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Kingsmore D, White RD, Mestres G, Stephens M, Calder F, Papadakis G, Aitken E, Jackson A, Inston N, Jones RG, Geddes C, Stevenson K, Szabo L, Thomson P, Stove C, Kasthuri R, Edgar B, Tozzi M, Franchin M, Sivaprakasam R, Karydis N. Recruitment into randomised trials of arteriovenous grafts: A systematic review. J Vasc Access 2024; 25:1069-1080. [PMID: 36905207 DOI: 10.1177/11297298231158413] [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: 03/12/2023] Open
Abstract
Although randomised controlled trials (RCT) are considered the optimal form of evidence, there are relatively few in surgery. Surgical RCT are particularly likely to be discontinued with poor recruitment cited as a leading reason. Surgical RCT present challenges over and above those seen in drug trials as the treatment under study may vary between procedures, between surgeons in one unit, and between units in multi-centred RCT. The most contentious and debated area of vascular access remains the role of arteriovenous grafts, and thus the quality of the data that is used to support opinions, guidelines and recommendations is critical. The aim of this review was to determine the extent of variation in the planning and recruitment in all RCT involving AVG. The findings of this are stark: there have been only 31 RCT performed in 31 years, the vast majority of which exhibited major limitations severe enough to undermine the results. This underlines the need for better quality RCT and data, and further inform the design of future studies. Perhaps most fundamental is the planning for a RCT that accounts for the intended population, the uptake of a RCT and the attrition for the significant co-morbidity in this population.
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Affiliation(s)
- David Kingsmore
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Spain
| | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Emma Aitken
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospital Birmingham, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, UK
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Laszlo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Ben Edgar
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | | | - Nikolaos Karydis
- Department of Renal and Transplant Surgery, University Hospital of Patras, Greece
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Kingsmore DB, Edgar B, Aitken E, Calder F, Franchin M, Geddes C, Inston N, Jackson A, Jones RG, Karydis N, Kasthuri R, Mestres G, Papadakis G, Sivaprakasam R, Stephens M, Stevenson K, Stove C, Szabo L, Thomson PC, Tozzi M, White RD. Quality assurance in surgical trials of arteriovenous grafts for haemodialysis: A systematic review, a narrative exploration and expert recommendations. J Vasc Access 2024:11297298241236521. [PMID: 38501338 DOI: 10.1177/11297298241236521] [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: 03/20/2024] Open
Abstract
BACKGROUND Introducing new procedures and challenging established paradigms requires well-designed randomised controlled trials (RCT). However, RCT in surgery present unique challenges with much of treatment tailored to the individual patient circumstances, refined by experience and limited by organisational factors. There has been considerable debate over the outcomes of arteriovenous grafts (AVG) compared to AVF, but any differences may reflect differing practice and potential variability. It is essential, therefore, when considering an RCT of a novel surgical procedure or device that quality assurance (QA) is defined for both the new approach and the comparator. The aim of this systematic review was to evaluate the QA standards performed in RCT of AVG using a multi-national, multi-disciplinary approach and propose an approach for future RCT. METHOD The methods of this have been previously registered (PROSPERO: CRD420234284280) and published. In summary, a four-stage review was performed: identification of RCT of AVG, initial review, multidisciplinary appraisal of QA methods and reconciliation. QA measures were sought in four areas - generic, credentialing, standardisation and monitoring, with data abstracted by a multi-national, multi-speciality review body. RESULTS QA in RCT involving AVG in all four domains is highly variable, often sub-optimally described and has not improved over the past three decades. Few RCT established or defined a pre-RCT level of experience, none documented a pre-trial education programme, or had minimal standards of peri-operative management, no study had a defined pre-trial monitoring programme, and none assessed technical performance. CONCLUSION QA in RCT is a relatively new area that is expanding to ensure evidence is reliable and reproducible. This review demonstrates that QA has not previously been detailed, but can be measured in surgical RCT of vascular access, and that a four-domain approach can easily be implemented into future RCT.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ben Edgar
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Emma Aitken
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Francis Calder
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marco Franchin
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Colin Geddes
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Inston
- Renal and Transplant Surgery, University Hospital Birmingham, Birmingham, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rob G Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nikolaos Karydis
- Department of Renal and Transplant Surgery, University of Athens, Athens, Greece
| | - Ram Kasthuri
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gaspar Mestres
