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Moya-Rodríguez A, Xie B, Cook D, Klineberg M, Nathan S, Hammes M, Basu A. Creating patient-specific vein models to characterize wall shear stress in hemodialysis population. Comput Struct Biotechnol J 2022; 20:5729-5739. [PMID: 36382195 PMCID: PMC9619312 DOI: 10.1016/j.csbj.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/04/2022] [Accepted: 10/04/2022] [Indexed: 12/05/2022] Open
Abstract
End-Stage Renal Disease (ESRD) patients require arteriovenous fistulas (AVF) that allow a mature vein to withstand hemodialysis. Unfortunately, venous thrombosis and stenosis in the cephalic vein arch after AVF placement is common and heavily influenced by hemodynamics. To better assess forces and flow behavior in the cephalic arch, we have built patient-specific millifluidic models that allow us to explore the complex interplay between patient-specific vein geometry and fluctuating hemodynamics. These 3D models were created from patient-specific intravascular ultrasound and venogram images obtained three- and twelve-months post AVF creation and fabricated into soft elastomer-based millifluidic devices. Geometric validation of fabricated phantom millifluidic device shows successful replication of original computational 3D model. Millifluidic devices were perfused with a blood-mimicking fluid containing fluorescent tracer beads under steady-state physiologic cephalic vein flow conditions (20 mL/min). Particle image velocimetry was employed to calculate wall shear stress (WSS) across the cephalic arches. Experimental WSS profile evaluation reveals that the physiologic cephalic arch model yields WSS values within physiologic range [76–760 mPa]. Moreover, upon comparing WSS profiles across all models, it is noticeable that WSS values increase as vein diameter decreases, which further supports employed experimental and analysis strategy. The presented millifluidic devices show promise for experimental WSS characterization under pathologic flow conditions to contrast from calculated physiologic hemodynamics and better understand WSS influence on thrombosis and stenosis in hemodialysis patients.
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Olivier CB, Sundaram V, Chertow GM, Shashidhar S, McDonnell LK, Ding VY, Desai M, Mahaffey KW, Mell M. A double-blind, randomized, placebo-controlled pilot trial to evaluate safety and efficacy of vorapaxar on arteriovenous fistula maturation. J Vasc Access 2019; 21:467-474. [PMID: 31774037 DOI: 10.1177/1129729819887269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Protease-activated receptor-1 antagonism by vorapaxar could facilitate arteriovenous fistula maturation but may increase bleeding risk. OBJECTIVE The primary objective of the Vorapaxar Study for Maturation of arteriovenous fistula for Hemodialysis Access (VorapAccess) was to determine if vorapaxar improves arteriovenous fistula functional maturation in patients with end-stage renal disease. METHODS VorapAccess was a randomized, placebo-controlled, double-blind pilot trial comparing 2.5 mg vorapaxar per day with placebo for twelve weeks starting on day two after arteriovenous fistula creation. The primary outcome was time to functional maturation defined as successful cannulation for six hemodialysis sessions within three weeks. The planned sample size was 50 participants. The study was terminated early after withdrawal of planned financial support. Given the small number of randomized patients, we performed descriptive analyses without inference testing. RESULTS A total of 13 participants were randomly allocated study drug (six vorapaxar and seven placebo). The median age was 56 years and seven participants (54%) were female. The median (minimum-maximum) days to functional maturation were 169 (77-287) days in the vorapaxar group and 145 (48-198) days in the placebo group. Six of the 13 (46%) participants had arteriovenous fistula functional maturation within 180 days; two of six (33%) in the vorapaxar group and four of seven (57%) in the placebo group. There was one bleeding event in the placebo group. CONCLUSION Fewer than half of participants had functional maturation within 180 days after surgery, suggesting a major need for agents or strategies that enhance arteriovenous fistula maturation.
