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Chang TI, Chen CH, Hsieh HL, Chen CY, Hsu SC, Cheng HS, Huang WC, Sue YM, Hsu YH, Lin FY, Shih CM, Lin SJ, Huang PH, Liu CT. Effects of cardiovascular medications on primary patency of hemodialysis arteriovenous fistula. Sci Rep 2020; 10:12135. [PMID: 32699337 PMCID: PMC7376157 DOI: 10.1038/s41598-020-69019-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
While the patency of vascular access is essential for hemodialysis patients, optimal pharmaceutical treatment to maintain arteriovenous fistula (AVF) patency remains lacking. As cardiovascular diseases are highly prevalent in patients with end-stage renal disease, various cardiovascular medications have also been used to maintain AVF patency. However, previous studies revealed inconsistent therapeutic effects and a comprehensive evaluation of this issue is needed. The present retrospective, longitudinal cohort study included patients receiving successful AVF creation. The evaluated cardiovascular medications included antiplatelet agents, antihypertensive agents, nitrates and nitrites, statins, dipyridamole, and pentoxifylline. The outcome was AVF primary patency. All laboratory data and medication profiles were recorded at baseline and followed at 3-month interval, until the end of the 2-year study period. Cox proportional regression model with time-dependent covariates was used to evaluate the risk for AVF patency loss. A total of 349 patients were included in the present study, in which 57% were men and the mean age was 65 ± 14 years. Among the included patients, 40% used antiplatelet agents, 27% used dipyridamole and 36% used statins at baseline. Of all the evaluated cardiovascular medications, only dipyridamole showed significant association with a higher risk for loss of AVF patency. To evaluate the effect of combination of antiplatelet agents and dipyridamole, the patients were classified into four groups, I: combine use of antiplatelet agents and dipyridamole, II: antiplatelet only, III: dipyridamole only; IV: none of both were used. Of the four groups, group IV exhibited highest AVF patency (52.4%), which was followed by group III (42.7%), group II (40%), and group I (28.6%), respectively. Compared with group IV, only group I showed a significantly higher risk for AVF patency loss. None of the cardiovascular medications evaluated in the present study showed a beneficial effect on AVF patency. Furthermore, dipyridamole showed an association with a higher risk of AVF patency loss. We do not suggest a beneficial effect of dipyridamole on maintaining AVF patency, particularly in combination with antiplatelet agents.
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Affiliation(s)
- Te-I Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Cheng-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Hui-Ling Hsieh
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Chun-You Chen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Chang Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ho-Shun Cheng
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yuh-Mou Sue
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Yung-Ho Hsu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Feng-Yen Lin
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Ming Shih
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Shing-Jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Taipei Medical University, Taipei, Taiwan.,Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Te Liu
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. .,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,TMU Research Center of Urology and Kidney, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Olivier CB, Sundaram V, Chertow GM, Shashidhar S, McDonnell LK, Ding VY, Desai M, Mahaffey KW, Mell M. A double-blind, randomized, placebo-controlled pilot trial to evaluate safety and efficacy of vorapaxar on arteriovenous fistula maturation. J Vasc Access 2019; 21:467-474. [PMID: 31774037 DOI: 10.1177/1129729819887269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Protease-activated receptor-1 antagonism by vorapaxar could facilitate arteriovenous fistula maturation but may increase bleeding risk. OBJECTIVE The primary objective of the Vorapaxar Study for Maturation of arteriovenous fistula for Hemodialysis Access (VorapAccess) was to determine if vorapaxar improves arteriovenous fistula functional maturation in patients with end-stage renal disease. METHODS VorapAccess was a randomized, placebo-controlled, double-blind pilot trial comparing 2.5 mg vorapaxar per day with placebo for twelve weeks starting on day two after arteriovenous fistula creation. The primary outcome was time to functional maturation defined as successful cannulation for six hemodialysis sessions within three weeks. The planned sample size was 50 participants. The study was terminated early after withdrawal of planned financial support. Given the small number of randomized patients, we performed descriptive analyses without inference testing. RESULTS A total of 13 participants were randomly allocated study drug (six vorapaxar and seven placebo). The median age was 56 years and seven participants (54%) were female. The median (minimum-maximum) days to functional maturation were 169 (77-287) days in the vorapaxar group and 145 (48-198) days in the placebo group. Six of the 13 (46%) participants had arteriovenous fistula functional maturation within 180 days; two of six (33%) in the vorapaxar group and four of seven (57%) in the placebo group. There was one bleeding event in the placebo group. CONCLUSION Fewer than half of participants had functional maturation within 180 days after surgery, suggesting a major need for agents or strategies that enhance arteriovenous fistula maturation.