- Department of Vascular Surgery, University of Barcelona, Barcelona, Spain
| | - Georgios Papadakis
- Renal & Transplant Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Mike Stephens
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Karen Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Callum Stove
- Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lazslo Szabo
- Dialysis Access Team, University Hospital of Wales, Cardiff, UK
| | - Peter C Thomson
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, Varesi, Italy
| | - Richard D White
- Department of Interventional Radiology, University Hospital of Wales, Cardiff, UK
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3
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Li J, Lu H, Xie Z, Li Q, Shi H. Outcomes of arteriovenous graft vs. fistula for haemodialysis access in the elderly: A systematic review and meta‑analysis. Exp Ther Med 2023; 26:399. [PMID: 37522056 PMCID: PMC10375446 DOI: 10.3892/etm.2023.12098] [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: 02/16/2023] [Accepted: 06/14/2023] [Indexed: 08/01/2023] Open
Abstract
The impact of the type of vascular access on the outcomes in the elderly haemodialysis patients is still unclear. The goal of the present study was to compare survival outcomes in elderly haemodialysis patients who received either arteriovenous graft (AVG) or arteriovenous fistula (AVF). A systematic literature search was performed in EMBASE, Cochrane, MEDLINE, ScienceDirect and Google Scholar databases for papers published from January 1954 until January 2022. Risk of bias in the selected publications was assessed by Newcastle Ottawa scale or Cochrane risk of bias tool depending on the study design. Meta-analysis was carried out using the random-effects model. Data were reported as pooled odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI). A total of 12 studies were included in the analysis. The majority of the studies had poor quality. Elderly patients receiving AVG had significantly worse survival rate compared with patients that received AVF for the haemodialysis access, with a pooled HR of 1.38 (95% CI, 1.24-1.53; I2=79.9%). Pooled HR for access survival was 1.60 (95% CI, 1.54-1.66; I2=0%). Pooled OR for primary patency rate, maturation failure and infections were 1.81 (95% CI, 0.73-4.49; I2=79.2%), 0.33 (95% CI, 0.12-0.91; I2=70.4%) and 9.74 (95% CI, 2.60-36.49; I2=52.4%), respectively. These results suggested that in elderly patients undergoing haemodialysis, AVG was associated with reduced overall survival and access survival, and higher infection rate, compared with AVF. Notably, AVG was also associated with a lower risk of maturation failure, presenting a potential advantage in specific patient populations (study registration: PROSPERO, no. CRD42022313199).
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Affiliation(s)
- Jia Li
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Hua Lu
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Zhen Xie
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Qingchao Li
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
| | - Hongguang Shi
- Department of Nephrology, Navy 971 Hospital, Qingdao, Shandong 266000, P.R. China
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Murea M, Gardezi AI, Goldman MP, Hicks CW, Lee T, Middleton JP, Shingarev R, Vachharajani TJ, Woo K, Abdelnour LM, Bennett KM, Geetha D, Kirksey L, Southerland KW, Young CJ, Brown WM, Bahnson J, Chen H, Allon M. Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial. BMC Nephrol 2023; 24:43. [PMID: 36829135 PMCID: PMC9960188 DOI: 10.1186/s12882-023-03086-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. METHODS This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups. DISCUSSION In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. TRIAL REGISTRATION This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Ali I Gardezi
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mathew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston- Salem, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N Wolfe St, Halsted 668, Baltimore, MD, USA
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Nephrology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - John P Middleton
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Roman Shingarev
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tushar J Vachharajani
- Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lama M Abdelnour
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kyla M Bennett
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Kevin W Southerland
- Division of Vascular & Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Carlton J Young
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William M Brown
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Judy Bahnson
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Haiying Chen
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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5
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Heggen BD, Ramspek CL, van der Bogt KEA, de Haan MW, Hemmelder MH, Hiligsmann MJC, van Loon MM, Rotmans JI, Tordoir JHM, Dekker FW, Schurink GWH, Snoeijs MGJ. Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e053108. [PMID: 35115352 PMCID: PMC8814743 DOI: 10.1136/bmjopen-2021-053108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients. METHODS AND ANALYSIS OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year. ETHICS AND DISSEMINATION Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines. TRIAL REGISTRATION NUMBER NL7933. PROTOCOL VERSION AND DATE V.5, 25 February 2021.