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Affiliation(s)
- Christoph B Olivier
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA.,Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg, Germany
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sumana Shashidhar
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Lori K McDonnell
- Division of Vascular Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Victoria Y Ding
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Matthew Mell
- Division of Vascular Surgery, School of Medicine, Stanford University, Stanford, CA, USA.,Division of Vascular Surgery, University of California at Davis, Sacramento, CA, USA
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Viecelli AK, Irish AB, Polkinghorne KR, Hawley CM, Johnson DW, Mori TA, Pascoe EM, Strippoli GF, Lok CE, Palmer SC. Omega-3 Polyunsaturated Fatty Acid Supplementation to Prevent Arteriovenous Fistula and Graft Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2018; 72:50-61. [DOI: 10.1053/j.ajkd.2017.11.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 11/06/2017] [Indexed: 02/01/2023]
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Viecelli AK, Pascoe EM, Polkinghorne KR, Hawley CM, Paul-Brent PA, Badve SV, Cass A, Johnson DW, Kerr PG, Mori TA, Scaria A, Hooi SL, Ong ML, Irish AB. Baseline characteristics of the omega-3 fatty acids (Fish oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) study. Nephrology (Carlton) 2016. [PMID: 26205903 DOI: 10.1111/nep.12573] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM The Fish oils and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) trial investigated whether 3 months of omega-3 polyunsaturated fatty acids, either alone or in combination with aspirin, will effectively reduce primary access failure of de novo arteriovenous fistulae. This report presents the baseline characteristics of all study participants, examines whether study protocol amendments successfully increased recruitment of a broader and more representative haemodialysis cohort, including patients already receiving aspirin, and contrasts Malaysian participants with those from Australia, New Zealand and the United Kingdom (UK). METHOD This international, randomized, double-blind, placebo-controlled trial included patients older than 19 years with stage 4 or 5 chronic kidney disease currently receiving, or planned within 12 months to receive haemodialysis. RESULTS Participants (n = 568) were overweight (28.6 ± 7.3 kg/m(2) ), relatively young (54.8 ± 14.3 years), and predominantly male (63%) with a high prevalence of diabetes mellitus (46%) but low rate of ischaemic heart disease (8%). Sixty one percent were planned for lower arm arteriovenous fistula creation. Malaysian participants (n = 156) were younger (51.8 ± 13.6 years vs 57.1 ± 14.2 years, P < 0.001) with a higher prevalence of diabetes mellitus (65% vs 43%, P < 0.001), but less ischaemic heart disease (5% vs 14%, P < 0.01) compared with the combined Australian, New Zealand and UK cohort (n = 228). Protocol modifications allowing for inclusion of patients receiving aspirin increased the prevalence of co-morbidities compared with the original cohort. CONCLUSIONS The FAVOURED study participants, while mostly similar to patients in contemporary national registry reports and comparable recent clinical trials, were on average younger and had less ischaemic heart disease. These differences were reduced as a consequence of including patients already receiving aspirin.
