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Shiri P, Rezaeian S, Abdi A, Jalilian M, Khatony A. Risk factors for thrombosis in dialysis patients: A comprehensive systematic review and meta-analysis. JOURNAL OF VASCULAR NURSING 2024; 42:165-176. [PMID: 39244328 DOI: 10.1016/j.jvn.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 09/09/2024]
Abstract
AIM To identify the factors associated with thrombosis in dialysis patients. BACKGROUND Thrombosis is a leading cause of vascular access failure in dialysis patients. Numerous risk factors contribute to thrombosis in this population. METHODS A systematic search was conducted across international databases using standardized keywords. The quality of the selected studies was assessed using the STROBE and CONSORT checklists. The findings were summarized in a Garrard table. Meta-analysis was performed using CMA software. The study adhered to the guidelines outlined in the PRISMA statement. RESULTS A total of 180 articles were reviewed. The odds ratio for thrombosis in patients with arteriovenous grafts compared to arteriovenous fistulas was 10.93 (95 % CI: 9.35-12.78), demonstrating statistical significance (P = 0.001). Similarly, hemodialysis patients had an odds ratio of thrombosis 3.60 times higher than non-hemodialysis patients (95 % CI: 3.54-4.19), with statistical significance (P = 0.001). Patients undergoing single-stage basilic vein transposition had a 1.89 times higher risk of thrombosis compared to those undergoing two-stage transposition (95 % CI: 1.04-3.46), also demonstrating statistical significance (P = 0.038). CONCLUSIONS Thrombosis in patients with end-stage renal disease undergoing dialysis was significantly associated with various factors, including graft access, single-stage basilic vein transposition, and hemodialysis. Additional contributing factors to thrombosis included diabetes, elevated homocysteine levels, female gender, age over 50, access location, and low access blood flow velocity. The analysis revealed a higher incidence of thrombosis in end-stage renal disease patients undergoing hemodialysis compared to those not undergoing dialysis, as well as in patients with arteriovenous grafts compared to those with arteriovenous fistulas. These findings underscore the importance of recognizing and managing these risk factors to prevent thrombotic events and enhance patient care within the dialysis setting.
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Affiliation(s)
- Parisa Shiri
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shabab Rezaeian
- Social Development and Health Promotion Research Centre, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Abdi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Milad Jalilian
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Khatony
- Social Development and Health Promotion Research Centre, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; Infectious Diseases Research Centre, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Bodington R, Hazara AM, Lamplugh A, Syed A, Bhandari S. Reassessing the utility of access recirculation and Kt/V for the prediction of arteriovenous fistula failure using online clearance monitoring: the SHUNT STUDY. J Nephrol 2023; 36:677-686. [PMID: 36445562 DOI: 10.1007/s40620-022-01525-4] [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: 04/07/2022] [Accepted: 11/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is prone to thrombosis which can be avoided by use of monitoring and surveillance programmes. Although surveillance imaging techniques have been shown to be more sensitive and specific than clinical monitoring during dialysis, monitoring may have significant advantages in terms of cost and time saving. In this study we evaluate the yield of two monitoring techniques [blood temperature monitoring (BTM) access recirculation (AR) and Kt/V via online-clearance-monitoring (OCM)]. METHODS In this single-centre prospective observational study, 101 patients were followed-up for one year. The primary outcome measure was a composite of AVF failure. OCM-Kt/V and BTM-AR were recorded at every dialysis session. RESULTS Of all baseline characteristics only a prior history of percutaneous transluminal angioplasty (PTA) to the AVF conferred a significant change in AVF survival (failure events/100 pt years with prior PTA vs. without = 64.0 vs. 17.3, log-rank p = 0.0014; unadjusted hazard ratio (HR) 3.74 (95% CI 1.56-8.94) p = 0.003). Participants with baseline AR < 10% vs. > 15% had poorer AVF survival (p = 0.0002) and HR for baseline AR 10-15% group vs. AR > 15% group = 4.5 (95% CI 1.55-13.05). There was no combination of change in (Δ) AR, ΔKt/V or its presence over any number of dialysis sessions that provided an acceptable combination of sensitivity and specificity or discrimination for AVF failure. CONCLUSIONS BTM-AR and OCM-Kt/V are specific but insufficiently sensitive tools for the prediction of AVF failure. BTM-AR and OCM-Kt/V use at every dialysis session appears to add little to the traditional, infrequent use of these evaluations.
