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Kim H, Park HS, Ban TH, Yang SB, Kwon YJ. Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database. Hemodial Int 2023. [PMID: 36943638 DOI: 10.1111/hdi.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/12/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years. METHODS In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared. RESULTS Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001). CONCLUSION Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Seung Boo Yang
- Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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He Y, Shiu YT, Imrey PB, Radeva MK, Beck GJ, Gassman JJ, Northrup HM, Roy-Chaudhury P, Berceli SA, Cheung AK. Association of Shear Stress with Subsequent Lumen Remodeling in Hemodialysis Arteriovenous Fistulas. Clin J Am Soc Nephrol 2023; 18:72-83. [PMID: 36446600 PMCID: PMC10101625 DOI: 10.2215/cjn.04630422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Blood flow-induced wall shear stress is a strong local regulator of vascular remodeling, but its effects on arteriovenous fistula (AVF) remodeling are unclear. METHODS In this prospective cohort study, we used computational fluid dynamics simulations and statistical mixed-effects modeling to investigate the associations between wall shear stress and AVF remodeling in 120 participants undergoing AVF creation surgery. Postoperative magnetic resonance imaging data at 1 day, 6 weeks, and 6 months were used to derive current wall shear stress by computational fluid dynamic simulations and to quantify subsequent changes in AVF lumen cross-sectional area at 1-mm intervals along the proximal artery and AVF vein. RESULTS Combining artery and vein data, prior mean wall shear stress was significantly associated with lumen area expansion. Mean wall shear stress at day 1 was significantly associated with change in lumen area from day 1 to week 6 (11% larger area per interquartile range [IQR] higher mean wall shear stress, 95% confidence interval [95% CI], 5% to 18%; n =101), and mean wall shear stress at 6 weeks was significantly associated with change in lumen area from 6 weeks to month 6 (14% larger area per IQR higher, 95% CI, 3% to 28%; n =52). The association of mean wall shear stress at day 1 with lumen area expansion from day 1 to week 6 differed significantly by diabetes ( P =0.009): 27% (95% CI, 17% to 37%) larger area per IQR higher mean wall shear stress without diabetes and 9% (95% CI, -1% to 19%) with diabetes. Oscillatory shear index at day 1 was significantly associated with change in lumen area from day 1 to week 6 (5% smaller area per IQR higher oscillatory shear index, 95% CI, 3% to 7%), and oscillatory shear index at 6 weeks was significantly associated with change in lumen from 6 weeks to month 6 (7% smaller area per IQR higher oscillatory shear index, 95% CI, 2% to 11%). Wall shear stress spatial gradient was not significantly associated with subsequent remodeling. In a joint model, wall shear stress and oscillatory shear index statistically significantly interacted in their associations with lumen area expansion in a complex nonlinear fashion. CONCLUSIONS Higher wall shear stress and lower oscillatory shear index were associated with greater lumen expansion after AVF creation surgery.