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Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Nephrology, St George Hospital, Sydney, New South Wales, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Trevor A Mori
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Anish Scaria
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Seong L Hooi
- Department of Medicine and Haemodialysis Unit, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Meng L Ong
- Department of Nephrology, Penang Hospital, Georgetown, Malaysia
| | - Ashley B Irish
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Department of Nephrology, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Viecelli AK, Pascoe E, Polkinghorne KR, Hawley C, Paul-Brent PA, Badve SV, Cass A, Heritier S, Kerr PG, Mori TA, Robertson A, Seong HL, Irish AB. The Omega-3 fatty acids (Fish Oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) study: the updated final trial protocol and rationale of post-initiation trial modifications. BMC Nephrol 2015; 16:89. [PMID: 26116581 PMCID: PMC4482267 DOI: 10.1186/s12882-015-0089-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 06/16/2015] [Indexed: 12/20/2022] Open
Abstract
Background The FAVOURED study is an international multicentre, double-blind, placebo-controlled trial which commenced recruitment in 2008 and examines whether omega-3 polyunsaturated fatty acids (omega-3 PUFAs) either alone or in combination with aspirin will effectively reduce primary access failure of de novo arteriovenous fistulae (AVF) in patients with stage 4 and 5 chronic kidney disease. Publication of new evidence derived from additional studies of clopidogrel and a high screen failure rate due to prevalent aspirin usage prompted an updated trial design. Methods/design The original trial protocol published in 2009 has undergone two major amendments, which were implemented in 2011. Firstly, the primary outcome ‘early thrombosis’ at 3 months following AVF creation was broadened to a more clinically relevant outcome of ‘AVF access failure’; a composite of thrombosis, AVF abandonment and cannulation failure at 12 months. Secondly, participants unable to cease using aspirin were allowed to be enrolled and randomised to omega-3 PUFAs or placebo. The revised primary aim of the FAVOURED study is to test the hypothesis that omega-3 PUFAs will reduce rates of AVF access failure within 12 months following AVF surgery. The secondary aims are to examine the effect of omega-3 PUFAs and aspirin on the individual components of the primary end-point, to examine the safety of study interventions and assess central venous catheter requirement as a result of access failure. Discussion This multicentre international clinical trial was amended to address the clinically relevant question of whether the usability of de novo AVF at 12 months can be improved by the early use of omega-3 PUFAs and to a lesser extent aspirin. This study protocol amendment was made in response to a large trial demonstrating that clopidogrel is effective in safely preventing primary AVF thrombosis, but ineffective at increasing functional patency. Secondly, including patients taking aspirin will enrol a more representative cohort of haemodialysis patients, who are significantly older with a higher prevalence of cardiovascular disease and diabetes which may increase event rates and the power of the study. Trial registration Australia & New Zealand Clinical Trial Register (ACTRN12607000569404)
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Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Elaine Pascoe
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia. .,Departments of Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia. .,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Sunil V Badve
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia. .,Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Stephane Heritier
- Department of Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia. .,Department of Medicine, Monash University, Melbourne, VIC, Australia.
| | - Trevor A Mori
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
| | - Amanda Robertson
- Department of Surgery, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Hooi L Seong
- Hospital Sultanah Aminah, Johor Bahru, Malaysia.
| | - Ashley B Irish
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia. .,Department of Renal Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA, 6150, Australia.
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Abacilar AF, Atalay H, Dogan OF. Oral prostacycline analog and clopidogrel combination provides early maturation and long-term survival after arteriovenous fistula creation: A randomized controlled study. Indian J Nephrol 2015; 25:136-42. [PMID: 26060361 PMCID: PMC4446916 DOI: 10.4103/0971-4065.139490] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Vascular access is used as a lifeline for hemodialysis in patients with end stage renal disease failure (ESRD). Failure of arteriovenous fistula (AVF) maturation is still high. The purpose of this study was to research the effects of clopidogrel in combination with oral iloprost, a synthetic analog of prostacyclin PGI2. Ninety-six diabetic ESRD patients were divided into two groups. In the first group (Group 1, N = 50), clopidogrel (75 mg daily dose) and an oral prostacycline analog (200 mg daily dose) were administered. In the second group (Group 2, N = 46), placebo was given. All patients took study medication 7-10 days prior to surgery. A Doppler ultrasound (USG) was performed for measurement of arterial and venous diameters, and peak systolic velocity of arterial flow based on subsequent fistula adequacy. Autogenous AVFs were constructed in forearm as distally as possible in all patients. Both groups were followed-up for a year. In the placebo group, early AVF thrombosis was detected in two patients (4.3%). AVF maturation failure was noted in 14 patients (30.4%) in placebo group and in four patients (8%) in clopidogrel plus oral prostacycline analog group in the early postoperative period (P = 0.001). The mean maturation time was 38 ± 6.5 and 53 ± 12.8 days in study and placebo groups, respectively (P = 0.023). The mean blood flow was 352 ± 94 mL/min in placebo group and 604 ± 125 mL/min in study group (P = 0.001). The arterial end diastolic velocity was 116 ± 14 cm/s in study group and 72 ± 21 cm/s in placebo group (P = 0.036) 1 year after the surgery. Our data indicated that clopidogrel and oral prostacycline analog combination is effective and safe for the prevention of primary AVF failure in hemodialysis patients and decreased acute and chronic thrombotic events.