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Affiliation(s)
- Richard Bodington
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, S5 7AU, UK.
| | - Adil M Hazara
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Archie Lamplugh
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ahsan Syed
- Department of Renal Medicine, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sunil Bhandari
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Pettersen EM, Avdal J, Fiorentini S, Salvesen Ø, Hisdal J, Torp H, Seternes A. Validation of a novel ultrasound Doppler monitoring device (earlybird) for measurements of volume flow rate in arteriovenous fistulas for hemodialysis. J Vasc Access 2021; 24:11297298211060960. [PMID: 34852698 DOI: 10.1177/11297298211060960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Controversy exists regarding surveillance of arteriovenous fistulas for hemodialysis to increase patency. A significant reduction in volume flow rate (VFR) should lead to diagnostic evaluation and eventually intervention. Several methods are available for VFR measurements, but all of them are associated with low reproducibility. VFR trend analysis is suggested as an improved solution. It is therefore a need to find user-friendly, cost and time-effective modalities. We present a novel Doppler ultrasound device (earlybird) which could bridge this gap. It includes an easy-to-use and light-weight single element transducer. METHODS In an experimental and clinical setting, we compared earlybird to duplex ultrasound to assess VFR. In a closed circuit of blood-mimicking fluid, 36 paired calculations of calibrated, duplex ultrasound and earlybird VFR was measured. In addition, 23 paired recordings of duplex ultrasound and earlybird VFR was measured in 16 patients with underarm arteriovenous fistulas. Pearson correlation, intraclass correlation coefficient, root-mean-square and Bland-Altman plots were analyzed. RESULTS Strong correlation (r = 0.991, p < 0.001), and excellent level of agreement (ICC = 0.970 (95% CI 0.932 - 0.985), p < 0.001) between earlybird and the calibrated VFR was found in the experimental setup. This was confirmed in the clinical setting, with a strong correlation (r = 0.781, p < 0.001) and moderate to good level of agreement (ICC = 0.750 (95% CI 0.502-0.885), p < 0.001) between earlybird and duplex ultrasound VFR measured at the arteriovenous fistulas outflow veins. In the Bland-Altman plot-analysis for the experimental setup, we found smaller limits of agreement, a smaller consistent and proportional bias, as well as greater accuracy of earlybird than DUS when compared to the calibrated VFR. CONCLUSION Earlybird is a feasible tool for VFR measurements and could be a future promising device for easy assessment and surveillance of AVF for hemodialysis.
