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Ghandour H, Cataneo JL, Asha A, Jaeger JK, Jacobs CE, Schwartz LB, El Khoury R. Slowly moving the needle away from Fistula First. J Vasc Surg 2024; 79:382-387. [PMID: 37952784 DOI: 10.1016/j.jvs.2023.11.007] [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: 09/23/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE In 2019, the management of end-stage kidney disease (ESKD) shifted away from "Fistula First" (FF) to "ESKD Life-Plan: Patient Life-Plan First then Access Needs." Indeed, some patients exhibit such excessive comorbidity that even relatively minor vascular surgery may be complicated. The purpose of this study was to retrospectively assess complications and mortality (and delineate operative futility) in patients undergoing arteriovenous fistula (AVF) creation in the FF era. METHODS Consecutive AVFs created in a single institution before 2021 were retrospectively reviewed. Operative futility was defined as never-accessed fistula, no initiation of dialysis, failure of access maturation (despite secondary intervention), hemodialysis access-induced distal ischemia requiring ligation, early loss of secondary patency, and/or patient mortality within the first 6 postoperative months. RESULTS A total of 401 AVFs were created including radial-cephalic (44%), brachial-cephalic (41%), and brachial-basilic (15%) constructions. Patients exhibited a mean age of 69 ± 15 years; 63% were male, and most (74%) were already being hemodialyzed at the time of fistula creation. Forty-five patients (11%) suffered a cardiac event, and five patients died (1%) within 90 days of their access surgery. Perioperative cardiac events were significantly more common after age 80 (19% vs 8%; P = .004); age >80 years was an independent predictor of major 90-day complications (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.04-3.39; P = .036) and the sole independent predictor of major morbidity defined as cardiopulmonary complications, stroke, or death within the first year (OR, 2.01; 95% CI, 1.24-3.25; P = .004). Operative futility was encountered in 52% of the cohort (n = 208 patients): 40% (n = 160) of primary AVFs failed to mature despite assistance, 19% (n = 77) had lost secondary patency by 6 months, 13% of patients (n = 53) were never started on dialysis after access creation, 4% (n = 16) were dead by 6 months, 2% of AVFs (n = 10) matured but were never accessed, and 2% (n = 9) required ligation for hemodialysis access-induced distal ischemia. Not surprisingly, the sole independent protector against operative futility was that catheter-based dialysis had been established prior to AVF creation (OR, 0.36; 95% CI, 0.22-0.59; P < .01). CONCLUSIONS Approximately 50% of primary AVF operations performed in the aggressive FF era were deemed futile. Octogenarians were particularly prone to futility and complications during this era. A paradigm shift, from FF to an "ESKD Life-Plan" will, hopefully, more thoughtfully match vascular access strategies to individual patient needs.
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Affiliation(s)
- Hani Ghandour
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Jose L Cataneo
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Ahmad Asha
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Jessica K Jaeger
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health Systems, Evanston, IL.
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2
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Wystrychowski W, Garrido SA, Marini A, Dusserre N, Radochonski S, Zagalski K, Antonelli J, Canalis M, Sammartino A, Darocha Z, Baczyński R, Cierniak T, Regele H, de la Fuente LM, Cierpka L, McAllister TN, L'Heureux N. Long-term results of autologous scaffold-free tissue-engineered vascular graft for hemodialysis access. J Vasc Access 2024; 25:254-264. [PMID: 35773955 DOI: 10.1177/11297298221095994] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The growing size of the end stage renal disease (ESRD) population highlights the need for effective dialysis access. Exhausted native vascular access options have led to increased use of catheters and prosthetic shunts, which are both associated with high risks of access failure and infection. Emerging alternatives include tissue-engineered vascular grafts (TEVG). Here we present the endpoint results for 10 ESRD patients with the scaffold-free tissue-engineered vascular access produced from sheets of extracellular matrix produced in vitro by human cells in culture. METHODS Grafts were implanted as arteriovenous shunts in 10 ESRD patients with a complex history of access failure. Follow-up included ultrasound control of graft morphology and function, dialysis efficiency, access failure, intervention rate, as well as immunohistochemical analysis of graft structure. RESULTS One patient died of unrelated causes and three shunts failed to become useable access grafts during the 3-month maturation phase. The 12-month primary and secondary patency for the other six shunts was 86%. Survival of six shunts functioning as the vascular access was 22 ± 12 months with longest primary patency of 38.6 months. The dialysis event rate of 3.34 per patient-year decreased significantly with the use of this TEVG to 0.67. CONCLUSIONS This living autologous tissue-engineered vascular graft seems to be an alternative to synthetic vascular access options, exhibiting advantages of native arteriovenous fistula.
