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Kuningas K, Stringer S, Cockwell P, Khawaja A, Inston N. Is there a role of the kidney failure risk equation in optimizing timing of vascular access creation in pre-dialysis patients? J Vasc Access 2023; 24:1305-1313. [PMID: 35343295 DOI: 10.1177/11297298221084799] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aims of this study were to assess the utility of using the Kidney Failure Risk Equation (KFRE) as an indicator to guide timing of vascular access creation in pre-dialysis patients. MATERIALS AND METHODS Patients referred for vascular access creation had KFRE calculated at the time of assessment and compared to standard criteria for referral. Receiver operating characteristic curves were produced for each parameter. The outcomes at 3 months, 6 months, and 1 year were used as time points for analysis. RESULTS Two hundred and three patients were assessed, and full data sets were available on 190 (94.6%). Access was created in 156 patients (82.1%) with a fistula in 153 (98.7%). Only 65.7% initiated dialysis within the follow up period. Those patients with an AV access created (n = 156) 37 (23.7%) did not reach end stage over the entire follow up period. Of the remaining patients (n = 119) that reached end stage 72.2% (n = 86) started on an AVF/AVG and 27.7% (n = 33) on a CVC. Using ROC analysis for referral eGFR, ACR and KFRE predicting dialysis initiation predictors resulted in C statistics for eGFR, ACR, and KFRE2 of 0.68 (0.58-0.79), 0.75 (0.65-0.84), and 0.72 (0.62-0.81) at 3 months; 0.73 (0.65-0.81), 0.70 (0.62-0.78), and 0.75 (0.67-0.81) at 6 months; and 0.65 (0.57-0.72); 0.67 (0.59-0.75), and 0.68 (0.61-0.77) at 12 months. CONCLUSIONS In a group of patients referred for vascular access creation the predictive models are relatively poor when applied to initiation of dialysis. The application of current guidelines to fistula creation appears to result in a high rate of unnecessary fistula formation and non-use. The study requires further evaluation in a test set of patients to confirm these findings and also identify where such risk based approaches may need modification.
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Affiliation(s)
- Külli Kuningas
- Department of Research and Development, Renal Research Institute, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephanie Stringer
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aurangzaib Khawaja
- Department of Renal Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nicholas Inston
- Department of Renal Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Gan W, Zhu F, Mao H, Xiao W, Chen W, Zeng X. The effect of early conversion from central venous catheter to arteriovenous fistula on hospitalization and mortality in incident haemodialysis patients. J Vasc Access 2023:11297298231196267. [PMID: 37638715 DOI: 10.1177/11297298231196267] [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: 08/29/2023] Open
Abstract
BACKGROUND Controversy remains as to whether initiating haemodialysis (HD) with a central venous catheter (CVC) and vascular access conversion are associated with the risk of morbidity and mortality in incident HD patients. METHODS At our dialysis centre, the vascular access strategy is to create an arteriovenous fistula (AVF) early and use the AVF to initiate HD. In emergency situations, HD is initiated with a CVC and subsequent conversion from a CVC to an AVF as soon as possible. The effects of early AVF conversion on hospitalization and mortality were analysed. RESULTS At HD initiation, 35.42% used AVF, 15.63% used CVC with immature AVF and 48.96% used CVC, and all patients were able to convert from CVC to AVF within approximately 3 months. Compared to starting HD using an AVF, using a CVC was associated with access-related hospitalizations at 2 years, regardless of whether an AVF was created before (incidence rate ratio (IRR) = 3.02, 95% CI 0.89-10.24, p = 0.03) or after (IRR = 4.10, 95% CI 1.55-10.85, p < 0.01) HD initiation. The Kaplan-Meier method showed that the 2-year survival probability was not statistically significant between the three groups (log-rank χ2 = 0.165, p = 0.921). Multivariate Cox proportional hazards regression showed that starting HD with a CVC was not associated with mortality at 2 years (p > 0.05). CONCLUSION In this cohort, initiating HD with a CVC was associated with more access-related hospitalizations. Under the impact of an early AVF conversion strategy, despite initiating HD with a CVC, subsequent conversion from a CVC to an AVF within approximately 3 months had no impact on all-cause mortality in incident HD patients.
