evaluating fistula outcomes. Literature searches were conducted in multiple databases to identify observational and interventional studies of mean fistula patency rates at 1 year, infection risk, maturation time, and abandonment. Digitisation software was used to simulate individual patient level data from Kaplan-Meier survival plots. RESULTS Over 8000 studies were reviewed, and from these, 318 studies were included comprising 62,712 accesses. For fistulas the primary unassisted, primary assisted, and secondary patency rates at one year were 64%, 73% and 79% respectively, however not all fistulas reported as patent could be confirmed as being clinically useful for dialysis (i.e. functional patency). For fistulas that were reported as mature, mean time to maturation was 3.5 months, however only 26% of created fistulas were reported as mature at 6 months and 21% of fistulas were abandoned without use. Overall risk of infection in fistula patients was 4.1% and the overall rate per 100 access days was 0.018. CONCLUSIONS Reported fistula patency rates may overstate their potential clinical utility when time to maturation, maturation rate, abandonment and infection are considered. Protracted maturation times, abandonment and infection all have a significant impact on evaluating the clinical utility of fistula creation. A rigorous and consistent set of outcomes definitions for hemodialysis access are necessary to clarify factors contributing to fistula success and the clinical consequence of fistula failure.
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21
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Duque JC, Martinez L, Tabbara M, Dvorquez D, Mehandru SK, Asif A, Vazquez-Padron RI, Salman LH. Arteriovenous fistula maturation in patients with permanent access created prior to or after hemodialysis initiation. J Vasc Access 2017; 18:185-191. [PMID: 28218361 PMCID: PMC10949904 DOI: 10.5301/jva.5000662] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Multiple factors and comorbidities have been implicated in the ability of arteriovenous fistulas (AVF) to mature, including vessel anatomy, advanced age, and the presence of coronary artery disease or peripheral vascular disease. However, little is known about the role of uremia on AVF primary failure. In this study, we attempt to evaluate the effect of uremia on AVF maturation by comparing AVF outcomes between pre-dialysis chronic kidney disease (CKD) stage five patients and those who had their AVF created after hemodialysis (HD) initiation. METHODS We included 612 patients who underwent AVF creation between 2003 and 2015 at the University of Miami Hospital and Jackson Memorial Hospital. Effects of uremia on primary failure were evaluated using univariate statistical comparisons and multivariate logistic regression analyses. RESULTS Primary failure occurred in 28.1% and 26.3% of patients with an AVF created prior to or after HD initiation, respectively (p = 0.73). The time of HD initiation was not associated with AVF maturation in multivariate logistic regression analysis (p = 0.57). In addition, pre-operative blood urea nitrogen (p = 0.78), estimated glomerular filtration rate (p = 0.66), and serum creatinine levels (p = 0.14) were not associated with AVF primary failure in pre-dialysis patients. CONCLUSIONS Our results show that clearance of uremia with regular HD treatments prior to AVF creation does not improve the frequency of vascular access maturation.