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Affiliation(s)
- Wojciech Wystrychowski
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Sergio A Garrido
- Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina
| | - Alicia Marini
- Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina
| | - Nathalie Dusserre
- Cytograft Tissue Engineering, Novato, CA, USA
- University of Bordeaux, INSERM, BIOTIS, Bordeaux, France
| | | | - Krzysztof Zagalski
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Jorge Antonelli
- Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina
| | - Manuel Canalis
- Fresenius Dialysis Center Hospital Alemán, Buenos Aires, Argentina
| | - Andrea Sammartino
- Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina
| | | | - Ryszard Baczyński
- Department of Nephrology, Voivodship Hospital in Bielsko-Biała, Bielsko-Biała, Poland
| | - Tomasz Cierniak
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Lech Cierpka
- Department of General, Vascular and Transplant Surgery, Medical University of Silesia, Katowice, Poland
| | | | - Nicolas L'Heureux
- Cytograft Tissue Engineering, Novato, CA, USA
- University of Bordeaux, INSERM, BIOTIS, Bordeaux, France
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3
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Davis S, Mohan S. Managing Patients with Failing Kidney Allograft: Many Questions Remain. Clin J Am Soc Nephrol 2022; 17:444-451. [PMID: 33692118 PMCID: PMC8975040 DOI: 10.2215/cjn.14620920] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patients who receive a kidney transplant commonly experience failure of their allograft. Transplant failure often comes with complex management decisions, such as when and how to wean immunosuppression and start the transition to a second transplant or to dialysis. These decisions are made in the context of important concerns about competing risks, including sensitization and infection. Unfortunately, the management of the failed allograft is, at present, guided by relatively poor-quality data and, as a result, practice patterns are variable and suboptimal given that patients with failed allografts experience excess morbidity and mortality compared with their transplant-naive counterparts. In this review, we summarize the management strategies through the often-precarious transition from transplant to dialysis, highlighting the paucity of data and the critical gaps in our knowledge that are necessary to inform the optimal care of the patient with a failing kidney transplant.
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Affiliation(s)
- Scott Davis
- Department of Medicine, University of Colorado, Aurora, Colorado,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Medicine, University of Colorado, Aurora, Colorado .,Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Quantifying The Costs of Creating and Maintaining Hemodialysis Access in An All-Payer Rate-Controlled Health System. Ann Vasc Surg 2021; 76:142-151. [PMID: 34153489 DOI: 10.1016/j.avsg.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The creation and maintenance of durable hemodialysis access is critically important for reducing patient morbidity and controlling overall costs within health systems. Our objective was to quantify the costs associated with hemodialysis access creation and its maintenance over time within a rate-controlled health system where charges equate to payments. METHODS The Maryland Health Services Cost Review Commission administrative claims database was used to identify patients who underwent first-time access creation from 2012-2020. Patients were identified using CPT codes for access creation, and costs were accrued for the initial encounter and all subsequent outpatient access-related encounters. T-tests and Wilcoxon tests were used to compare reinterventions and access-related costs ($USD) between arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Multivariable modeling was used to quantify the association of access type with charge variation. RESULTS Overall, 12,716 patients underwent first-time access creation (69.3% AVF vs. 30.7% AVG). There was no difference in freedom from reintervention between the two access types at any point following creation (HR: 1.03, 95%CI: 0.97-1.10); however, AVF were associated with a lower number of cumulative reinterventions (1.50 vs. 2.24) compared to AVG (P<0.0001). AVF was associated with lower overall costs in the year of creation ($9,388 vs. $13,539, P<0.0001), a difference that remained significant over the subsequent 3 years. The lower costs associated with AVF were present both in the costs associated with creation and subsequent maintenance. On multivariable analysis, AVF was associated with a $3,557 reduction in total access-related costs versus AVG (95%CI -$3828, -3287). CONCLUSION AVF require fewer interventions and are associated with lower costs at placement and over the first three years of maintenance compared to AVG. The use of AVF for first-time hemodialysis access represents an opportunity for healthcare savings in appropriately selected patients with a high preoperative likelihood of AVF maturation.
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5
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Abstract
End-stage kidney disease (ESKD) is a common and morbid disease that affects patients' quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants-even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient's "life plan," and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.
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Affiliation(s)
- Ryan Gupta
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
| | - Karen Woo
- Division of Vascular Surgery, University of California Los Angeles, David Geffen School of Medicine, 200 UCLA Medical Plaza, Suite 526, Los Angeles, CA 90095.
| | - Jeniann A Yi
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
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Mehra K, Manikandan R, Dorairajan LN, Sreenivasan Kodakkattil S, Kalra S, Kumar R, Murali P. Outcomes of Transposition of Brachiobasilic Arteriovenous Fistula in Two-Stage Technique: A Single-Centre Experience With Literature Review. Cureus 2020; 12:e9949. [PMID: 32983655 PMCID: PMC7510181 DOI: 10.7759/cureus.9949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Arteriovenous fistulae (AVF) are considered a better option for long-term dialysis access. The distal radiocephalic AVF is the most preferred followed by proximal radiocephalic, brachiocephalic and brachiobasilic AVFs (BBAVF) with basilic vein transposition. In case of failure of AVF at other anatomical locations, BBAVF may improve the outcomes for patients needing dialysis for long term. The two-stage technique of BBAVF has easier dissection and lesser devascularisation risk. The disadvantages are need for two interventions and delay in maturation. Materials and Method It was a retrospective observational study including 42 patients who underwent transposition of BBAVF as two-stage procedure from June 2014 to July 2018. The data recorded were demographic characteristics, such as median age, gender, dialysis status at AVF creation and operative duration. Complications like postoperative limb oedema, bleeding and thrombosis of AVF were recorded. Patency and access outcome of AVF were documented at three-month follow-up. Results Among 42 patients, 27 (64.3%) were males. The median age was 50 years. Around 14% of patients had minor complications like oedema. Eight (19%) patients needed re-exploration due to bleeding or thrombosis. The early access failure rate that is a failure before discharge was 4.7%. The patency rate at three months was 90.5%, but the primary functional rate was 74%. Conclusion Transposition of BBAVF as a two-step technique is associated with reasonable patency rate and primary functional rate. The related complications were low, and a good number of fistulae could be saved with timely intervention.
