1
|
Giannikouris IE, Georgiadis GS, Giannakopoulos T, Passadakis P, Spiliopoulos S. Results of a hemodialysis vascular access routine ultrasound surveillance protocol and frequency of surveillance guided pre-emptive access maintenance interventions. J Vasc Access 2023:11297298231207427. [PMID: 37953744 DOI: 10.1177/11297298231207427] [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: 11/14/2023] Open
Abstract
BACKGROUND To evaluate the implementation of routine surveillance using ultrasound on hemodialysis vascular access (VA) outcomes and determine the number and frequency of corrective, surveillance-guided procedures performed. METHODS Multicenter, prospective, observational study that includes consecutive hemodialysis patients receiving therapy from native arteriovenous fistulae (AVF) or grafts (AVG). Participants were assigned to a routine VA Color Doppler ultrasound surveillance (DUS) protocol from January 2019 to December 2021. Patients were referred for corrective procedures (endovascular or surgical) based on clinical or DUS findings (pre-emptive procedures; PEP). Primary endpoint was the estimation of primary unassisted (PUP) and secondary patency (SP) rates. Secondary endpoints were the determination of the number and frequency of PEP and VA survival rates. RESULTS In total, 223 patients with 243 VA (192 AVF and 51 AVG) were included. Access PUP and SP rates were 83% and 93% at 12 months, 75% and 88% at 24 months, and 72% and 83% at 36 months follow-up. Autologous fistulae PUP and SP were 89% and 96% at 12 months, 81% and 93% at 24 months, and 80% and 89% at 36 months, respectively. Graft PUP and SP were 56% and 80% at 12 months, 44% and 65% at 24 months, and 39% and 54% at 36 months, respectively. In total, 56 corrective procedures (38/56 PEP; 65.5%) were performed (0.13 procedures/year), of which 34 were in AVF patients (0.09 procedures/year) and 22 in AVG patients (0.40 procedures/year). Overall, 33 VA losses occurred (0.06 failures/year), 17 in AVF (0.04 failures/year), and 16 in AVG patients (0.20 failures/year). CONCLUSION The use of DUS resulted in the timely diagnosis of dysfunction, satisfactory overall VA survival, and patency rates, with a low PEP frequency. Randomized controlled trials are required to establish the value of DUS surveillance on access patency and whether DUS-guided interventions could improve VA outcomes.
Collapse
Affiliation(s)
- Ioannis E Giannikouris
- Department of Nephrology and Hemodialysis Unit, Mediterraneo Hospital, Glyfada, Athens, Attika, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | | | - Ploumis Passadakis
- Department of Nephrology, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | - Stavros Spiliopoulos
- 2nd Radiology Department, Division of Interventional Radiology, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Chaidari, Athens, Attika, Greece
| |
Collapse
|
2
|
Calotta NA, Astor BC, Ross JR. Automated 3D ultrasound enables novice users to measure arteriovenous fistula maturation parameters with comparable accuracy to conventional duplex by trained sonographers: Results of a benchtop study. J Vasc Access 2023; 24:1398-1406. [PMID: 35259945 PMCID: PMC10523460 DOI: 10.1177/11297298221074462] [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: 11/08/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Arteriovenous fistulae (AVF) are considered the preferred hemodialysis access but up to 50% of all AVF created in the United States never mature. Doppler ultrasound (DUS) is useful for predicting fistula maturity and impending fistula failure. DUS is resource-intensive and is associated with poor compliance rates in dialysis patients, ranging from 12% to 33%. METHODS EchoSure is an FDA-cleared 3D Doppler ultrasound device that automatically delivers quantitative blood flow and anatomic vascular information. The technology can be used at the bedside by personnel without formal sonographic training, nullifying limitations of traditional Duplex ultrasound imaging. This study compared the EchoSure system in the hands of inexpert personnel to a traditional expert-operated DUS for rapid assessment of a benchtop model vascular system with flow, diameter, and depth expected in a human AVF. RESULTS Both Duplex and EchoSure performed within the expected tolerance of ultrasound readings (35%) for volume flow, with the average error (AE) between the observed measurement and the ground truth being 8% for Duplex and 8% for EchoSure. However, the average coefficient of variation (CV) for Duplex pooled over all flow rate measurements was 17% versus 4% for EchoSure. Regarding diameter, Duplex measurements had AE of 15% with an average CV of 6% across all measurements versus EchoSure AE of 4% and average CV of 2%. Duplex and EchoSure measurements over all depths had the same AE of 2%. The two modalities were not statistically different for depth measurement (p = 0.05) but EchoSure measured closer to the ground truth for flow rate and vessel diameter (flow: p = 0.028, ρ = -0.07; diameter: p < 0.001, ρ = 0.69). The inexpert personnel using EchoSure acquired data 62% faster than the expert sonographers using the Duplex ultrasound (141 min for Duplex vs 87 min for EchoSure). CONCLUSIONS EchoSure may offer an accurate and convenient alternative for imaging fistulas in the clinic.
