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Barba Teba R, López Arsuaga L, Firket L, Ferreira F, Moest W, Stoneman S, Georgopoulou GA, Bratsiakou A, Gallieni M. Vascular access hands-on training for young nephrologists: The fellows' experience of the N-PATH project REVAC module. J Vasc Access 2024; 25:1371-1375. [PMID: 37337422 DOI: 10.1177/11297298231180325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Chronic kidney disease is a major public health problem, as population studies record a prevalence of 7.2% in individuals over 30 years and is expected to increase in the future. Many of them will end up undergoing hemodialysis treatment, and vascular access is not only an essential requirement for the technique, but also a determining factor in their prognosis; for all these reasons, every nephrologist should have both theoretical and practical knowledge of vascular access; however, the practical training is generally uneven and dependent on the hospital in which you train. It is within this context that the N-PATH (Nephrology Partnership for Advancing Technology in Healthcare) program was born with the objective of training 40 young European nephrologists in theoretical and practical aspects of Interventional Nephrology. To fulfill its mission, the 2-year program is composed of four modules of 6 months each including theoretical courses and hands-on training: Renal Expert in Molecular Pathology (REMAP), Renal Expert in Vascular Access (REVAC), Renal Expert in Medical Ultrasound (REMUS), and Renal Expert in Peritoneal Dialysis (REPED). By bringing together young nephrologists from all over Europe, the goal is also to create a strong network and promote Nephrology career at the European level. This publication highlights the experience of fellows who attended the REVAC hands-on training in Milan, focused on simulation and virtual reality for vascular access, and its impact on their nephrology training.
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Affiliation(s)
- Raquel Barba Teba
- Division of Nephrology, Infanta Leonor University Hospital, Madrid, Spain
| | | | - Louis Firket
- Division of Nephrology, CH Citadelle, Liège, Belgium
| | - Filipa Ferreira
- Division of Nephrology, São João University Hospital, Porto, Portugal
| | - Wouter Moest
- Division of Nephrology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sinead Stoneman
- Division of Nephrology, Cork University Hospital, Cork, Ireland
| | | | | | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
- Department of Biomedical and Clinical Sciences, Università di Milano, Milano, Italy
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Lawrie K, Waldauf P, Balaz P, Lacerda R, Aitken E, Letachowicz K, D'Oria M, Di Maso V, Stasko P, Gomes A, Fontainhas J, Pekar M, Srdelic A, O'Neill S. Validation of arteriovenous access stage (AVAS) classification: a prospective, international multicentre study. Clin Kidney J 2024; 17:sfae272. [PMID: 39329073 PMCID: PMC11426276 DOI: 10.1093/ckj/sfae272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Indexed: 09/28/2024] Open
Abstract
Background The arteriovenous access stage (AVAS) classification provides evaluation of upper extremity vessels for vascular access (VA) suitability. It divides patients into classes within three main groups: suitable for native fistula (AVAS1) or prosthetic graft (AVAS2), and patients not suitable for conventional native or prosthetic VA (AVAS3). We validated this system on a prospective dataset. Methods A prospective, international observational study (NCT04796558) involved 11 centres from 8 countries. Patient recruitment was from March 2021 to January 2024. Demographic data, risk factors, vessels parameters, VA types, AVAS class and early VA failure were collected. Percentage agreement was used to assess predictive ability of AVAS (comparison of AVAS and created VA) and consistency of AVAS assessment between evaluators. Pearson's Chi-squared test was used for comparison of early failure rate of conventional (predicted by AVAS) and unconventional (not predicted by AVAS) VA. Results From 1034 enrolled patients, 935 had arteriovenous fistula or graft, 99 patients did not undergo VA creation due opting for alternative renal replacement therapies, experiencing health complications, death or non-compliance. AVAS1 had 91.2%, AVAS2 7.2% and AVAS3 1.6% of patients. Agreement between evaluators was 89%. The most frequently created VAs were radial-cephalic (46%) and brachial-cephalic (27%) fistulae. The accuracy of AVAS versus created access was 79%. In comparison, VA predicted by clinicians versus created access was 62.1%. Inaccuracy of AVAS prediction was more common with higher AVAS classes, and the most common reason for inaccuracy was creation of distal VA despite less favourable anatomy (17%). Patients with unconventional VA had higher early failure rate than patients with conventional VA (20% vs 9.3%, respectively, P = .002). Conclusion AVAS is effective in predicting VA creation, but overall accuracy is reduced at higher AVAS classes when the complexity of decision-making increases and proximal vessels require preservation. When AVAS was followed by clinicians, early failure was significantly decreased.
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Affiliation(s)
- Katerina Lawrie
- Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Petr Waldauf
- Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
- Department of Anaesthesiology and Resuscitation, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Peter Balaz
- Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
- Division of Vascular Surgery, University Hospital Královské Vinohrady, Prague, Czech Republic
- Cardiocenter, University Hospital Královské Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Vascular Surgery, National Institute for Cardiovascular Disease, Bratislava, Slovakia
| | - Ricardo Lacerda
- RL Vascular Surgery and Interventional Radiology, Private Practice, Salvador, Brazil
| | - Emma Aitken
- Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Krzysztof Letachowicz
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardio-Thoracic-Vascular Department, University Hospital of Trieste, Trieste, Italy
| | - Vittorio Di Maso
- Nephrology and Dialysis Unit, Department of Medicine, ASUGI – University Hospital of Trieste, Trieste, Italy
| | - Pavel Stasko
- AdNa s.r.o., Vascular Surgery Clinic, Košice, Slovakia
| | - Antonio Gomes
- Department of General Surgery, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Joana Fontainhas
- Department of General Surgery, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Matej Pekar
- Centre for Vascular and Mini-invasive Surgery, Hospital AGEL, Třinec-Podlesí, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alena Srdelic
- Division of Nephrology and Haemodialysis, Internal Medicine Department, University Hospital of Split, Split, Croatia
| | - Stephen O'Neill
- Centre for Medical Education, Queen's University Belfast, Belfast, UK
- Department of Transplant Surgery and Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
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Cho MS, Javed Z, Patel R, Karim MS, Chan MR, Astor BC, Gardezi AI. Impact of COVID-19 pandemic on hemodialysis access thrombosis. J Vasc Access 2024; 25:467-473. [PMID: 35953895 PMCID: PMC9379590 DOI: 10.1177/11297298221116236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Delay in care of suspected stenosis or thrombosis can increase the chance of losing a functioning hemodialysis access. Access to care and resources were restricted during the COVID-19 pandemic. To evaluate the impact of the pandemic on arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures we have assessed the number and success of thrombectomies done before and during the COVID-19 pandemic. METHODS We examined all AVF and AVG angiograms with and without interventions, including thrombectomies, performed at a single center during April 2017-March 2021 (pre-COVID-19 era) and April 2020-March 2021 (COVID-19 era). RESULTS The proportion of procedures that were thrombectomies was higher during the COVID-19 era compared to the pre-COVID-19 era (13.3% vs 8.7%, p = 0.009). The proportion of thrombectomy procedures was higher during COVID-19 for AVF (8.2% vs 3.0%, p < 0.001) but there was no difference for AVG (26.5% vs 27%, p = 0.99). There was a trend toward a higher likelihood of unsuccessful thrombectomy during COVID-19 (33.3% vs 20.4%, p = 0.08). CONCLUSIONS More dialysis access thromboses and unsuccessful thrombectomies were noted during the COVID-19 pandemic. This difference could be due to a delay in patients getting procedures to maintain their dialysis accesses.