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Affiliation(s)
- Wenyuan Gan
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Fan Zhu
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huihui Mao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Xiao
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenli Chen
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xingruo Zeng
- Department of Nephrology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Kazes I, Moranne O, Lassalle M. [REIN: a tool to evaluate practices]. Nephrol Ther 2023; 18:46-49. [PMID: 37638508 DOI: 10.1016/s1769-7255(22)00567-3] [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: 11/07/2022]
Abstract
On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its role in practices evaluation, the following key messages were retained. The evaluation of our practices allows improving them as proposed by the concept of the Edward Deming wheel (Plan, Do, Check, Act). Measurement also allows setting goals and targets. Where there are recommendations available, the REIN indicators allow comparison with the identified targets. The REIN registry is an interesting tool to observe the deployment and impact of the recommendations in dialysis units and to evaluate the professional practices taking into account the patients’ characteristics and the changes in the recommendations. Finally, the treatment indicators analysed using REIN data show the great diversity of practices from one region to another, the result of habits, training of nephrologists, the history of the care offered and sometimes the geography of the region and its population.
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Affiliation(s)
- Isabelle Kazes
- Coordination régionale Champagne-Ardenne, CHU Reims, France
| | - Olivier Moranne
- Hôpital universitaire de Nîmes, Caremau, Nîmes, UMR INSERM-UM, Institut Desbrest d’épidémiologie et santé publique (IDESP), Campus Santé,
641 avenue du Doyen-Gaston-Giraud, 34093 Montpellier, France
| | - Mathilde Lassalle
- Coordination nationale REIN, Agence de la biomédecine, Saint-Denis-La Plaine, France
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Prabhakaran M, Mahapatra HS, Nath RK, Pursnani L, Balakrishnan M, Singh A, Singh A, Patil S, Gautam A. Comparison of clinical examination, doppler and fistulogram for arterio-venous fistula surveillance in detecting secondary failure. J Vasc Access 2023:11297298231161461. [PMID: 37318136 DOI: 10.1177/11297298231161461] [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: 06/16/2023] Open
Abstract
BACKGROUND Arteriovenous Fistula (AVF) surveillance is required to detect early dysfunction (thrombosis, stenosis) and its timely correction prolongs access-patency. Clinical examination (CE) and doppler have been used as screening/surveillance of AVF, for early detection of AVF dysfunction. Since there was inadequate evidence for KDOQI to make recommendations on AVF surveillance and on secondary failure rate. We compared CE, doppler and fistulogram as surveillance modalities in detecting a secondary failure in matured AVF. METHODOLOGY This prospective-observational, single-center study, was done between December 2019-April 2021. CKD stage 5 patients on dialysis/Not-on-dialysis with matured AVF were included at third month. CE, doppler (blood flow, vein diameter, depth), and fistulogram were done at third and sixth month. Secondary failure was assessed at sixth month classifying AVF to patent/functional and failed group. Diagnostic tests were performed by comparing three methods considering fistulogram as gold-standard. Residual urine output is also monitored to look for any contrast induced residual renal function loss. RESULTS Of total 407 created AVF, 98 (24%) had primary failure. Twenty-five (6%) had surgical complications including unsuccessful AVF and aneurysm/rupture, 156 lost follow-up at third month, 104 consented patients were enrolled, 16 lost to follow-up subsequently, and 88 patients' data were analyzed at the end. At the sixth month, 76(86.4%) had patent AVF, 8 (9.1%) had secondary failure (Thrombosis-4, Central Venous Stenosis-4), and 4 (4.1%) patients expired. Considering fistulogram as a diagnostic standard, CE showed 87.5% sensitivity, and 93.4% specificity (cohen's kappa value of 0.66). Doppler had sensitivity and specificity of 87% and 96% respectively (cohen's kappa value of 0.75), Combination of clinical examination with doppler showed sensitivity and specificity of 100% and 89% respectively. CONCLUSION Although the secondary AVF failure rate is less than the primary, CE is an important and valuable tool in the diagnosis and surveillance of AVF in detecting its dysfunction. Moreover, CE with doppler can be used as a surveillance protocol that can detect early AVF dysfunction at par with Fistulogram.