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Affiliation(s)
- A F Abacilar
- Department of Cardiovascular Surgery, Izmir Sifa University, Bornova Educational Hospital, İzmir, Turkey
| | - H Atalay
- Department of Cardiovascular Surgery, Mersin Private Meadleeast Hospital, Mersin, Turkey
| | - O F Dogan
- Department of Cardiovascular Surgery, Adana Numune Education and Training Hospital, Adana, Turkey
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Santoro D, Benedetto F, Mondello P, Pipitò N, Barillà D, Spinelli F, Ricciardi CA, Cernaro V, Buemi M. Vascular access for hemodialysis: current perspectives. Int J Nephrol Renovasc Dis 2014; 7:281-94. [PMID: 25045278 PMCID: PMC4099194 DOI: 10.2147/ijnrd.s46643] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%-60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.
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Affiliation(s)
- Domenico Santoro
- Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy
| | | | | | | | - David Barillà
- Unit of Vascular Surgery, University of Messina, Italy
| | | | - Carlo Alberto Ricciardi
- Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy
| | - Valeria Cernaro
- Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy
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Salmela B, Hartman J, Peltonen S, Albäck A, Lassila R. Thrombophilia and arteriovenous fistula survival in ESRD. Clin J Am Soc Nephrol 2013; 8:962-8. [PMID: 23411429 DOI: 10.2215/cjn.03860412] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The role of thrombophilia in failing arteriovenous fistula (AVF) among patients with ESRD undergoing hemodialysis is not established. This study aimed to assess whether AVF primary patency is associated with thrombophilia and coagulation abnormalities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This observational study screened 219 patients between 2002 and 2004 for thrombophilia before AVF surgery. Thrombophilia included factor V Leiden and prothrombin G20210A mutations, protein C and antithrombin activities, and protein S. Coagulation abnormalities included high factor VIII:C, homocysteine, fibrinogen, and d-dimer levels; presence of antiphospholipid antibodies; and short thrombin time. We reviewed patient charts for comorbid conditions, AVF maturation and interventions, kidney transplantation, and patient survival (mean follow-up duration, 3.6 [range, 2.3-5.8] years). Primary patency from the AVF placement and functional primary patency from the first AVF cannulation were analyzed with Kaplan-Meier and Cox proportional hazards models. RESULTS Thrombophilia was present in 9% of the patients, and coagulation abnormalities occurred in 77%. One-year primary patency was 68%; 46% of the AVF failures occurred before the initiation of hemodialysis. Female sex (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.7-4.1) and thrombophilia (HR, 2.2; 95% CI, 1.2-4.2) were independent risk factors for loss of primary patency. Thrombophilia mutations or low antithrombin level (HR, 3.8), female sex (HR, 2.5), and diabetes (HR, 1.9) were associated with shortened functional primary patency of AVF. CONCLUSIONS Against the background of frequent coagulation abnormalities, thrombophilia and female sex predispose patients with ESRD to access failure, mostly due to thrombosis or stenosis.