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Affiliation(s)
- Min S Cho
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Zain Javed
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Ravi Patel
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Muhammad S Karim
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Micah R Chan
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Brad C Astor
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
- Department of Population Health
Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
| | - Ali I Gardezi
- Division of Nephrology, Department of
Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
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Turner MA, Mathlouthi A, Patel RJ, Perreault M, Malas MB, Al-Nouri O. Small Arteriovenous Anastomosis in Fistula Creation: Establishing a Functional Vascular Access while Minimizing Steal Syndrome. Ann Vasc Surg 2024; 99:142-147. [PMID: 37926140 DOI: 10.1016/j.avsg.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The size selection of the arteriovenous (AV) anastomosis in dialysis access creation requires a careful balance: the diameter must be large enough to accommodate sufficient flow for hemodialysis but small enough to minimize the complication of steal syndrome. Steal syndrome affects up to 10% of patients after creation of dialysis access with sometimes devastating consequences. Conventional teaching recommends a 7-10 mm anastomosis. We sought to assess the efficacy of using a smaller (5-6 mm) anastomosis in new arteriovenous fistula (AVF) creation. METHODS We conducted a comparative retrospective analysis of patients who underwent fistula creation with a small versus regular size anastomosis at any upper extremity anatomic site between March 2019 and October 2020 at our institution. Anatomic sites included radiocephalic, brachiocephalic, and brachiobasilic. All AV anastomoses were measured intraoperatively to be 5-6 mm in diameter for the small size groups and 8-10 mm for the regular size group. Endpoints included steal syndrome, functional patency, primary patency, and secondary patency. RESULTS Out of 110 patients who underwent an AVF creation, 59.1% received a 5-6 mm anastomosis with a median follow-up time of 10 ± 6 months. Patients' demographics and comorbidities were relatively similar between the 2 groups except for a higher rate of hyperlipidemia (55.4% vs. 28.9%, P = 0.008) in the small size group. Patients in the small size group were more likely to undergo a radiocephalic fistula (40% vs. 4.5%, P < 0.001) and to have a smaller mean vein diameter on preoperative duplex ultrasound (3.2±1 mm vs. 3.9±1 mm, P = 0.0016) when compared to their regular size counterparts. During follow-up, none of the patients in the small group developed steal syndrome (0% vs. 9%, P = 0.015). At 1 year, patients in the regular size group achieved higher rates of primary patency (67.9% vs. 46.9%, P = 0.02); however, no difference was seen in 1-year primary-assisted patency (84.9% vs. 73.6%, P = 0.3), secondary patency (89.6% vs. 79.5%, P = 0.3), or functional patency (87.7% vs. 82.2%, P = 0.64) between the small and regular size groups, respectively. CONCLUSIONS The use of a 5-6 mm anastomosis in the creation of new AVFs of the upper extremities appears to be a technically safe option for dialysis access. Our experience suggests that smaller anastomosis still creates enough flow to maintain a functional AV access while minimizing the incidence of steal syndrome. Additionally, even with smaller vein sizes preoperative, adequate dialysis access can be created via a small sized anastomosis, including distal arm access. Larger studies with longer follow-up are needed to evaluate long-term outcomes of small anastomosis fistulas.
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Affiliation(s)
- Michael A Turner
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Rohini J Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Mark Perreault
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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Hudson R, Pascoe EM, See YP, Cho Y, Polkinghorne KR, Paul-Brent PA, Hooi LS, Ong LM, Mori TA, Badve SV, Cass A, Kerr PG, Voss D, Hawley CM, Johnson DW, Irish AB, Viecelli AK. A comparison of arteriovenous fistula failure between Malaysian and Australian and New Zealand participants enrolled in the FAVOURED trial. J Vasc Access 2024; 25:193-202. [PMID: 35686506 DOI: 10.1177/11297298221099134] [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] [Indexed: 11/17/2022] Open
Abstract
AIM To describe and compare de novo arteriovenous fistula (AVF) failure rates between Australia and New Zealand (ANZ), and Malaysia. BACKGROUND AVFs are preferred for haemodialysis access but are limited by high rates of early failure. METHODS A post hoc analysis of 353 participants from ANZ and Malaysia included in the FAVOURED randomised-controlled trial undergoing de novo AVF surgery was performed. Composite AVF failure (thrombosis, abandonment, cannulation failure) and its individual components were compared between ANZ (n = 209) and Malaysian (n = 144) participants using logistic regression adjusted for patient- and potentially modifiable clinical factors. RESULTS Participants' mean age was 55 ± 14.3 years and 64% were male. Compared with ANZ participants, Malaysian participants were younger with lower body mass index, higher prevalence of diabetes mellitus and lower prevalence of cardiovascular disease. AVF failure was less frequent in the Malaysian cohort (38% vs 54%; adjusted odds ratio (OR) 0.53, 95% confidence interval (CI) 0.31-0.93). This difference was driven by lower odds of cannulation failure (29% vs 47%, OR 0.45, 95% CI 0.25-0.80), while the odds of AVF thrombosis (17% vs 20%, OR 1.24, 95% CI 0.62-2.48) and abandonment (25% vs 23%, OR 1.17, 95% CI 0.62-2.16) were similar. CONCLUSIONS The risk of AVF failure was significantly lower in Malaysia compared to ANZ and driven by a lower risk of cannulation failure. Differences in practice patterns, including patient selection, surgical techniques, anaesthesia or cannulation techniques may account for regional outcome differences and warrant further investigation.
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Affiliation(s)
- Rebecca Hudson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yong Pey See
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peta-Anne Paul-Brent
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Lai-Seong Hooi
- Haemodialysis Unit, Department of Medicine, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Loke-Meng Ong
- Department of Nephrology, Penang Hospital, George Town, Malaysia
| | - Trevor A Mori
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, St George Hospital, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - David Voss
- Middlemore Renal Services, Middlemore Hospital, Auckland, New Zealand
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Ashley B Irish
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Nephrology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Okubo A, Doi T, Yamada Y, Morii K, Nishizawa Y, Yamashita K, Fudaba Y, Shigemoto K, Mizuiri S, Usui K, Arita M, Naito T, Masaki T. Early arteriovenous fistula failure associated with mortality and major adverse cardiovascular events in patients undergoing incident hemodialysis. J Vasc Access 2023:11297298231215106. [PMID: 38053252 DOI: 10.1177/11297298231215106] [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: 12/07/2023] Open
Abstract
BACKGROUND Arteriovenous fistula (AVF) patency is important for patients undergoing hemodialysis. The association between early AVF failure and the prognosis, including all-cause mortality and major adverse cardiovascular events (MACE), has not been fully investigated. The present study was performed to investigate the association between early AVF failure and 3-year mortality, cardiovascular disease (CVD) mortality, and MACE. METHODS We analyzed 358 patients who started hemodialysis in our institution from October 2008 to February 2020. We defined early AVF failure as cases requiring percutaneous transluminal angioplasty or reoperation within 1 year after AVF surgery. The patients were divided into two groups according to the presence or absence of early AVF failure, and the prognosis of each group was examined. The association between early AVF failure and outcomes (3-year all-cause mortality, CVD mortality, and MACE) was determined using Cox proportional hazards regression analysis. RESULTS During the 3-year follow-up, 75 (20.9%) patients died (cardiovascular death: n = 39) and 145 patients developed MACE. According to the multivariable analysis, the early AVF failure group had a significantly higher risk of 3-year all-cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09-1.83; p = 0.009), CVD mortality (HR, 1.54; 95% CI, 1.29-2.08; p < 0.001), and MACE (HR, 1.68; 95% CI, 1.25-2.26; p < 0.001). When the patients were stratified by age, early AVF failure was associated with 3-year all-cause mortality in all groups except for the younger group (<65 years of age). CONCLUSIONS Early AVF failure was associated with an increased risk of 3-year all-cause mortality, CVD mortality, and MACE.
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Affiliation(s)
- Aiko Okubo
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Toshiki Doi
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yumi Yamada
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Kenichi Morii
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshiko Nishizawa
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Kazuomi Yamashita
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Yasuhiro Fudaba
- Department of Surgery, Ichiyokai Harada Hospital, Hiroshima, Japan
| | | | - Sonoo Mizuiri
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Koji Usui
- Ichiyokai Ichiyokai Clinic, Hiroshima, Japan
| | | | | | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
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Gasparin C, Lima HDN, Regueira A, Marques AGB, Erzinger G. Predictors of arteriovenous fistula maturation in hemodialysis patients: a prospective cohort from an ambulatory surgical center in Joinville, Brazil. J Bras Nefrol 2023; 45:287-293. [PMID: 36511850 PMCID: PMC10697164 DOI: 10.1590/2175-8239-jbn-2022-0120en] [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: 07/20/2022] [Accepted: 10/10/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The high rate of arteriovenous fistula maturation failure is a concern in a scenario of growing numbers of patients on hemodialysis. Non-vascular factors tied to maturation success have not been fully discussed. METHODS This prospective observational cohort study included patients with CKD on dialysis or pre-dialysis prescribed arteriovenous fistula creation for the first time in an ambulatory surgical center in Joinville, Brazil, from January 2021 to July 2021. Anthropometric aspects, sociodemographic characteristics, comorbidities, and vascular parameters observed in Doppler ultrasound were analyzed. Variables associated with maturation were analyzed in multivariate models by logistic regression. RESULTS Eighty-eight of 145 participants (60.1%) were males. Included patients had a median age of 59 years. Successful arteriovenous fistula maturation occurred in 113 (77.9%) patients. Factors such as increased BMI, hematocrit, arm circumference, and skinfold thickness were associated with lower chances of arteriovenous fistula maturation in univariate analysis. On the other hand, larger vein and artery diameter and fistulas in the more proximal portion of the arm were associated with higher maturation success. In multivariate analysis, smoking and larger skinfold and arm circumference were associated with lower chances of successful maturation. Increased systolic blood pressure and vein diameter were associated with greater chance of success. CONCLUSION In addition to the vascular parameters assessed in Doppler ultrasonography, factors related to obesity and/or nutritional aspects may influence arteriovenous fistula maturation.