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Affiliation(s)
- Christoph B Olivier
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA.,Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center, University of Freiburg, Freiburg, Germany
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sumana Shashidhar
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Lori K McDonnell
- Division of Vascular Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Victoria Y Ding
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Matthew Mell
- Division of Vascular Surgery, School of Medicine, Stanford University, Stanford, CA, USA.,Division of Vascular Surgery, University of California at Davis, Sacramento, CA, USA
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Copeland T, Lawrence P, Woo K. Outcomes of initial hemodialysis vascular access in patients initiating dialysis with a tunneled catheter. J Vasc Surg 2019; 70:1235-1241. [PMID: 31147122 DOI: 10.1016/j.jvs.2019.02.036] [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] [Received: 10/09/2018] [Accepted: 02/15/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our aim was to determine factors that influence time to removal of tunneled hemodialysis catheter (THC), probability of repeat vascular access creation, and time to repeat vascular access. METHODS The Optum Clinformatics Data Mart claims database was queried from 2011 to 2017 for patients who initiated hemodialysis with a THC. Time from initial arteriovenous fistula (AVF)/graft (AVG) to THC removal and time to repeat AVF/AVG were analyzed using Cox proportional hazards. The likelihood of repeat AVF/AVG was analyzed using logistic regression. RESULTS A total of 8941 vascular access met the inclusion criteria: 6913 (77%) AVF and 2028 (23%) AVG. Median follow-up was 595 days among AVF patients (range, 1-2543 days) and 579 days among AVG patients (range, 1-2529 days). Patients undergoing AVF were younger, more likely to be male, of white race, and obese. Patients undergoing AVF were also slightly less likely to have diabetes, cardiac arrhythmia, congestive heart failure, and peripheral vascular disease than patients undergoing AVG. At 90 days and at 180 days after index access creation, significantly more patients who underwent index AVG had their THC removed compared with patients who underwent index AVF. By day 365, 78% of patients in both AVF and AVG had their THC removed. A total of 2550 (28.5%) patients underwent a repeat vascular access creation during the follow-up period: 30% of index AVF and 24% of index AVG. At 90 days, 180 days, and 365 days, significantly more patients in the index AVF group underwent a repeat vascular access creation than those in the index AVG group. Multivariate analysis demonstrated a significant interaction between vascular access type and age ≥70 years (P < .001) for time to THC removal, likelihood of repeat vascular access, and time to repeat vascular access. In the age <70 group, patients who underwent AVG were 60% more likely to have a shorter time to THC, had a 50.4% lower odds of repeat vascular access, and were 47% more likely to have a longer time to repeat vascular access compared with patients who underwent index AVF. In the age ≥70 group, patients who underwent AVG were 98% more likely to have a shorter time to THC removal, had 69.7% lower odds of repeat vascular access, and were 66% more likely to have a longer time to repeat vascular access. CONCLUSIONS Creation of AVG vs AVF significantly decreases the time to THC removal in dialysis-dependent patients, with a larger difference in patients aged ≥70 vs <70. Initial AVG was associated with lower odds of repeat vascular access and longer time to repeat vascular access. These results suggest that the dictum of "fistula first" is not appropriate for all patient populations and supports judicious use of AVG in achieving the more recent shift toward "catheter last."
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Affiliation(s)
- Timothy Copeland
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, Calif.
| | - Peter Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
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