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Affiliation(s)
- Juan C. Duque
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Denise Dvorquez
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Sushil K. Mehandru
- Department of Medicine, Division of Nephrology, Jersey Shore University Medical Center, Hackensack-Meridian Seton Hall School of Medicine, Neptune, New York - USA
| | - Arif Asif
- Department of Medicine, Division of Nephrology, Jersey Shore University Medical Center, Hackensack-Meridian Seton Hall School of Medicine, Neptune, New York - USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Loay H. Salman
- Division of Nephrology, Albany Medical College, Albany, New York - USA
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22
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Park SC, Ko SY, Kim JI, Moon IS, Kim SD. Balloon-assisted maturation for arteriovenous fistula maturation failure: an early period experience. Ann Surg Treat Res 2016; 90:272-8. [PMID: 27186572 PMCID: PMC4865705 DOI: 10.4174/astr.2016.90.5.272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/21/2016] [Accepted: 03/12/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Balloon-assisted maturation (BAM) is emerging as a salvage management for arteriovenous fistula maturation failure (AVF MF). However, BAM is a relatively new, yet controversial technique for AVF maturation. Therefore, we evaluated the effectiveness of BAM for AVF MF. METHODS Between January 2012 and December 2014, 249 AVFs were created. The total MF rate was 24.8%. But, only 110 AVFs were enrolled, including 74 brachiocephalic (BC) AVFs and 36 radiocephalic (RC) AVFs. The follow-up period was 12 months. Among those, there were 42 MFs (22 BC AVFs and 20 RC AVFs) and 68 maturation successes (MS) (52 BC AVFs and 16 RC AVFs). BAM was involved in MF group. We compared the clinical characteristics, AVF flows, and AVF flow ratios of MF and MS groups. Also, we evaluated the etiology, management, and result of MF. RESULTS There was no difference in clinical characteristics between MF and MS groups. In MF group, 39 balloon angioplasties (BAs) for 42 AVF MFs were performed. Number of BA was 1.45 ± 0.57 and duration of BA was 21.30 ± 21.24 weeks. BAM rate was 46.2%. For 1 year after AVF creation, AVF flows of MS group were significantly larger than those of MF group (P < 0.05) but there was no difference in AVF flow ratio between MF and MS groups (P > 0.05). CONCLUSION BA for AVF MF is a relatively applicable and effective modality. Although a large volume study is necessary, we suggest BAM is an effective salvage management for AVF MF.
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Affiliation(s)
- Sun Cheol Park
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Yeon Ko
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Il Kim
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Sung Moon
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Dong Kim
- Division of Vascular and Transplant Surgery, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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23
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Kim JK, Choi SR, Lee WY, Park MJ, Lee HS, Song YR, Kim HJ, Kim SG. Leptin, pre-existing vascular disease, and increased arteriovenous fistula maturation failure in dialysis patients. J Vasc Surg 2016; 64:402-410.e1. [PMID: 27134129 DOI: 10.1016/j.jvs.2016.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/01/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The adipocytokine leptin is an independent cardiovascular risk factor and exerts proatherogenic effect. Pre-existing vascular disease is an important cause of arteriovenous fistula (AVF) maturation failure. We explored the association between serum leptin, pre-existing vascular disease, and AVF maturation failure in incident hemodialysis patients. METHODS Vein samples from 62 patients were collected at the time of AVF creation. Pre-existing vascular disease was evaluated with histologic changes and immunohistochemical characteristics of cellular phenotypes in intima. AVF maturation failure was defined as an AVF that could not be used successfully by the third month after its creation. RESULTS The prevalence of body mass index ≥30 kg/m2 was 17%, and AVF maturation failure occurred in 28 (45%) patients. Patients within the highest leptin tertile showed significantly higher maturation failure rate, independent of age, gender, diabetes, and body mass index. On histologic examination, significant differences in intimal hyperplasia (13.3 ± 4.5 vs 18.2 ± 5.2 vs 30.3 ± 14.3 μm) and medial thickening (76.8 ± 23.7 vs 103.9 ± 33.6 vs 109.3 ± 36.5 μm) were observed across leptin tertiles. Similarly, medial fibrosis was most severe in the highest tertile. According to the immunohistochemical staining, most intimal cells were α-smooth muscle actin-positive, vimentin-positive, desmin-negative myofibroblasts. However, in the lowest tertile, desmin-positive contractile smooth muscle cells were also frequently observed, suggesting relatively slow phenotypic changes in this group. Furthermore, as leptin tertiles increased, the expression of leptin receptor in the luminal border of intima was significantly decreased. CONCLUSIONS Obesity-related higher fistula maturation failure rate may be partly mediated by higher leptin level-associated pre-existing vascular diseases in end-stage renal disease patients. Decreased expression of leptin receptor may be related to this association.
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Affiliation(s)
- Jwa-Kyung Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea; Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sun Ryoung Choi
- Department of Nephrology, Sahmyook Medical Center, Seoul, Korea
| | - Won Yong Lee
- Department of Cardiovascular and Thoracic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi Jin Park
- Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyung Suk Lee
- Department of Nephrology, Sahmyook Medical Center, Seoul, Korea
| | - Young Rim Song
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyung Jik Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea; Department of Clinical Immunology, Hallym University Sacred Heart Hospital, Anyang, Korea.
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