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Affiliation(s)
- Ketan Mehra
- Urology and Renal Transplantation, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Ramanitharan Manikandan
- Urology and Renal Transplantation, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Lalgudi N Dorairajan
- Urology and Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, IND
| | | | - Sidhartha Kalra
- Urology and Renal Transplantation, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, IND
| | - Rajeev Kumar
- Urology and Renal Transplantation, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Padyala Murali
- Urology and Renal Transplantation, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
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7
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Hussein WF, Mohammed H, Browne L, Plant L, Stack AG. Prevalence and correlates of central venous catheter use among haemodialysis patients in the Irish health system - a national study. BMC Nephrol 2018; 19:76. [PMID: 29609535 PMCID: PMC5880000 DOI: 10.1186/s12882-018-0873-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 03/15/2018] [Indexed: 11/28/2022] Open
Abstract
Background Central venous catheters (CVC) are associated with substantial morbidity and mortality among patients undergoing haemodialysis (HD), yet they are frequently used as the primary vascular access for many patients on HD. The goal of this study was to determine the prevalence and variation in CVC use across centres in the Irish health system. Methods Data from the National Kidney Disease Clinical Patient Management System (KDCPMS) was used to determine CVC use and patterns across centres. Data on demographic characteristics, primary cause of end-stage kidney disease (ESKD), comorbid conditions, laboratory values and centre affiliation were extracted for adult HD patients (n = 1, 196) who were on dialysis for at least three months up to end of December 2016. Correlates of CVC use were explored using multivariable logistic regression. Results Overall prevalence of CVC use was 54% and varied significantly across clinical sites from 43% to 73%, P < 0.001. In multivariate analysis, the likelihood of CVC use was lower with increasing dialysis vintage, OR 0.40 (0.26–0.60) for 4 years vs 1 year vintage, rising serum albumin, OR 0.73 (0.59–0.90) per 5 g/L), and with cystic disease as a cause of ESKD, OR 0.38 (95% CI 0.21–0.6). In contrast, catheter use was greater for women than men, OR 1.77 (1.34–2.34) and for 2 out of 10 regional dialysis centres, OR 1.98 (1.02–3.84) and OR 2.86 (1.67–4.90) respectively compared to referent group). Conclusions Catheters are the predominant type of vascular access in patients undergoing HD in the Irish health system. Substantial centre variation exists which is not explained by patient-level characteristics. Electronic supplementary material The online version of this article (10.1186/s12882-018-0873-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wael F Hussein
- Department of Nephrology, University Hospital Limerick, St Nessans Rd, Dooradoyle, Limerick, Ireland. .,Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - Husham Mohammed
- Department of Nephrology, University Hospital Limerick, St Nessans Rd, Dooradoyle, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Leonard Browne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Liam Plant
- National Renal Office, HSE Clinical Programmes and Strategy Division, Dublin, Ireland.,Department of Renal Medicine, University College Cork, Cork, Ireland
| | - Austin G Stack
- Department of Nephrology, University Hospital Limerick, St Nessans Rd, Dooradoyle, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
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Patzer RE, Smith K, Basu M, Gander J, Mohan S, Escoffery C, Plantinga L, Melanson T, Kalloo S, Green G, Berlin A, Renville G, Browne T, Turgeon N, Caponi S, Zhang R, Pastan S. The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: a Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity. Kidney Int Rep 2017; 2:433-441. [PMID: 28845470 PMCID: PMC5568836 DOI: 10.1016/j.ekir.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION The United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplant. METHODS We describe the ASCENT (Allocation System Changes for Equity in KidNey Transplantation) study, a randomized controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis-facility specific transplant performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States. RESULTS This study is estimated to enroll ~600 U.S. dialysis facilities with low waitlisting in all 18 ESRD Networks. The co-primary outcomes include change in waitlisting, and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplant, and a medical director's intent to refer patients for transplant evaluation. CONCLUSION The results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased-donor kidney waitlist and reduce racial disparities in waitlisting.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322.,Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322.,Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Kayla Smith
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Jennifer Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Cam Escoffery
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322
| | - Laura Plantinga
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Taylor Melanson
- Department of Health Policy Management, Rollins School of Public Health, Emory School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Sean Kalloo
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Gary Green
- American Association of Kidney Patients, 2701 N. Rocky Point Drive, Suite 150, Tampa, FL 33607
| | - Alex Berlin
- Southeastern Kidney Transplant Coalition, Atlanta, GA 30322
| | - Gary Renville
- National Kidney Foundation, 270 Peachtree St NE #1040, Atlanta, GA 30303
| | - Teri Browne
- University of South Carolina, College of Social Work, 902 Sumter Street, Columbia, SC 29208
| | - Nicole Turgeon
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Susan Caponi
- US ESRD Network 2, 1979 Marcus Ave, Lake Success, NY 11042
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Stephen Pastan
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