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Affiliation(s)
- Erik Mulder Pettersen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, Sørlandet Hospital Kristiansand, Kristiansand, Norway
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway
| | - Jørgen Avdal
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stefano Fiorentini
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Øyvind Salvesen
- Clinical Research Unit, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonny Hisdal
- Section of Vascular Investigations, Division of Cardiovascular and Pulmonary Diseases, Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- CIMON Medical, NTNU Technology Transfer AS, Trondheim, Norway
| | - Arne Seternes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Section of Vascular Surgery, Department of Surgery, Trondheim University Hospital, St. Olavs Hospital, Trondheim, Norway
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A Multicenter Randomized Clinical Trial of Hemodialysis Access Blood Flow Surveillance Compared to Standard of Care: The Hemodialysis Access Surveillance Evaluation (HASE) Study. Kidney Int Rep 2020; 5:1937-1944. [PMID: 33163714 PMCID: PMC7609971 DOI: 10.1016/j.ekir.2020.07.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Arteriovenous (AV) access thrombosis remains 1 of the most troubling AV access–related complications affecting hemodialysis patients. It necessitates an urgent and occasionally complicated thrombectomy procedure and increases the risk of AV access loss. AV access stenosis is found in the majority of thrombosed AV accesses. The routine use of AV access surveillance for the early detection and management of stenosis to reduce the thrombosis rate remains controversial. Methods We have conducted a multicenter, prospective, randomized clinical trial comparing the standard of care coupled with ultrasound dilution technique (UDT) flow measurement monthly surveillance with the standard of care alone. Results We prospectively randomized 436 patients with end-stage renal disease on hemodialysis with arteriovenous fistula (AVF) or arteriovenous graft (AVG) using cluster (shift) randomization to surveillance and control groups. There were no significant differences in the baseline demographic data between the 2 groups, except for ethnicity (P = 0.017). Patients were followed on average for 15.2 months. There were significantly less per-patient thrombotic events (Poisson rate) in the surveillance group (0.12/patient) compared with the control group (0.23/patient) (P = 0.012). There was no statistically significant difference in the total number of procedures between the 2 groups, irrespective of whether thrombectomy procedures were included or excluded, and no statistically significant differences in the rate of or time to the first thrombotic event or the number of catheters placed due to thrombosis. Conclusion The use of UDT flow measurement monthly AV access surveillance in this multicenter randomized controlled trial reduced the per-patient thrombotic events without significantly increasing the total number of angiographic procedures. Even though there is a trend, surveillance did not reduce the first thrombotic event rate.
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Mo YW, Sun CY, Song L, Zhou LF, Zhuang TT, Zhong M, Zheng SQ, Chen YG, Chen YH, Liu SX, Liang XL, Fu X. How to carry out monthly blood flow surveillance of fistula in large-scale hemodialysis units: A cross-sectional study. J Vasc Access 2020; 22:75-80. [PMID: 32476548 DOI: 10.1177/1129729820923939] [Citation(s) in RCA: 4] [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 important effect of regular blood flow surveillance on arteriovenous fistula maintenance is emphasized. The ultrasonic dilution technique for blood flow surveillance can be performed during hemodialysis, but there are some limitations. Blood flow is traditionally measured by duplex Doppler ultrasound during the nondialysis period. However, the surveillance workload for arteriovenous fistula has increased with the rapid increase in the hemodialysis population size. Efficient methods for blood flow surveillance during hemodialysis are needed. METHODS Eighty-four hemodialysis patients with a forearm radiocephalic arteriovenous fistula were enrolled in this cross-sectional study. Each received blood flow measurements using ultrasonic dilution technique and duplex Doppler ultrasound during hemodialysis. Duplex Doppler ultrasound measurements included the blood flow of the brachial artery and radial artery. The correlations between these variables were analyzed. RESULTS The correlation coefficients (r) between flow measured by ultrasonic dilution technique and brachial artery flow measured by duplex Doppler ultrasound, between flow measured by ultrasonic dilution technique and radial artery flow measured by duplex Doppler ultrasound, and between brachial artery flow and radial artery flow measured by duplex Doppler ultrasound were 0.724, 0.784, and 0.749, respectively (all p < 0.001). CONCLUSION Blood flow measured by ultrasonic dilution technique was positively correlated with blood flow measured by duplex Doppler ultrasound during hemodialysis, suggesting that duplex Doppler ultrasound can be used to monitor the trends in the blood flow of the brachial artery and radial artery for timely intervention to improve patency during hemodialysis.
