The Impact of Vascular Access Types on Hemodialysis Patient Long-term Survival

Five-year survival analysis and predictors of mortality of adult hemodialysis patients in Indonesia: a nationwide database analysis

BACKGROUND

Hemodialysis (HD) is the modality of renal replacement therapy (RRT) with the highest mortality rate. The identification of prognostic factors will help achieve better outcomes among HD patients. In this study, we sought to conduct a survival analysis and determine the predictors of mortality among adult Indonesian HD patients using data obtained from Indonesian Renal Registry (IRR).

METHODS

This is a retrospective cohort study which reviewed all adult hemodialysis patients in Indonesia based on the records of IRR during 2007-2022. Variables analyzed in this study include age, sex, etiology of CKD, cause of death, HD frequency, and initial vascular access. A 5-year follow-up was performed until the outcome of death or drop out was found.

RESULTS

Among 99,552 eligible patients, the mean survival length was 1536.21 ± 2.50 days. The 5-year survival rate was 77%. Cox proportional hazard regression model revealed demographic and clinical characteristics that are significantly associated with mortality: male sex (HR: 1.038, 95% CI 1.002-1.075), age of 60 years or older (HR: 1.329, 95% CI 1.281-1.379), diabetic nephropathy (HR: 1.347, 95% CI 1.249-1.452), twice-weekly hemodialysis frequency (HR: 1.080, 95% CI 1.011-1.155), initial vascular accesses with femoral vein puncture (HR: 2.710, 95% CI 2.568-2.860), and CVC (HR: 2.992, 95% CI 2.848-3.144).

CONCLUSIONS

The 5-year survival rate of Indonesian HD patients is 77. Male sex, age of HD onset at 60 years or older, diabetic nephropathy, twice-weekly HD frequency, and the initial vascular accesses with femoral vein puncture and CVC are associated with increased risk of mortality.

DeepVAQ : an adaptive deep learning for prediction of vascular access quality in hemodialysis patients

BACKGROUND

Chronic kidney disease is a prevalent global health issue, particularly in advanced stages requiring dialysis. Vascular access (VA) quality is crucial for the well-being of hemodialysis (HD) patients, ensuring optimal blood transfer through a dialyzer machine. The ultrasound dilution technique (UDT) is used as the gold standard for assessing VA quality; however, its limited availability due to high costs impedes its widespread adoption. We aimed to develop a novel deep learning model specifically designed to predict VA quality from Photoplethysmography (PPG) sensors.

METHODS

Clinical data were retrospectively gathered from 398 HD patients, spanning from February 2021 to February 2022. The DeepVAQ model leverages a convolutional neural network (CNN) to process PPG sensor data, pinpointing specific frequencies and patterns that are indicative of VA quality. Meticulous training and fine-tuning were applied to ensure the model's accuracy and reliability. Validation of the DeepVAQ model was carried out against established diagnostic standards using key performance metrics, including accuracy, specificity, precision, F-score, and area under the receiver operating characteristic curve (AUC).

RESULT

DeepVAQ demonstrated superior performance, achieving an accuracy of 0.9213 and a specificity of 0.9614. Its precision and F-score stood at 0.8762 and 0.8364, respectively, with an AUC of 0.8605. In contrast, traditional models like Decision Tree, Naive Bayes, and kNN demonstrated significantly lower performance across these metrics. This comparison underscores DeepVAQ's enhanced capability in accurately predicting VA quality compared to existing methodologies.

CONCLUSION

Exemplifying the potential of artificial intelligence in healthcare, particularly in the realm of deep learning, DeepVAQ represents a significant advancement in non-invasive diagnostics. Its precise multi-class classification ability for VA quality in hemodialysis patients holds substantial promise for improving patient outcomes, potentially leading to a reduction in mortality rates.