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Are early cannulation arteriovenous grafts (ecAVG) a viable alternative to tunnelled central venous catheters (TCVCs)? An observational "virtual study" and budget impact analysis. J Vasc Access 2016; 17:220-8. [PMID: 27032450 DOI: 10.5301/jva.5000519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Early cannulation arteriovenous grafts (ecAVGs) are advocated as an alternative to tunnelled central venous catheters (TCVCs). A real-time observational "virtual study" and budget impact model was performed to evaluate a strategy of ecAVG as a replacement to TCVC as a bridge to definitive access creation. METHODOLOGY Data on complications and access-related bed days was collected prospectively for all TCVCs inserted over a six-month period (n = 101). The feasibility and acceptability of an alternative strategy (ecAVGs) was also evaluated. A budget impact model comparing the two strategies was performed. Autologous access in the form of native fistula was the goal wherever possible. RESULTS We found 34.7% (n = 35) of TCVCs developed significant complications (including 17 culture-proven bacteraemia and one death from line sepsis). Patients spent an average of 11.9 days/patient/year in hospital as a result of access-related complications. The wait for TCVC insertion delayed discharge in 35 patients (median: 6 days). The ecAVGs were a practical and acceptable alternative to TCVCs in over 80% of patients. Over a 6-month period, total treatment costs per patient wereGBP5882 in the TCVC strategy and GBP4954 in the ecAVG strategy, delivering potential savings ofGBP927 per patient. The ecAVGs had higher procedure and re-intervention costs (GBP3014 vs. GBP1836); however, these were offset by significant reductions in septicaemia treatment costs (GBP1322 vs. GBP2176) and in-patient waiting time bed costs (GBP619 vs. GBP1870). CONCLUSIONS Adopting ecAVGs as an alternative to TCVCs in patients requiring immediate access for haemodialysis may provide better individual patient care and deliver cost savings to the hospital.
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10
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Arteriovenous Fistula Construction with the VasQ™ External Support Device: A Pilot Study. J Vasc Access 2016; 17:243-8. [DOI: 10.5301/jva.5000527] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2015] [Indexed: 11/20/2022] Open
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11
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Rowse JW, Kirksey L. Surgical Approach to Hemodialysis Access. Semin Intervent Radiol 2016; 33:21-4. [PMID: 27011424 DOI: 10.1055/s-0036-1572357] [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: 10/22/2022]
Abstract
With the increasing incidence of end-stage renal disease, hemodialysis vascular access presents an ongoing struggle, and a multidisciplinary approach must be considered to provide long-term durable access for patients on chronic hemodialysis. Surgeons must be very thoughtful in planning the steps of access for these patients and consider fistula first and catheter last, without forgetting that prosthetic grafts may be a legitimate first option for patients. This article provides a review of surgical management of dialysis access, including primary access options and follow-up of this difficult patient population.
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Affiliation(s)
- Jarrad W Rowse
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lee Kirksey
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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12
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Murea M, Satko S. Looking Beyond "Fistula First" in the Elderly on Hemodialysis. Semin Dial 2016; 29:396-402. [PMID: 26931575 DOI: 10.1111/sdi.12481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vascular access preparation, a pervasive challenge in hemodialysis (HD), is emerging as a multidimensional subject in geriatric nephrology. Previously published guidelines declared arteriovenous fistulas (AVF) as the preferred vascular access for all patients on HD. In this article, the benefit-risk evidence for using AVF versus an alternative access (arteriovenous graft [AVG] or tunneled central venous catheter [TCVC]) in the elderly is pondered. Compared to their younger counterparts, the elderly have significantly lower survival rates independent of the vascular access used for HD. Recent studies point to comparable dialysis survival rates between AVF and AVG or TCVC in subgroups of elderly patients, as well as lower rates of access-related infections, and lower catheter dependence after AVG compared to AVF construction in these patients. Comprehensive and longitudinal assessments that integrate comorbidities, physical function, cognitive status, and quality of life to estimate prognosis and assist with vascular access selection ought to be employed. In circumstances where patient survival is limited by comorbidities and functional status, AVF is unlikely to confer meaningful benefits compared to AVG or even TCVC in the ill elderly.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine-Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Scott Satko
- Department of Internal Medicine-Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Interventional Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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O'Shaughnessy MM, Montez-Rath ME, Zheng Y, Lafayette RA, Winkelmayer WC. Differences in Initial Hemodialysis Vascular Access Use Among Glomerulonephritis Subtypes in the United States. Am J Kidney Dis 2016; 67:638-47. [PMID: 26774466 DOI: 10.1053/j.ajkd.2015.