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Ebner A, Gallo S, Castellano J, Filartiga M, Haarstad A, Pries C, Gahlbeck K, McMahon M, Herrera C, Avila M, Schankereli K, Murphy R, Stenoien M, Syedain Z, Wasse H. First-in-human evaluation of a biological regenerative vascular conduit for hemodialysis access. J Vasc Access 2024; 25:1271-1278. [PMID: 36895135 DOI: 10.1177/11297298221147709] [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: 03/11/2023] Open
Abstract
INTRODUCTION The long-term survival and low complication rate of autogenous fistulas for hemodialysis access is often offset by early thrombosis and slow or failed maturation leading to the use of central venous catheters. A regenerative material may have the potential to overcome these limitations. A completely biological acellular vascular conduit was investigated in this first-in-human clinical study. METHODS With approval of the ethics board and patients' informed consent, five subjects were enrolled based on predetermined inclusion criteria. Five patients underwent implant of a novel acellular, biological tissue conduit (TRUE AVC™) in the upper arm in a curved configuration between brachial artery and axillary vein. After maturation, standard dialysis was commenced through the new access. Patients were followed up to 26 weeks with ultrasound and physical exam. Serum samples were evaluated for an immune response to the novel allogeneic human tissue implant. RESULTS This new tissue conduit handled well surgically, with properties similar to that of native human vein. Post procedure conduit flow was excellent in all cases, averaging 1098 ± 388 ml/min at week 4 and remaining stable through 1248 ± 355 ml/min at 26 weeks. Surgical site healing was normal with no edema or erythema by week 4. Six-month primary assisted patency was 80% and secondary patency was 100%. Prescribed dialysis was successfully delivered without infection, and there was no significant change in conduit diameter. Serum testing showed no increase in PRA or IgG specific to the TRUE AVC. One implant required intervention at 5 months with thrombectomy and covered stent procedure. CONCLUSION This first-in-human 6-month study with favorable patency and low complication rate establishes the initial safety and feasibility of this novel biological tissue conduit for dialysis access in patients with end-stage kidney disease. Its mechanical durability and lack of immune response establishes TRUE AVC as a potential regenerative material for clinical use.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Zeeshan Syedain
- Vascudyne, Inc., St. Paul, MN, USA
- University of Minnesota, Minneapolis, MN, USA
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Hartono YL, Shahverdyan R. Proximalization of arteriovenous inflow as native loop utilizing the upper arm basilic and forearm cephalic veins for the treatment of hemodialysis access induced hand ischemia. J Vasc Access 2024; 25:1328-1331. [PMID: 37439208 DOI: 10.1177/11297298231187920] [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: 07/14/2023] Open
Abstract
BACKGROUND Up to 10% of hemodialysis patients with an arteriovenous fistula (AVF) suffer hemodialysis access induced distal ischemia (HAIDI). We report a treatment option of HAIDI by proximalization of arterial inflow (PAI) to the axillary artery as native upper arm loop and salvaging the matured forearm cephalic vein after previous creation of a radio-cephalic AVF (RCAVF). METHODS A 79-years-old multimorbid male patient with end-stage kidney disease presented with an elsewhere placed left-sided RCAVF. With the start of cannulations, the patient suffered severe HAIDI. Due to the low/normal AVF-flow of 550 ml/min, a PAI procedure using the matured forearm cephalic and upper arm basilic veins in a form of native upper arm loop was performed. RESULTS Patient's symptoms resolved postoperatively with successful cannulations and tunneled dialysis catheter removal after 5 weeks. During a follow-up period of 64 months, several interventions were performed to maintain the patency, yet the AVF remained patent for >5 years. CONCLUSIONS This modified PAI technique using native vessels in form of upper arm loop graft is a feasible and durable option to maintain long-term cumulative patency and should be considered as a valid native treatment option for HAIDI.
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Alencar de Pinho N, Prezelin-Reydit M, Harambat J, Couchoud C, Glaudet F, Combe C, Rondeau V, Leffondré K. Arteriovenous access creation and hazards of hospitalization and death in patients starting hemodialysis. Nephrol Dial Transplant 2024; 39:978-988. [PMID: 38012126 DOI: 10.1093/ndt/gfad251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Recent evidence suggests an overestimation of the benefits associated with arteriovenous (AV) fistula versus graft in certain populations. We assessed hazards of all-cause and cause-specific hospitalization and death associated with AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex and comorbidities. METHODS We performed a target trial emulation including patients who initiated hemodialysis with a catheter from 2010 through 2018 and were followed by the REIN Registry. We identified first-created fistula or graft through the French national health-administrative database. We used joint frailty models to deal with recurrent hospitalizations and potential informative censoring by death, and inverse probability weighting to account for confounding. RESULTS From the 18 800 patients included (mean age 68 ± 15 years, 35% women), 5% underwent AV graft creation first. The weighted hazard ratio (wHR) of all-cause hospitalization associated with graft was 1.08 [95% confidence interval (CI) 1.02 to 1.15], that of vascular access-related hospitalization was 1.43 (95% CI 1.32 to 1.55), and those of cardiovascular- and infection-related hospitalizations were 1.14 (95% CI 1.03 to 1.26) and 1.11 (95% CI 0.97 to 1.28), respectively. Results were consistent for most subgroups, except that the highest hazard of all-cause, cardiovascular- and infection-related hospitalizations with graft was blunted in patients with comorbidities (i.e. diabetes, wHR 1.01, 95% CI 0.93 to 1.10; 1.10, 95% CI 0.96 to 1.26; and 0.94, 95% CI 0.78 to 1.12, respectively). CONCLUSIONS In patients starting hemodialysis with a catheter, AV graft creation is associated with increased hazard of vascular access-related hospitalizations compared with fistula. This may not be the case for death or other causes of hospitalization.
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Affiliation(s)
- Natalia Alencar de Pinho
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
| | - Mathilde Prezelin-Reydit
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- Maison du Rein - AURAD Aquitaine, Gradignan, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
| | - Jerome Harambat
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
- Department of Pediatric Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Cécile Couchoud
- Registre REIN, Agence de la biomédecine, Saint Denis La Plaine, France
| | - Florence Glaudet
- Cellule régionale REIN Limousin, Department of Nephrology, CHU Dupuytren 2, Limoges, France
| | - Christian Combe
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
- Department of Nephrology Transplantation Dialysis and Apheresis, CHU de Bordeaux, Univ. Bordeaux, Bordeaux, France
- Université de Bordeaux, Inserm U1026, Bordeaux, France
| | - Virginie Rondeau
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
| | - Karen Leffondré
- Université de Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR1219, CIC1401-EC, Bordeaux, France
- INSERM, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, Bordeaux, France
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Kanbay M, Basile C, Battaglia Y, Mantovani A, Yavuz F, Pizzarelli F, Luyckx VA, Covic A, Liakopoulos V, Mitra S. Shared decision making in elderly patients with kidney failure. Nephrol Dial Transplant 2024; 39:742-751. [PMID: 37742209 PMCID: PMC11045282 DOI: 10.1093/ndt/gfad211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Indexed: 09/26/2023] Open
Abstract
'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.
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Affiliation(s)
- Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Yuri Battaglia
- Department of Medicine, University of Verona, Verona, Italy
- Nephrology and Dialysis Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Furkan Yavuz
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | | | - Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital, and ‘Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Vassilios Liakopoulos
- Second Department of Nephrology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre (MAHSC), Manchester University Hospitals and University of Manchester, Manchester, UK
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Yan T, Gameiro J, Grilo J, Filipe R, Rocha E. Hemodialysis vascular access in elderly patients: A comprehensive review. J Vasc Access 2024; 25:27-39. [PMID: 35546530 DOI: 10.1177/11297298221097233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.