End-stage renal disease in a critical patient with superior vena cava syndrome with central vein catheters inserted via the superficial femoral vein: A case study

Superior vena cava syndrome (SVCS) is caused by obstruction to the blood flow through this vein. Indwelling central venous devices, such as cardiac pacemakers and haemodialysis catheters have emerged as the most common benign aetiology of SVCS. SVCS is particularly severe in patients with end-stage renal disease who require continuous renal replacement therapy plus infusion therapy. The presence of SVCS results in a reduction of available venous access for affected patients. Therefore, venous access plays a crucial role in the management of these patients. The importance of dealing with vascular access (VA) in critical patients with these conditions cannot be overstated. This case describes an 81-year-old man with respiratory failure who had end-stage renal disease complicated with SVCS. Using ultrasound-guided puncture, we inserted a peripherally inserted central catheter (PICC) into the superficial femoral vein to meet his infusion requirements in intensive care. After successful placement, the catheter tip position was adjusted using imaging to position the tip relative to the haemodialysis catheter. Whenever patients with severe renal dysfunction are treated, central veins should be preserved. Safe PICC access is possible via the superficial femoral vein to protect the last central VA for rational use. This meets urgent needs for infusion and deserves promotion.

Vascular access type and mortality in elderly incident hemodialysis patients

INTRODUCTION

The ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients.

METHODS

Single-center retrospective study of 99 incident HD patients aged≥80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan-Meier survival curves and Cox's proportional hazards model.

RESULTS

When compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32-2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02-2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28-3.64)] and hemoglobin [HR 4.10(95% CI 1.69-9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11-3.14)] were also associated with increased mortality risk in our cohort, p<0.05.

CONCLUSION

Our findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.

The impact of vascular access satisfaction on health-related quality of life in patients receiving maintenance hemodialysis: A 2-year follow-up study

Background:

Health-related quality of life (HRQoL) has been demonstrated to predict mortality in patients receiving maintenance hemodialysis (MHD). Vascular access (VA) is critical for MHD patients. The aim of this study was to investigate the change in HRQoL among MHD patients with a 2-year follow-up and to explore the impact of VA satisfaction on HRQoL in this population.

Methods:

229 MHD patients in two dialysis centers were included in this observational prospective study. VA satisfaction was assessed using the Vascular Access Questionnaire (VAQ). The 36 Item Short-Form Health Survey (SF-36) questionnaire was employed to evaluate HRQoL scores. Multiple logistic regression analysis was used to evaluate the influencing factors of HRQoL.

Results:

A total of 229 MHD patients were enrolled in the study, and 198 individuals (86.46%) completed the 2-year follow-up. HRQoL decreased statistically significantly from baseline to the 2-year follow-up across all dimensions. Multivariable analyses showed that the overall score, social functioning score, dialysis-related complication score of VAQ influenced HRQoL in the study population. Furthermore, HRQoL total scores and scores on the physical component summary (PCS) and mental component summary (MCS) domains were significantly higher in the satisfied VA group than in the dissatisfied group at baseline. After the 2-year follow-up, patients with a higher level of VA satisfaction reported higher HRQoL than patients with lower VA satisfaction.

Conclusion:

Our data suggested that VA satisfaction was significantly associated with HRQoL in MHD patients. These findings imply that surgeons and nephrologists should incorporate patient satisfaction into VA surgical decision-making.

Differences in Malnutrition Inflammation Score of Hemodialysis Patients Associated With Hemodialysis Factors. A Spanish Multicenter Epidemiologic Study

OBJECTIVES

The aims of this study are to analyze the prevalence of malnutrition in hemodialysis (HD) patients in Spain, and to assess the association of malnutrition in these patients with sociodemographic characteristics, comorbidity, and parameters related to HD.

DESIGN AND METHODS

A multicenter, retrospective, cross-sectional study in HD patients from centers all over Spain was conducted. Nutritional status of patients was assessed using Malnutrition Inflammation Score (MIS), and was stratified according to MIS values into 5 categories: ≤2, normal nutrition; >2 to ≤5, mild malnutrition or risk of malnutrition; >5 to ≤7, moderate malnutrition; >7 to ≤10, severe malnutrition, and >10, extreme malnutrition.

RESULTS

A total of 52 Spanish HD Units participated in the study enrolling 2,748 patients. Mean age of patients was 68.20 ± 14.24 years, 1,811 (65.9%) were men. Mean time on HD was 55.63 ± 63.25 months. Using an MIS cut-off point of 2 for malnutrition, 89% of patients were malnourished (MIS > 2). However, with a cut-off point of 5, more commonly described in the literature, the percentage of patients with malnutrition was reduced to 51.7%. Using this cut-off, we observed significant differences between patients with malnutrition and normo-nourished patients in biochemical parameters, age, Charlson Index, HD residual renal function, scheme, and vascular access (permanent catheter vs arteriovenous fistula). A multivariate regression analysis showed that age, sex, HD scheme, vascular access, residual renal function, and comorbidity index were predictive factors for malnutrition. We found that a high percentage of HD patients with malnutrition did not receive oral supplementation.