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Affiliation(s)
- Claudete Gasparin
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
- Fundação Pró-Rim, Joinville, SC, Brazil
| | - Helbert do Nascimento Lima
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
| | | | | | - Gilmar Erzinger
- Universidade da Região de Joinville, Programa de Pós-Graduação em
Saúde e Meio Ambiente, Joinville, SC, Brazil
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8
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Gasparin C, Lima HDN, Regueira Filho A, Marques AGB, Erzinger G. Preditores da maturação de fístula arteriovenosa de pacientes em hemodiálise: coorte prospectiva de um centro cirúrgico ambulatorial, Joinville, Brasil. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0120pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Resumo Introdução: A alta taxa de falha na maturação da fístula arteriovenosa é motivo de preocupação para o crescente número de pacientes em hemodiálise. Os fatores não vasculares não foram totalmente estudados em relação ao sucesso da maturação. Métodos: Estudo de coorte prospectivo, observacional de pacientes com DRC diálise ou pré-diálise encaminhados para a primeira criação de fístula arteriovenosa em um centro cirúrgico ambulatorial de Joinville, Brasil, de janeiro de 2021 a julho de 2021. Aspectos antropométricos, características sociodemográficas, comorbidades, além de fatores vasculares verificados pelo ultrassom Doppler. As variáveis associadas à maturação foram analisadas em modelos multivariados por regressão logística. Resultados: Dos 145 pacientes participantes, 88 (60,1%) eram homens, com idade mediana de 59 anos. Houve sucesso na maturação da fístula arteriovenosa em 113 (77,9%) pacientes. Fatores como aumento do IMC, hematócrito, circunferência do braço e valor das dobras cutâneas foram associados a menor chance de maturação da fístula arteriovenosa na análise univariada. Por outro lado, o maior diâmetro da veia e da artéria e fístulas na porção mais proximal do membro superior foram associados a maior sucesso de maturação. Na análise multivariada, tabagismo, maior dobra cutânea e circunferência do braço foram associados a menor chance de sucesso da maturação. O aumento da pressão arterial sistólica e o do diâmetro da veia foram associados a maior chance de sucesso. Conclusão: Além dos aspectos vasculares avaliados pela ultrassonografia Doppler, fatores relacionados à obesidade e/ou a aspectos nutricionais podem influenciar a maturação da fístula arteriovenosa.
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Affiliation(s)
- Claudete Gasparin
- Universidade da Região de Joinville, Brazil; Fundação Pró-Rim, Brazil
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Zhang Y, Thamer M, Lee T, Crews DC, Allon M. Racial Disparities in Arteriovenous Fistula Use Among Hemodialysis Patients: The Role of Surgeon Supply. Kidney Int Rep 2022; 7:1575-1584. [PMID: 35812267 PMCID: PMC9263254 DOI: 10.1016/j.ekir.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction Factors contributing to racial disparities in arteriovenous fistula (AVF) use among hemodialysis (HD) patients remain poorly defined. We evaluated whether the Black/White race disparity in AVF use is affected by vascular access surgeon supply. Methods Using Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb) and Medicare claims data from the US Renal Data System (USRDS), competing risk analyses of all US patients initiating HD with a central venous catheter (CVC) from 2016 to 2017 (n = 100,227) were performed. The likelihood of successful AVF use was compared between Black and White patients after adjusting for vascular access surgeon supply. Results Compared with the first (lowest) quartile of surgeon supply, higher supply levels were associated with modestly increased adjusted likelihoods of overall AVF use: 4% (95% CI 1.4%-7.2%), 4% (95% CI 1.4%-7.1%), and 3% (0.0%-6.1%) for second, third, and fourth quartiles, respectively. Although areas with lower surgeon supply had a higher proportion of Black patients, residing in areas with a greater surgeon supply was not significantly associated with a mitigation in racial disparity. Specifically, compared with White patients, Black patients were 10% (95% CI 7%-13%) and 8% (95% CI 5%-11%) less likely to have successful AVF use in lower and higher surgeon supply areas, respectively. Conclusion Regions with lower surgeon supply had a higher proportion of Black dialysis patients. However, racial disparities in AVF use among patients initiating HD with a CVC were similar in regions with a high and low surgeon supply. Other patient, provider, and practice factors should be evaluated toward mitigating lower rates of AVF use among Black HD patients.
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Affiliation(s)
- Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland, USA
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland, USA
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
- Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Alabama, USA
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10
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Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors. Ann Vasc Surg 2022; 87:495-501. [PMID: 35780948 DOI: 10.1016/j.avsg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.
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11
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Mousavi SF, Sepehri MM, Khasha R, Mousavi SH. Improving vascular access creation among hemodialysis patients: An agent-based modeling and simulation approach. Artif Intell Med 2022; 126:102253. [DOI: 10.1016/j.artmed.2022.102253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 01/25/2022] [Accepted: 01/29/2022] [Indexed: 11/02/2022]
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12
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Ng S, Pascoe EM, Johnson DW, Hawley CM, Polkinghorne KR, McDonald S, Clayton PA, Rabindranath KS, Roberts MA, Irish AB, Viecelli AK. Center-Effect of Incident Hemodialysis Vascular Access Use: Analysis of a Bi-national Registry. KIDNEY360 2021; 2:674-683. [PMID: 35373038 PMCID: PMC8791318 DOI: 10.34067/kid.0005742020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/27/2021] [Indexed: 02/04/2023]
Abstract
Background Commencing hemodialysis (HD) with an arteriovenous access is associated with superior patient outcomes compared with a catheter, but the majority of patients in Australia and New Zealand initiate HD with a central venous catheter. This study examined patient and center factors associated with arteriovenous fistula/graft access use at HD commencement. Methods We included all adult patients starting chronic HD in Australia and New Zealand between 2004 and 2015. Access type at HD initiation was analyzed using logistic regression. Patient-level factors included sex, age, race, body mass index (BMI), smoking status, primary kidney disease, late nephrologist referral, comorbidities, and prior RRT. Center-level factors included size; transplant capability; home HD proportion; incident peritoneal dialysis (average number of patients commencing RRT with peritoneal dialysis per year); mean weekly HD hours; average blood flow; and achievement of phosphate, hemoglobin, and weekly Kt/V targets. The study included 27,123 patients from 61 centers. Results Arteriovenous access use at HD commencement varied four-fold from 15% to 62% (median 39%) across centers. Incident arteriovenous access use was more likely in patients aged 51-72 years, males, and patients with a BMI of >25 kg/m2 and polycystic kidney disease; but use was less likely in patients with a BMI of <18.5 kg/m2, late nephrologist referral, diabetes mellitus, cardiovascular disease, chronic lung disease, and prior RRT. Starting HD with an arteriovenous access was less likely in centers with the highest proportion of home HD, and no center factor was associated with higher arteriovenous access use. Adjustment for center-level characteristics resulted in a 25% reduction in observed intercenter variability of arteriovenous access use at HD initiation compared with the model adjusted for only patient-level characteristics. Conclusions This study identified several patient and center factors associated with incident HD access use, yet these factors did not fully explain the substantial variability in arteriovenous access use across centers.
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Affiliation(s)
- Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Elaine M. Pascoe
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Carmel M. Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Kevan R. Polkinghorne
- Department of Nephrology, Monash Medical Center, Melbourne, Australia
- Department of Medicine, Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Philip A. Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Matthew A. Roberts
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Ashley B. Irish
- Medical School, University of Western Australia, Perth, Australia
- Department of Nephrology, Fiona Stanley Hospital, Perth, Australia
| | - Andrea K. Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
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13
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Copeland TP, Lawrence PF, Woo K. Surgeon Factors Have a Larger Effect on Vascular Access Type and Outcomes than Patient Factors. J Surg Res 2021; 265:33-41. [PMID: 33882377 DOI: 10.1016/j.jss.2021.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/22/2021] [Accepted: 02/27/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Though patient factors are frequently linked to hemodialysis vascular access selection and outcomes, variability by surgeon and surgeon specialty may play a role as well. The objective of this study is to examine the extent to which individual surgeons influence selection of vascular access type, removal of tunneled hemodialysis catheter (THC), and repeat vascular access. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A national claims database was used to identify patients initiating hemodialysis via a THC between 2011 and 2017. Likelihood of repeat AVF/AVG was analyzed using mixed-effects logistic regression. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Weibull proportional hazard models. Individual surgeon identifier served as the random effect in all models. RESULTS 6,908 AVF/AVG met the inclusion criteria: 5366 (78%) AVF and 1,542 (22%) AVG. Surgeon specialty only had a significant influence on access type, with vascular surgeons having 26% greater odds of performing AVG compared to general surgeons (P = 0.006). Relative to the other independent variables, individual surgeon identifier had the greatest magnitude of effect on access type (median odds ratio, 2.36; 95% CI, 2.09-2.72). Individual surgeon identifier had the second greatest magnitude of effect likelihood of THC removal (median hazard ratio, 1.66; 95% CI, 1.58-1.77) and second access (median hazard ratio, 1.83; 95% CI, 1.66-2.05), in both cases second only to the effect of AVG, which was associated with greater likelihood of THC removal (hazard ratio 1.91; 95% CI, 1.77-2.07) and lower likelihood of second access (hazard ratio 0.44; 95% CI, 0.38-0.52). CONCLUSION Individual surgeons are associated with greater variation in vascular access type and likelihood of repeat access than surgeon specialty and measurable patient demographics/co-morbidities. Future research should focus on identifying which surgeon factors are associated with improved outcomes.