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Affiliation(s)
- Manoj Prabhakaran
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Ranjith Kumar Nath
- Department of Cardiology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Lalit Pursnani
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | | | - Anamika Singh
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Amandeep Singh
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sanket Patil
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Abhisek Gautam
- Department of Nephrology, ABVIMS, Dr. Ram Manohar Lohia Hospital, New Delhi, India
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5
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Coscas R, Petrica N, Massy Z, Jayet J, De Launay J. Readmissions Following Arteriovenous Access Creation for Haemodialysis in a French National Database. Eur J Vasc Endovasc Surg 2022; 64:703-710. [PMID: 35988860 DOI: 10.1016/j.ejvs.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE There is a lack of large real world data on arteriovenous (AV) access results. This study aimed to describe the required hospital care during the first year following creation of AV access. METHODS Data from all adult patients who underwent creation of AV access performed in 2017 in a public or private facility were collected through the French national hospitalisation database. Patients were classified into two groups ("de novo" and "secondary") according to their history of prior AV access creation. The primary outcome was the proportion of patients with at least one hospital readmission related to the AV access recorded during the first 12 post-operative months. RESULTS In 2017, 10 476 adult patients underwent AV access creation in France, including 8 690 (83%) de novo creations. An AV fistula was created for 92% of the patients (95% de novo vs. 78% secondary; p < .001). During the first 12 post-operative months, 6 591 (63%) patients recorded at least one related readmission (68% secondary vs. 62% de novo; p < .001). A total of 5 557 (53%) recorded a readmission for surgical/interventional procedure and 2 852 (27%) were observed with a readmission for medical complications. The mean (± standard deviation) number of related readmissions at 12 months was 1.4 ± 1.6 per patient (1.7 ± 1.9 secondary vs. 1.3 ± 1.5 de novo; p < .001). Patients with an AV graft were more frequently readmitted than those with an AV fistula (1.8 ± 2 vs. 1.3 ± 1.5 readmission; p < .001). CONCLUSION This study highlights the high frequency of readmissions during the first 12 months following creation of AV access, particularly in patients who had already undergone creation of a previous AV access or had an AV graft implanted. Further research should focus on tailoring AV access strategies to improve patient quality of life and decrease the healthcare cost burden.
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Affiliation(s)
- Raphael Coscas
- Department of Vascular Surgery, CHU Ambroise Paré, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Centre for Research in Epidemiology and Population Health (CESP), Inserm UMRS 1018, team 5, France; University Versailles-Saint Quentin, University Paris-Saclay, Villejuif, France.
| | | | - Ziad Massy
- Centre for Research in Epidemiology and Population Health (CESP), Inserm UMRS 1018, team 5, France; University Versailles-Saint Quentin, University Paris-Saclay, Villejuif, France; Department of Nephrology, CHU Ambroise Paré, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Jérémie Jayet
- Department of Vascular Surgery, CHU Ambroise Paré, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Centre for Research in Epidemiology and Population Health (CESP), Inserm UMRS 1018, team 5, France; University Versailles-Saint Quentin, University Paris-Saclay, Villejuif, France
| | - Jérôme De Launay
- Becton, Dickinson and Company - BD Interventional, Health Economics Department, Voisins-le-Bretonneux, France
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6
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Descriptions des hospitalisations au cours de l’année 2019 des patients dialysés en France. Nephrol Ther 2022; 18:534-540. [DOI: 10.1016/j.nephro.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 11/21/2022]
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Tal MG, Yevzlin AS. Initial Clinical Experience with a Symmetric Tip Tunneled Hemodialysis Catheter Without Side Holes. ASAIO J 2021; 67:1257-1262. [PMID: 34534128 PMCID: PMC8555951 DOI: 10.1097/mat.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this article is to assess the performance and safety of a novel, symmetric, side-hole-free tunneled cuffed catheter hypothesized to sustain adequate flow without the need for side holes. Between November 2016 and January 2019, Pristine hemodialysis catheters were placed de novo in 45 end-stage renal disease patients (27 males and 18 females) at a single investigational site. Forty-one catheters were placed in the right and four in the left internal jugular vein. There were no incidents of insertion failure. Patients had dialysis three times per week and were followed at four investigational sites. Nominal catheter flows, incidence of poor flow, and catheter-related infections were recorded at each dialysis session and analyzed. The average follow-up time was 161.69 days for a total of 7116 catheter days. Nine patients died from reasons unrelated to the catheter and one patient switched to fistula. Four patients had poor flows necessitating catheter replacement. Four patients had catheter-related bloodstream infections which resolved with antibiotics. These equate to 0.56 events per 1000 catheter days. Catheter survival was 100%, 97.6%, and 89.7% at 30, 90, and 180 days, respectively. The initial clinical assessment of the symmetric Pristine hemodialysis catheter featuring a Y-tip devoid of side holes revealed good catheter performance and survival and a low complication rate.