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Affiliation(s)
- Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Milena K. Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gerald J. Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Jennifer J. Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Hannah M. Northrup
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
- Department of Medicine, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida
- Vascular Surgery Section, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
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Hyperphosphatemia and its relationship with blood pressure, vasoconstriction, and endothelial cell dysfunction in hypertensive hemodialysis patients. BMC Nephrol 2022; 23:291. [PMID: 35999520 PMCID: PMC9396889 DOI: 10.1186/s12882-022-02918-0] [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: 04/04/2022] [Accepted: 08/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background Hyperphosphatemia occurs frequently in end-stage renal disease patients on hemodialysis and is associated with increased mortality. Hyperphosphatemia contributes to vascular calcification in these patients, but there is emerging evidence that it is also associated with endothelial cell dysfunction. Methods We conducted a cross-sectional study in hypertensive hemodialysis patients. We obtained pre-hemodialysis measurements of total peripheral resistance index (TPRI, non-invasive cardiac output monitor) and plasma levels of endothelin-1 (ET-1) and asymmetric dimethylarginine (ADMA). We ascertained the routine peridialytic blood pressure (BP) measurements from that treatment and the most recent pre-hemodialysis serum phosphate levels. We used generalized linear regression analyses to determine independent associations between serum phosphate with BP, TPRI, ET-1, and ADMA while controlling for demographic variables, parathyroid hormone (PTH), and interdialytic weight gain. Results There were 54 patients analyzed. Mean pre-HD supine and seated systolic and diastolic BP were 164 (27), 158 (21), 91.5 (17), and 86.1 (16) mmHg. Mean serum phosphate was 5.89 (1.8) mg/dL. There were significant correlations between phosphate with all pre-hemodialysis BP measurements (r = 0.3, p = .04; r = 0.4, p = .002; r = 0.5, p < .0001; and r = 0.5, p = .0003.) The correlations with phosphate and TPRI, ET-1, and ADMA were 0.3 (p = .01), 0.4 (p = .007), and 0.3 (p = .04). In our final linear regression analyses controlling for baseline characteristics, PTH, and interdialytic weight gain, independent associations between phosphate with pre-hemodialysis diastolic BP, TPRI, and ET-1 were retained (β = 4.33, p = .0002; log transformed β = 0.05, p = .005; reciprocal transformed β = -0.03, p = .047). Conclusions Serum phosphate concentration is independently associated with higher pre-HD BP, vasoconstriction, and markers of endothelial cell dysfunction. These findings demonstrate an additional negative impact of hyperphosphatemia on cardiovascular health beyond vascular calcification. Trial registration The study was part of a registered clinical trial, NCT01862497 (May 24, 2013).
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Northrup H, Somarathna M, Corless S, Falzon I, Totenhagen J, Lee T, Shiu YT. Analysis of Geometric and Hemodynamic Profiles in Rat Arteriovenous Fistula Following PDE5A Inhibition. Front Bioeng Biotechnol 2021; 9:779043. [PMID: 34926425 PMCID: PMC8675087 DOI: 10.3389/fbioe.2021.779043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Arteriovenous fistula (AVF) is essential for chronic kidney disease (CKD) patients on hemodialysis, but treatment for AVF maturation failure remains an unmet clinical need. Successful AVF remodeling occurs through sufficient lumen expansion to increase AVF blood flow and lumen area. Aberrant blood flow is thought to impair AVF remodeling, but previous literature has largely focused on hemodynamics averaged over the entire AVF or at a single location. We hypothesized that hemodynamics is heterogeneous, and thus any treatment's effect size is heterogeneous in the AVF. To test our hypothesis, we used the PDE5A inhibitor sildenafil to treat AVFs in a rat model and performed magnetic resonance imaging (MRI) based computational fluid dynamics (CFD) to generate a detailed spatial profile of hemodynamics in AVFs. 90 mg/kg of sildenafil was administered to rats in their drinking water for 14 days. On day 14 femoral AVFs were created in rats and sildenafil treatment continued for another 21 days. 21 days post-AVF creation, rats underwent non-contrast MRI for CFD and geometrical analysis. Lumen cross-sectional area (CSA) and flow rate were used to quantify AVF remodeling. Parameters used to describe aberrant blood flow include velocity magnitude, wall shear stress (WSS), oscillatory shear index (OSI), and vorticity. Geometrical parameters include arterial-venous (A-V) distance, anastomosis angle, tortuosity, and nonplanarity angle magnitude. When averaged across the entire AVF, sildenafil treated rats had significantly higher CSA, flow rate, velocity, WSS, OSI, and vorticity than control rats. To analyze heterogeneity, the vein was separated into zones: 0-5, 5-10, 10-15, and 15-20 mm from the anastomosis. In both groups: 1) CSA increased from the 0-5 to 15-20 zone; 2) velocity, WSS, and vorticity were highest in the 0-5 zone and dropped significantly thereafter; and 3) OSI increased at the 5-10 zone and then decreased gradually. Thus, the effect size of sildenafil on AVF remodeling and the relationship between hemodynamics and AVF remodeling depend on location. There was no significant difference between control and sildenafil groups for the other geometric parameters. Rats tolerated sildenafil treatment well, and our results suggest that sildenafil may be a safe and effective therapy for AVF maturation.