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Affiliation(s)
- Timothy P Copeland
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, California
| | - Peter F Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, California
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, California.
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14
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Smojver H, Neretljak I, Sučić M, Erdelez L. Learning curve for arteriovenous fistula creation. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_59_21] [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] Open
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15
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Han Y, Saran R. Global Dialysis Perspective: United States. KIDNEY360 2020; 1:1137-1142. [PMID: 35368785 DOI: 10.34067/kid.0001602020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/14/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Yun Han
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.,Department of Epidemiology, Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, Michigan
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16
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Fila B. Quality indicators of vascular access procedures for hemodialysis. Int Urol Nephrol 2020; 53:497-504. [PMID: 32869172 DOI: 10.1007/s11255-020-02609-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
Improved quality of surgical procedures can minimize complications, the morbidity and mortality of patients, and in addition decrease costs. Quality indicators in angioaccess surgery are, however, not clearly defined. The aim of this review article is therefore to find the most important factors affecting quality in vascular access procedures. Even though autogenous arteriovenous fistula has been recognized as the best vascular access for hemodialysis, the high percentage of unsuccessful attempts associated with it raises the question about quality assessment in angioaccess procedures. Unfortunately, quality indicators in vascular access surgery are difficult to define and measure. Among those that can be obtained are: the time between the presentation of patients to a vascular access surgeon and the construction of a fistula, the percentage of autogenous fistulas, the percentage of functional fistulas in prevalent and incident hemodialysis patients, the percentage of creation of a functional fistula in the first attempt, and durability of an access. Organizational improvement and educational programs are also necessary at institutions with inferior quality indicators of vascular access care, as even small increase in quality may mean the survival of an individual patient. Quality indicators in angioaccess surgery can also serve as a helpful tool in choosing the best vascular access surgeon or vascular access center. The choice can consequently reflect on increased survival and quality of life in patients needing hemodialysis.
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Affiliation(s)
- Branko Fila
- Department of Vascular Surgery, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000, Zagreb, Croatia.
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17
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Lee SYD, Xiang J, Kshirsagar AV, Steffick D, Saran R, Wang V. Supply and Distribution of Vascular Access Physicians in the United States: A Cross-Sectional Study. ACTA ACUST UNITED AC 2020; 1:763-771. [PMID: 34355198 DOI: 10.34067/kid.0002722020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Because functioning permanent vascular access (arteriovenous fistula [AVF] or arteriovenous graft [AVG]) is crucial for optimizing patient outcomes for those on hemodialysis, the supply of physicians placing vascular access is key. We investigated whether area-level demographic and healthcare market attributes were associated with the distribution and supply of AVF/AVG access physicians in the United States. Methods A nationwide registry of physicians placing AVFs/AVGs in 2015 was created using data from the United States Renal Data System and the American Physician Association's Physician Masterfile. We linked the registry information to the Area Health Resource File to assess the supply of AVF/AVG access physicians and their professional attributes by hospital referral region (HRR). Bivariate analysis and Poisson regression were performed to examine the relationship between AVF/AVG access physician supply and demographic, socioeconomic, and health resource conditions of HRRs. The setting included all 50 states. The main outcome was supply of AVF/AVG access physicians, defined as the number of physicians performing AVF and/or AVG placement per 1000 prevalent patients with ESKD. Results The majority of vascular access physicians were aged 45-64 (average age, 51.6), male (91%), trained in the United States (76%), and registered in a surgical specialty (74%). The supply of physicians varied substantially across HRRs. The supply was higher in HRRs with a higher percentage white population (β=0.44; SEM=0.14; P=0.002), lower unemployment rates (β=-10.74; SEM=3.41; P=0.002), and greater supply of primary care physicians (β=0.18; SEM=0.05; P=0.001) and nephrologists (β=15.89; SEM=1.22; P<0.001). Conclusions Geographic variation was observed in the supply of vascular access physicians. Higher supply of such specialist physicians in socially and economically advantaged areas may explain disparities in vascular access and outcomes in the United States and should be the subject of further study and improvement.
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Affiliation(s)
- Shoou-Yih D Lee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.,Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Jie Xiang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Abhijit V Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Diane Steffick
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
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18
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Gumus F. Patency Rates After Successful Arteriovenous Fistula Thrombectomy: Relevance of the Flow/d-Dimer Ratio in the Decision-Making. Vasc Endovascular Surg 2020; 54:670-675. [PMID: 32720863 DOI: 10.1177/1538574420945064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Surgical thrombectomy for acute arteriovenous fistula (AVF) thrombosis is one of the primary salvage intervention. The independent risk factors affecting the patency of AVF after a successful thrombectomy are yet unknown. Here, the author aimed to report the results of surgically corrected AVFs and the independent risk factors which may cause early failure following the surgical salvage. METHODS The study cohort comprised 24 patients who had acute AVF thrombosis and underwent successful surgical thrombectomy in the first 24 to 48 hours between January 2016 and April 2020 in our center. The study group was divided into patients with recurrent AVF thrombosis (n = 11, 45.8%) and without recurrent AVF thrombosis (n = 13, 54.1%) following surgical thrombectomy with a follow-up of 22.4 ± 6.8 months. Postthrombectomy primary and secondary patency of AVF were also evaluated. RESULTS The mean age of the cohort was 58.1 ± 15.2 years. A simple thrombectomy was performed for all cases. Only 2 cases have required a revision at the anastomosis due to severe intimal hyperplasia. Postthrombectomy primary patency rate was 45.5% for 18 months. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.81 (95% CI: 0.35-0.94, P = .006) for flow (mL)/d-dimer (ng/mL) <0.63 in predicting recurrent AVF thrombosis following surgical thrombectomy. CONCLUSIONS Flow (mL)/d-dimer (ng/mL) <0.63 was independent predictor of recurrent thrombosis (RT) of a surgically salvaged AVF. The patients at risk for RT or who may benefit from further intervention should be identified with predictive parameters.
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Affiliation(s)
- Fatih Gumus
- Department of Cardiovascular Surgery, Bartın State Hospital, Turkey
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19
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Hicks CW, Wang P, Kernodle A, Lum YW, Black JH, Makary MA. Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access. JAMA Surg 2020; 154:844-851. [PMID: 31188411 DOI: 10.1001/jamasurg.2019.1736] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009. Objective To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use. Design, Setting, and Participants This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed. Exposures Placement of an AVF or AVG for initial permanent hemodialysis access. Main Outcomes and Measures A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use. Results A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution. Conclusions and Relevance In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ying W Lum
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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20
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Sharp S, Gascue L, Goldman D, Lawrence PF, Romley J, Woo K. Higher Surgeon Procedure Volume is Associated with Improved Hemodialysis Vascular Access Outcomes. Am Surg 2020. [DOI: 10.1177/000313481908501001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AV G ( P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure ( P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.
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Affiliation(s)
- Sydney Sharp
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Gascue
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | - Dana Goldman
- School of Pharmacy, University of Southern California, Los Angeles, California; and
- Sol Price School of Public Policy, University of Southern California, Los Angeles, California
| | - Peter F. Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - John Romley
- Sol Price School of Public Policy, University of Southern California, Los Angeles, California
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
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21
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Can Native Arteriovenous Fistula Be Safely Made by Trainees? Comparison of Results of Native Arteriovenous Fistula for Vascular Access Made by Trainees with that by Consultant. Indian J Surg 2020. [DOI: 10.1007/s12262-019-01963-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Stegmayr B, Willems C, Groth T, Martins A, Neves NM, Mottaghy K, Remuzzi A, Walpoth B. Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions. Int J Artif Organs 2020; 44:3-16. [PMID: 32438852 PMCID: PMC7780365 DOI: 10.1177/0391398820922231] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients’ quality of life.