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/19/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The type of vascular access used for hemodialysis affects patient morbidity and mortality. Whether vascular access types differ by glomerulonephritis (GN) subtype in the US hemodialysis population has not been investigated. STUDY DESIGN Cross-sectional observational study. SETTING & PARTICIPANTS We identified all adult (aged ≥ 18 years) patients within the US Renal Data System who initiated hemodialysis therapy from July 2005 through December 2011 with a diagnosis of end-stage renal disease attributed to any of 4 primary (focal segmental glomerulosclerosis, immunoglobulin A nephropathy [reference group], membranous nephropathy, and membranoproliferative GN) or 2 secondary (lupus nephritis and vasculitis) GN subtypes. PREDICTOR GN subtype. OUTCOMES ORs with 95% CIs for arteriovenous fistula versus central venous catheter (CVC) use and for arteriovenous graft versus CVC use were computed using multinomial logistic regression, with adjustment for demographic, socioeconomic, comorbidity, and duration of nephrology care covariates. RESULTS Among 29,015 patients, CVC use at initiation of hemodialysis therapy was substantially higher in patients with lupus nephritis (89.2%) or vasculitis (91.2%) compared with patients with primary GN subtypes (72.7%-79.8%). After adjustment and compared with patients with immunoglobulin A nephropathy, patients with lupus nephritis or vasculitis were as likely to have used an arteriovenous graft (ORs of 0.94 [95% CI, 0.70-1.27] and 0.80 [95% CI, 0.56-1.13], respectively) but significantly less likely to have used an arteriovenous fistula (ORs of 0.66 [95% CI, 0.57-0.76] and 0.54 [95% CI, 0.45-0.63], respectively), whereas patients with any comparator primary GN subtype were at least as likely to have used either of these 2 access types. LIMITATIONS Potential misclassification of exposure; residual confounding by unmeasured covariates; inability to determine causes of observed associations; lacking longitudinal data for vascular access use. CONCLUSIONS Significant differences in vascular access distributions at initiation of hemodialysis therapy are apparent among GN subtypes. The unacceptably high use of CVCs in patients with lupus nephritis and vasculitis is particularly concerning. Further studies are needed to identify any potentially modifiable factors underlying these findings.
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Affiliation(s)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Richard A Lafayette
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
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Transcatheter Anastomosis Connector System for Vascular access Graft Placement: Results from a First-in-human Pilot Study. J Vasc Access 2015; 17:111-7. [DOI: 10.5301/jva.5000481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2015] [Indexed: 12/29/2022] Open
Abstract
Purpose A lengthy healing and maturation period follows standard surgical preparation of a permanent arteriovenous access, often requiring or extending use of a venous catheter (VC) for hemodialysis. The InterGraft™ Anastomotic Connector System was developed for minimally invasive anastomosis of an arteriovenous graft (AVG). The venous and arterial InterGraft™ connectors are designed to provide optimized flow dynamics and may result in reduction of AVG stenosis. This pilot study evaluated placement procedure success, patency and safety of the InterGraft™ connectors. Methods Nine AVGs were implanted in nine patients currently receiving dialysis with a VC. The study allowed use of both connectors (n = 5) or use of the venous connector with a sutured arterial anastomosis (n = 4). Monthly ultrasound examinations were performed throughout the six-month follow-up. AVG angiography was performed at five months. Endpoints included procedure success (acceptable graft flow at end of procedure, without significant bleeding or need for emergent surgery), patency, and device-related major adverse events. Results Procedure success was attained in all patients. AVGs were used for dialysis within 17 days, on average, and VCs were removed. Three patients exited the study early for reasons unrelated to the InterGraft™ connectors. The remaining six patients had patent grafts: two with assisted and four with unassisted patency. AVG flow rates were greater than 1 L/minute. No dilatations or aneurysms were observed by angiography. There were no device-related major adverse events. Conclusions The InterGraft™ connectors can be safely and successfully used for AVG anastomoses, with acceptable near-term patency. Further clinical evaluation is warranted.
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Surgical Options in the Problematic Arteriovenous Haemodialysis Access. Cardiovasc Intervent Radiol 2015; 38:1405-15. [DOI: 10.1007/s00270-015-1155-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/30/2015] [Indexed: 11/27/2022]
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Plantinga LC, Patzer RE, Drenkard C, Pastan SO, Cobb J, McClellan W, Lim SS. Comparison of quality-of-care measures in U.S. patients with end-stage renal disease secondary to lupus nephritis vs. other causes. BMC Nephrol 2015; 16:39. [PMID: 25884409 PMCID: PMC4389993 DOI: 10.1186/s12882-015-0037-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) due to lupus nephritis (LN-ESRD) may be followed by multiple providers (nephrologists and rheumatologists) and have greater opportunities to receive recommended ESRD-related care. We aimed to examine whether LN-ESRD patients have better quality of ESRD care compared to other ESRD patients. METHODS Among incident patients (7/05-9/11) with ESRD due to LN (n = 6,594) vs. other causes (n = 617,758), identified using a national surveillance cohort (United States Renal Data System), we determined the association between attributed cause of ESRD and quality-of-care measures (pre-ESRD nephrology care, placement on the deceased donor kidney transplant waitlist, and placement of permanent vascular access). Multivariable logistic and Cox proportional hazards models were used to estimate adjusted odds ratios (ORs) and hazard ratios (HRs). RESULTS LN-ESRD patients were more likely than other ESRD patients to receive pre-ESRD care (71% vs. 66%; OR = 1.68, 95% CI 1.57-1.78) and be placed on the transplant waitlist in the first year (206 vs. 86 per 1000 patient-years; HR = 1.42, 95% CI 1.34-1.52). However, only 24% had a permanent vascular access (fistula or graft) in place at dialysis start (vs. 36%; OR = 0.63, 95% CI 0.59-0.67). CONCLUSIONS LN-ESRD patients are more likely to receive pre-ESRD care and have better access to transplant, but are less likely to have a permanent vascular access for dialysis, than other ESRD patients. Further studies are warranted to examine barriers to permanent vascular access placement, as well as morbidity and mortality associated with temporary access, in patients with LN-ESRD.