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Affiliation(s)
- Hannah Northrup
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - Maheshika Somarathna
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Savanna Corless
- Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - Isabelle Falzon
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States.,Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.,Veterans Affairs Medical Center, Birmingham, AL, United States
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah Department of Internal Medicine, Salt Lake City, UT, United States.,Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Ilaria P, Mario M, Ilaria F. Advances in vascular anatomy and pathophysiology using high resolution and multiparametric sonography. J Vasc Access 2021; 22:1-8. [PMID: 34338066 PMCID: PMC8606621 DOI: 10.1177/11297298211020150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
B-mode and Color Doppler are the first-line imaging modalities in cardiovascular diseases. However, conventional ultrasound (US) provides a lower spatial and temporal resolution (70-100 frames per second) compared to ultrafast technology which acquires several thousand frames per second. Consequently, the multiparametric ultrafast platforms manage new imaging algorithms as high-frequency ultrasound, contrast-enhanced ultrasound, shear wave elastography, vector flow, and local pulse wave imaging. These advances allow better ultrasound performances, more detailed blood flow visualization and vessel walls' characterization, and many future applications for vascular viscoelastic properties evaluation.In this paper, we provide an overview of each new technique's principles and concepts and the real or potential applications of these modalities on the study of the artery and venous anatomy and pathophysiology of the upper limb before and after creating a native or prosthetic arterio-venous fistula. In particular, we focus on high-frequency ultrasound that could predict cannulation readiness and its potential role in the venous valvular status evaluation before vascular access creation; on contrast-enhanced ultrasound that could improve the peri-operative imaging evaluation during US-guided angioplasty; on shear wave elastography and local pulse wave imaging that could evaluate preoperative vessels stiffness and their potential predictive role in vascular access failure; on vector flow imaging that could better characterize the different components of the vascular access complex flow.
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Affiliation(s)
- Petrucci Ilaria
- Institute of Life Sciences, S. Anna School of Advanced Studies, Pisa, Italy
| | - Meola Mario
- Institute of Life Sciences, S. Anna School of Advanced Studies, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Fiorina Ilaria
- Radiodiagnostic and Interventional Radiology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Theodorakopoulou MP, Dipla K, Zafeiridis A, Sarafidis P. Εndothelial and microvascular function in CKD: Evaluation methods and associations with outcomes. Eur J Clin Invest 2021; 51:e13557. [PMID: 33774823 DOI: 10.1111/eci.13557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/19/2021] [Accepted: 03/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiovascular disease is the major cause of morbidity and mortality in patients with chronic kidney disease (CKD). Endothelial dysfunction, the hallmark of atherosclerosis, is suggested to be involved pathogenetically in cardiovascular and renal disease progression in these patients. METHODS This is a narrative review presenting the techniques and markers used for assessment of microvascular and endothelial function in patients with CKD and discussing findings of the relevant studies on the associations of endothelial dysfunction with co-morbid conditions and outcomes in this population. RESULTS Venous Occlusion Plethysmography was the first method to evaluate microvascular function; subsequently, several relevant techniques have been developed and used in patients with CKD, including brachial Flow-Mediated Dilatation, and more recently, Near-Infrared Spectroscopy and Laser Speckle Contrast Analysis. Furthermore, several circulating biomarkers are commonly used in clinical research. Studies assessing endothelial function using the above techniques and biomarkers suggest that endothelial dysfunction occurs early in CKD and contributes to the target organ damage, cardiovascular events, death and progression towards end-stage kidney disease. CONCLUSIONS Older and newer functional methods and several biomarkers have assessed endothelial dysfunction in CKD; accumulated evidence supports an association of endothelial dysfunction with outcomes. Future research with new, non-invasive and easily applicable methods could further delineate the role of endothelial dysfunction on cardiovascular and renal disease progression in patients with CKD.