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Affiliation(s)
- Teófilo Yan
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - João Grilo
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Rui Filipe
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
| | - Ernesto Rocha
- Division of Nephrology, Department of Medicine, Unidade Local de Saúde de Castelo Branco, EPE, Castelo Branco, Portugal
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Pai MF, Tung KT, Hsu SP, Peng YS, Lin WY, Yang JY, Wu HY, Chiu YL, Shu KH, Tsai WC. Adverse events following the first, second and third doses of a COVID-19 vaccine in hemodialysis patients. Ren Fail 2023; 45:2172432. [PMID: 36715434 PMCID: PMC9888469 DOI: 10.1080/0886022x.2023.2172432] [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] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND This study aimed to identify adverse events following the first three doses of COVID-19 vaccines in hemodialysis (HD) patients. Risk factors associated with postvaccination adverse events were explored. METHODS Postvaccination adverse events in 438 HD patients who received 3 doses of COVID-19 vaccines were prospectively assessed. The adverse events among three doses were compared using generalized linear mixed models. Factors associated with adverse events were assessed with multivariate analyses. RESULTS The vast majority of participants received Oxford/AstraZeneca ChAdOx1 as their first two doses and Moderna mRNA-1273 as their third dose. Overall, 79%, 50% and 84% of the participants experienced at least one adverse event after their first, second, and third doses, respectively. These adverse events were mostly minor, short-lived and less than 5% reported daily activities being affected. Compared with the first dose, the second dose caused a lower rate of adverse events. Compared with the first dose, the third dose elicited a higher rate of injection site reactions and a lower rate of systemic reactions. Multivariate analyses showed that every 10-year increase of age (odds ratio 0.67, 95% confidence intervals 0.57-0.79) was associated with decreased risk of adverse events, while female sex (2.82, 1.90-4.18) and arteriovenous fistula (1.73, 1.05-2.84) were associated with increased risk of adverse events. Compared with Oxford/AstraZeneca ChAdOx1, Moderna mRNA-1273 was associated with an increased risk of injection site reactions. CONCLUSIONS COVID-19 vaccination was well tolerated in HD patients. Age, sex, dialysis vascular access and vaccine types were associated with postvaccination adverse events.
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Affiliation(s)
- Mei-Fen Pai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Kuei-Ting Tung
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Ping Hsu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan,School of Life Science, National Taiwan Normal University, Taipei City, Taiwan
| | - Yu-Sen Peng
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Applied Cosmetology, Lee-Ming Institute of Technology, New Taipei City, Taiwan,Department of Electrical Engineering, Yuan Ze University, Taoyuan City, Taiwan
| | - Wan-Yu Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Ju-Yeh Yang
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan,Center for General Education, Lee-Ming Institute of Technology, New Taipei City, Taiwan
| | - Hon-Yen Wu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Yen-Ling Chiu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan,Graduate Program in Biomedical Informatics, Yuan Ze University, Taoyuan City, Taiwan
| | - Kai-Hsiang Shu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Wan-Chuan Tsai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Center for General Education, Lee-Ming Institute of Technology, New Taipei City, Taiwan,CONTACT Wan-Chuan Tsai Division of Nephrology, Department of Internal Medicine; Center for General Education, Lee-Ming Institute of Technology, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Rd, Banciao District, New Taipei City 220, New Taipei City, Taiwan
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Murea M, Allon M. The reasons for comparative effectiveness clinical trials of arteriovenous fistula versus graft strategy in older adults on hemodialysis with a catheter. Clin Nephrol 2023; 100:243-248. [PMID: 37877300 PMCID: PMC10795491 DOI: 10.5414/cn111227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/09/2023] [Indexed: 10/26/2023] Open
Abstract
Clinicians and patients are guided by observational studies to make one of the most consequential decisions for patients with advanced kidney disease: the selection of the "right" hemodialysis vascular access. More than a decade ago, a call for randomized clinical trials was made to equitably compare clinical outcomes between arteriovenous (AV) fistulas (AVFs) and AV grafts (AVGs). Mounting evidence suggests that trade-offs between AVF- and AVGrelated outcomes are context dependent. In this article, we summarize four streams of evidence that collectively underpin the burden of equipoise between the two types of AV access in older adults with comorbidities who are on hemodialysis with a central venous catheter.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, and
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Gan W, Zhu F, Mao H, Xiao W, Chen W, Zeng X. Effect of preoperative arterial diameter on hospitalization and mortality in patients undergoing hemodialysis with forearm arteriovenous fistula access. J Vasc Access 2023:11297298231211361. [PMID: 37997027 DOI: 10.1177/11297298231211361] [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: 11/25/2023] Open
Abstract
BACKGROUND As pointed out by the recent Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access, the current quality of evidence supporting preoperative vascular anatomy and patient outcomes is suboptimal and insufficient to make recommendations. This study assessed arteriovenous fistulas (AVFs) created with different preoperative arterial diameters on hospitalization and mortality rates in patients undergoing hemodialysis at the authors' center. METHODS Data from 261 patients who underwent HD between 2017 and 2019 were retrospectively examined. Differences in mortality and hospitalization rates between patients with different preoperative arterial diameters were compared, and risk factors for mortality and hospitalization were analyzed. RESULTS Smaller preoperative artery diameter (<2 mm) was associated with all-cause mortality (risk ratio [RR] 1.61 [95% confidence interval (CI) 1.45-1.90]; p < 0.01), and access-related (RR 1.68 [95% CI 1.24-2.44]; p < 0.01), and congestive heart failure (CHF)-related (RR 0.67 [95% CI 0.38-1.01]; p = 0.04) hospitalization. Longer catheter-dependent duration (⩾60 days) was associated with access-related hospitalization (RR 1.48 [95% CI 1.07-2.11]; p = 0.03), and higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with CHF-related hospitalization (RR 1.58 [95% CI 1.02-2.29]; p < 0.01). Higher postoperative brachial artery blood flow (⩾1500 mL/min) was associated with all-cause mortality (hazard ratio [HR] 1.20 [95% CI 1.09-2.32]; p = 0.04), whereas preoperative artery diameter (HR 0.98 [95% CI 0.93-1.86]; p = 0.08) and catheter-dependent duration (HR 1.06 [95% CI 0.47-2.13]; p = 0.82) were not associated with all-cause mortality. CONCLUSION In this cohort, smaller preoperative artery diameter was associated with all-cause and access-related hospitalizations, while a larger preoperative artery and higher postoperative brachial blood flow were associated with CHF-related hospitalization. However, only higher postoperative brachial blood flow was associated with all-cause mortality.
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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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Wu HHL, Chinnadurai R. Weighing up telehealth for older adults receiving home dialysis. THE LANCET. HEALTHY LONGEVITY 2023; 4:e455-e456. [PMID: 37659425 DOI: 10.1016/s2666-7568(23)00139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 09/04/2023] Open
Affiliation(s)
- Henry H L Wu
- Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital and The University of Sydney, Sydney, NSW 2065, Australia; Department of Renal Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, NSW, Australia.
| | - Rajkumar Chinnadurai
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, 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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Roldão M, Figueiredo C, Escoli R, Gonçalves H, Sofia F, Lopes K. Vascular access type and mortality in elderly incident hemodialysis patients. Nefrologia 2023; 43:452-457. [PMID: 36517357 DOI: 10.1016/j.nefroe.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/20/2022] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION The ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients. METHODS Single-center retrospective study of 99 incident HD patients aged≥80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan-Meier survival curves and Cox's proportional hazards model. RESULTS When compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32-2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02-2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28-3.64)] and hemoglobin [HR 4.10(95% CI 1.69-9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11-3.14)] were also associated with increased mortality risk in our cohort, p<0.05. CONCLUSION Our findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.