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Affiliation(s)
| | - Rachel E Patzer
- Department of Surgery, Emory University, Atlanta, Georgia, USA.
| | | | - Stephen O Pastan
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
- Emory Transplant Center, Emory Healthcare, Atlanta, Georgia, USA.
| | - Jason Cobb
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
| | - William McClellan
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA.
| | - Sung Sam Lim
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
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Bashar K, Healy DA, Elsheikh S, Browne LD, Walsh MT, Clarke-Moloney M, Burke PE, Kavanagh EG, Walsh SR. One-stage vs. two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis. PLoS One 2015; 10:e0120154. [PMID: 25751655 PMCID: PMC4353636 DOI: 10.1371/journal.pone.0120154] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 01/20/2015] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION A brachiobasilic arteriovenous fistula (BB-AVF) can provide access for haemodialysis in patients who are not eligible for a more superficial fistula. However, it is unclear whether one- or two-stage BB-AVF is the best option for patients. AIM To systematically assess the difference between both procedures in terms of access maturation, patency and postoperative complications. METHODS Online search for randomised controlled trials (RCTs) and observational studies that compared the one-stage versus the two-stage technique for creating a BB-AVF. RESULTS Eight studies were included (849 patients with 859 fistulas), 366 created using a one-stage technique, while 493 in a two-stage approach. There was no statistically significant difference between the two groups in the rate of successful maturation (Pooled risk ratio = 0.95 [0.82, 1.11], P = 0.53). Similarly, the incidence of postoperative haematoma (Pooled risk ratio = 0.73 [0.34, 1.58], P = 0.43), wound infection (Pooled risk ratio = 0.77 [0.35, 1.68], P = 0.51) and steal syndrome (Pooled risk ratio = 0.65 [0.27, 1.53], P = 0.32) were statistically comparable. CONCLUSION Although more studies seem to favour the two-stage BVT approach, evidence in the literature is not sufficient to draw a final conclusion as the difference between the one-stage and the two-stage approaches for creation of a BB-AVF is not statistically significant in terms of the overall maturation rate and postoperative complications. Patency rates (primary, assisted primary and secondary) were comparable in the majority of studies. Large randomised properly conducted trials with superior methodology and adequate sub-group analysis are needed before making a final recommendation.
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Affiliation(s)
- Khalid Bashar
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Donagh A. Healy
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Sawsan Elsheikh
- Department of Acute Medicine, James Connolly Memorial Hospital, Dublin, Ireland
| | - Leonard D. Browne
- Centre for Applied Biomedical Engineering Research (CABER), Department of Mechanical, Aeronautical & Biomedical Engineering, Materials and Surface Science Institute, University of Limerick, Limerick, Ireland
| | - Michael T. Walsh
- Centre for Applied Biomedical Engineering Research (CABER), Department of Mechanical, Aeronautical & Biomedical Engineering, Materials and Surface Science Institute, University of Limerick, Limerick, Ireland
| | - Mary Clarke-Moloney
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Paul E. Burke
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Eamon G. Kavanagh
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Stewart R. Walsh
- Department of Surgery, National University of Ireland, Galway, Ireland
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Plantinga LC, Drenkard C, Patzer RE, Klein M, Kramer MR, Pastan S, Lim SS, McClellan WM. Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis. Arthritis Rheumatol 2015; 67:761-72. [PMID: 25692867 PMCID: PMC5340148 DOI: 10.1002/art.38983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/02/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region. METHODS National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region. RESULTS Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care. CONCLUSION LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.