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Affiliation(s)
- Marieta P Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantina Dipla
- Laboratory of Exercise Physiology and Biochemistry, Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Andreas Zafeiridis
- Laboratory of Exercise Physiology and Biochemistry, Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Serres, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Theodorakopoulou MP, Schoina M, Sarafidis P. Assessment of Endothelial and Microvascular Function in CKD: Older and Newer Techniques, Associated Risk Factors, and Relations with Outcomes. Am J Nephrol 2020; 51:931-949. [PMID: 33311014 DOI: 10.1159/000512263] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endothelium is the inner cellular lining of the vessels that modulates multiple biological processes including vasomotor tone, permeability, inflammatory responses, hemostasis, and angiogenesis. Endothelial dysfunction, the basis of atherosclerosis, is characterized by an imbalance between endothelium-derived relaxing factors and endothelium-derived contracting factors. SUMMARY Starting from the semi-invasive venous occlusion plethysmography, several functional techniques have been developed to evaluate microvascular function and subsequently used in patients with CKD. Flow-mediated dilatation of the forearm is considered to be the "gold standard," while in the last years, novel, noninvasive methods such as laser speckle contrast imaging and near-infrared spectroscopy are scarcely used. Moreover, several circulating biomarkers of endothelial function have been used in studies in CKD patients. This review summarizes available functional methods and biochemical markers for the assessment of endothelial and microvascular function in CKD and discusses existing evidence on their associations with comorbid conditions and outcomes in this population. Key Messages: Accumulated evidence suggests that endothelial dysfunction occurs early in CKD and is associated with target organ damage, progression of renal injury, cardiovascular events, and mortality. Novel methods evaluating microvascular function can offer a detailed, real-time assessment of underlying phenomena and should be increasingly used to shed more light on the role of endothelial dysfunction on cardiovascular and renal disease progression in CKD.
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Affiliation(s)
- Marieta P Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Schoina
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece,
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Lee T, Qian J, Thamer M, Allon M. Gender Disparities in Vascular Access Surgical Outcomes in Elderly Hemodialysis Patients. Am J Nephrol 2018; 49:11-19. [PMID: 30544112 DOI: 10.1159/000495261] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite national vascular access guidelines promoting the use of arteriovenous fistulas (AVF) over arteriovenous grafts (AVGs) for dialysis, AVF use is substantially lower in females. We assessed clinically relevant AVF and AVG surgical outcomes in elderly male and female patients initiating hemodialysis with a central venous catheter (CVC). METHODS Using the United States Renal Data System standard analytic files linked with Medicare claims, we assessed incident hemodialysis patients in the United States, 9,458 elderly patients (≥67 years; 4,927 males and 4,531 females) initiating hemodialysis from July 2010 to June 2011 with a catheter and had an AVF or AVG placed within 6 months. We evaluated vascular access placement, successful use for dialysis, assisted use (requiring an intervention before successful use), abandonment after successful use, and rate of interventions after successful use. RESULTS Females were less likely than males to receive an AVF (adjusted likelihood 0.57, 95% CI 0.52-0.63). Among patients receiving an AVF, females had higher adjusted likelihoods of unsuccessful AVF use (hazard ratio [HR] 1.46, 95% CI 1.36-1.56), assisted AVF use (OR 1.34, 95% CI 1.17-1.54), and AVF abandonment (HR 1.28, 95% CI 1.10-1.50), but similar relative rate of AVF interventions after successful use (relative risk [RR] 1.01, 95% CI 0.94-1.08). Among patients receiving an AVG, females had a lower likelihood of unsuccessful AVG use (HR 0.83, 95% CI 0.73-0.94), similar rates of assisted AVG use (OR 1.05, 95% CI 0.78-1.40) and AVG abandonment, and greater relative rate of interventions after successful AVG use (RR 1.16, 95% CI 1.01-1.33). CONCLUSIONS While AVFs should be considered the preferred vascular access in most circumstances, clinical AVF surgical outcomes are uniformly worse in females. Clinicians should also consider AVGs as a viable alternative in elderly female patients initiating hemodialysis with a CVC to avoid extended CVC dependence.