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Affiliation(s)
- Marisa Roldão
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal.
| | - Cátia Figueiredo
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Rachele Escoli
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Hernâni Gonçalves
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Flora Sofia
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
| | - Karina Lopes
- Department of Nephrology, Centro Hospitalar do Médio Tejo, Torres Novas, Portugal
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12
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Laham G, Pujol GS, Guzman J, Boccia N, Abib A, Diaz CH. Early start hemodialysis with a catheter may be associated with greater mortality: A propensity score analysis. Semin Dial 2023; 36:294-302. [PMID: 37088891 DOI: 10.1111/sdi.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/30/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Deciding when and how to initiate hemodialysis (HD) is still controversial. An early start (ES) seems to show a lack of benefit. "Lead time bias" and comorbidities have been associated with different outcomes in ES groups. On the other hand, it is well accepted that the impact the type of vascular access (VA) has on patient survival. Our aim was to evaluate survival with early start (ES) versus late start (LS) on HD, taking into account the vascular access (VA) used. METHODS Between 01/1995 and 06/2018, 503 incidental patients initiated HD at our Dialysis Unit. eGFR was estimated by the CKD-EPI equation. Diabetes mellitus (DM), coronary disease (CD), and peripheral vascular disease (PVD) were considered comorbid conditions. According to eGFR and VA, patients were divided into four groups: G1: ES (eGFR > 7 mL/min) with catheter (ES + C), G2: ES with fistula or graft (F/G) (ES + F/G), G3: LS (eGFR< 7 mL/min) with catheter (LS + C), and G4: LS with F/G (LS + F/G). The cut-off value to define ES or LS was based on median eGFR for these 503 patients. We compared patient's survival rates by Kaplan-Meier and log-rank test. The four groups were compared before and after matching with propensity scores (PS). Cox analysis was performed to determine the impact of predictors of mortality. RESULTS Median eGFR was 7 (5.3-9.5) mL/min/1.73 m2 , median follow-up time was 30.9 (13-50) months, 52.1% had F/G access at entry, and 46.9% died during the observation period. Among the four groups, the ES + C were significantly older, and there were more diabetics and comorbid conditions, while phosphatemia, iPTH, albumin, and hemoglobin were significantly higher in the LS groups. Before propensity score (PS) matching, the ES + C group had a poor survival rate (p < 0.0001), while LS + F/G access had the best survival. After PS, a total of 180 patients were selected in the same four groups and ES + C kept showing a statistically significant poorer survival. Multivariate analysis revealed that ES + C was an independent predictor of mortality. CONCLUSION In this retrospective study, ES + C on HD was associated with a higher mortality rate than LS. This association persisted after PS matching.
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Affiliation(s)
- Gustavo Laham
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Gervasio Soler Pujol
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Jenny Guzman
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Natalia Boccia
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Anabel Abib
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Carlos H Diaz
- Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
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13
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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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14
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Murakami M, Fujii N, Kanda E, Kikuchi K, Wada A, Hamano T, Masakane I. Association of Four Types of Vascular Access Including Arterial Superficialization with Mortality in Maintenance Hemodialysis Patients: A Nationwide Cohort Study in Japan. Am J Nephrol 2023; 54:83-94. [PMID: 36917960 PMCID: PMC11232950 DOI: 10.1159/000529991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Vascular access usage varies widely across countries. Previous studies have evaluated the association of clinical outcomes with the three types of vascular access, namely, arteriovenous fistula (AVF), arteriovenous graft (AVG), and tunneled and cuffed central venous catheter (TC-CVC). However, little is known regarding the association between arterial superficialization (AS) and the mortality of patients. METHODS A nationwide cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry (2006-2007). We included patients aged ≥20 years undergoing hemodialysis with a dialysis vintage ≥6 months. The exposures of interest were the four types of vascular access: AVF, AVG, AS, and TC-CVC. Cox proportional hazard models were used to evaluate the associations of vascular access types with 1-year all-cause and cause-specific mortality. RESULTS A total of 183,490 maintenance hemodialysis patients were included: 90.7% with AVF, 6.9% with AVG, 2.0% with AS, and 0.4% with TC-CVC. During the 1-year follow-up period, 13,798 patients died. Compared to patients with AVF, those with AVG, AS, and TC-CVC had a significantly higher risk of all-cause mortality after adjustment for confounding factors: adjusted hazard ratios (95% confidence intervals) - 1.30 (1.20-1.41), 1.56 (1.39-1.76), and 2.15 (1.77-2.61), respectively. Similar results were obtained for infection-related and cardiovascular mortality. CONCLUSION This nationwide cohort study conducted in Japan suggested that AVF usage may have the lowest risk of all-cause mortality. The study also suggested that the usage of AS may be associated with better survival rates compared to those of TC-CVC in patients who are not suitable for AVF or AVG.
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Affiliation(s)
- Minoru Murakami
- Department of Nephrology, Saku Central Hospital, Nagano, Japan
| | - Naohiko Fujii
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Medical and Research Center for Nephrology and Transplantation, Hyogo Prefectural Nishinomiya Hospital, Hyogo, Japan
| | - Eiichiro Kanda
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Medical Science, Kawasaki Medical School, Okayama, Japan
| | - Kan Kikuchi
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Division of Nephrology, Shimoochiai Clinic, Tokyo, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Takayuki Hamano
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
- Department of Nephrology, Yabuki Hospital, Yamagata, Japan
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15
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Li X, Reddy SN, Clark TWI, Vance AZ. Endovascular creation of hemodialysis arteriovenous fistulae: the current status and future perspective-a literature review. Cardiovasc Diagn Ther 2023; 13:173-189. [PMID: 36864953 PMCID: PMC9971305 DOI: 10.21037/cdt-21-600] [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: 09/22/2021] [Accepted: 02/10/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective End-stage renal disease (ESRD) is increasingly prevalent among Americans. Traditionally, the gold standard of dialysis fistulae creation is surgical arteriovenous fistulae (AVF), which is preferred over central venous catheter (CVC) and arteriovenous graft (AVG). However, it is associated with many challenges, particularly its high primary failure rate, which is partially attributed to neointimal hyperplasia. Endovascular creation of arteriovenous fistulae (endoAVF) is a recently emerging method, and is thought to circumvent many of the surgical challenges. It is theorized to reduce the peri-operative trauma to the vessel, thus reducing the amount of neointimal hyperplasia. In this article, we aim to review the current status and future perspectives of endoAVF. Methods An electronic search was performed on MEDLINE and Embase to identify relevant articles from 2015 to 2021. Key Content and Findings The initial trial data has been promising, resulting in the increased adoption of endoAVF devices in clinical practice. Further, short- and mid-term data has shown that endoAVF has been associated with good maturation rate, re-intervention rate, primary and secondary patency rates. In comparison to historical surgical data, endoAVF has been shown to be comparable in certain aspects. Lastly, endoAVF has been used in an increasing range of clinical applications, including wrist AVF and two-stage transposition procedure. Conclusions Although current data has been promising, endoAVF is associated with a host of unique challenges, and the current data has mostly been derived from selective patient population. Further studies are required to further assess its usefulness and its role in the dialysis care algorithm.
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Affiliation(s)
- Xin Li
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shilpa N Reddy
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ansar Z Vance
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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16
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Vascular access type and mortality in elderly incident hemodialysis patients. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Lyu B, Chan MR, Yevzlin AS, Astor BC. Catheter Dependence After Arteriovenous Fistula or Graft Placement Among Elderly Patients on Hemodialysis. Am J Kidney Dis 2021; 78:399-408.e1. [DOI: 10.1053/j.ajkd.2020.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/25/2020] [Indexed: 11/11/2022]
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18
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Wu HHL, Nixon AC, Dhaygude AP, Jayanti A, Mitra S. Is home hemodialysis a practical option for older people? Hemodial Int 2021; 25:416-423. [PMID: 34133069 DOI: 10.1111/hdi.12949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/23/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.
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Affiliation(s)
- Henry H L Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.,Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ajay P Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK.,Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK
| | - Anu Jayanti
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sandip Mitra
- Faculty of Medical and Human Sciences, Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.,Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
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19
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Weaver ML, Holscher CM, Sorber RA, Lum YW, Reifsnyder T. Redo Hemodialysis Access in Elderly Patients has Acceptable Outcomes With Similar Patency of Arteriovenous Fistulas as Compared to Grafts. Ann Vasc Surg 2021; 76:128-133. [PMID: 34004325 DOI: 10.1016/j.avsg.2021.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Selecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients. METHODS All patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression. RESULTS Overall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47). CONCLUSIONS These results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible.