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Affiliation(s)
- Bernd Stegmayr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Christian Willems
- Department of Biomedical Materials, Institute of Pharmacy, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Thomas Groth
- Department of Biomedical Materials, Institute of Pharmacy, Martin Luther University of Halle-Wittenberg, Halle, Germany.,Interdisciplinary Center of Material Research, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Albino Martins
- 3B's Research Group, I3Bs-Research Institute on Biomaterials, Biodegradables and Biomimetics of University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark-Parque de Ciência e Tecnologia, Barco, Portugal
| | - Nuno M Neves
- 3B's Research Group, I3Bs-Research Institute on Biomaterials, Biodegradables and Biomimetics of University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, AvePark-Parque de Ciência e Tecnologia, Barco, Portugal
| | - Khosrow Mottaghy
- Department of Physiology, RWTH Aachen University, Aachen, Germany
| | | | - Beat Walpoth
- Department of Cardiovascular Surgery (Emeritus), University of Geneva, Geneva, Switzerland
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Farrington CA, Robbin ML, Lee T, Barker-Finkel J, Allon M. Early Predictors of Arteriovenous Fistula Maturation: A Novel Perspective on an Enduring Problem. J Am Soc Nephrol 2020; 31:1617-1627. [PMID: 32424000 DOI: 10.1681/asn.2019080848] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 03/26/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Preoperative ultrasound mapping is routinely used to select vessels meeting minimal threshold diameters for surgical arteriovenous fistula (AVF) creation but fails to improve AVF maturation rates. This suggests a need to reassess the preoperative ultrasound criteria used to optimize AVF maturation. METHODS We retrospectively identified 300 catheter-dependent patients on hemodialysis with a new AVF created between 2010 and 2016. We then evaluated the associations of preoperative vascular measurements and hemodynamic factors with unassisted AVF maturation (successful use for dialysis without prior intervention) and overall maturation (successful use with or without prior intervention). Multivariable logistic regression was used to identify preoperative factors associated with unassisted and overall AVF maturation. RESULTS Unassisted AVF maturation associated with preoperative arterial diameter (adjusted odds ratio [aOR], 1.50 per 1-mm increase; 95% confidence interval [95% CI], 1.23 to 1.83), preoperative systolic BP (aOR, 1.16 per 10-mm Hg increase; 95% CI, 1.05 to 1.28), and left ventricular ejection fraction (aOR, 1.07 per 5% increase; 95% CI, 1.01 to 1.13). Overall AVF maturation associated with preoperative arterial diameter (aOR, 1.36 per 1-mm increase; 95% CI, 1.10 to 1.66) and preoperative systolic BP (aOR, 1.17; 95% CI, 1.06 to 1.30). Using receiver operating curves, the combination of preoperative arterial diameter, systolic BP, and left ventricular ejection fraction was fairly predictive of unassisted maturation (area under the curve, 0.69). Patient age, sex, race, diabetes, vascular disease, obesity, and AVF location were not associated with maturation. CONCLUSIONS Preoperative arterial diameter may be an under-recognized predictor of AVF maturation. Further study evaluating the effect of preoperative arterial diameter and other hemodynamic factors on AVF maturation is needed.
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Affiliation(s)
- Crystal A Farrington
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle L Robbin
- Department of Radiology, University of Alabama at Birmingham, Birmingham Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama
| | - Jill Barker-Finkel
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Patel DV, Saad TF, Hentschel DM. Advances in Endovascular Salvage. Adv Chronic Kidney Dis 2020; 27:219-227. [PMID: 32891306 DOI: 10.1053/j.ackd.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 11/11/2022]
Abstract
Endovascular salvage plays an important role in dialysis access care. Angioplasty using standard high- and ultrahigh-pressure balloon is the mainstay of therapy, while the use of cutting balloons and balloons designed to deliver pharmacologically active agents to the site of recurrent stenosis is demonstrating improved performance for specific targets that have to be further defined. Stents and stent grafts are additional tools for use at access segments predisposed for inward remodeling such as the cephalic arch or basilic swing point. The juxta-anastomotic segment has particular relevance in maturation of autogenous accesses as well as maintenance of access flow volume. Depending on the location of the access in the forearm or upper arm, and which artery is feeding into the access vein, any type of balloon angioplasty and stent or stent graft placement may be used to establish and maintain patency. Successful management of dialysis access options relies on preservation of venous real estate during the chronic kidney disease phase of kidney disease as well as on knowledgeable evaluation of arm veins and the access by physical examination, bed side ultrasound, and angiographic studies.
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25
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Meyer A, Flicker E, König ST, Vetter AS. Determinants of successful arteriovenous fistulae creation including intraoperative transit time flow measurement. J Vasc Access 2019; 21:387-394. [PMID: 31621478 DOI: 10.1177/1129729819874312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The prevalence of hemodialysis patients is increasing, and it is important to create the arteriovenous fistula as early as possible to avoid hemodialysis by central venous catheter. International guidelines recommend arteriovenous fistula as the vascular access of first choice. Arteriovenous fistulae are associated with a failure rate of 23%. The success of an arteriovenous fistula can be evaluated intraoperatively by physical examination and by measuring the blood flow. OBJECTIVES The aim of the study is to describe the predictive value of various factors for fistula maturation in the context to the current literature. METHODS We report on a prospective cohort study of 41 patients, undergoing a primary arteriovenous fistula at the upper extremity. The primary endpoint of the study was the successful fistula maturation after 6 weeks. RESULTS The intraoperative measurement of the blood flow in the outflow vein has been identified as the unique significant parameter for the fistula maturation. CONCLUSION The predictive value of intraoperative flow measurement is superior to intraoperative physical examination and could help reduce the fistula dysmaturation rate. Intraoperative transit time flow measurement is an easy method and can be used to predict successful fistula maturation in a high percentage rate.
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Affiliation(s)
- Alexander Meyer
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
| | - Eberhard Flicker
- Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany.,Nephrological Center Moers, Moers, Germany
| | - Sascha T König
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
| | - Anne Sabine Vetter
- Department of General and Vascular Surgery, Johanniter Krankenhaus Rheinhausen, Duisburg, Germany.,Interdisciplinary Vascular Access Center Duisburg, Duisburg, Germany
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26
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Shahinian VB, Zhang X, Tilea AM, He K, Schaubel DE, Wu W, Pisoni R, Robinson B, Saran R, Woodside KJ. Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study. Am J Kidney Dis 2019; 75:158-166. [PMID: 31585684 DOI: 10.1053/j.ajkd.2019.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015. EXPOSURES Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation. OUTCOMES Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014. ANALYTICAL APPROACH Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects. RESULTS Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile. LIMITATIONS The study relied on administrative data, limiting capture of some factors affecting access outcomes. CONCLUSIONS There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.
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Affiliation(s)
- Vahakn B Shahinian
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Xiaosong Zhang
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Anca M Tilea
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Kevin He
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Wenbo Wu
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, University of Michigan, Ann Arbor, MI
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
| | - Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
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Allon M. Lessons From International Differences in Vascular Access Practices and Outcomes. Am J Kidney Dis 2019; 71:452-454. [PMID: 29579416 DOI: 10.1053/j.ajkd.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/08/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
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28
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Al Adas Z, Haddad G, Patel BC, Kumbar L, Al-Abid B, Balraj P, Kabbani LS. Post-anastomotic venous stenosis after Optiflow deployment: An unexpected outcome. SAGE Open Med Case Rep 2019; 7:2050313X19851002. [PMID: 31210936 PMCID: PMC6545635 DOI: 10.1177/2050313x19851002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 04/18/2019] [Indexed: 11/16/2022] Open
Abstract
Arteriovenous fistula failure represents a major cause of hospitalization and a significant economic burden for end-stage renal disease patients on hemodialysis. The Optiflow (Bioconnect Systems Inc., Ambler, PA) is a new device developed to improve arteriovenous fistula outcomes and decrease failure rates by reducing the risk of stenosis and improving maturation rates. This case report describes a 50-year-old male with hypertensive nephropathy on dialysis who had multiple arteriovenous fistula failures in the past. He was scheduled to undergo brachiocephalic fistula construction using the Optiflow device. After 8 months of use, the new fistula developed a peri-anastomotic venous stenosis, just distal to the Optiflow device. To our knowledge, this is the first time such a complication has been reported.
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Affiliation(s)
- Ziad Al Adas
- Department of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - George Haddad
- Department of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Bhavin C Patel
- Department of Nephrology, Henry Ford Hospital, Detroit, MI, USA
| | | | - Baha Al-Abid
- Department of Nephrology, Henry Ford Hospital, Detroit, MI, USA
| | - Praveen Balraj
- Department of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Loay S Kabbani
- Department of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
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29
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Weigert A, Drozdz M, Silva F, Frazão J, Alsuwaida A, Krishnan M, Kleophas W, Brzosko S, Johansson FK, Jacobson SH. Influence of gender and age on haemodialysis practices: a European multicentre analysis. Clin Kidney J 2019; 13:217-224. [PMID: 32296527 PMCID: PMC7147302 DOI: 10.1093/ckj/sfz069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
Background Women of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist. Methods This retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups. Results Body weight and the prescribed dialysis blood flow rate were lower in women (P < 0.001), whereas treated blood volume per kilogram per session was higher (P < 0.01), resulting in higher single-pool Kt/V in women than in men (P < 0.001). Haemoglobin was significantly higher in men (P = 0.01), but the proportion of patients within target range (10–12 g/dL) was similar. Men more often had an arteriovenous fistula than women (80% versus 73%; P < 0.01) with a similar percentage of central venous catheters. There were no gender-specific differences in terms of dialysis adequacy, anaemia parameters or mineral and bone disorder parameters, or in the attainment of KDIGO targets between women and men >80 years of age. Conclusions This large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.