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Affiliation(s)
- Laura C. Plantinga
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
| | - Cristina Drenkard
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
| | - Rachel E. Patzer
- Rachel E. Patzer, PhD, MPH, Stephen Pastan, MD: Emory University and Emory Transplant Center, Emory Healthcare, Atlanta, Georgia
| | - Mitchel Klein
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
| | - Michael R. Kramer
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
| | - Stephen Pastan
- Rachel E. Patzer, PhD, MPH, Stephen Pastan, MD: Emory University and Emory Transplant Center, Emory Healthcare, Atlanta, Georgia
| | - S. Sam Lim
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
| | - William M. McClellan
- Laura C. Plantinga, PhD, Cristina Drenkard, MD, PhD, Mitchel Klein, PhD, Michael R. Kramer, PhD, S. Sam Lim, MD, MPH, William M. McClellan, MD, MPH: Emory University, Atlanta, Georgia
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Bashar K, Clarke-Moloney M, Burke PE, Kavanagh EG, Walsh SR. The role of venous diameter in predicting arteriovenous fistula maturation: when not to expect an AVF to mature according to pre-operative vein diameter measurements? A best evidence topic. Int J Surg 2015; 15:95-9. [PMID: 25659365 DOI: 10.1016/j.ijsu.2015.01.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 12/27/2014] [Accepted: 01/31/2015] [Indexed: 12/20/2022]
Abstract
This best evidence topic was investigated according to a described protocol. We asked the question: what is the minimal vein diameter that can successfully predict maturation of an arteriovenous fistula (AVF) in patients undergoing dialysis. Using the reported search 804 papers were found, of which five represented the best evidence to answer the clinical question. All studies assessed the association between successful AVF maturation and the size of vein used. The strongest evidence came from a nonrandomised controlled follow-up study in which 76% of fistulas created using >2 mm cephalic vein successfully matured compared to 16% when the vein measured ≤2 mm. Another prospective, multicentre study showed 65% successful maturation using veins >4 mm compared to 45% with veins <3 mm. Vein diameter was found to be an independent predictor of maturation in multivariate regression analysis in two retrospective observational studies. Another retrospective observational study found that using venous measurements of ≥2.5 mm following tourniquet application resulted in more fistulas been created that would have otherwise been denied based on venous ultrasound mapping. A large multicentre randomised clinical trial assessing the use of different vein sizes both with and without tourniquet application using proper statistical tools - such as receiver operating characteristic - is required to make a final recommendation. Until then, a vein diameter of <2.5 mm should be considered inadequate for formation of an AVF, particularly if those measurements remain unchanged following the use of tourniquet.
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Affiliation(s)
- K Bashar
- Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland.
| | - M Clarke-Moloney
- Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland
| | - P E Burke
- Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland
| | - E G Kavanagh
- Department of Vascular Surgery University Hospital Limerick, Limerick, Ireland
| | - S R Walsh
- Department of Surgery, National University of Ireland, Galway, Ireland
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20
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The use of Tunneled Central Venous Catheters: Inevitable or System Failure? J Vasc Access 2014; 15:344-50. [DOI: 10.5301/jva.5000206] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2013] [Indexed: 11/20/2022] Open
Abstract
Purpose To evaluate reasons for tunneled central venous catheter (TCVC) usage in our prevalent hemodialysis population and assess the impact of a surgically aggressive approach to definitive access creation. Methods Clinical review of all patients in the West of Scotland dialyzing via a TCVC in November 2010 was performed. Reasons for TCVC usage and TCVC complications were evaluated. Over the subsequent year, aggressive intervention was undertaken to achieve definitive access in all suitable patients and outcomes re-evaluated a year later (November 2011). Results There was no significant difference in the proportion of patients dialyzing via a TCVC in 2010 compared to 2011 (30.3% (n=193) vs. 31.7% (n=201), respectively; p=0.56). All patients now have a “vascular access plan.” Of patients dialyzing via a TCVC in 2010, 37% had died by 2011, 22% remained on long-term line, 20% had successful arteriovenous fistula (AVF) creation, 1% had an arteriovenous graft and 2% were transplanted; 10.4% developed complications of vascular access and required ligation of a functioning AVF. A further 6.5% died within 28 days of surgery. The incidence of culture-positive Staphylococcus aureus bacteremia was 1.6 per 1,000 catheter days. Conclusions Aggressive strategies of AVF creation resulted in one-fifth of patients on a long-term TCVC having successful creation of an AVF. This was offset against high failure and significant complication rate from AVF creation in this population. One-third of patients dialyzing via a TCVC died in the subsequent year. Correct patient selection for AVF creation is essential and predialysis care must be optimized to avoid the need for TCVCs entirely.
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Plantinga LC, Kim M, Goetz M, Kleinbaum DG, McClellan W, Patzer RE. Pre-end-stage renal disease care not associated with dialysis facility neighborhood poverty in the United States. Am J Nephrol 2014; 39:50-8. [PMID: 24434854 DOI: 10.1159/000358067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/12/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Receipt of nephrology care prior to end-stage renal disease (ESRD) is a strong predictor of decreased mortality and morbidity, and neighborhood poverty may influence access to care. Our objective was to examine whether neighborhood poverty is associated with lack of pre-ESRD care at dialysis facilities. METHODS In a multi-level ecological study using geospatially linked 2007-2010 Dialysis Facility Report and 2006-2010 American Community Survey data, we examined whether high neighborhood poverty (≥20% of households in census tract living below poverty) was associated with dialysis facility-level lack of pre-ESRD care (percentage of patients with no nephrology care prior to dialysis start) in mixed-effects models, adjusting for facility and neighborhood confounders and allowing for neighborhood and regional random effects. RESULTS Among the 5,184 facilities examined, 1,778 (34.3%) were located in a high-poverty area. Lack of pre-ESRD care was similar in poverty areas (30.8%) and other neighborhoods (29.6%). With adjustment, the absolute increase in percentage of patients at a facility with no pre-ESRD care associated with facility location in a poverty area versus other neighborhood was only 0.08% (95% CI -1.32, 1.47; p = 0.9). Potential effect modification by race and income inequality was detected. CONCLUSION Despite previously reported detrimental effects of neighborhood poverty on health, facility neighborhood poverty was not associated with receipt of pre-ESRD care, suggesting no need to target interventions to increase access to pre-ESRD care at facilities in poorer geographic areas.