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Affiliation(s)
- M Libby Weaver
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
| | - Courtenay M Holscher
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca A Sorber
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ying Wei Lum
- Department of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Reifsnyder
- Division of Vascular Surgery, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD
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20
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Abstract
End-stage kidney disease (ESKD) is a common and morbid disease that affects patients' quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants-even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient's "life plan," and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.
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Affiliation(s)
- Ryan Gupta
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
| | - Karen Woo
- Division of Vascular Surgery, University of California Los Angeles, David Geffen School of Medicine, 200 UCLA Medical Plaza, Suite 526, Los Angeles, CA 90095.
| | - Jeniann A Yi
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz School of Medicine, Aurora, CO
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21
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Dicken Q, Sather K, Farber A, Mendez L, Castro V, Zhang Y, Levin SR, Talutis SD, Raulli SJ, Siracuse JJ. Octogenarians and Nonoctogenarians Have Similar Outcomes after Upper Extremity Hemodialysis Access Creation. Ann Vasc Surg 2020; 69:34-42. [DOI: 10.1016/j.avsg.2020.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022]
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Qian J, Lee T, Thamer M, Zhang Y, Crews DC, Allon M. Racial Disparities in the Arteriovenous Fistula Care Continuum in Hemodialysis Patients. Clin J Am Soc Nephrol 2020; 15:1796-1803. [PMID: 33082199 PMCID: PMC7769016 DOI: 10.2215/cjn.03600320] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Arteriovenous fistulas are the optimal vascular access type for patients on hemodialysis. However, arteriovenous fistulas are used less frequently in Black than in White individuals. The arteriovenous fistula care continuum comprises a series of sequential steps. A better understanding is needed of where disparities exist along the continuum in order to mitigate racial differences in arteriovenous fistula use. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using Medicare claims data from the United States Renal Data System, longitudinal analyses of patients ≥67 years initiating hemodialysis with a central venous catheter between July 1, 2010 and June 30, 2012 were performed. Three patient cohorts were identified: patients initiating hemodialysis with a catheter (n=41,814), patients with arteriovenous fistula placement within 6 months of dialysis initiation (n=14,077), and patients whose arteriovenous fistulas were successfully used within 6 months of placement (n=7068). Three arteriovenous fistula processes of care outcomes were compared between Blacks and Whites: (1) arteriovenous fistula creation, (2) successful arteriovenous fistula use, and (3) primary arteriovenous fistula patency after successful use. RESULTS An arteriovenous fistula was placed within 6 months of dialysis initiation in 37% of patients initiating dialysis with a catheter. Among the patients with arteriovenous fistula placement, the arteriovenous fistula was successfully used for dialysis within 6 months in 48% of patients. Among patients with successful arteriovenous fistula use, 21% maintained primary arteriovenous fistula patency at 3 years. After adjusting for competing risks, Black patients on hemodialysis were 10% less likely to undergo arteriovenous fistula placement (adjusted subdistribution hazard ratio, 0.90; 95% confidence interval, 0.87 to 0.94); 12% less likely to have successful arteriovenous fistula use after placement (adjusted subdistribution hazard ratio, 0.88; 95% confidence interval, 0.83 to 0.93); and 22% less likely to maintain primary arteriovenous fistula patency after successful use (subdistribution hazard ratio, 0.78; 95% confidence interval, 0.74 to 0.84). CONCLUSIONS Lower arteriovenous fistula use among Blacks older than 67 years of age treated with hemodialysis was attributable to each step along the continuum of arteriovenous fistula processes of care.
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Affiliation(s)
- Joyce Qian
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama .,Veterans Affairs Medical Center, Medical Service and Section of Nephrology, Birmingham, Alabama
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Affiliation(s)
- Robert S. Brown
- Nephrology Division Department of Medicine Beth Israel Deaconess Medical Center and Harvard Medical School Boston MA USA
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Yoshida M, Doi S, Nakashima A, Kyuden Y, Kawai T, Kawaoka K, Takahashi S, Ueno T, Nishizawa Y, Masaki T. Different risk factors are associated with vascular access patency after construction and percutaneous transluminal angioplasty in patients starting hemodialysis. J Vasc Access 2020; 22:707-715. [PMID: 32985321 DOI: 10.1177/1129729820959934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The objective of this multicenter, prospective observational study was to determine the factors related to patency rates after construction of vascular access (VA) and the first percutaneous transluminal angioplasty (PTA). METHODS The 24-month primary and secondary patency rates after construction of a radiocephalic arteriovenous fistula (RC-AVF) and arteriovenous graft (AVG) were evaluated using the Kaplan-Meier method and log-rank test. The 12-month post-PTA patency rate was also investigated. A Cox proportional hazard model was used to identify clinical parameters associated with the primary patency rate and the post-PTA patency rate. RESULTS A total of 611 patients were enrolled in the study. The primary patency rate after VA construction was lower in hemodialysis (HD) patients with an AVG than in those with an AVF. Aging (hazard ratio [HR], 1.02 per 1 year; p < 0.001), female sex (HR, 1.41; p = 0.03), diabetes mellitus (HR, 1.37; p = 0.03), low serum albumin (HR, 0.76 per 1-g/dL decrease; p = 0.02), and use of an erythropoietin-stimulating agent (HR, 1.62; p = 0.02) were risk factors for VA problems. The post-PTA patency rate was associated with aging (HR, 1.02; p < 0.001), diabetes mellitus (HR, 1.49; p = 0.02), polycystic kidney disease (HR, 2.14; p = 0.01), temporary catheter use for initiation of HD (HR, 1.60; p = 0.02), and period from VA construction to use (HR, 0.99; p = 0.04). CONCLUSION Although a poor patency rate is commonly associated with advanced age and diabetes, different risk factors affect patency between VA construction and the first PTA.
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Affiliation(s)
- Mahoko Yoshida
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigehiro Doi
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Ayumu Nakashima
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Stem Cell Biology and Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | | | | | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center, Kure, Japan
| | - Toshinori Ueno
- Department of Nephrology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yoshiko Nishizawa
- Department of Nephrology, Ichiyokai Harada Hospital, Hiroshima, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
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25
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Celik S, Gok Oguz E, Ulusal Okyay G, Selen T, Ayli MD. The impact of arteriovenous fistulas and tunneled cuffed venous catheters on morbidity and mortality in hemodialysis patients: A single center experience. Int J Artif Organs 2020; 44:229-236. [PMID: 32962489 DOI: 10.1177/0391398820952808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIM Hemodialysis is the most used renal replacement therapy option for patients with end-stage renal disease. Arteriovenous fistulas (AVFs) and tunnel-cuffed venous catheters (tCVC) are commonly used vascular access routes and have advantages and disadvantages compared to each other. This study focuses on the effects of AVFs and tCVCs on morbidity and mortality in hemodialysis patients. METHODS The records (between January 2015 and January 2017) of 110 patients (55 patients with AVF and 55 patients with tCVC) under hemodialysis therapy for at least 6 months were evaluated retrospectively. The data about blood tests, hospitalizations, and mortality were compared between patients with AVF and tCVC. FINDINGS Fifty-five patients (25 male, 58 ± 14 years old) were undergoing hemodialysis via AVF. Fifty-five patients (17 male, 63 ± 14 years old) were undergoing hemodialysis via tunneled CVCs. Thirty (54.5%) of the hospitalization patients had AVF and 46 (83.6%) had CVCs (p < 0.01). The only independent predictor of hospitalization was the use of tCVC as vascular access, according to multivariate regression analysis (p = 0.01). Seven (30%) of the dead patients had AVF and 16 (69.6%) had CVCs (p = 0.035). Use of tCVC appeared to be a mortality predictor in univariate regression analysis (p = 0.039). But the significance did not continue in multivariate model (p = 0.578) in which the duration of hemodialysis appeared as the only significant factor (p = 0.002). CONCLUSION Patients undergoing hemodialysis via AVF had fewer all-cause hospitalizations and mortality rate than those using tunneled CVCs.