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Affiliation(s)
- Birgitta Salmela
- Coagulation Disorders, Department of Hematology, HUSLAB Laboratory Services, Helsinki University Central Hospital, Helsinki, Finland
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Allon M, Lok CE. Dialysis Fistula or Graft: The Role for Randomized Clinical Trials. Clin J Am Soc Nephrol 2010; 5:2348-54. [DOI: 10.2215/cjn.06050710] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Irish A, Dogra G, Mori T, Beller E, Heritier S, Hawley C, Kerr P, Robertson A, Rosman J, Paul-Brent PA, Starfield M, Polkinghorne K, Cass A. Preventing AVF thrombosis: the rationale and design of the Omega-3 fatty acids (Fish Oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) study. BMC Nephrol 2009; 10:1. [PMID: 19159453 PMCID: PMC2637871 DOI: 10.1186/1471-2369-10-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Accepted: 01/21/2009] [Indexed: 12/05/2022] Open
Abstract
Background Haemodialysis (HD) is critically dependent on the availability of adequate access to the systemic circulation, ideally via a native arteriovenous fistula (AVF). The Primary failure rate of an AVF ranges between 20–54%, due to thrombosis or failure of maturation. There remains limited evidence for the use of anti-platelet agents and uncertainty as to choice of agent(s) for the prevention of AVF thrombosis. We present the study protocol for a randomised, double-blind, placebo-controlled, clinical trial examining whether the use of the anti-platelet agents, aspirin and omega-3 fatty acids, either alone or in combination, will effectively reduce the risk of early thrombosis in de novo AVF. Methods/Design The study population is adult patients with stage IV or V chronic kidney disease (CKD) currently on HD or where HD is planned to start within 6 months in whom a planned upper or lower arm AVF is to be the primary HD access. Using a factorial-design trial, patients will be randomised to aspirin or matching placebo, and also to omega-3 fatty acids or matching placebo, resulting in four treatment groups (aspirin placebo/omega-3 fatty acid placebo, aspirin/omega-3 fatty acid placebo, aspirin placebo/omega-3 fatty acid, aspirin/omega-3 fatty acid). Randomisation will be achieved using a dynamic balancing method over the two stratification factors of study site and upper versus lower arm AVF. The medication will be commenced pre-operatively and continued for 3 months post surgery. The primary outcome is patency of the AVF at three months after randomisation. Secondary outcome measures will include functional patency at six and twelve months, primary patency time, secondary (assisted) patency time, and adverse events, particularly bleeding. Discussion This multicentre Australian and New Zealand study has been designed to determine whether the outcome of surgery to create de novo AVF can be improved by the use of aspirin and/or omega-3 fatty acids. Recently a placebo-controlled trial has shown that clopidogrel is effective in safely preventing primary AVF thrombosis, but ineffective at increasing functional patency. Our study presents significant differences in the anti-platelet agents used, the study design, and surgical and patient demographics that should contribute further evidence regarding the efficacy of anti-platelet agents. Trial Registration Australia & New Zealand Clinical Trials Register (ACTRN12607000569404).
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Affiliation(s)
- Ashley Irish
- Renal Unit, Royal Perth Hospital, Perth, WA, Australia.
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11
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Ethier J. In Reply. Am J Kidney Dis 2008. [DOI: 10.1053/j.ajkd.2008.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dember LM, Beck GJ, Allon M, Delmez JA, Dixon BS, Greenberg A, Himmelfarb J, Vazquez MA, Gassman JJ, Greene T, Radeva MK, Braden GL, Ikizler TA, Rocco MV, Davidson IJ, Kaufman JS, Meyers CM, Kusek JW, Feldman HI. Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA 2008; 299:2164-71. [PMID: 18477783 PMCID: PMC4943222 DOI: 10.1001/jama.299.18.2164] [Citation(s) in RCA: 577] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT The arteriovenous fistula is the preferred type of vascular access for hemodialysis because of lower thrombosis and infection rates and lower health care expenditures compared with synthetic grafts or central venous catheters. Early failure of fistulas due to thrombosis or inadequate maturation is a barrier to increasing the prevalence of fistulas among patients treated with hemodialysis. Small, inconclusive trials have suggested that antiplatelet agents may reduce thrombosis of new fistulas. OBJECTIVE To determine whether clopidogrel reduces early failure of hemodialysis fistulas. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007. Eight hundred seventy-seven participants with end-stage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later. INTERVENTION Participants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n = 441) or placebo (n = 436) for 6 weeks starting within 1 day after fistula creation. MAIN OUTCOME MEASURES The primary outcome was fistula thrombosis, determined by physical examination at 6 weeks. The secondary outcome was failure of the fistula to become suitable for dialysis. Suitability was defined as use of the fistula at a dialysis machine blood pump rate of 300 mL/min or more during 8 of 12 dialysis sessions. RESULTS Enrollment was stopped after 877 participants were randomized based on a stopping rule for intervention efficacy. Fistula thrombosis occurred in 53 (12.2%) participants assigned to clopidogrel compared with 84 (19.5%) participants assigned to placebo (relative risk, 0.63; 95% confidence interval, 0.46-0.97; P = .018). Failure to attain suitability for dialysis did not differ between the clopidogrel and placebo groups (61.8% vs 59.5%, respectively; relative risk, 1.05; 95% confidence interval, 0.94-1.17; P = .40). CONCLUSION Clopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis. Trial Registration clinicaltrials.gov Identifier: NCT00067119.