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Affiliation(s)
- Michael G. Tal
- From the Division of Interventional Radiology, Hadassah Medical Center, Jerusalem, Israel
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8
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[CKD care in French nephrology practices]. Nephrol Ther 2021; 17:496-506. [PMID: 34384728 DOI: 10.1016/j.nephro.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/14/2021] [Accepted: 06/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND To be able to assess the impact of the bundled payment system on real-life management of patients with chronic kidney disease, an overview of patient-care management before its implementation is needed. PATIENTS AND METHODS We describe patterns of nephrology care over 3 years in 2835 patients with moderate to severe chronic kidney disease, who were followed-up from 2013 to 2019 in the CKD-REIN cohort study. Compliance with health authority guidelines during this period is also studied. RESULTS At baseline, patients' mean age was 67 years, 65% were men, and 43% had chronic kidney disease stage 4 or 5. The mean number of nephrology visits increased from 1.1 to 2.7 per year, from chronic kidney disease stage 3A to stage 5. The minimum number of nephrology visits as recommended by health authorities was achieved in 84%, 63%, and 33% of patients with chronic kidney disease stages 3B, 4, and 5, respectively. In chronic kidney disease stages 4 and 5, only 34% and 40% of patients had seen a dietitian, and 33% and 54% had received information about treatment options, respectively. The average waiting time for a first appointment with a nephrologist was longer, 60 days and its duration shorter, 30 vs 38 to 40 minutes, in university hospitals compared with non-university hospitals and private clinics. CONCLUSION The significant gap between received and recommended care reflects human resources and organizational limits in chronic kidney disease management in the nephrology setting. Improvements with bundled payment are expected.
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Hussein WF, Ahmed G, Browne LD, Plant WD, Stack AG. Evolution of Vascular Access Use among Incident Patients during the First Year on Hemodialysis: A National Cohort Study. KIDNEY360 2021; 2:955-965. [PMID: 35373090 PMCID: PMC8791378 DOI: 10.34067/kid.0006842020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/21/2021] [Indexed: 11/27/2022]
Abstract
Background Although the arteriovenous fistula (AVF) confers superior benefits over central venous catheters (CVCs), utilization rates remain low among prevalent patients on hemodialysis (HD). The goal of this study was to determine the evolution of vascular access type in the first year of dialysis and identify factors associated with conversion from CVC to a functioning AVF. Methods We studiedadult patients (n=610) who began HD between the January 1, 2015 and December 31, 2016 and were treated for at least 90 days, using data from the National Kidney Disease Clinical Patient Management System in the Irish health system. Prevalence of vascular access type was determined at days 90 and 360 after dialysis initiation and at 30-day intervals. Multivariable logistic regression explored factors associated with CVC at day 90, and Cox regression evaluated predictors of conversion from CVC to AVF on day 360. Results CVC use was present in 77% of incident patients at day 90, with significant variation across HD centers (from 63% to 91%, P<0.001), which persisted after case-mix adjustment. From day 90 to day 360, AVF use increased modestly from 23% to 41%. Conversion from CVC to AVF increased over time, but the likelihood was lower for older patients (for age >77 years versus referent, adjusted hazard ratio [HR], 0.43; 95% CI, 0.19 to 0.96), for patients with a lower BMI (per unit decrease in BMI, HR, 0.95; 95% CI, 0.93 to 0.98), and varied significantly across HD centers (from an HR of 0.25 [95% CI, 0.08 to 0.74] to 2.09 [95% CI, 1.04 to 4.18]). Conclusion CVCs are the predominant type of vascular access observed during the first year of dialysis, with low conversion rates from CVC to AVF. There is substantial center variation in the Irish health system that is not explained by patient-related factors alone.