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Affiliation(s)
- Serhat Celik
- Department of Internal Medicine, University of Health Sciences, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Ebru Gok Oguz
- Department of Nephrology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Gulay Ulusal Okyay
- Department of Nephrology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Tamer Selen
- Department of Nephrology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
| | - Mehmet Deniz Ayli
- Department of Nephrology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
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Zanoni F, Pavone L, Binda V, Tripepi G, D'Arrigo G, Scalamogna A, Messa P. Catheter-related bloodstream infections in a nephrology unit: Analysis of patient- and catheter-associated risk factors. J Vasc Access 2020; 22:337-343. [PMID: 32648807 DOI: 10.1177/1129729820939762] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Central venous catheter use is rising in chronic and acute hemodialysis. Catheter-related bloodstream infections are a major complication of central venous catheter use. This article examines clinical factors associated with catheter-related bloodstream infections incidence. METHODS In this retrospective, single-center study, 413 patients undergoing extracorporeal treatments between 1 February 2014 and 31 January 2017 with 560 central venous catheters were recruited. Clinical parameters, such as gender, age, kidney disease status, diabetes, immunosuppression, and vintage dialysis, were collected at study entry. An incidence rate ratio (95% confidence interval) was calculated to assess the association between catheter-related bloodstream infections incidence rate and each clinical variable/central venous catheter type. Significant associations at the univariate analyses were investigated with multivariate Cox models. RESULTS During a cumulative time of 66,686 catheter-days, 54 catheter-related bloodstream infections (incidence rate: 0.81) events occurred. Gram negative bacteria were more frequent in patients with age < 80 years (16 (36%) vs. 0, p = 0.02). At the univariate analyses, male sex (incidence rate ratio: 1.9 (1.1-3.5), p = 0.03), age < 80 years (incidence rate ratio: 2.4 (1.1-5.5), p = 0.016) and acute kidney injury (incidence rate ratio: 5.6 (3.1-10), p < 0.0001) were associated with higher catheter-related bloodstream infections incidence rate. Compared with tunneled jugular central venous catheter, higher catheter-related bloodstream infections incidence rate was associated with non-tunneled jugular (incidence rate ratio: 6.45 (2.99-13.56), p < 0.0001) and non-tunneled femoral (incidence rate ratio: 12.90 (5.87-27.61), p < 0.0001) central venous catheter use; tunneled femoral central venous catheter was associated with higher non-significant incidence rate (incidence rate ratio: 2.45 (0.93-5.85), p = 0.07). The multivariate analyses showed that acute kidney injury (hazard ratio: 3.03 (1.38-6.67), p = 0.006), non-tunneled (hazard ratio: 3.11 (1.30-7.41), p = 0.01) and femoral (hazard ratio: 2.63 (1.36-5.07), p = 0.004) central venous catheter were associated with higher catheter-related bloodstream infections incidence rate. CONCLUSION Central venous catheter characteristics and acute kidney injury are independently associated with higher catheter-related bloodstream infections rate.
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Affiliation(s)
- Francesca Zanoni
- Unit of Adult Nephrology, Dialysis and Renal Transplant, Department of Medicine, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Pavone
- Unit of Adult Nephrology, Dialysis and Renal Transplant, Department of Medicine, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Binda
- Unit of Adult Nephrology, Dialysis and Renal Transplant, Department of Medicine, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Tripepi
- CNR-IFC, Institute of Clinical Physiology of Reggio Calabria, Pisa, Italy
| | - Graziella D'Arrigo
- CNR-IFC, Institute of Clinical Physiology of Reggio Calabria, Pisa, Italy
| | - Antonio Scalamogna
- Unit of Adult Nephrology, Dialysis and Renal Transplant, Department of Medicine, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Unit of Adult Nephrology, Dialysis and Renal Transplant, Department of Medicine, Foundation Ca' Granda IRCCS Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Choi J, Ban TH, Choi BS, Baik JH, Kim BS, Kim YO, Park CW, Yang CW, Jin DC, Park HS. Comparison of vascular access patency and patient survival between native arteriovenous fistula and synthetic arteriovenous graft according to age group. Hemodial Int 2020; 24:309-316. [PMID: 32372545 DOI: 10.1111/hdi.12836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/06/2020] [Accepted: 04/16/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Arteriovenous fistula (AVF) is historically known to be the ideal option for vascular access (VA) for hemodialysis compared with arteriovenous graft (AVG). However, this approach has been recently questioned in the aging population because of their poor vessel quality and multiple comorbidities. METHODS Data from a total of 2200 patients from the VA category of The Catholic Medical Center nephrology registry from March 2009 to February 2017 were analyzed. We compared VA patency and patient survival between two groups, AVF and AVG, according to age. FINDINGS Compared with the AVG group, survival benefit in the AVF group continued even in patients ≥80 years. In the whole population, all the primary patency (PP), primary-assisted patency (PAP), and secondary patency (SP) measures were superior in the AVF group. With regard to subgroups, PP was comparable between the two groups in patients ≥65 years, whereas PAP and SP were superior in the AVF group even in septuagenarian patients who are from 70 to 79 years old. In patients ≥80 years, all the patency measures were comparable between the two groups. When the separate comparison of lower-arm AVF (or upper-arm AVF) and AVG, lower-arm AVF failed to demonstrate its superiority in any kind of patency in septuagenarian patients compared with AVG, whereas upper-arm AVF demonstrated its superiority in PAP and SP in septuagenarian patients. However, even upper-arm AVF failed to demonstrate its superiority in any kind of patency in patients ≥80 years. DISCUSSION Arteriovenous fistula if using upper-arm vessel showed the superior VA patency up to septuagenarian patients, whereas, in HD patients ≥80 years, AVF and AVG were comparable in VA patency.
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Affiliation(s)
- Joonsung Choi
- Department of Radiology, The Catholic University of Korea School of Medicine/ St. Vincent's Hospital, Suwon, 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.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Jun Hyun Baik
- Department of Radiology, The Catholic University of Korea School of Medicine/ St. Vincent's Hospital, Suwon, Republic of Korea
| | - Byung Soo Kim
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Young Ok Kim
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Dong Chan Jin
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea.,Departmentof Internal Medicine, The Catholic University of Korea School of Medicine/ Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 952] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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Wongmahisorn Y. Survival and Prognostic Predictors of Primary Arteriovenous Fistula for Hemodialysis. Ann Vasc Dis 2019; 12:493-499. [PMID: 31942207 PMCID: PMC6957894 DOI: 10.3400/avd.oa.19-00058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: This study aims to evaluate the survival and prognostic predictors of arteriovenous fistulas (AVFs) among patients undergoing AVF creation. The significant predictors were incorporated into a prognostic model to determine its prognostic performance for five-year AVF survival. Materials and Methods: Data on 290 patients who underwent first-time AVF creation and who had been followed up for at least 5 years or until AVF failure were reviewed. The Kaplan–Meier survival curves and Cox proportional hazards model were generated to determine the AVF survival and associated prognostic predictors. Significant predictors were used to derive a prognostic model. Results: The mean age of the patients was 59.7±14.6 years, and the 5-year AVF survival rate was 34.5%. Three features were found to be independent prognostic factors for the five-year AVF survival: old age, diabetes mellitus, and prior central venous catheter placement. These three significant factors were integrated into a prognostic scoring model that ranged from zero to five points. According to this model, the patients whose scores were 0, 1, 2, 3 and 4 or more had five-year AVF survival rates of 60.0%, 45.3%, 36.6%, 15.0%, and 2.9%, respectively. Conclusion: The five-year survival rate of AVFs was modest, and a prognostic model could excellently estimate the five-year AVF survival.