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Affiliation(s)
- Boudewijn Dc Heggen
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Koen E A van der Bogt
- Department of Surgery, Haaglanden Medical Centre, The Hague, Netherlands
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Michiel W de Haan
- Department of Radiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Mickaël J C Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Magda M van Loon
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
| | - Jan H M Tordoir
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Geert Willem H Schurink
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Maarten G J Snoeijs
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
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Murea M, Grey CR, Lok CE. Shared decision-making in hemodialysis vascular access practice. Kidney Int 2021; 100:799-808. [PMID: 34246655 PMCID: PMC8463450 DOI: 10.1016/j.kint.2021.05.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | - Carl R Grey
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Charmaine E Lok
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Murea M, Woo K. New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making. KIDNEY360 2021; 2:1380-1389. [PMID: 35369664 PMCID: PMC8676387 DOI: 10.34067/kid.0002882021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 02/04/2023]
Abstract
Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen Woo
- Department of Surgery, University of California Los Angeles, Los Angeles, California
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8
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Lyu B, Chan MR, Yevzlin AS, Gardezi A, Astor BC. Arteriovenous Access Type and Risk of Mortality, Hospitalization, and Sepsis Among Elderly Hemodialysis Patients: A Target Trial Emulation Approach. Am J Kidney Dis 2021; 79:69-78. [PMID: 34118301 DOI: 10.1053/j.ajkd.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Evidence is mixed regarding the optimal choice of the first permanent vascular access for elderly patients receiving hemodialysis (HD). Lacking data from randomized controlled trials, we used a target trial emulation approach to compare arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation among elderly patients receiving HD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Elderly patients included in the US Renal Data System who initiated HD with a catheter and had an AVF or AVG created within 6 months of starting HD. EXPOSURE Creation of an AVF versus an AVG as the incident arteriovenous access. OUTCOMES All-cause mortality, all-cause and cause-specific hospitalization, and sepsis. ANALYTICAL APPROACH Target trial emulation approach, high-dimensional propensity score and inverse probability of treatment weighting, and instrumental variable analysis using the proclivity of the operating physician to create a fistula as the instrumental variable. RESULTS A total of 19,867 patients were included, with 80.1% receiving an AVF and 19.9% an AVG. In unweighted analysis, AVF creation was associated with significantly lower risks of mortality and hospitalization, especially within 6 months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of mortality and hospitalization within 6 months after creation (hazard ratios of 0.82 [95% CI, 0.75-0.91] and 0.82 [95% CI, 0.78-0.87] for mortality and all-cause hospitalization, respectively), but not between 6 months and 3 years after access creation. No association between AVF creation and mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization was found in instrumental variable analyses. However, AVF creation was associated with a lower risk of access-related hospitalization not due to infection. LIMITATIONS Potential for unmeasured confounding, analyses limited to elderly patients, and absence of data on actual access use during follow-up. CONCLUSIONS Using observational data to emulate a target randomized controlled trial, the type of initial arteriovenous access created was not associated with the risks of mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization among elderly patients who initiated HD with a catheter.
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Affiliation(s)
- Beini Lyu
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Micah R Chan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin
| | | | - Ali Gardezi
- Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Medicine, University of Wisconsin School of Medicine and Public Health; Madison, Wisconsin.
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9
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Robinson T, Geary RL, Davis RP, Hurie JB, Williams TK, Velazquez-Ramirez G, Moossavi S, Chen H, Murea M. Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial. Kidney Med 2021; 3:248-256.e1. [PMID: 33851120 PMCID: PMC8039401 DOI: 10.1016/j.xkme.2020.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background It is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial. Study Design Pilot randomized parallel-group open-label trial. Setting & Participants Patients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist. Intervention Participants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF. Outcomes Index AV access primary failure, successful cannulation, adjuvant interventions and infections. Results Of 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively. Limitations Small sample size precludes statistical inference. Conclusions Almost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available. Funding Government funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01). Trial Registration NCT03545113.
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Affiliation(s)
- Todd Robinson
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Randolph L Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Shahriar Moossavi
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Haiying Chen
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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