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Affiliation(s)
- Wael F Hussein
- School of Medicine, University of Limerick, Limerick, Ireland.,Department of Nephrology, University Hospital Limerick, Limerick, Ireland
| | - Gasim Ahmed
- School of Medicine, University of Limerick, Limerick, Ireland.,Department of Nephrology, University Hospital Limerick, Limerick, Ireland
| | - Leonard D Browne
- School of Medicine, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - William D Plant
- Department of Nephrology, Cork University Hospital, Cork, Ireland.,National Renal Office, Health Service Executive Clinical Programmes and Strategy Division, Dublin, Ireland
| | - Austin G Stack
- School of Medicine, University of Limerick, Limerick, Ireland.,Department of Nephrology, University Hospital Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
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10
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Chung EY, Knagge D, Cheung S, Sun J, Heath L, McColl H, Guo H, Gray L, Srivastava T, Sandy J, McGinn S, Fisher C. Factors associated with functional arteriovenous fistula at hemodialysis start and arteriovenous fistula non-use in a single-center cohort. J Vasc Access 2021; 23:558-566. [PMID: 33752497 DOI: 10.1177/11297298211002574] [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
BACKGROUND The gold standard of commencing hemodialysis with a functional arteriovenous fistula (AVF) is challenging. We aim to review factors associated with functional AVF at hemodialysis start at a tertiary hospital. METHODS We retrospectively reviewed incident hemodialysis patients or who had AVF creation at a single tertiary hospital from 2011 to 2016. Data was extracted for patient comorbidities, duration from referral to AVF creation and hemodialysis start, estimated glomerular filtration rate (eGFR) at surgical referral, referring nephrologist, events accelerating eGFR decline, and revisions for "failing to mature" AVF to assess factors associated with non-functioning AVF or late AVF creation, using multinomial logistic regression. RESULTS Two hundred two patients received hemodialysis and 51 had AVF creation but did not dialyze (AVF futility rate 20%). Of these, 133 (66%) commenced hemodialysis with a central venous catheter (CVC) and 69 (34%) with an AVF. Patients with functional AVFs at hemodialysis start were referred earlier than those with non-functional AVFs (median 256 vs 66 days before hemodialysis start, p = 0.001). Age, sex, eGFR at surgical referral, and comorbidities were not predictive of patients with functional AVFs. Events accelerating eGFR decline were associated with an increased incidence of CVC at hemodialysis start (risk ratio (RR) 4.21, 95% confidence interval (CI) 1.96-9.03, p < 0.0001). Referring nephrologists external to our renal unit may be associated with non-functional AVF at hemodialysis start (RR 6.60, 95% CI 1.74-25.13, p = 0.006). CONCLUSIONS We found that functional AVFs required referral a median of 256 days prior to hemodialysis start and events accelerating eGFR decline increase the incidence of CVC at hemodialysis start. Age, sex, eGFR at surgical referral, and comorbidities did not inform the likelihood of timely AVF creation and evaluation of further predictive pre-dialysis factors is necessary to identify patients requiring early AVF creation whilst minimizing the cost of unnecessary procedures.
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Affiliation(s)
- Edmund Ym Chung
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Sydney Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Debbie Knagge
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Simone Cheung
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jessica Sun
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lauren Heath
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Hayden McColl
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Henry Guo
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lauren Gray
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Tarini Srivastava
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Joshua Sandy
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Stella McGinn
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Charles Fisher
- Department of Vascular Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
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Stolić RV, Bukumiric Z, Mitrovic V, Sipic M, Krdzic B, Relic G, Nikolic G, Sovtic S, Suljkovic NE. Are There Differences in Arteriovenous Fistulae Created for Hemodialysis between Nephrologists and Vascular Surgeons? Med Princ Pract 2021; 30:178-184. [PMID: 33120382 PMCID: PMC8114068 DOI: 10.1159/000512632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Many studies have reported insufficient support from surgical services, resulting in nephrologists creating arteriovenous fistulas in many centers. The aim of this study was to compare risk factors of arteriovenous fistula dysfunction in patients whose fistulas were created by nephrologists versus vascular surgeons. METHODS This was a retrospective, analytical study of interventions by nephrologists and vascular surgeons during a period of 15 years. Out of a total of 1,048 fistulas, 764 (72.9%) were created by nephrologists patients, while vascular surgeons were responsible for 284 (27.1%) fistulae. Laboratory, demographic, and clinical parameters which might affect functioning of these arteriovenous fistulae were analyzed. RESULTS Patients whose arteriovenous fistula was formed by nephrologists differed significantly from those created by vascular surgeons in relation to the preventive character of the arteriovenous fistula (p = 0.011), lumen of the vein (p < 0.001) and systolic blood pressure (p = 0.047). Multivariate logistic regression of arteriovenous fistula dysfunction showed that risk factors were female gender (odds ratio [OR] = 1.56, 95% CI 1.16-2.07), whether the fistulae were created by vascular surgeons or nephrologists (OR = 1.38; 95% CI 1.01-1.89) and the site of the arteriovenous fistula (OR = 0.64; 95% CI 0.48-0.85). CONCLUSIONS Arteriovenous fistulae created by vascular surgeons, female gender, and the location are risk factors of dysfunction.