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Affiliation(s)
- Yuthapong Wongmahisorn
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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30
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Jhee JH, Hwang SD, Song JH, Lee SW. The Impact of Comorbidity Burden on The Association between Vascular Access Type and Clinical Outcomes among Elderly Patients Undergoing Hemodialysis. Sci Rep 2019; 9:18156. [PMID: 31796787 PMCID: PMC6890785 DOI: 10.1038/s41598-019-54191-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
The optimal vascular access type for elderly hemodialysis patients is controversial. We evaluated the impact of comorbidity burden on the association between vascular access type and mortality risk among 23,100 hemodialysis patients aged ≥65 years from the Korean Society of Nephrology End-Stage Renal Disease registry data. Subjects were stratified into tertiles according to the simplified Charlson comorbidity index (sCCI), and the survival and hospitalization rates were compared with respect to vascular access type: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). Among all tertiles of sCCI, CVC use showed highest risk of mortality than AVF use. In the lowest to middle tertile, no difference was observed in survival rates between the use of AVF and AVG. However, in the highest tertile, AVG use showed higher risk of mortality than AVF use. When subjects were classified according to a combination of sCCI tertile and access type (AVF vs. AVG), patients with the highest CCI with AVG showed 1.75-folded increased risk of mortality than those with the lowest sCCI with AVF. Hospitalization rates due to access malfunction were highest in patients with CVC in all sCCI tertiles. In the highest tertile, patients with AVG showed increased rates of hospitalization compared to those with AVF due to access malfunction. However, hospitalization rates due to access infection were highest in patients with AVG in all tertiles. The use of AVF may be of benefit and switching to AVF should be considered in elderly hemodialysis patients with a high burden of comorbidity.
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Affiliation(s)
- Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea.
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31
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Lee T, Qian JZ, Zhang Y, Thamer M, Allon M. Long-Term Outcomes of Arteriovenous Fistulas with Unassisted versus Assisted Maturation: A Retrospective National Hemodialysis Cohort Study. J Am Soc Nephrol 2019; 30:2209-2218. [PMID: 31611240 DOI: 10.1681/asn.2019030318] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/29/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND About half of arteriovenous fistulas (AVFs) require one or more interventions before successful dialysis use, a process called assisted maturation. Previous research suggested that AVF abandonment and interventions to maintain patency after maturation may be more frequent with assisted maturation versus unassisted maturation. METHODS Using the US Renal Data System, we retrospectively compared patients with assisted versus unassisted AVF maturation for postmaturation AVF outcomes, including functional primary patency loss (requiring intervention after achieving AVF maturation), AVF abandonment, and frequency of interventions. RESULTS We included 7301 patients ≥67 years who initiated hemodialysis from July 2010 to June 2012 with a catheter and no prior AVF; all had an AVF created within 6 months of starting hemodialysis and used for dialysis (matured) within 6 months of creation, with 2-year postmaturation follow-up. AVFs matured without prior intervention for 56% of the patients. Assisted AVF maturation with one, two, three, or four or more prematuration interventions occurred in 23%, 12%, 5%, and 4% of patients, respectively. Patients with prematuration interventions had significantly increased risk of functional primary patency loss compared with patients who had unassisted AVF maturation, and the risk increased with the number of interventions. Although the likelihood of AVF abandonment was not higher among patients with up to three prematuration interventions compared with patients with unassisted AVF maturation, it was significantly higher among those with four or more interventions. CONCLUSIONS For this cohort of patients undergoing assisted AVF maturation, we observed a positive association between the number of prematuration AVF interventions and the likelihood of functional primary patency loss and frequency of postmaturation interventions.
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Affiliation(s)
- Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; .,Veterans Affairs Medical Center, Birmingham, Alabama; and
| | - Joyce Zhang Qian
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Auguste BL, Chan CT. Home Dialysis Among Elderly Patients: Outcomes and Future Directions. Can J Kidney Health Dis 2019; 6:2054358119871031. [PMID: 31523436 PMCID: PMC6732853 DOI: 10.1177/2054358119871031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 06/16/2019] [Indexed: 12/18/2022] Open
Abstract
Elderly patients who receive home dialysis (peritoneal dialysis or home hemodialysis) may have reduced survival compared to younger patients. Therefore, it is important to ascertain the goals of home dialysis in the elderly rather than simply fixate on standard metrics such as technique survival. As Canada's population continues to age, the prevalence of end-stage kidney disease among the elderly population is increasing. Patients with multiple comorbidities are now surviving long enough to be started on dialysis. Although home dialysis has been associated with better survival and improved quality of life, its impact on the frail and elderly populations require further elucidation. Home dialysis patients can either independently perform tasks or have support in the home to safely conduct dialysis. Moreover, patients burdened with frailty and multiple comorbidities who lack support in the home may not be able to perform home dialysis safely. Innovative strategies to improve accessibility to home-based therapies need further exploration. In addition, the concept of goal-directed dialysis promotes more individualized treatment. Future continuous quality improvement initiatives must examine if goal-directed dialysis leads to better quality of life outcomes in the elderly.
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Weigert A, Drozdz M, Silva F, Frazão J, Alsuwaida A, Krishnan M, Kleophas W, Brzosko S, Johansson FK, Jacobson SH. Influence of gender and age on haemodialysis practices: a European multicentre analysis. Clin Kidney J 2019; 13:217-224. [PMID: 32296527 PMCID: PMC7147302 DOI: 10.1093/ckj/sfz069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/30/2019] [Indexed: 11/25/2022] Open
Abstract
Background Women of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist. Methods This retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups. Results Body weight and the prescribed dialysis blood flow rate were lower in women (P < 0.001), whereas treated blood volume per kilogram per session was higher (P < 0.01), resulting in higher single-pool Kt/V in women than in men (P < 0.001). Haemoglobin was significantly higher in men (P = 0.01), but the proportion of patients within target range (10–12 g/dL) was similar. Men more often had an arteriovenous fistula than women (80% versus 73%; P < 0.01) with a similar percentage of central venous catheters. There were no gender-specific differences in terms of dialysis adequacy, anaemia parameters or mineral and bone disorder parameters, or in the attainment of KDIGO targets between women and men >80 years of age. Conclusions This large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.