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Affiliation(s)
- Laura M Dember
- Boston University, School of Medicine, Renal Section, EBRC 504, 650 Albany St, Boston, Massachusetts 02118, USA.
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Ethier J, Bragg-Gresham JL, Piera L, Akizawa T, Asano Y, Mason N, Gillespie BW, Young EW. Aspirin prescription and outcomes in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2007; 50:602-11. [PMID: 17900460 DOI: 10.1053/j.ajkd.2007.07.007] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 07/05/2007] [Indexed: 01/26/2023]
Abstract
BACKGROUND We investigated aspirin-prescribing patterns and potential benefits on cardiovascular morbidity and mortality in hemodialysis patients. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS Data included 28,320 randomly selected hemodialysis patients from the Dialysis Outcomes and Practice Patterns Study I and II. PREDICTOR Aspirin prescription at study baseline. OUTCOMES & MEASUREMENTS Prescription was investigated by means of logistic regression. All-cause mortality, all-cause hospitalization, cardiac event, myocardial infarction, cerebrovascular (CVA), gastrointestinal bleed, transient ischemic attack, and subdural hematoma were examined. Cox regression examined the risk of mortality and hospitalization. All models accounted for facility clustering and demographics and comorbid conditions. RESULTS Wide variation was found in aspirin prescription, from 8% in Japan to 41% in Australia and New Zealand. Characteristics significantly associated with increased odds of prescription included coronary artery disease, cerebrovascular disease, diabetes, male sex, nonblack race, peripheral vascular disease, age, hypertension, and absence of gastrointestinal bleeding. Aspirin was associated with decreased risk of stroke in all patients (relative risk [RR], 0.82; P < 0.01) and increased risk of myocardial infarction (RR, 1.21; P = 0.01) and cardiac event (RR, 1.08; P < 0.01) in all patients, with similar results for patients with coronary artery disease. There was no increase in gastrointestinal bleeding. LIMITATIONS Observational studies are not protected from biases, despite adjustments. There is potential for aspirin use to be underreported because of its availability without prescription. CONCLUSIONS The hypothesis that prescribing aspirin to hemodialysis patients decreases cardiovascular disease risk is not supported. Aspirin might decrease CVA and appears not to increase hemorrhagic risk. This should be an incentive for randomized controlled trials.
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Affiliation(s)
- Jean Ethier
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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Abstract
Optimizing vascular access outcomes remains an ongoing challenge for clinical nephrologists. All other things being equal, fistulas are preferred over grafts, and grafts are preferred over catheters. Mature fistulas have better longevity and require fewer interventions, as compared with mature grafts. The major hurdle to increasing fistula use is the high rate of failure to mature of newly created fistulas. There is a desperate need for enhanced understanding of the mechanisms of failure to mature and the optimal type and timing of interventions to promote maturity. Grafts are prone to frequent stenosis and thrombosis. Surveillance for graft stenosis with preemptive angioplasty may reduce graft thrombosis, but recent randomized clinical trials have questioned the efficacy of this approach. Graft stenosis results from aggressive neointimal hyperplasia, and pharmacologic approaches to slowing this process are being investigated in clinical trials. Catheters are prone to frequent thrombosis and infection. The optimal management of catheter-related bacteremia is a subject of ongoing debate. Prophylaxis of catheter-related bacteremia continues to generate important clinical research. Close collaboration among nephrologists, surgeons, radiologists, and the dialysis staff is required to optimize vascular access outcomes and can be expedited by having a dedicated access coordinator to streamline the process. The goal of this review is to provide an update on the current status of vascular access management.