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Affiliation(s)
- Radojica V Stolić
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia,
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Vekoslav Mitrovic
- Faculty of Medicine Foca, University of East Sarajevo, Foca, Bosnia and Herzegovina
| | - Maja Sipic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Biljana Krdzic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Goran Relic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Gordana Nikolic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Sasa Sovtic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
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Tal MG, Livne R, Neeman R. Clot accumulation at the tip of hemodialysis catheters in a large animal model. J Vasc Access 2020; 23:128-134. [PMID: 33356813 PMCID: PMC8899813 DOI: 10.1177/1129729820983617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The issue of side holes in the tips of the tunneled cuffed central venous
catheters is complex and has been subject to longstanding debate. This study
sought to compare the clotting potential of the side-hole-free Pristine
hemodialysis catheter with that of a symmetric catheter with side holes. Methods: Both jugular veins of five goats were catheterized with the two different
catheters. The catheters were left in place for 4 weeks and were flushed and
locked with heparin thrice weekly. The aspirated intraluminal clot length
was assessed visually prior to each flushing. In addition, the size and
weight of the clot were recorded upon catheter extraction at the end of the
4-week follow-up Results: The mean intraluminal clot length observed during the entire study follow-up
measured up to a mean of 0.66 cm in the GlidePath (95% CI, 0.14–1.18) and
0.19 cm in the Pristine hemodialysis catheter (95% CI, −0.33 to 0.71), the
difference being statistically significant (p = 0.026). On
average, 0.01 g and 0.07 g of intraluminal clot were retrieved from the
Pristine and GlidePath catheters, respectively
(p = 0.052). Conclusion: The Pristine hemodialysis catheter was largely superior to a standard side
hole catheter in impeding clot formation, and, contrary to the side hole
catheter, allowed for complete aspiration of the intraluminal clot.
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Affiliation(s)
| | - Ron Livne
- Pristine Access Technologies, Tel Aviv, Israel
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13
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Baláž P, Hanko J, Magowan H, Masengu A, Lawrie K, O'Neill S. The arteriovenous access stage (AVAS) classification. Clin Kidney J 2020; 14:1747-1751. [PMID: 34221382 PMCID: PMC8243270 DOI: 10.1093/ckj/sfaa189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/21/2020] [Indexed: 01/17/2023] Open
Abstract
Background Key anatomical factors mean that individuals needing arteriovenous access are unique and have different possibilities for fistula creation. The aim of this article is to describe a new classification system for all patients needing haemodialysis vascular access in the upper extremity with the purpose to simplify sharing the information about suitability for surgical access creation depending on vascular anatomy. Methods According to the patient's vascular anatomy in right and left superior extremities, patients were separated into three arteriovenous access stages (AVAS). The AVAS was validated by three blinded observers using a sample of 70 upper limb arteriovenous maps that were performed using ultrasound on patients referred for vascular access assessment. A sample size calculation was performed and calculated that for three observers, a minimum of 67 maps were required to confirm significant agreement at a Kappa value of 0.9 (95% confidence interval 0.75-0.99). Results The Kappa value for inter-rater reliability using Fleiss' Kappa coefficient was 0.94 and all patients fitted into the AVAS classification system. Conclusion The AVAS classification system is a simplified way to share information about vascular access options based on a patient's vascular anatomy with high inter-rater reliability.