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Affiliation(s)
- Ya-Wen Mo
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China.,Ya-wen Mo and Chun-yan Sun contributed equally to the article
| | - Chun-Yan Sun
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China.,Ya-wen Mo and Chun-yan Sun contributed equally to the article
| | - Li Song
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li-Fang Zhou
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
| | - Ting-Ting Zhuang
- Department of Rehabilitation Medicine, Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
| | - Mi Zhong
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shu-Qian Zheng
- School of Nursing, Southern Medical University, Guangzhou, China.,Division of Nephrology, Guangzhou Nansha Central Hospital, Guangzhou, China
| | - Ying-Gui Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
| | - Yuan-Han Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuang-Xin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin-Ling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xia Fu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
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Hwang SD, Kim K, Kim YJ, Lee SW, Lee JH, Song JH. Effect of statins on cardiovascular complications in chronic kidney disease patients: A network meta-analysis. Medicine (Baltimore) 2020; 99:e20061. [PMID: 32481375 DOI: 10.1097/md.0000000000020061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The rates of cardiovascular mortality and morbidity are increased in advanced chronic kidney disease (CKD). Mild to moderate CKD is associated with an increase in cardiovascular events. This study aims to investigate the effects of statins on patient mortality and cardiac events. STUDY APPRAISAL AND SYNTHESIS METHODS Studies on statins (atorvastatin, rosuvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, and simvastatin + ezetimibe) in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded databases from 1970 to February 2019 were analyzed. Inclusion criteria were randomized control trials and adult patients (>18 years old). Reviews, observational studies, and clinical trials that did not clearly define outcomes or that did not have thrombosis as an outcome were excluded. We performed direct and indirect network meta-analysis using Bayesian models and ranked different statins using generation mixed treatment comparison (GeMTC) and Stata version 13. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) of network meta-analysis approach specified 4 levels of certainty for a given result: high, moderate, low, and very low. The outcomes were cardiac events, cardiac mortality, and all-cause mortality. RESULTS Nineteen studies (45,863 patients) were included. Compared with placebos, pravastatin 40 mg group showed a significantly lower patient mortality (odds ratio 0.66 [95% credible interval, 0.46-0.91]).Atorvastatin 80 mg, fluvastatin 40 mg, lovastatin 20 mg, pravastatin 40 mg, and simvastatin 40 mg showed significant results in reducing cardiac events.In rank probability, pravastatin showed the best effect at all-cause mortality rate. Lovastatin, fluvastatin, and pravastatin showed good effects in the 1st, 2nd, and 3rd ranks in cardiac events. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Pravastatin 40 mg demonstrated the best effect on all-cause mortality, and was observed to be effective with high ranking in cardiac events. We anticipate that the data of this study will assist physicians in making informed decisions when selecting statins, such as pravastatin, as a treatment option for CKD patients.
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Affiliation(s)
- Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Kipyo Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Yoon Ji Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mediplex Sejong Hospital, Incheon
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan, South Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
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Park HS, Kim WJ, Choi J, Kim HW, Baik JH, Kim YO, Park CW, Yang CW, Jin DC. The effect of vascular access type on intra-access flow volume during hemodialysis. J Vasc Access 2019; 20:746-751. [PMID: 31148508 DOI: 10.1177/1129729819850942] [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: 11/15/2022] Open
Abstract
INTRODUCTION Previous studies have revealed that vascular access resistance is constant during hemodialysis, but differs according to vascular access type. It is possible that intra-access flow volume (Qac) variation during hemodialysis may also differ according to vascular access type. We conducted this study to investigate whether there are differences in Qac according to vascular access type during hemodialysis. METHODS A total of 58 lower-arm arteriovenous fistula, 14 lower-arm arteriovenous graft, 27 upper-arm arteriovenous fistula, and 45 upper-arm arteriovenous graft cases were studied. Three consecutive Qac values (at 30, 120, and 240 min after the start of hemodialysis) were measured in each patient by the ultrasound dilution technique. Variations in Qac over time were analyzed using repeated measures analysis of variance and multivariate regression analyses, to assess the impact of different factors on Qac variation. RESULTS The repeated measures analysis of variance revealed that a significant interaction exists between time and vascular access type (p < 0.001). This suggests that vascular access type affects Qac change (%) variation over time during hemodialysis. In a multivariate analysis, mean arterial pressure change during hemodialysis (p = 0.009), access type (p < 0.001), and access location (p < 0.001) were independent variables causing Qac change variation. CONCLUSION This study showed that there is a significant difference in Qac variation according to vascular access type during hemodialysis and that arteriovenous graft (vs arteriovenous fistula) and the lower-arm location (vs upper arm) were associated with a decrease in Qac during hemodialysis. This suggests that consideration of vascular access type is required to minimize Qac variation during hemodialysis.