CONCLUSIONS

The prevalence of malnutrition in HD patients in Spain, assessed using the MIS scale, was high. Higher malnutrition was associated with the use of catheter versus fistula, and standard HD versus online hemodiafiltration, and with the absence of residual renal function, older age, greater comorbidity, and male sex. Malnourished patients had a low rate of oral supplementation.

Health insurance provider and endovascular treatment availability are associated with different hemodialysis vascular access profiles: A Brazilian national survey

In Brazil, most hemodialysis (HD) patients are treated by the country's public health system. However, accessibility to healthcare is different for public and private patients. This study aimed to identify the profile of vascular access in a Brazilian HD sample. Additionally, it aimed to examine the influence of public and private health insurance, accessibility to endovascular treatments, and timely arteriovenous access creation on the prevalence of tunneled catheters (TCs), non-tunneled catheters (NTCs), and arteriovenous (AV) access. We conducted a cross-sectional electronic survey across 834 centers. Centers were inquired about the number of patients with public and private health insurance, the profiles of vascular access, time for AV access creation, accessibility to TC insertion and endovascular treatments, and the availability of peritoneal dialysis and kidney transplantation. Logistic regression and multilevel logistic regression were performed to evaluate possible interactions between the independent variables. A total of 7,973 patients across 47 HD centers were included in the survey. Public health patients accounted for 77% of the study sample. The overall vascular access profiles of the public and private insurance groups were significantly different (p < 0.001). For patients with public health insurance, the prevalence of any catheter was 25%, while that for private patients was 31.8% (p < 0.001). The prevalence of TCs was more common in private patients (15.3% vs. 23.1%, p < 0.001). AV accesses were more common in public health patients (75% vs. 68.2%, p < 0.001), as were fistulas (72.4% vs. 63.1%, p < 0.001). AV grafts were more prevalent among patients with private insurance (2.6 vs. 5.1%, p < 0.001). The availability of endovascular treatments increased the chance of having a TC by 2.3-fold (OR = 2.33, 95% CI = 1.30-4.18); however, it did not reduce the chance of having any catheter. A high chance of having a catheter was found when the time to AV access creation exceeded 60 days. The differences between public and private patients may be explained by underpayments and the decreased accessibility to care infrastructure in the public system, especially for endovascular treatments. In this sample, public health patients had a decreased risk of having a TC over an NTC. Differences in care accessibility and insurance type might influence the type of vascular access.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Semi-Implantable Bioelectronics

Developing techniques to effectively and real-time monitor and regulate the interior environment of biological objects is significantly important for many biomedical engineering and scientific applications, including drug delivery, electrophysiological recording and regulation of intracellular activities. Semi-implantable bioelectronics is currently a hot spot in biomedical engineering research area, because it not only meets the increasing technical demands for precise detection or regulation of biological activities, but also provides a desirable platform for externally incorporating complex functionalities and electronic integration. Although there is less definition and summary to distinguish it from the well-reviewed non-invasive bioelectronics and fully implantable bioelectronics, semi-implantable bioelectronics have emerged as highly unique technology to boost the development of biochips and smart wearable device. Here, we reviewed the recent progress in this field and raised the concept of "Semi-implantable bioelectronics", summarizing the principle and strategies of semi-implantable device for cell applications and in vivo applications, discussing the typical methodologies to access to intracellular environment or in vivo environment, biosafety aspects and typical applications. This review is meaningful for understanding in-depth the design principles, materials fabrication techniques, device integration processes, cell/tissue penetration methodologies, biosafety aspects, and applications strategies that are essential to the development of future minimally invasive bioelectronics.

Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Prognostic Value of the Malnutrition-inflammation Score in Hospitalization and Mortality on Long-term Hemodialysis

OBJECTIVE

Since its development, cumulative evidence has accumulated regarding the prognostic value of the Malnutrition-Inflammation Score (MIS/Kalantar score) prognostic value; however, there is a shortage of recent and large studies with comprehensive statistical methodologies that contribute to support a higher level of evidence and a consensual cutoff. The aim of this study was to assess the strength of MIS association with hospitalization and mortality in a nationwide cohort.

METHODS

This was a historical cohort study of hemodialysis patients from 25 outpatient centers followed up for 48 months. Univariable and multivariable Cox additive regression models were used to analyze the data. The C-index was estimated to assess the performance of the final model.

RESULTS

Two thousand four hundred forty-four patients were analyzed, 59.0% males, 32.0% diabetic, and median age of 71 years (P₂₅ = 60, P₇₅ = 79). During a median period of 45-month follow-up, with a maximum of 48 months (P₂₅ = 31; P₇₅ = 48), 875 patients presented an MIS <5 (35.8%) and 860 patients (35.2%) died. The proportion of deaths was 23.1% for patients with the MIS <5 and 41.9% if the MIS ≥5 (P < .001). A total of 1,528 patients (62.5%) were hospitalized with a median time to the first hospitalization of 26 months (P₂₅ = 9; P₇₅ = 45). A new cutoff point regarding the risk of death, MIS ≥6, was identified for this study data set. In multivariable analysis for hospitalization risk, a higher MIS, higher comorbidity index, and arteriovenous graft or catheter increased the risk, whereas higher Kt/V and higher albumin had a protective effect. In multivariable analysis for mortality risk, adjusting for age, albumin, normalized protein catabolic rate, Charlson comorbidity index, interdialytic weight gain, Kt/V, diabetes, hematocrit, and vascular access, patients with the MIS ≥6 showed a hazard ratio of 1.469 (95% confidence interval: 1.262-1.711; P < .001). Higher age, higher interdialytic weight gain, higher comorbidity index, and catheter increased significantly the risk, whereas higher Kt/V, higher albumin, and higher normalized protein catabolic rate (≥1.05 g/kg/d) reduced the risk.

CONCLUSION

The MIS maintains its relevant and significant association with hospitalization and mortality.

Medical Adjuvant Therapy in Reducing Thrombosis With Arteriovenous Grafts and Fistulae Use: A Meta-Analysis of Randomized Controlled Trials

Hemodialysis is required for patients with end-stage renal disease (ESRD) that require arteriovenous (AV) grafts or fistulas for vascular access. These access points are prone to thrombosis. To determine the effect of medical adjuvant therapy on AV graft/fistula patency among patients with ESRD on hemodialysis. Adhering to the PRISMA 2020 statement, a systematic search was conducted until August 20, 2021, with keywords including arteriovenous graft, fistula, patency, thrombosis, hemodialysis, adjuvant treatment. The following databases were searched: PubMed, Scopus, Web of Science, CINAHL Plus, and Cochrane. A random-effects model was employed using Review Manager 5.4 for data analysis. The meta-analysis pooled in 1985 participants with 1000 (50.4%) in the medical adjuvant treatment group. At a snapshot, medical adjuvant therapy reduced the risk for graft thrombosis (RR = 0.64, P = .02). Notable medications included aspirin for graft thrombosis (RR = 0.36, P = .006) and ticlopidine for fistula thrombosis (RR = 0.53, P = .01). Certain antiplatelet therapies (aspirin and ticlopidine) reduced the number of patients with AV fistula/graft thrombosis among patients with high heterogeneity among the trials. Other therapies (fish oil, sulfinpyrazone, clopidogrel, and aspirin/dipyridamole) did not demonstrate significant improvement but may be promising once concrete evidence is available. Potential benefits of anti-platelet therapies may be explored to maintain the potency of AV grafts/fistulas through well-designed placebo-controlled trials and long-term follow-up.

The effect of high-flow arteriovenous fistulas on systemic haemodynamics and brain oxygenation

Aims

High‐flow arteriovenous fistula (AVF) for haemodialysis leads to profound haemodynamic changes and sometimes to heart failure (HF). Cardiac output (CO) is divided between the AVF and body tissues. The term effective CO (COef) represents the difference between CO and AVF flow volume (Qa) and better characterizes the altered haemodynamics that may result in organ hypoxia. We investigated the effects of Qa reduction on systemic haemodynamics and on brain oxygenation.