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Affiliation(s)
| | - Maciej Drozdz
- Department of Nephrology, DaVita International, Krakow, Poland
| | - Fatima Silva
- Department of Nephrology, DaVita, Lisbon, Portugal
| | - João Frazão
- Department of Nephrology, DaVita, Porto, Portugal
| | | | | | | | | | - Fredrik K Johansson
- Unit for Medical Statistics, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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30
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Gameiro J, Ibeas J. Factors affecting arteriovenous fistula dysfunction: A narrative review. J Vasc Access 2019; 21:134-147. [PMID: 31113281 DOI: 10.1177/1129729819845562] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vascular access dysfunction is one of the most important causes of morbidity and mortality in haemodialysis patients, contributing to up to one third of hospitalisations and accounting for a significant amount of the health care costs of these patients. In the past decades, significant scientific advances in understanding mechanisms of arteriovenous fistula maturation and failure have contributed to an increase in the amount of research into techniques for creation and strategies for arteriovenous fistula dysfunction prevention and treatment, in order to improve patient care and outcomes. The aim of this review is to describe the pathogenesis of vascular access failure and provide a comprehensive analysis of the associated risk factors and causes of vascular access failure, in order to interpret possible future therapeutic approaches. Arteriovenous fistula failure is a multifactorial process resulting from the combination of upstream and downstream events with consequent venous neo-intimal hyperplasia and/or inadequate outward remodelling. Inflammation appears to be central in the biology of arteriovenous fistula dysfunction but important triggers still need to be revealed. Given the significant association of arteriovenous fistula failure and patient's prognosis, it is therefore imperative to further research in this area in order to improve prevention, surveillance and treatment, and ultimately patient care and outcomes.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Jose Ibeas
- Nephrology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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31
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Vatazin AV, Zulkarnaev AB, Fominykh NM, Kardanakhishvili ZB, Strugailo EV. The creation and maintenance of vascular access for chronic hemodialysis in the Moscow region: a five-year experience of a regional center. ACTA ACUST UNITED AC 2019. [DOI: 10.15825/1995-1191-2018-4-44-53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aim:to analyze the results of the regional center for the creation and maintenance of vascular access for hemodialysis.Materials and methods.We performed a retrospective analysis. In five years (2012–2016) we performed 3,837 different operations on vascular access (VA) in 1,862 patients.Results.There is a strong dependence of type VA and the cause of CKD 5D. At the time of the HD start, the proportion of arteriovenous fistula (AVF), synthetic vascular graft (SVG) and central venous catheter (CVC) was 73.7, 0.3 and 26% for glomerulonephritis; 58.4, 0.4 and 41% for pyelonephritis; 53, 1 and 26% for diabetes mellitus; 32, 8 and 60% for polycystic disease and 33, 2 and 65% for systemic processes, respectively. After one year on HD the shares of AVF, SVG and CVC were 89, 2 and 9% for glomerulonephritis; 76, 6 and 18% of pyelonephritis; 70, 5 and 25% for diabetes mellitus; 68, 10 and 22% for polycystic disease and 53, 5 and 42% for systemic processes, respectively. In a case of start of HD via AVF, five years survival was 61% [95% CI 51.8; 71.9]; in a case of start HD via CVC with followed by conversion to AVF – 53.9% [95% CI 42.5; 67]; in a case of CVC remained the only access – 31.6% [21.4; 41.4]. Non-maturation of AVF was observed in 5.9% of new AVF (the risk increased in a case of diabetes mellitus), early thrombosis (before the first use of AVF) was observed in 12.7% of new AVF (the risk increased with diabetes, polycystic and systemic diseases). Creation of AVF a week before the start of HD or 1–2 weeks later significantly increased the risk of thrombosis. Primary patency in a year, three and five years was 77.2% (95% CI 71.7; 81.7); 48% (95% CI 41.6, 54.1); 34.1% (95% CI 27.8, 40.5) respectively; secondary patency – 87% [95% CI 83.7; 89.7]; 74.4% [95% CI 70.3; 78,12]; 60.9% [95% CI 56.4; 65.1] respectively. The use of temporary CVC is associated with a three-fold increase of the risk of infection compared with permanent CVC: IRR 3,31 (2,46; 4,43), p < 0,0001.Conclusion.A more detailed analysis is required to identify risk factors for complications of vascular access and to optimize approaches to its creation and maintenance.
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Affiliation(s)
- A. V. Vatazin
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
| | - A. B. Zulkarnaev
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
| | - N. M. Fominykh
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
| | | | - E. V. Strugailo
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
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Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, Haage P, Hamilton G, Hedin U, Kamper L, Lazarides MK, Lindsey B, Mestres G, Pegoraro M, Roy J, Setacci C, Shemesh D, Tordoir JH, van Loon M, ESVS Guidelines Committee, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Naylor R, Vega de Ceniga M, Vermassen F, Verzini F, ESVS Guidelines Reviewers, Mohaupt M, Ricco JB, Roca-Tey R. Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:757-818. [DOI: 10.1016/j.ejvs.2018.02.001] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Woodside KJ, Bell S, Mukhopadhyay P, Repeck KJ, Robinson IT, Eckard AR, Dasmunshi S, Plattner BW, Pearson J, Schaubel DE, Pisoni RL, Saran R. Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study. Am J Kidney Dis 2018; 71:793-801. [PMID: 29429750 PMCID: PMC6551206 DOI: 10.1053/j.ajkd.2017.11.020] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. STUDY DESIGN Nonconcurrent observational cohort study. SETTING & PARTICIPANTS Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. PREDICTORS Demographics, geographic location, dialysis vintage, comorbid conditions. OUTCOMES Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. MEASUREMENTS AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014. RESULTS In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. LIMITATIONS This study relies on administrative data, with monthly recording of access use. CONCLUSIONS We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.
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Affiliation(s)
- Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sarah Bell
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Purna Mukhopadhyay
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Kaitlyn J Repeck
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Ian T Robinson
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Ashley R Eckard
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Sudipta Dasmunshi
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Brett W Plattner
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
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Venkatesan VK, McHenry ZD, Ertel AE, Ahmad SA, Sussman JJ, Hanseman D, Shah SA, Abbott DE. Programmatic change leads to enhanced resource utilization and efficiency in port placement. J Surg Res 2018; 229:294-301. [PMID: 29937005 DOI: 10.1016/j.jss.2018.04.030] [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] [Received: 12/10/2017] [Revised: 04/02/2018] [Accepted: 04/13/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Central venous port (CVP) placement is performed by a variety of surgeons in different subspecialties, and our previous work suggests that individual surgeons-regardless of training-are the strongest predictor of outcomes. We sought to prospectively evaluate a programmatic shift toward a resource-conscious, patient-focused algorithm for this common and simple surgical procedure. MATERIALS AND METHODS After implementation of a systems-level program for efficient CVP placement, 78 CVPs were placed by a single surgeon. Primary outcomes were procedure time, total operating room (OR) time, total facility time, and procedure-related complications. These prospective data were compared with retrospective cohorts of surgically placed and interventional radiology-placed CVP. Demographic data were analyzed by chi-square analysis, whereas time data were analyzed by the Wilcoxon rank-sum test. RESULTS The programmatic delivery (prospective) set showed significantly shorter procedural (median 16 min versus 26-40, P <0.05), OR times (median 36 min versus 46-70, P <0.05), and facility times (median 235 min versus 299-319, P <0.05) except for the interventional radiology facility time (median 187 versus 235, P <0.05). The range of OR time savings with the prospective versus comparison groups was 10-34 min, representing 22%-49% reductions in OR time (P <0.05). Complication rates were not significantly different (P = 0.13). CONCLUSIONS Through a programmatic change emphasizing efficiency and patient-centered outcomes, procedural/OR/facility time can be reduced greatly without changing complication rates. These data provide compelling evidence that common and ostensibly simple operative procedures can be substantially improved upon with thoughtful, data-driven systems-level enhancements.
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Affiliation(s)
- Vijay K Venkatesan
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio; Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Zachary D McHenry
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Audrey E Ertel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Syed A Ahmad
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Jeffrey J Sussman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Dennis Hanseman
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Pisoni RL, Zepel L, Fluck R, Lok CE, Kawanishi H, Süleymanlar G, Wasse H, Tentori F, Zee J, Li Y, Schaubel D, Burke S, Robinson B. International Differences in the Location and Use of Arteriovenous Accesses Created for Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2018; 71:469-478. [DOI: 10.1053/j.ajkd.2017.09.012] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 09/13/2017] [Indexed: 11/11/2022]
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Abstract
Internationally, vascular access (VA) surgery is delivered in a varied and diverse fashion and subsequently, training in vascular access is poorly defined. Experience of VA during surgical training has implications on future practice. The scope of VA procedures is increasing, yet the focus in vascular training remains largely in the technical aspects of surgery rather than the more comprehensive aspects of surgery applied to dialysis and renal care. To achieve special skills in vascular access surgery may require a change to traditional training with an additional focus on developing an extended portfolio of knowledge and skills. A small number of specialized courses and training facilities are developing to address these issues.
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Dumaine CS, Brown RS, MacRae JM, Oliver MJ, Ravani P, Quinn RR. Central venous catheters for chronic hemodialysis: Is "last choice" never the "right choice"? Semin Dial 2017; 31:3-10. [PMID: 29098715 DOI: 10.1111/sdi.12655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.