Collapse
Affiliation(s)
| | - Brad C Astor
- Departments of Medicine and Population Health Sciences, University of Wisconsin Schools of Medicine and Public Health, Madison, WI, USA
| | - John R Ross
- Dialysis Access Institute, Regional Medical Center of Orangeburg and Calhoun Counties, Orangeburg, SC, USA
| |
Collapse
|
3
|
Forcey D, Tran D, Connor J, Ayudhya PKN, Ocampo C, Nelson C, Crikis S. Improving assessment and escalation of threatened haemodialysis access: results of a nursing-led program. BMC Nephrol 2023; 24:268. [PMID: 37704969 PMCID: PMC10500889 DOI: 10.1186/s12882-023-03321-z] [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: 03/12/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Optimal vascular access is critical to successful haemodialysis. Acute thrombosis of haemodialysis access often leads to unplanned hospital admissions and interventions to restore patency. Western Health is a large health service in Victoria, Australia. During the period February 2019 to January 2020, the rate of arteriovenous fistula (AVF) and arteriovenous graft (AVG) at Western Health satellite dialysis units was 0.33 episodes per 1000 patient-days, higher than the reported rate in the literature of 0.24 events per 1000 patient-days, and was associated with a cumulative total of 139 days of inpatient stay (2.2 per 1000 patient-days). METHODS The above results prompted creation of an education and escalation pathway for threatened haemodialysis access, based upon clinical markers of vascular access stenosis or imminent thrombosis assessed by nursing staff in satellite haemodialysis centres. In the period February 2020 to January 2021, the education and escalation pathway was implemented. We assessed referrals via the pathway, rates of AVF/AVG thrombosis and associated hospital length of stay in the following 12-month period (February 2021 to January 2022). RESULTS Following introduction of the pathway, rates of AVF/AVG thrombosis declined to 0.15 per 1000 patient-days (p = 0.02), associated with a decline in attributable cumulative inpatient stay to 55 days (0.69 per 1000 patient-days). CONCLUSIONS Our program demonstrates that the majority of thrombosed vascular access can be predicted and potentially averted with vigilant and well-practiced routine clinical assessment by trained nursing staff. Our nursing-led education and escalation program successfully identified vascular access at risk of imminent thrombosis, reduced rates of acute thrombosis and associated healthcare costs. Despite these improvements, there are still disparities in outcomes for patients with thrombosed vascular access, with regards to length of stay and requirement for insertion of a temporary central venous catheter (CVC) for urgent dialysis whilst awaiting intervention, and these are areas for further investigation and improvement.
Collapse
Affiliation(s)
- Dana Forcey
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia.
| | - Dan Tran
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia
| | - Jenny Connor
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia
| | | | - Christian Ocampo
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia
| | - Craig Nelson
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia
- Department of Medicine, Western Health, The University of Melbourne, Melbourne, VIC, Australia
- Western Health Chronic Disease Alliance, St Albans, VIC, Australia
| | - Sandra Crikis
- Department of Nephrology, Western Health, 176 Furlong Road, St Albans, VIC, 3021, Australia
- Department of Medicine, Western Health, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
4
|
Bodington R, Hazara AM, Lamplugh A, Syed A, Bhandari S. Reassessing the utility of access recirculation and Kt/V for the prediction of arteriovenous fistula failure using online clearance monitoring: the SHUNT STUDY. J Nephrol 2023; 36:677-686. [PMID: 36445562 DOI: 10.1007/s40620-022-01525-4] [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: 04/07/2022] [Accepted: 11/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is prone to thrombosis which can be avoided by use of monitoring and surveillance programmes. Although surveillance imaging techniques have been shown to be more sensitive and specific than clinical monitoring during dialysis, monitoring may have significant advantages in terms of cost and time saving. In this study we evaluate the yield of two monitoring techniques [blood temperature monitoring (BTM) access recirculation (AR) and Kt/V via online-clearance-monitoring (OCM)]. METHODS In this single-centre prospective observational study, 101 patients were followed-up for one year. The primary outcome measure was a composite of AVF failure. OCM-Kt/V and BTM-AR were recorded at every dialysis session. RESULTS Of all baseline characteristics only a prior history of percutaneous transluminal angioplasty (PTA) to the AVF conferred a significant change in AVF survival (failure events/100 pt years with prior PTA vs. without = 64.0 vs. 17.3, log-rank p = 0.0014; unadjusted hazard ratio (HR) 3.74 (95% CI 1.56-8.94) p = 0.003). Participants with baseline AR < 10% vs. > 15% had poorer AVF survival (p = 0.0002) and HR for baseline AR 10-15% group vs. AR > 15% group = 4.5 (95% CI 1.55-13.05). There was no combination of change in (Δ) AR, ΔKt/V or its presence over any number of dialysis sessions that provided an acceptable combination of sensitivity and specificity or discrimination for AVF failure. CONCLUSIONS BTM-AR and OCM-Kt/V are specific but insufficiently sensitive tools for the prediction of AVF failure. BTM-AR and OCM-Kt/V use at every dialysis session appears to add little to the traditional, infrequent use of these evaluations.