Methods and results

This is a single‐centre interventional study. Twenty‐six patients on chronic haemodialysis with high Qa (>1500 mL/min) were indicated for surgical Qa reduction for HF symptoms and/or signs of structural heart disease on echocardiography. The included patients underwent three sets of examinations: at 4 months and then 2 days prior and 6 weeks post‐surgical procedure. Clinical status, echocardiographical haemodynamic assessment, Qa, and brain oximetry were recorded. All parameters remained stable from selection to inclusion. After the procedure, Qa decreased from 3.0 ± 1.4 to 1.3 ± 0.5 L/min, P < 0.00001, CO from 7.8 ± 1.9 to 6.6 ± 1.5 L/min, P = 0.0002, but COef increased from 4.6 ± 1.4 to 5.3 ± 1.4 L/min, P = 0.036. Brain tissue oxygen saturation increased from 56 ± 11% to 60 ± 9%, P = 0.001.

Conclusions

Qa reduction led to increased COef. This was explained by a decreased proportion of CO running through the AVF in patients with Qa > 2.0 L/min. These observations were mirrored by higher brain oxygenation and might explain HF symptoms and improved haemodynamics even in asymptomatic high Qa patients.

Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation

BACKGROUND

In the United States, many low-income patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to predialysis care may delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. The 2014 Affordable Care Act expanded eligibility for Medicaid among low-income adults, but not every state adopted this measure. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation.

METHODS

We queried the United States Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creation from 2011 to 2018. We evaluated associations of receiving initial AV access in states that expanded Medicaid with concurrent TDC use, survival, and insurance coverage.

RESULTS

Data were available for patients in 31 states: 19 states expanded Medicaid from January 2014 to February 2015. Among 8462 patients in the postexpansion period from March 2015 to December 2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs. 48%, P < 0.001). In multivariable analysis, Medicaid expansion was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6-0.8, P < 0.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs. 85.2%, P = 0.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82-1.1, P = 0.482). In difference-in-differences analysis, Medicaid expansion was associated with a 9.2-percentage point increase in Medicaid coverage (95% CI 2.7-15.8, P = 0.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI 0.3-59.9, P = 0.048).

CONCLUSIONS

Patients in Medicaid expansion states were less likely to have TDCs during initial AV access creation, suggesting earlier predialysis care. Hispanic patients benefited from increased insurance coverage. Expanding insurance options for the underserved may improve quality metrics and cost-savings for hemodialysis patients.

The management of vascular access in hemodialysis patients during the coronavirus disease 2019 epidemic: A multicenter cross-sectional study

Background:

Coronavirus disease 2019 is an epidemic disease throughout the world. The management of vascular access during the epidemic is currently unknown.

Methods:

In this multicenter cross-sectional study, we collected vascular access data from hemodialysis patients treated at 44 hospitals in Hubei from 22 January to 10 March 2020. We estimated the management of vascular access during the coronavirus disease 2019 outbreak.

Results:

Of the 9231 hemodialysis patients included, 5387 patients (58.4%) were men and 2959 patients (32.1%) were older than 65 years. Arteriovenous fistula was the predominant type of vascular access, accounting for 76.5%; 496 patients (5.4%) developed vascular access complications; catheter flow reduction was the most common vascular access complication, and stenosis was the predominant complication among those with arteriovenous access. Overall, 280 vascular access sites were placed in patients newly diagnosed with uremia, of whom 260 (92.8%) underwent catheter insertion; 149 rescue procedures were carried out to treat the vascular access complications, which consisted of 132 catheters, 7 percutaneous transluminal angioplasties, 6 arteriovenous fistula repairs, and 4 arteriovenous fistulas. Occlusion of the arteriovenous access had the highest rescue rate (92.7%), while many other vascular access complications remained untreated; 69 and 142 patients were diagnosed with confirmed and suspected coronavirus disease 2019, respectively. A total of 146 patients died, of whom 29 patients (19.9%) died due to vascular access complications.

Conclusion:

Catheter flow reduction and stenosis of arteriovenous access were the major vascular access complications. Most of the vascular access sites established were catheters, and many of the vascular access complications remained untreated.