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Affiliation(s)
- Chance S Dumaine
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert S Brown
- Division of Nephrology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jennifer M MacRae
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Pietro Ravani
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Alencar de Pinho N, Coscas R, Metzger M, Labeeuw M, Ayav C, Jacquelinet C, Massy ZA, Stengel B. Predictors of nonfunctional arteriovenous access at hemodialysis initiation and timing of access creation: A registry-based study. PLoS One 2017; 12:e0181254. [PMID: 28749967 PMCID: PMC5531527 DOI: 10.1371/journal.pone.0181254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 06/28/2017] [Indexed: 12/21/2022] Open
Abstract
Determinants of nonfunctional arteriovenous (AV) access, including timing of AV access creation, have not been sufficiently described. We studied 29 945 patients who had predialysis AV access placement and were included in the French REIN registry from 2005 through 2013. AV access was considered nonfunctional when dialysis began with a catheter. We estimated crude and adjusted odds ratio (OR) with 95% confidence intervals (CI) of nonfunctional versus functional AV access associated with case-mix, facility characteristics, and timing of AV access creation. Analyses were stratified by dialysis start condition (planned or as an emergency) and comorbidity profile. Overall, 18% patients had nonfunctional AV access at hemodialysis initiation. In the group with planned dialysis start, female gender (OR 1.43, 95% CI 1.32–1.56), diabetes (OR 1.28, 95% CI 1.15–1.44), and a higher number of cardiovascular comorbidities (OR 1.27, 95% CI 1.09–1.49, and 1.31, 1.05–1.64, for 3 and >3 cardiovascular comorbidities versus none, respectively) were independent predictors of nonfunctional AV access. A higher percentage of AV access creation at the region level was associated with a lower rate of nonfunctional AV access (OR 0.98, 95% CI 0.98–0.99 per 1% increase). The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with fewer than 2 cardiovascular comorbidities and 6 months in patients with diabetes or 2 or more such comorbidities. In conclusion, both patient characteristics and clinical practices may play a role in successful AV access use at hemodialysis initiation. Adjusting the timing of AV access creation to patients’ comorbidity profiles may improve functional AV access rates.
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Affiliation(s)
- Natalia Alencar de Pinho
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- * E-mail:
| | - Raphael Coscas
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- Division of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
| | - Marie Metzger
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
| | | | - Carole Ayav
- Epidémiologie et Evaluations Cliniques, Pôle S2R, CHRU Nancy, Nancy, France
- CIC-1433 Epidémiologie Clinique, Inserm, Nancy, France
| | | | - Ziad A. Massy
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- Division of Nephrology, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
| | - Bénédicte Stengel
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
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Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access Care. Cardiovasc Eng Technol 2017; 8:244-254. [PMID: 28695442 DOI: 10.1007/s13239-017-0319-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/26/2017] [Indexed: 10/19/2022]
Abstract
The vascular access is the lifeline for the hemodialysis patient. In the United States, the Fistula First Breakthrough Initiative (FFBI) has been influential in improving use of arteriovenous fistulas (AVF) in prevalent hemodialysis patients. Currently, prevalent AVF rates are near the goal of 66% set forth by the original FFBI. However, central venous catheter (CVC) rates remain very high in the United States in patients initiating hemodialysis, nearly exceeding 80%. A new direction of the of the FFBI has focused on strategies to reduce CVC use, and subsequently the FFBI has now been renamed the "Fistula First-Catheter Last Initiative". However, an AVF may not be the best vascular access in all hemodialysis patients, and arteriovenous grafts (AVG) and CVCs may be appropriate and the best access for a subset of hemodialysis patients. Unfortunately, there still remains very little emphasis within vascular access initiatives and guidelines directed towards evaluation of the individual patient context, specifically patients with poor long-term prognoses and short life expectancies, patients with multiple comorbidities, patients who are more likely to die than reach end stage renal disease (ESRD), and patients of elderly age with impaired physical and cognitive function. Given the complexity of medical and social issues in advanced CKD and ESRD patients, planning, selection, and placement of the most appropriate vascular access are ideally managed within a multidisciplinary setting and requires consideration of several factors including national vascular access guidelines. Thus, the evolution of the FFBI should underscore the need for multidisciplinary health teams with a major emphasis placed on "the right access for the right patient" and improving the patient's overall quality of life.
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Sex and gender differences in chronic kidney disease: progression to end-stage renal disease and haemodialysis. Clin Sci (Lond) 2017; 130:1147-63. [PMID: 27252402 DOI: 10.1042/cs20160047] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/29/2016] [Indexed: 01/04/2023]
Abstract
Sex and gender differences are of fundamental importance in most diseases, including chronic kidney disease (CKD). Men and women with CKD differ with regard to the underlying pathophysiology of the disease and its complications, present different symptoms and signs, respond differently to therapy and tolerate/cope with the disease differently. Yet an approach using gender in the prevention and treatment of CKD, implementation of clinical practice guidelines and in research has been largely neglected. The present review highlights some sex- and gender-specific evidence in the field of CKD, starting with a critical appraisal of the lack of inclusion of women in randomized clinical trials in nephrology, and thereafter revisits sex/gender differences in kidney pathophysiology, kidney disease progression, outcomes and management of haemodialysis care. In each case we critically consider whether apparent discrepancies are likely to be explained by biological or psycho-socioeconomic factors. In some cases (a few), these findings have resulted in the discovery of disease pathways and/or therapeutic opportunities for improvement. In most cases, they have been reported as merely anecdotal findings. The aim of the present review is to expose some of the stimulating hypotheses arising from these observations as a preamble for stricter approaches using gender for the prevention and treatment of CKD and its complications.
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Lok CE, Rajan DK, Clement J, Kiaii M, Sidhu R, Thomson K, Buldo G, Dipchand C, Moist L, Sasal J. Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT). Am J Kidney Dis 2017. [PMID: 28624422 DOI: 10.1053/j.ajkd.2017.03.026] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hemodialysis arteriovenous fistulas (AVFs) are suboptimally used primarily due to problems with maturation, early thrombosis, and patient nonacceptance. An endovascular approach to fistula creation without open surgery offers another hemodialysis vascular access option. STUDY DESIGN Prospective, single-arm, multicenter study (Novel Endovascular Access Trial [NEAT]). SETTINGS & PARTICIPANTS Consecutive adult non-dialysis-dependent and dialysis-dependent patients referred for vascular access creation at 9 centers in Canada, Australia, and New Zealand. INTERVENTION Using catheter-based endovascular technology and radiofrequency energy, an anastomosis was created between target vessels, resulting in an endovascular AVF (endoAVF). OUTCOMES Safety, efficacy, functional usability, and patency end points. MEASUREMENTS Safety as percentage of device-related serious adverse events; efficacy as percentage of endoAVFs physiologically suitable (brachial artery flow ≥ 500mL/min, vein diameter ≥ 4mm) for dialysis within 3 months; functional usability of endoAVFs to provide prescribed dialysis via 2-needle cannulation; primary and cumulative endoAVF patencies per standardized definitions. RESULTS 80 patients were enrolled (20 roll-in and 60 participants in the full analysis set; the latter are reported). EndoAVFs were created in 98% of participants; 8% had a serious procedure-related adverse event (2% device related). 87% were physiologically suitable for dialysis (eg, mean brachial artery flow, 918mL/min; endoAVF vein diameter, 5.2mm [cephalic vein]). EndoAVF functional usability was 64% in participants who received dialysis. 12-month primary and cumulative patencies were 69% and 84%, respectively. LIMITATIONS Due to the unique anatomy and vessels used to create endoAVFs, this was a single-arm study without a surgical comparator. CONCLUSIONS An endoAVF can be reliably created using a radiofrequency magnetic catheter-based system, without open surgery and with minimal complications. The endoAVF can be successfully used for hemodialysis and demonstrated high 12-month cumulative patencies. It may be a viable alternative option for achieving AVFs for hemodialysis patients in need of vascular access.