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Affiliation(s)
- Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at, Birmingham, Alabama, USA,
- Veterans Affairs Medical Center, Birmingham, Alabama, USA,
| | - Joyce Qian
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland, USA
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland, USA
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at, Birmingham, Alabama, USA
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Kopel T, Kaufman JS, Hamburg N, Sampalis JS, Vita JA, Dember LM. Endothelium-Dependent and -Independent Vascular Function in Advanced Chronic Kidney Disease. Clin J Am Soc Nephrol 2017; 12:1588-1594. [PMID: 28784655 PMCID: PMC5628728 DOI: 10.2215/cjn.12811216] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/09/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES CKD is associated with increased cardiovascular risk not fully attributable to traditional risk factors. We compared endothelium-dependent and -independent vascular function among individuals with advanced CKD with function in those with vascular disease but preserved kidney function. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Matched cohort analysis randomly selected from 1259 participants at a single center with measurements of brachial artery flow-mediated dilation, an endothelium-dependent process, and nitroglycerin-mediated dilation, an endothelium-independent process. Patients with advanced CKD (n=70) were matched 1:1 to controls with preserved kidney function and (1) no overt vascular disease, (2) hypertension, and (3) coronary artery disease. RESULTS The trend toward lower flow-mediated dilation (mean±SEM) in advanced CKD (5.4%±0.5%) compared with no overt vascular disease (7.3%±0.6%), hypertension (6.2%±0.5%), and coronary artery disease (5.8%±0.5%) did not reach statistical significance in adjusted analyses (P=0.05). Nitroglycerin-mediated dilation was lower in advanced CKD compared with in the other groups (adjusted nitroglycerin-mediated dilation: 6.9%±0.8%, 11.8%±0.9%, 11.0%±0.7%, and 10.5%±0.7% in advanced CKD, no overt vascular disease, hypertension, and coronary artery disease groups, respectively; P<0.001). Using tertiles generated from the full cohort and no overt vascular disease as the reference, the adjusted odds of flow-mediated dilation falling within the lowest tertile was higher in both the advanced CKD (odds ratio, 4.84; 95% confidence interval, 2.09 to 11.25) and coronary artery disease (odds ratio, 4.17; 95% confidence interval, 1.76 to 9.87) groups. In contrast, the adjusted odds of lowest tertile nitroglycerin-mediated dilation was higher in advanced CKD (odds ratio, 24.25; 95% confidence interval, 7.16 to 82.13) but not in the hypertension (odds ratio, 0.79; 95% confidence interval, 0.23 to 2.77) or coronary artery disease (odds ratio, 2.34; 95% confidence interval, 0.74 to 7.40) group. CONCLUSIONS Impairment in endothelium-dependent vascular function is present in patients with CKD and those with clinically evident vascular disease but preserved kidney function. In contrast, substantial reduction in endothelium-independent function was observed only in the CKD group, suggesting differences in severity and pathophysiology of vascular dysfunction between CKD and other disease states.
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Affiliation(s)
- Tal Kopel
- Division of Nephrology, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - James S. Kaufman
- Research Service and Renal Section, VA New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | - Naomi Hamburg
- Division of Cardiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - John S. Sampalis
- Faculty of Medicine, McGill University and Université de Montréal, Montreal, Quebec, Canada; and
| | - Joseph A. Vita
- Division of Cardiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Surgical technique determines the outcome of the Brescia/Cimino AVF. J Vasc Access 2017; 18:1-4. [PMID: 28297045 DOI: 10.5301/jva.5000698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 12/19/2022] Open
Abstract
Over the past 50 years, since Dr. Appel performed the first internal vascular access procedure for hemodialysis, the distal radiocephalic arteriovenous fistula continues to be the access of choice. Over time, failure to maturation has evolved as a major problem associated with this procedure depriving its benefits to many patients with end-stage renal disease. A variable incidence of this problem within similar patients suggests that surgical technique may play an important role in the development of non-maturation. Evaluating the current surgical techniques based on the hemodynamic consequences of anatomic and physiologic alterations following this procedure highlights the role of surgical technique in mitigating or reducing complications. Piggy-back straight line on-lay, a technique that helps to tailor the blood flow and reduce the oscillatory shear stress appears to reduce the incidence of early juxta-anastomotic problems, which contribute significantly to the problem of non-maturation.
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