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Affiliation(s)
| | - Maciej Drozdz
- Department of Nephrology, DaVita International, Krakow, Poland
| | - Fatima Silva
- Department of Nephrology, DaVita, Lisbon, Portugal
| | - João Frazão
- Department of Nephrology, DaVita, Porto, Portugal
| | | | | | | | | | - Fredrik K Johansson
- Unit for Medical Statistics, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Murea M, Geary RL, Edwards MS, Moossavi S, Davis RP, Goldman MP, Hurie J, Williams TK, Velazquez-Ramirez G, Robinson TW, Bagwell B, Tuttle AB, Callahan KE, Rocco MV, Houston DK, Pajewski NM, Divers J, Freedman BI, Williamson JD. A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design. Contemp Clin Trials Commun 2019; 14:100357. [PMID: 31016270 PMCID: PMC6475715 DOI: 10.1016/j.conctc.2019.100357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/27/2019] [Accepted: 04/05/2019] [Indexed: 11/22/2022] Open
Abstract
Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Randolph L. Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew S. Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ross P. Davis
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew P. Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Justin Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Todd W. Robinson
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Benjamin Bagwell
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Audrey B. Tuttle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E. Callahan
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael V. Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Denise K. Houston
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jasmin Divers
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeff D. Williamson
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Allon M. Vascular Access for Hemodialysis Patients: New Data Should Guide Decision Making. Clin J Am Soc Nephrol 2019; 14:954-961. [PMID: 30975657 PMCID: PMC6556719 DOI: 10.2215/cjn.00490119] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This commentary critically examines key assumptions and recommendations in the 2006 Kidney Disease Outcomes Quality Initiative vascular access guidelines, and argues that several are not relevant to the contemporary United States hemodialysis population. First, the guidelines prefer arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs), on the basis of their superior secondary survival and lower frequency of interventions and infections. However, intent-to-treat analyses that incorporate the higher primary failure of AVFs, demonstrate equivalent secondary survival of both access types. Moreover, the lower rate of AVF versus AVG infections is counterbalanced by the higher rate of catheter-related bloodstream infections before AVF maturation. In addition, AVFs with assisted maturation (interventions before successful AVF use), which account for about 50% of new AVFs, are associated with inferior secondary patency compared with AVGs without intervention before successful use. Second, the guidelines posit lower access management costs for AVFs than AVGs. However, in patients who undergo AVF or AVG placement after starting dialysis with a central venous catheter (CVC), the overall cost of access management is actually higher in patients receiving an AVF. Third, the guidelines prefer forearm over upper arm AVFs. However, published data demonstrate superior maturation of upper arm versus forearm AVFs, likely explaining the progressive increase in upper arm AVFs in the United States. Fourth, AVFs are thought to fail primarily because of aggressive juxta-anastomotic stenosis. However, recent evidence suggests that many AVFs mature despite neointimal hyperplasia, and that suboptimal arterial vasodilation may be an equally important contributor to AVF nonmaturation. Finally, CVC use is believed to result in excess mortality in patients on hemodialysis. However, recent data suggest that CVC use is simply a surrogate marker of sicker patients who are more likely to die, rather than being a mediator of mortality.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Adwaney A, Lim C, Blakey S, Duncan N, Ashby DR. Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis. Clin J Am Soc Nephrol 2019; 14:378-384. [PMID: 30765534 PMCID: PMC6419278 DOI: 10.2215/cjn.07010618] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/03/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Central venous catheters have traditionally provided access for urgent hemodialysis, but are also sometimes advocated as an option for older or more comorbid patients. Adverse effects of this type of dialysis access include central venous stenosis, for which the risk factors and consequences are incompletely understood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted two studies within the same population cohort, comprising all patients starting hemodialysis in a single center from January 2006 to December 2013. First, patients were retrospectively analyzed for the presence of central venous stenosis; their access outcomes are described and survival compared with matched controls drawn from the same population. Second, a subset of patients with a history of catheter access within this cohort was analyzed to determine risk factors for central venous stenosis. RESULTS Among 2811 patients, central venous stenosis was diagnosed in 120 (4.3%), at a median dialysis vintage of 2.9 (interquartile range, 1.8-4.6) years. Compared with matched controls, patients with central venous stenosis had similar survival (median 5.1 versus 5.2 years; P=0.54). Among a subset of 500 patients, all with a history of catheter use, 34 (6.8%) developed central venous stenosis, at a rate of 2.2 per 100 patient-years. The incidence of central venous stenosis was higher with larger number of previous catheters (relative risk [RR], 2.2; 95% confidence interval [95% CI]. 1.6 to 2.9), pacemaker insertion (RR, 3.9; 95% CI, 1.7 to 8.9), and was lower with older age (RR, 0.7 per decade; 95% CI, 0.6 to 0.8). In a Cox proportional hazards model, the catheter number, pacemaker, and younger age at dialysis initiation were all significant independent risk factors for central venous stenosis. CONCLUSIONS Central venous stenosis occurred in a minority of patients on hemodialysis, and was associated with compromised future access, but unchanged survival. Among patients with a history of catheter use, risk related to both the number of catheters and the total catheter duration, although nondialysis factors such as pacemakers were also important. Central venous stenosis risk was lower in older patients, supporting the selective use of tunneled catheters in this group.
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Affiliation(s)
- Anamika Adwaney
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, UK
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Mohamed H, Ali A, Browne LD, O'Connell NH, Casserly L, Stack AG, Hussein WF. Determinants and outcomes of access-related blood-stream infections among Irish haemodialysis patients; a cohort study. BMC Nephrol 2019; 20:68. [PMID: 30808313 PMCID: PMC6390569 DOI: 10.1186/s12882-019-1253-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background Infections are the second leading cause of death and hospitalisation among haemodialysis (HD) patients. Rates of access-related bloodstream infections (AR-BSI) are influenced by patient characteristics and local protocols. We explored factors associated with AR-BSI in a contemporary cohort of HD patients at a tertiary nephrology centre. Methods A retrospective cohort of 235 chronic HD patients was identified from a regional dialysis programme between Jan 2015 and Dec 2016. Data on demographics, primary renal disease, comorbid conditions and dialysis access type were obtained from the Kidney Disease Clinical Patient Management System (KDCPMS). Data on blood cultures were captured from the microbiology laboratory. Poisson regression with robust variance estimates was used to compare infection rates and relative risk of AR-BSI according to the site and type of vascular access. Results The mean age was 65 (± 15) years, 77% were men, and the median follow up was 19 months (IQR: 10–24 months), accumulating 2030 catheter-months and 1831 fistula-months. Overall rates of AR-BSI were significantly higher for central venous catheter (CVC) compared to arteriovenous fistula (AVF), (2.22, 95% (CI): 1.62–2.97) versus 0.11 (0.01–0.39) per 100 patient-months respectively), with a rate ratio of 20.29 (4.92–83.66), p < 0.0001. This pattern persisted across age, gender and diabetes subgroups. Within the CVC subgroup, presence of a femoral CVC access was associated with significantly higher rates of AR-BSI (adjusted RR 4.93, 95% CI: 2.69–9.01). Older age (75+ versus < 75 years) was not associated with significant differences in rates of AR-BSI in the unadjusted or the adjusted analysis. Coagulase negative Staphylococcus (61%) and Staphylococcus aureus (23%) were the predominant culprits. AR-BSIs resulted in access loss and hospitalisation in 57 and 72% of events respectively, and two patients died with concurrent AR-BSI. Conclusions Rates of AR-BSI are substantially higher in CVC than AVF in contemporary HD despite advances in catheter design and anti-infective protocols. This pattern was consistent in all subgroups. The policy of AVF preference over CVC should continue to minimise patient morbidity while at the same time improving anti-infective strategies through better care protocols and infection surveillance. Electronic supplementary material The online version of this article (10.1186/s12882-019-1253-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Husham Mohamed
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Alaa Ali
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Leonard D Browne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Division of Microbiology, Department of Medicine, University Hospital Limerick, Limerick, Ireland
| | - Liam Casserly
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Austin G Stack
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland. .,Graduate Entry Medical School, University of Limerick, Limerick, Ireland. .,Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Wael F Hussein
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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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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Bae E, Lee H, Kim DK, Oh KH, Kim YS, Ahn C, Han JS, Min SI, Min SK, Kim HC, Joo KW. Autologous arteriovenous fistula is associated with superior outcomes in elderly hemodialysis patients. BMC Nephrol 2018; 19:306. [PMID: 30400882 PMCID: PMC6218981 DOI: 10.1186/s12882-018-1109-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/19/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The number of elderly patients with end-stage renal disease is increasing rapidly. The higher prevalence of comorbidities and shorter life expectancy in these patients make it difficult to decide on the type of vascular access (VA). We explored the optimal choice for VA in elderly hemodialysis patients. METHODS We included elderly patients (> 65 years) visiting our VA clinic and divided them into three groups as follows: radiocephalic arteriovenous fistula (AVF), brachiocephalic AVF, and prosthetic arteriovenous graft (AVG). The primary outcomes were VA abandonment and all-cause mortality. The secondary outcome was maturation failure (MF). RESULTS Of 529 patients, 61.2% were men. The mean age was 73.6 ± 6.0 years. The VA types were as follows: 49.9% radiocephalic AVF, 31.8% brachiocephalic AVF, and 18.3% AVG. Patients with an AVG tended to be older, female, and have a lower body mass index. More than half of patients (n = 302, 57.1%) started dialysis with central catheters, but the proportion of predialysis central catheter placement was not different among the VA types. Radiocephalic AVF was significantly superior to AVG in terms of VA abandonment (P = 0.005) and all-cause mortality (P < 0.001) in spite of a higher probability of MF. Brachiocephalic AVF was associated with a shorter time to the first needling and fewer interventions before maturation than radiocephalic AVF. CONCLUSIONS Autologous AVF was suggested as the preferred VA choice in terms of long-term outcomes in elderly patients.