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Vazquez M. DAC Update and the Future of DAC. J Vasc Access 2006. [DOI: 10.1177/112972980600700421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- M. Vazquez
- The University of Texas Southwestern Medical Center, Dallas, TX - USA
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Vazquez M. The NIH-DAC Study: Improved Patency through Medicine? (Lecture). J Vasc Access 2005. [DOI: 10.1177/112972980500600332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- M.A. Vazquez
- The University of Texas Southwestern Medical Center at Dallas, Dallas, TX - USA
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Casserly LF, Dember LM. Correspondence: Reply to Tveit and Abbott. Semin Dial 2004. [DOI: 10.1111/j.1525-139x.2004.17122.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Klaus Konner
- Merheim Hospital, Medical Faculty, University of Cologne, Germany
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Abstract
Although renal failure has classically been associated with a bleeding tendency, thrombotic events are common among patients with end-stage renal disease (ESRD). A variety of thrombosis-favoring hematologic alterations have been demonstrated in these patients. In addition, "nontraditional" risk factors for thrombosis, such as hyperhomocysteinemia, endothelial dysfunction, inflammation, and malnutrition, are present in a significant proportion of chronic dialysis patients. Hemodialysis (HD) vascular access thrombosis, ischemic heart disease, and renal allograft thrombosis are well-recognized complications in these patients. Deep venous thrombosis and pulmonary embolism are viewed as rare in chronic dialysis patients, but recent studies suggest that this perception should be reconsidered. Several ESRD treatment factors such as recombinant erythropoietin (EPO) administration, dialyzer bioincompatibility, and calcineurin inhibitor administration may have prothrombotic effects. In this article we review the pathogenesis and clinical manifestations of thrombosis in ESRD and evaluate the evidence that chronic renal failure or its management predisposes to thrombotic events.
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Affiliation(s)
- Liam F Casserly
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Abstract
National guidelines promote increasing the prevalence of fistula use among hemodialysis patients. The prevalence of fistulas among hemodialysis patients reflects both national, regional, and local practice differences as well as patient-specific demographic and clinical factors. Increasing fistula prevalence requires increasing fistula placement, improving maturation of new fistulas, and enhancing long-term patency of mature fistulas for dialysis. Whether a patient receives a fistula depends on several factors: timing of referral for dialysis and vascular access, type of fistula placed, patient demographics, preference of the nephrologist, surgeon, and dialysis nurses, and vascular anatomy of the patient. Whether the placed fistula is useable for dialysis depends on additional factors, including adequacy of vessels, surgeon's experience, patient demographics, nursing skills, minimal acceptable dialysis blood flow, and attempts to revise immature fistulas. Whether a mature fistula achieves long-term patency depends on the ability to prevent and correct thrombosis. An optimal outcome is likely when there is (1) a multidisciplinary team approach to vascular access; (2) consensus about the goals among all interested parties (nephrologists, surgeons, radiologists, dialysis nurses, and patients); (3) early referral for placement of vascular access; (4) restriction of vascular access procedures to surgeons with demonstrable interest and experience; (5) routine, preoperative mapping of the patient's arteries and veins; (6) close, ongoing communication among the involved parties; and (7) prospective tracking of outcomes with continuous quality assessment. Implementing these measures is likely to increase the prevalence of fistulas in any given dialysis unit. However, differences among dialysis units are likely to persist because of differences in gender, race, and co-morbidity mix of the patient population.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 1900 University Boulevard, S. THT 647, Birmingham, AL 35294, USA.
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