Collapse
Affiliation(s)
- Richard Bodington
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, S5 7AU, UK.
| | - Adil M Hazara
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Archie Lamplugh
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ahsan Syed
- Department of Renal Medicine, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sunil Bhandari
- Renal Research Department, Hull University Teaching Hospitals NHS Trust, Hull, UK
| |
Collapse
|
5
|
Yii E, Lee L, Polkinghorne K, Thwaites S, Saunder A, Yii MK. Optimal flow volume measurements in forearm versus arm arteriovenous fistulas. Nephrology (Carlton) 2023; 28:175-180. [PMID: 36594889 DOI: 10.1111/nep.14142] [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: 11/17/2022] [Revised: 12/24/2022] [Accepted: 12/31/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Successful haemodialysis is dependent on optimal arteriovenous (AV) access flow. Although 600 ml/min is frequently quoted as the critical level for functional flow volume (Qa) according to the National Kidney Foundation guideline, this may not be applicable for the different configurations of AV fistulas (AVF) or AV grafts (AVG). This study evaluates ultrasound derived Qa measurement in the inflow brachial artery to autologous AVF in the forearm radiocephalic and arm brachiocephalic/basilic configurations in relation to significant flow related AV dysfunction. METHODS Five hundred and eleven duplex ultrasound (DUS) scans were analysed in 193 patients. The end points were therapeutic intervention and/or thrombosis of AVF versus no complication within 3 months of the scan. Receiver operating characteristic (ROC) curves were used to determine the optimal threshold Qa of the brachial artery supplying the AVF. RESULTS Of the 511 scans, 155 scans were assigned to the intervention group, that is, AVF requiring intervention or thrombosing within 3 months of the DUS. Using ROC curve analysis, the area under the curve (AUC) for all AVF is 0.90 (CI: 0.88-0.93) with an optimal threshold Qa of 686 ml/min. In forearm AVF, the threshold Qa is 589 ml/min while in arm AVF the threshold Qa is 877 ml/min. Forearm Qa is statistically different from arm Qa. CONCLUSION Forearm AVF Qa threshold at 589 ml/min is distinct from arm AVF Qa at 877 ml/min and these are predictive of the need for impending intervention or thrombosis due to flow-limiting stenosis.
Collapse
Affiliation(s)
- Erwin Yii
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Vascular Surgery Unit at Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Limi Lee
- Vascular and Transplant Surgery Unit at Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Kevan Polkinghorne
- Department of Nephrology at Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Stephen Thwaites
- Vascular and Transplant Surgery Unit at Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Alan Saunder
- Vascular and Transplant Surgery Unit at Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Ming Kon Yii
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Vascular and Transplant Surgery Unit at Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| |
Collapse
|
6
|
Chen MCY, Weng MJ, Chao LH. Characterization of hemodialysis fistulas experienced abrupt thrombosis and determination of a proper follow-up protocol: A retrospective cohort study and an interventionist's perspective. PLoS One 2023; 18:e0282891. [PMID: 36913383 PMCID: PMC10010559 DOI: 10.1371/journal.pone.0282891] [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: 01/10/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023] Open
Abstract
Abrupt thrombosis is a form of thrombosis that occurs unexpectedly and without being preceded by hemodialysis fistula (AVF) dysfunction during dialysis. We found that AVFs with a history of abrupt thrombosis (abtAVF) appeared to have more episodes of thrombosis and required more frequent interventions than those without such history. Therefore, we sought to characterize the abtAVFs and examined our follow-up protocols to determine which one is optimal. We performed a retrospective cohort study using routinely collected data. The thrombosis rate, AVF loss rate, thrombosis-free primary patency, and secondary patency were calculated. Additionally, the restenosis rates of the AVFs under the follow-up protocol/sub-protocols and the abtAVFs were determined. The thrombosis rate, procedure rate, AVF loss rate, thrombosis-free primary patency, and secondary patency of the abtAVFs were 0.237/pt-yr, 2.702/pt-yr, 0.027/pt-yr, 78.3%, and 96.0%, respectively. The restenosis rate for AVFs in the abtAVF group and the angiographic follow-up sub-protocol were similar. However, the abtAVF group had a significantly higher thrombosis rate and AVF loss rate than AVFs without a history of abrupt thrombosis (n-abtAVF). The lowest thrombosis rate was observed for n-abtAVFs, followed up periodically under the outpatient or angiographic sub-protocols. AVFs with a history of abrupt thrombosis had a high restenosis rate, and periodic angiographic follow-up with a mean interval of 3 months was presumed appropriate. For selected populations, such as salvage-challenging AVFs, periodic outpatient or angiographic follow-up was mandatory to extend their usable lives for hemodialysis.