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Affiliation(s)
- Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Internal Medicine, The Catholic University of Korea School of Medicine/St. Vincent's Hospital, Suwon, Republic of Korea
| | - Woo Jeong Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Internal Medicine, The Catholic University of Korea School of Medicine/St. Vincent's Hospital, Suwon, Republic of Korea
| | - Joonsung Choi
- Department of Radiology, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Hyung Wook Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Internal Medicine, The Catholic University of Korea School of Medicine/St. Vincent's Hospital, Suwon, Republic of Korea
| | - Jun Hyun Baik
- Department of Radiology, St. Vincent's Hospital, School of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Young Ok Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Chan Jin
- Division of Nephrology, Department of Internal Medicine, School of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Internal Medicine, The Catholic University of Korea School of Medicine/St. Vincent's Hospital, Suwon, Republic of Korea
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Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
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Hwang SD, Lee JH, Lee SW, Kim JK, Kim MJ, Song JH. Comparison of ultrasound scan blood flow measurement versus other forms of surveillance in the thrombosis rate of hemodialysis access: A systemic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11194. [PMID: 30045249 PMCID: PMC6078674 DOI: 10.1097/md.0000000000011194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The benefit of access flow surveillance in preventing vascular access thrombosis and failure remains controversial, as many randomized clinical trials (RCTs) have failed to demonstrate consistent results. The aim of this study was to perform a meta-analysis including newly published RCTs with a subgroup analysis for arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs). METHODS A systematic review of the available literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An electronic search was conducted using the MEDLINE, EMBASE, and Cochrane Library databases of RCTs conducted from 1970 to 2017 that involved access flow surveillance. As a result, 9 RCTs met our criteria. The control group was defined by indirect and various surveillance methods such as dynamic venous pressure measurement and physical examination. Conversely, the interventional group was defined as a noninvasive duplex ultrasound scan (USS) or ultrasound dilution that directly measured the flow of vascular access. RESULTS The studies included 990 patients comprising 658 native AVFs and 332 AVGs. The prevalence of diabetes was 29.3%and 30.5% in the interventional and control groups, respectively. The estimated overall pooled risk ratio (RR) of thrombosis was 0.782 [95% confidence interval (95% CI), 0.553-1.107; P = .17], favoring interventional group, although this was not statistically significant. In the subgroup analysis, the pooled RR of thrombosis was .562 (95% CI, 0.346-0.915; P = .02) for AVFs, which significantly favored the interventional group. Conversely, the pooled RR for AVGs was 1.104 (95% CI, 0.672-1.816; P = .70). CONCLUSION The surveillance method to measure access flow through USS showed a significant benefit for reducing thrombosis in AVFs. The result encourages adherence to the current guidelines for AVFs. However, no benefit was found regarding AVGs. Recent guidelines with a "one-size-fits-all" approach may be revised to a "tailored-to-risk" approach.