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Affiliation(s)
- Charmaine E Lok
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario; University of Toronto, Toronto, Ontario.
| | - Dheeraj K Rajan
- University of Toronto, Toronto, Ontario; Division of Vascular & Interventional Radiology, Department of Medical Imaging, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario
| | - Jason Clement
- Department of Radiology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ravi Sidhu
- Division of Vascular Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ken Thomson
- Department of Radiology, Alfred Hospital, Melbourne, Australia
| | - George Buldo
- Division of Nephrology, Department of Medicine, Lakeridge Health, Oshawa, ON
| | - Christine Dipchand
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS
| | - Louise Moist
- Division of Nephrology, Department of Medicine, London Health Sciences Centre, London
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Surgeon experience affects outcome of forearm arteriovenous fistulae more than outcomes of upper-arm fistulae. J Vasc Access 2017; 18:120-125. [PMID: 28058709 DOI: 10.5301/jva.5000639] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION There is still an ongoing discussion about the influence of vascular surgeon experience on the immediate and long-term outcome of newly created arteriovenous fistula (AVF) for patients on hemodialysis (HD). The aim of this study was to compare failure and patency rates of AVF between experienced consultants and resident trainees with special focus on location of the anastomosis on the forearm or upper arm. METHODS Between November 2012 and September 2016, 159 patients (83 on HD and 76 preemptive) received an AVF (90 radiocephalic [RCAVF] on the forearm; 69 brachiocephalic [BCAVF] in the elbow) by two experienced vascular surgeons (group A; n = 74) or five residents in training with one-to-four years of experience (group B; n = 85). We compared the two groups for demographic and treatment data, immediate failures (IF), bleeding complications and patency rates. RESULTS There were no significant differences in demographic data between the two groups. Vessel diameters were significantly lower for forearm compared to upper arm arteries (p = 0.026) and veins (p = 0.05). There was a significantly increased risk for IF in group B for RCAVF (p = 0.003), but not for BCAVF (p = 1.000). Furthermore, the cumulative primary patency was reduced in group B for RCAVF (p<0.001), but not for BCAVF (p = 0.899). CONCLUSION Surgeon experience seems to have more influence on the immediate and long-term outcome of newly created forearm AVF compared to those located on the upper arm.
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Optiflow anastomotic device for hemodialysis vascular access creation. J Vasc Access 2017; 18:84-87. [PMID: 28297067 DOI: 10.5301/jva.5000664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2016] [Indexed: 11/20/2022] Open
Abstract
The need to have consistent methods and consistent technique to optimize hemodialysis outcomes is behind the concept of the Optiflow™ device. This device was created to allow for consistency in size of the arterial anastomosis and consistency in angle of the vein to the artery at the anastomosis. Early data suggest that allowing these two technical entities can improve outcomes in regards to flow and maturity in arteriovenous fistula creation. This article is a summary of early data that demonstrate the impact the Optiflow device on brachial cephalic fistulas.
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Sequeira A, Naljayan M, Vachharajani TJ. Vascular Access Guidelines: Summary, Rationale, and Controversies. Tech Vasc Interv Radiol 2017; 20:2-8. [DOI: 10.1053/j.tvir.2016.11.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vascular access conversion and patient outcome after hemodialysis initiation with a nonfunctional arteriovenous access: a prospective registry-based study. BMC Nephrol 2017; 18:74. [PMID: 28222688 PMCID: PMC5320699 DOI: 10.1186/s12882-017-0492-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about vascular access conversion and outcomes for patients starting hemodialysis with nonfunctional arteriovenous (AV) access. We assessed mortality risk associated with nonfunctional AV access at hemodialysis initiation, taking subsequent changes in vascular access into account. METHODS We studied the 53,092 incident adult hemodialysis patients included in the French REIN registry from 2005 through 2012. AV access placed predialysis was considered nonfunctional when dialysis began with a central venous catheter. Information about vascular access changes was obtained from treatment modality updates. RESULTS At hemodialysis initiation, AV access was functional for 47% of patients and nonfunctional for 9%; 44% had a catheter alone. After a 3-year follow-up, 63% of patients beginning hemodialysis with a nonfunctional AV access had changed to a functional one, 4% had had a transplant, 19% had died before any vascular access change, and 13% still used a catheter. Cox proportional hazard models with vascular access treated as a time-dependent variable showed an adjusted mortality hazard ratio (95% confidence interval) for patients with nonfunctional AV access who subsequently converted to functional access of 0.95 (95% CI 0.89-1.03) compared with the reference group with functional AV access since first hemodialysis, versus 1.43 (95% CI 1.31-1.55) for those who did not convert. CONCLUSIONS Among patients starting hemodialysis with a nonfunctional AV access, a substantial percentage may never experience successful vascular access conversion. Poor survival seems to be limited to these patients, while those who subsequently convert to functional AV access have similar mortality risk compared to patients with such access since hemodialysis initiation. Every effort should be made to obtain functional AV access in all suitable patients.
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MacRae JM, Dipchand C, Oliver M, Moist L, Lok C, Clark E, Hiremath S, Kappel J, Kiaii M, Luscombe R, Miller LM. Arteriovenous Access Failure, Stenosis, and Thrombosis. Can J Kidney Health Dis 2016; 3:2054358116669126. [PMID: 28270918 PMCID: PMC5332078 DOI: 10.1177/2054358116669126] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 01/29/2023] Open
Abstract
Vascular access–related complications can lead to patient morbidity and reduced patient quality of life. Some of the common arteriovenous access complications include failure to mature, stenosis formation, and thrombosis.
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Affiliation(s)
- Jennifer M MacRae
- Cumming School of Medicine and Department of Cardiac Sciences, University of Calgary, Alberta, Canada
| | | | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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MacRae JM, Oliver M, Clark E, Dipchand C, Hiremath S, Kappel J, Kiaii M, Lok C, Luscombe R, Miller LM, Moist L. Arteriovenous Vascular Access Selection and Evaluation. Can J Kidney Health Dis 2016; 3:2054358116669125. [PMID: 28270917 PMCID: PMC5332074 DOI: 10.1177/2054358116669125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/11/2022] Open
Abstract
When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.
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Affiliation(s)
- Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
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Intradialytic Ultrafiltration Volume and Vascular Access Outcomes: A Japan Dialysis Outcomes and Practice Patterns Study Subanalysis. J Vasc Access 2016; 17:489-493. [DOI: 10.5301/jva.5000603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 11/20/2022] Open
Abstract
Introduction The relationship between intradialytic ultrafiltration volume and vascular access (VA) patency remains unclear. Using data from the Japan Dialysis Outcomes and Practice Patterns Study, we analyzed whether large-volume ultrafiltration was associated with VA failure in hemodialysis patients. Methods We included 2736 patients for whom it was possible to evaluate VA patency and bodyweight change during dialysis. Patients were divided into three groups according to the tertile of intradialytic ultrafiltration by bodyweight: low, -9.5%-3.8%; middle, 3.8%-5.1%; and high, 5.1%-13.7%. Primary VA patency was defined as the time to first VA intervention, and secondary patency as the time to creation of a new VA. Hazard ratios for VA failure were compared across groups by using Cox regression models adjusted for age, sex, body mass index, diabetes, hemoglobin and phosphorus levels, Kt/V, and erythropoiesis-stimulating agent and antiplatelet use. Results For the low, middle, and high groups, the incidences of primary and secondary VA patency were 4.7, 5.6, and 6.7 events/100 person-years and 1.3, 1.6, and 1.7 events/100 person-years, respectively. Adjusted hazard ratios for primary VA patency in the middle and high groups versus the low group were 1.16 (95% confidence interval [CI], 0.88-1.52) and 1.41 (95% CI, 1.07-1.87), respectively; those for secondary VA patency were 1.29 (95% CI, 0.78-2.13) and 1.45 (95% CI, 0.86-2.45), respectively. Discussion Large-volume ultrafiltration during dialysis tended to increase VA failure in hemodialysis patients. We thus recommend smaller ultrafiltration volumes during hemodialysis to secure VA safely.
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Woo K, Lok CE. New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients? Clin J Am Soc Nephrol 2016; 11:1487-1494. [PMID: 27401524 PMCID: PMC4974877 DOI: 10.2215/cjn.02190216] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts.
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Affiliation(s)
- Karen Woo
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California; and
| | - Charmaine E. Lok
- Division of Nephrology, University Health Network–Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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50
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Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016; 388:294-306. [PMID: 27226132 PMCID: PMC6563337 DOI: 10.1016/s0140-6736(16)30448-2] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
More than 2 million people worldwide are being treated for end-stage kidney disease (ESKD). This Series paper provides an overview of incidence, modality use (in-centre haemodialysis, home dialysis, or transplantation), and mortality for patients with ESKD based on national registry data. We also present data from an international cohort study to highlight differences in haemodialysis practices that affect survival and the experience of patients who rely on this therapy, which is both life-sustaining and profoundly disruptive to their quality of life. Data illustrate disparities in access to renal replacement therapy of any kind and in the use of transplantation or home dialysis, both of which are widely considered preferable to in-centre haemodialysis for many patients with ESKD in settings where infrastructure permits. For most patients with ESKD worldwide who are treated with in-centre haemodialysis, overall survival is poor, but longer in some Asian countries than elsewhere in the world, and longer in Europe than in the USA, although this gap has reduced. Commendable haemodialysis practice includes exceptionally high use of surgical vascular access in Japan and in some European countries, and the use of longer or more frequent dialysis sessions in some countries, allowing for more effective volume management. Mortality is especially high soon after ESKD onset, and improved preparation for ESKD is needed including alignment of decision making with the wishes of patients and families.
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Affiliation(s)
- Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA.
| | - Tadao Akizawa
- Showa University School of Medicine, Shinagawa, Tokyo, Japan
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam-Zuidoost, Netherlands
| | - Peter G Kerr
- Monash Medical Centre and Monash University Clayton, Clayton, VIC, Australia
| | - Rajiv Saran
- Department of Internal Medicine and Nephrology, University of Michigan, Ann Arbor, MI, USA
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