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Affiliation(s)
- Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin Suk Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Kidney Reasearch Institute, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
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Lomonte C, Basile C, Mitra S, Combe C, Covic A, Davenport A, Kirmizis D, Schneditz D, van der Sande F. Should a fistula first policy be revisited in elderly haemodialysis patients? Nephrol Dial Transplant 2018; 34:1636-1643. [DOI: 10.1093/ndt/gfy319] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/05/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
Life-sustaining haemodialysis requires a durable vascular access (VA) to the circulatory system. The ideal permanent VA must provide longevity for use with minimal complication rate and supply sufficient blood flow to deliver the prescribed dialysis dosage. Arteriovenous fistulas (AVFs) have been endorsed by many professional societies as the VA of choice. However, the high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and arterial hypertension in elderly people, usually make VA creation more difficult in the elderly. Many of these patients may have an insufficient vasculature for AVF maturation. Furthermore, many AVFs created prior to the initiation of haemodialysis may never be used due to the competing risk of death before dialysis is required. As such, an arteriovenous graft and, in some cases, a central venous catheter, become a valid alternative form of VA. Consequently, there are multiple decision points that require careful reflection before an AVF is placed in the elderly. The traditional metrics of access patency, failure and infection are now being seen in a broader context that includes procedure burden, quality of life, patient preferences, morbidity, mortality and cost. This article of the European Dialysis (EUDIAL) Working Group of ERA-EDTA critically reviews the current evidence on VA in elderly haemodialysis patients and concludes that a pragmatic patient-centred approach is mandatory, thus considering the possibility that the AVF first approach should not be an absolute.
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Affiliation(s)
- Carlo Lomonte
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre (MAHSC) & NIHR Devices for Dignity MedTech Co-operative, Manchester, UK
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Unité INSERM 1026, Université de Bordeaux, Bordeaux, France
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C.I. PARHON University Hospital, Iasi, Romania
- Grigori T. Popa University of Medicine, Iasi, Romania
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, Division of Medicine, University College, London, UK
| | | | | | - Frank van der Sande
- Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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Brown RS, Brickel K, Davis RB. Two-Year Observational Study of Bloodstream Infection Rates in Hemodialysis Facility Patients with and without Catheters. Clin J Am Soc Nephrol 2018; 13:1381-1388. [PMID: 30194227 PMCID: PMC6140562 DOI: 10.2215/cjn.13551217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/20/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Bloodstream infection rates of patients on hemodialysis with catheters are greater than with other vascular accesses and are an important quality measure. Our goal was to compare relative bloodstream infection rates of patients with and without catheters as a quality parameter among the facilities providing hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used CROWNWeb and National Healthcare Safety Network data from all 179 Medicare facilities providing adult outpatient hemodialysis in New England for >6 months throughout 2015-2016 (mean, 12,693 patients per month). There was a median of 60 (interquartile range, 43-93) patients per facility, with 17% having catheters. RESULTS Among the five batch-submitting dialysis organizations, the bloodstream infection rate in patients with a catheter in four organizations had adjusted risk ratios of 1.44 (95% confidence interval, 1.07 to 1.93) to 1.91 (95% confidence interval, 1.39 to 2.63) times relative to the reference dialysis provider group (P<0.001). The percentage of catheters did not explain the difference in bloodstream infection rates among dialysis provider organizations. The bloodstream infection rates in patients with a catheter were negatively correlated with the facility's proportion of this patient group. Facilities with <10%, 10%-14.9%, 15%-19.9%, and ≥20% catheter patients had bloodstream infection rates of 4.4, 2.2, 1.9, and 1.5 per 100 patient-months, respectively, in that patient group (adjusted P<0.001). This difference was not seen in patients without catheters. There was no effect of facility patient census or season of the year. CONCLUSIONS A study of the adult outpatient hemodialysis facilities in New England in 2015-2016 found that four dialysis provider groups had significantly higher bloodstream infection rates in patients with a catheter than the best-performing dialysis provider group. Hemodialysis facilities with lower proportions of patients with a catheter have significantly higher bloodstream infection rates in this patient group than facilities with >20% catheters, a finding that did not explain the difference among provider organizations.
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Affiliation(s)
| | | | - Roger B. Davis
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and
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Lee T, Qian J, Thamer M, Allon M. Tradeoffs in Vascular Access Selection in Elderly Patients Initiating Hemodialysis With a Catheter. Am J Kidney Dis 2018; 72:509-518. [PMID: 29784614 DOI: 10.1053/j.ajkd.2018.03.023] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/13/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE National vascular access guidelines recommend placement of arteriovenous fistulas (AVFs) over grafts (AVGs) in hemodialysis patients, but have not been comprehensively assessed in the elderly. We evaluated clinically relevant vascular access outcomes in elderly patients receiving an AVF or AVG after hemodialysis therapy initiation. STUDY DESIGN Retrospective cohort study using national administrative data. SETTINGS & PARTCIPANTS Claims data from the US Renal Data System of 9,458 US patients 67 years and older who initiated hemodialysis therapy from July 1, 2010, to June 30, 2011, with a catheter and received an AVF (n=7,433) or AVG (n=2,025) within the ensuing 6 months. PREDICTOR Arteriovenous access subtype, AVF or AVG. OUTCOMES Successful use of vascular access, interventions to make vascular access functional, duration of catheter dependence before successful use of vascular access, frequency of interventions, and abandonment after successful use of vascular access. ANALYTICAL APPROACH Multivariable logistic regression analysis was used to compare the need for intervention before successful use of AVFs and AVGs, and negative bionomial regression was used to calculate the frequency of intervention after successful use of vascular access. RESULTS Unsuccessful use of vascular access within 6 months of creation was higher for AVFs versus AVGs (51% vs 45%; adjusted HR, 1.86; 95% CI, 1.73-1.99). Interventions to make vascular access functional were greater in AVFs versus AVGs (42% vs 23%; OR, 2.66; 95% CI, 2.26-3.12). AVFs had a lower 1-year abandonment rate after successful use compared with AVGs (OR, 0.71; 95% CI, 0.62-0.83) and required one-fourth fewer interventions after successful use (relative risk, 0.75; 95% CI, 0.69-0.81). Patients receiving an AVF had substantially longer catheter dependence before successful use than those receiving an AVG (median time, 3 vs 1 month; P<0.001). LIMITATIONS Residual confounding due to vascular access choice, restriction to an elderly population, and 1-year follow-up period. CONCLUSIONS In elderly hemodialysis patients initiating hemodialysis therapy with a catheter, the optimal vascular access selection depends on tradeoffs between shorter catheter dependence and less frequent interventions to make the vascular access (AVG) functional versus longer access patency and fewer interventions after successful use of the vascular access (AVF).
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Affiliation(s)
- Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL; Veterans Affairs Medical Center, Birmingham, AL.
| | - Joyce Qian
- Medical Technology and Practice Patterns Institute, Bethesda, MD
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, MD
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL
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Halinski C, Koncicki HM. Planning and evaluation for vascular access in the elderly. Semin Dial 2018; 31:362-366. [PMID: 29736915 DOI: 10.1111/sdi.12699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vascular access is of vital importance for patients requiring dialysis therapies. AV fistulas have been endorsed by many professional societies as the access of choice, however, subsequent creation does not go without consequences. As the population ages and patients become more medically complex, access failure has become a major cause of treatment complication. For the elderly, this is especially true and there are multiple decision points that require careful reflection before an AVF is placed. This article reviews access considerations for AVF placement in the elderly population and considers the possibility that the fistula first approach to vascular access should not be an absolute.
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Affiliation(s)
- Candice Halinski
- Department of Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Holly M Koncicki
- Division of Nephrology, Department of Internal Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Sherman RA. Briefly Noted. Semin Dial 2018. [DOI: 10.1111/sdi.12689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Golestaneh L. Decreasing hospitalizations in patients on hemodialysis: Time for a paradigm shift. Semin Dial 2018; 31:278-288. [DOI: 10.1111/sdi.12675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Ladan Golestaneh
- Nephrology Division; Department of Medicine; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx NY USA
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