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Affiliation(s)
- Peter Baláž
- Department of Surgery, Faculty Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Vascular Surgery, National Institute for Cardiovascular Disease, Bratislava, Slovak Republic
| | - Jennifer Hanko
- Department of Transplant Surgery, and Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
| | - Hannah Magowan
- Department of Transplant Surgery, and Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
| | - Agnes Masengu
- Department of Transplant Surgery, and Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
| | - Katarina Lawrie
- Department of Surgery, Faculty Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stephen O'Neill
- Department of Transplant Surgery, and Regional Nephrology Unit, Belfast City Hospital, Belfast, UK
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14
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Tazza L, Angelici L, Marino C, Di Napoli A, Bossola M, De Cicco C, Davoli M, Agabiti N. Determinants of venous catheter hemodialysis onset and subsequent switch to arteriovenous fistula: An epidemiological study in Lazio region. J Vasc Access 2020; 22:749-758. [PMID: 32993439 DOI: 10.1177/1129729820959942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The factors associated with the inability to start hemodialysis with an arteriovenous fistula (AVF) in chronic kidney disease patients are not fully understood. AIM Evaluating factors associated with type of vascular access at the first chronic hemodialysis and at 1 year after it. METHODS The study cohort includes patients registered in the Regional Dialysis and Transplant Registry of Lazio undergoing first hemodialysis between 2008 and 2015. Logistic regression models were used to evaluate the association between socio-demographic, clinical and care/organizational factors, and vascular access at first hemodialysis. Cox regression models were used to assess the odds of switching to AVF during the first year of hemodialysis among patients starting dialysis with central venous catheter (CVC). RESULTS In the cohort of 6208 incident hemodialysis patients, 52.7% had an AVF and 47.3% had a CVC. Among the 2939 incident patients with CVC, 27.4% switched to FAV after 1 year. A higher probability of starting dialysis with AVF was observed among males (OR = 1.83; 95% CI 1.63-2.06), while a lower probability was observed among patients aged >85 years (OR 0.64; IC 95% 0.51-0.80). Patients with early referral to a nephrologist had a triple probability of start dialysis with AVF. We observed a higher odds of switch to AVF among males (HR = 1.62; 95% CI 1.40-1.89) and a lower odds among patients over 65 years. CONCLUSION The observed high rate of AVF at the start of hemodialysis and of the switch from CVC to AVF in the first year, although declining since 2008, is a positive outcome. However, over one-third of patients maintain the CVC as vascular access for the first year because of unmodifiable factors, such as gender, age, comorbidity. The present study suggests that logistics/management and assistance/welfare problems may contribute to the delay or lack of AVF placement in incident hemodialysis patients or within the first year of dialysis.
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Affiliation(s)
- Luigi Tazza
- Catholic University, Rome, Rome, Italy.,Ars Medica Clinic, Rome, Italy
| | - Laura Angelici
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Claudia Marino
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Anteo Di Napoli
- National Institute for Health, Migration and Poverty, Rome, Italy
| | - Maurizio Bossola
- Department of Nephrology, Fondazione Agostino Gemelli, IRCCS, Rome, Italy
| | | | - Marina Davoli
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
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15
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Lassalle M, Monnet E, Ayav C, Hogan J, Moranne O, Couchoud C. 2017 Annual Report Digest of the Renal Epidemiology Information Network (REIN) registry. Transpl Int 2019; 32:892-902. [DOI: 10.1111/tri.13466] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/01/2019] [Accepted: 05/25/2019] [Indexed: 01/16/2023]
Affiliation(s)
- Mathilde Lassalle
- REIN Registry Agence de la biomédecine Saint Denis La Plaine Cedex France
| | - Elisabeth Monnet
- Unité Epidémiologie- Santé Publique CIC INSERM 1431 CHRU Besançon Besançon France
| | - Carole Ayav
- CIC 1433 Epidémiologie Clinique, Inserm CHRU, Université de Lorraine, CHRU de Nancy – Hôpitaux de Brabois Nancy France
| | | | - Olivier Moranne
- Hopital Caremau, CHU Nîmes, Institut Universitaire de Recherche Clinique - EA2415, Université de Montpellier Nîmes France
| | - Cécile Couchoud
- REIN Registry Agence de la biomédecine Saint Denis La Plaine Cedex France
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16
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Murea M, Geary RL, Davis RP, Moossavi S. Vascular access for hemodialysis: A perpetual challenge. Semin Dial 2019; 32:527-534. [PMID: 31209966 DOI: 10.1111/sdi.12828] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Randolph L Geary