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Affiliation(s)
- Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Ga., USA
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Riella MC, Roy-Chaudhury P. Vascular access in haemodialysis: strengthening the Achilles' heel. Nat Rev Nephrol 2013; 9:348-57. [DOI: 10.1038/nrneph.2013.76] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Malani PN, Heung M. Optimizing antimicrobial use in hemodialysis: time to take a hard look in the mirror. Infect Control Hosp Epidemiol 2013; 34:358-60. [PMID: 23466907 DOI: 10.1086/669961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Preeti N Malani
- Department of Internal Medicine, Divisions of Infectious Diseases and Geriatric and Palliative Medicine, University of Michigan Health System, Ann Arbor, MI 48105, USA.
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Fishbane S, Hazzan A. Meeting the 2012 QIP (Quality Incentive Program) clinical measures: strategies for dialysis centers. Am J Kidney Dis 2012; 60:S5-13; quiz S14-7. [PMID: 23063058 DOI: 10.1053/j.ajkd.2012.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 07/11/2012] [Indexed: 11/11/2022]
Abstract
The US Centers for Medicare & Medicaid Services end-stage renal disease Quality Incentive Program (QIP) is a pay-for-performance program that reduces dialysis center payments by up to 2% for suboptimal patient care. In January 2012, the performance year began for payment year 2014, bringing significant changes to the QIP by introducing 6 quality indicators (3 clinical measures and 3 reporting measures) and a new scoring methodology. To succeed under the new QIP, dialysis facilities must meet 3 clinical measures that assess anemia management, hemodialysis adequacy, and vascular access type in patients receiving dialysis treatment, as well as 3 reporting measures that involve the reporting of dialysis safety events, attestation of administering a patient satisfaction survey, and attestation of patient mineral metabolism monitoring. To help dialysis providers reach these targets, this article provides an overview of the 3 clinical measures and the QIP scoring methodology, as well as a description of patient claims that are excluded when the scores for these measures are calculated. Strategies and solutions that address provider- and patient-related factors also are discussed to help ensure that more dialysis centers meet the new QIP clinical measures for performance year 2012/payment year 2014.
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Affiliation(s)
- Steven Fishbane
- North Shore-LIJ Health System, Department of Medicine, Division of Nephrology, Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, USA.
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Dukkipati R, Peck M, Dhamija R, Hentschel DM, Reynolds T, Tammewar G, McAllister T. Biological grafts for hemodialysis access: historical lessons, state-of-the-art and future directions. Semin Dial 2012; 26:233-9. [PMID: 22909001 DOI: 10.1111/j.1525-139x.2012.01106.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The vast majority of arteriovenous grafts (AVG) have been constructed using expanded polytetrafluoroethylene (ePTFE). While ePTFE grafts have the advantage of being relatively inexpensive and easy to manufacture, distribute, ship, and store, their primary patency rates are disappointing when compared with the native AVF. Though use of arteriovenous fistulas (AVF) in the United States has increased substantially, approximately 25% of hemodialysis patients continue to use AVG as their vascular access. We present here a comprehensive review of biological grafts and their use in hemodialysis vascular access. In this review, we discuss the use of synthetics and then explore the evolution of biological grafts over the past 20 years, their clinical impact, and future challenges in widespread clinical use in hemodialysis patients. Provided are in depth descriptions of currently used nonbiological arteriovenous grafts and the recent approaches in increasing the patency of synthetic grafts. Recent technological advances using tissue-engineered AVGs have shown promise for patients receiving hemodialysis and their potential to provide an attractive, viable option for vascular access have been discussed.
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Affiliation(s)
- Ramanath Dukkipati
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90509, USA.
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Vascular access in patients receiving hemodialysis in Libya. J Vasc Access 2012; 13:468-74. [PMID: 22865528 DOI: 10.5301/jva.5000089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A native arteriovenous fistula (AVF) represents the optimal form of Vascular Access (VA) for patients receiving hemodialysis (HD). In Libya there are several barriers to AVF creation including lack of adequate preparation for dialysis and surgical services. We aimed to conduct the first comprehensive study of VA utilisation in HD patients in Libya. METHODS A prospective observational study included all adult patients receiving HD treatment in 25 HD facilities in Libya from May 2009 to Nov 2011. Researchers gathered data regarding VA through interviews with staff and patients as well as medical records. Patients with definitive VA were re-interviewed after 1 year. RESULTS At baseline the majority of patients (91.9%; n=1573) were using permanent VA in the form of AVF or arteriovenous graft. Patients with permanent VA were more likely to be male and less likely to be diabetic than those with CVCs. Most patients had commenced HD using a temporary CVC (91.8%). VA-related complications were: thrombosis (46.7%), aneurysm (22.6%), infection (11.5%) and haemorrhage (10.2%). Incident VA thrombosis was reported by 14.7% in 1 year. Independent risk factors for incident thrombosis were female gender and diabetes. Hospitalisation for VA related complications was reported by 31.4%. CONCLUSIONS Few patients in Libya initiate HD with definitive VA, but most achieve it thereafter. Improved dialysis preparation and increased provision of surgical services are required to increase the proportion of patients initiating HD with definitive VA and should be a priority in rebuilding health services in Libya after the recent conflict.
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