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Affiliation(s)
- Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Bongseng-Memorial Hospital, Busan, Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Joong kyung Kim
- Division of Nephrology, Department of Internal Medicine, Bongseng-Memorial Hospital, Busan, Korea
| | - Moon-Jae Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
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Hwang S, Lee J, Lee S, Park KM, Kim J, Kim MJ, Song J. Efficacy and Safety of Induction Therapy in Kidney Transplantation: A Network Meta-Analysis. Transplant Proc 2018; 50:987-992. [DOI: 10.1016/j.transproceed.2018.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/05/2018] [Accepted: 01/30/2018] [Indexed: 12/24/2022]
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Castro A, Moreira C, Almeida P, de Matos N, Loureiro L, Teixeira G, Rego D, Teixeira S, Pinheiro J, Carvalho T, Fonseca I, Queirós J. The Role of Doppler Ultrassonography in Significant and Borderline Stenosis Definition. Blood Purif 2018; 46:94-102. [DOI: 10.1159/000488442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 03/15/2018] [Indexed: 02/02/2023]
Abstract
Background: The definition of significant stenosis (SS) remains controversial. Methods: We retrospectively reviewed 1,040 consultations. SS was defined in the presence of clinical and echo-Doppler (DDU) criteria: Qa <500 mL/min or Qa decrease >25%; RI >0.7 in the feeding artery or absolute minimal luminal stenosis diameter <2.0 mm. Stenosis without any additional criteria were considered borderline stenosis (BS). Results: Two hundred twenty-one arteriovenous fistulas (AVFs) were included: 58.8% had SS, 18.6% had BS, and 22.6% had no dysfunctional access (ND). SS had a significantly higher thrombotic events than BS and ND (13.1 vs. 4.4%, p = 0.018). The annual thrombosis rate was 0.007, 0.037, and 0.004 in the ND, SS, and BS, respectively. AVF cumulative survival at 5 years was significantly lower in SS (89.5%) compared to BS (100%) and ND (97.4%; p = 0.03). BS had an HR for AVF failure of 1.1, p = 0.955, while the SS presented an HR of 5.9, p = 0.09. Conclusion: AVF clinical monitoring with additional DDU criteria appear to be appropriate for therapeutic referral.
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Roca-Tey R, Ibeas J, Moreno T, Gruss E, Merino JL, Vallespín J, Hernán D, Arribas P. Dialysis arteriovenous access monitoring and surveillance according to the 2017 Spanish Guidelines. J Vasc Access 2018; 19:422-429. [PMID: 29544403 DOI: 10.1177/1129729818761307] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology (S.E.N.), vascular surgery (SEACV), interventional radiology (SERAM-SERVEI), infectious diseases (SEIMC), and nephrology nursing (SEDEN)), along with the methodological support of the Iberoamerican Cochrane Centre, has developed the Spanish Clinical Guidelines on Vascular Access for Hemodialysis. This article summarizes the main issues from the guideline's chapter entitled "Monitoring and surveillance of arteriovenous access." We will analyze the current evidence on conflicting topics such as the value of the flow-based screening methods for the arteriovenous access surveillance or the role of Doppler ultrasound as the imaging exploration to confirm suspected stenosis. In addition, the concept of significant stenosis and the criteria to perform the elective intervention for stenosis were reviewed. The adoption of these guidelines will hopefully translate into a reduced risk of thrombosis and increased patency rates for both arteriovenous fistulas and grafts.
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Affiliation(s)
- Ramon Roca-Tey
- 1 Department of Nephrology, Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - José Ibeas
- 2 Department of Nephrology, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Moreno
- 3 Department of Radiology, Hospital Juan Ramón Jiménez, Complejo Hospitalario Universitario de Huelva, Huelva, Spain
| | - Enrique Gruss
- 4 Department of Nephrology, Hospital Universitario Fundación de Alcorcón, Alcorcón, Spain
| | - José Luis Merino
- 5 Department of Nephrology, Hospital Universitario del Henares, Coslada, Spain
| | - Joaquín Vallespín
- 6 Department of Vascular Surgery, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernán
- 7 Fundación Renal Íñigo Álvarez de Toledo, Madrid, Spain
| | - Patricia Arribas
- 8 Department of Nephrology, Hospital Infanta Leonor, Madrid, Spain
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Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized controlled trial. J Vasc Access 2017; 18:352-358. [DOI: 10.5301/jva.5000700] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 02/03/2023] Open
Abstract
Purpose Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity. Methods We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [ M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103). The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3). Results At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935). There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029). Total vascular access-related costs were higher in the control group (€227.194 vs. €133.807; p = 0.029). Conclusions QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.
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