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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17
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C-reactive protein as a prognostic risk factor for loss of arteriovenous fistula patency in hemodialyzed patients. J Vasc Surg 2019; 70:208-215. [PMID: 30792061 DOI: 10.1016/j.jvs.2018.10.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 10/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Inflammation is a cardiovascular risk factor in hemodialysis patients, but its influence on vascular access patency is still debatable. Our prospective study investigated this issue. METHODS A total of 258 patients receiving an arteriovenous fistula (AVF) between 2006 and 2016 at the Municipal Hospital Arad were included. Demographic, clinical, and laboratory characteristics were collected at the time of creation of the AVF. The primary study end point was AVF patency loss, defined as an event occurring at least 2 months after AVF formation and requiring surgical revision or replacement of the fistula. The patients were followed up for a median time of 26 months. RESULTS In our group, the mean age was 59.7 ± 13.2 years (median, 62 years), and 60.1% were male. During follow-up, 134 patients (51.9%) maintained AVF patency, whereas 124 (48.1%) lost AVF patency within a mean time of 23.3 ± 28.1 months (median, 10.5 months). We found that age (hazard ratio [HR], 1.015; P = .035) and C-reactive protein (CRP) level (HR, 1.17; P < .0001) were associated with a higher risk of loss of AVF patency. The protective factors for AVF patency were autosomal dominant polycystic kidney disease (HR, 0.336; P = .009), pre-emptive AVF (HR, 0.648; P = .031), and higher level of triglycerides (HR, 0.998; P = .035). In the multivariate adjusted Cox model, CRP level remained an independent predictor for loss of AVF patency (HR, 1.17; 95% confidence interval, 1.1-1.3; P < .0001). CONCLUSIONS In our study, CRP level was an independent predictor of AVF patency loss, whereas better AVF survival was independently associated with autosomal dominant polycystic kidney disease and pre-emptive AVF. As a simple noninvasive marker of chronic inflammation, CRP level may be a useful tool to predict AVF outcomes. Further research is needed to assess the protective effects of inflammation reduction on AVF survival.
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18
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Hemodialysis access type is associated with blood pressure variability and echocardiographic changes in end-stage renal disease patients. J Nephrol 2019; 32:627-634. [PMID: 30666583 DOI: 10.1007/s40620-018-00574-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/18/2018] [Indexed: 02/05/2023]
Abstract
Arteriovenous fistula (AVF) strategy has been recommended in clinical guidelines for a long time due to the survival benefits associated with it. However, the underlying mechanism still needs to be explored. This retrospective cohort study included 611 patients who received hemodialysis in West China Hospital Medical Center between January 1, 2014 and December 31, 2014. Patient characteristics, dialysis parameters, and 1-year blood pressure records were collected at baseline. Echocardiographic changes and clinical outcomes were assessed during the 59-month follow-up. Our study showed that fistulas were associated with lower long-term systolic blood pressure (SBP) standard deviation (SD) (P < 0.0001), lower long-term SBP residual metric (P < 0.0001), and lower intradialytic SBP residual (P = 0.001). Fistulas were also associated with a higher but non-significant proportion of the newly developed left ventricular (LV) hypertrophy (8.29% vs. 6.78%, P = 0.116) and increased LV volume (8.29% vs. 4.52%, P = 0.139), as well as a lower proportion of the newly developed left ventricular ejection fraction (LVEF) dysfunction (1.62% vs. 2.82%, P = 0.586). After a median of 59-month follow-up, catheter group showed a higher risk of cardiovascular events (hazard ratio [HR] 1.21; 95% confidence interval [95%CI] 1.01-1.52), all-cause infection (HR 1.25; 95%CI 1.07-1.47), and access-related infection (HR 2.88; 95%CI 1.76-4.68). However, the advantage of fistulas only retained in low-albumin subgroup (serum albumin < 40 g/l) except for access-related infections. Our results suggested the possible attribution of BPV and other patient factors to fistula-associated survival benefits.
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19
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Abstract
Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.
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20
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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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21
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Bosanquet DC, Davies CG. Letter r.e. "Clinical Utility of a New Predicting Score for Radiocephalic Arteriovenous Fistula Survival". Ann Vasc Surg 2017; 43:353-354. [PMID: 28549962 DOI: 10.1016/j.avsg.2017.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/08/2017] [Indexed: 01/17/2023]
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