Collapse
Affiliation(s)
- Matt Chiung-Yu Chen
- Department of Interventional Radiology, Yuan’s General Hospital, Kaohsiung, Taiwan
- * E-mail:
| | - Mei-Jui Weng
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Lee-Hua Chao
- Department of Interventional Radiology, Yuan’s General Hospital, Kaohsiung, Taiwan
| |
Collapse
|
7
|
Development and Validation of a Machine Learning Model Predicting Arteriovenous Fistula Failure in a Large Network of Dialysis Clinics. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312355. [PMID: 34886080 PMCID: PMC8656573 DOI: 10.3390/ijerph182312355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/22/2021] [Indexed: 12/27/2022]
Abstract
Background: Vascular access surveillance of dialysis patients is a challenging task for clinicians. We derived and validated an arteriovenous fistula failure model (AVF-FM) based on machine learning. Methods: The AVF-FM is an XG-Boost algorithm aimed at predicting AVF failure within three months among in-centre dialysis patients. The model was trained in the derivation set (70% of initial cohort) by exploiting the information routinely collected in the Nephrocare European Clinical Database (EuCliD®). Model performance was tested by concordance statistic and calibration charts in the remaining 30% of records. Features importance was computed using the SHAP method. Results: We included 13,369 patients, overall. The Area Under the ROC Curve (AUC-ROC) of AVF-FM was 0.80 (95% CI 0.79–0.81). Model calibration showed excellent representation of observed failure risk. Variables associated with the greatest impact on risk estimates were previous history of AVF complications, followed by access recirculation and other functional parameters including metrics describing temporal pattern of dialysis dose, blood flow, dynamic venous and arterial pressures. Conclusions: The AVF-FM achieved good discrimination and calibration properties by combining routinely collected clinical and sensor data that require no additional effort by healthcare staff. Therefore, it can potentially enable risk-based personalization of AVF surveillance strategies.
Collapse
|
8
|
Chytilova E, Jemcov T, Malik J, Pajek J, Fila B, Kavan J. Role of Doppler ultrasonography in the evaluation of hemodialysis arteriovenous access maturation and influencing factors. J Vasc Access 2021; 22:42-55. [PMID: 34281411 PMCID: PMC8607314 DOI: 10.1177/1129729820965064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The goal of vascular access creation is to achieve a functioning arteriovenous
fistula (AVF) or arteriovenous graft (AVG). An autologous fistula has been shown
to be superior to AVG or to central venous catheters (CVCs) with lowest rate of
re-intervention, but vessel obstruction or immaturity accounts for 20 % to 54%
of cases with primary failure of AVF. This review is focused on the factors
influencing maturation; indication and timing of preoperative mapping/creation
of vascular access; ultrasound parameters for creation AVF/AVG; early
postoperative complications following creation of a vascular access; ultrasound
determinants of fistula maturation and endovascular intervention in vascular
access with maturation failure. However, vascular accesses that fail to develop,
have a high incidence of correctable abnormalities, and these need to be
promptly recognized by ultrasonography and managed effectively if a high success
rate is to be expected. We review approaches to promoting fistula maturation and
duplex ultrasonography (DUS) of evaluating vascular access maturation.
Collapse
Affiliation(s)
- Eva Chytilova
- Third Department of Internal Medicine, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tamara Jemcov
- Department of Nephrology, Clinical Hospital Centre Zemun, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jan Malik
- Third Department of Internal Medicine, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jernej Pajek
- Department of Nephrology, Ljubljana University Medical Centre, Slovenia
| | - Branko Fila
- Depatment of Vascular Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Jan Kavan
- Department of Radiology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| |
Collapse
|
9
|
Rogers S, Simm K, McCollum C, Kiyegga S, Haque A, Lea S, Chandrasekar R. Arteriovenous Fistula Surveillance Using Tomographic 3D Ultrasound. Eur J Vasc Endovasc Surg 2021; 62:82-88. [PMID: 33896727 DOI: 10.1016/j.ejvs.2021.03.007] [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: 08/25/2020] [Revised: 02/24/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A well functioning arteriovenous fistula (AVF) is essential for haemodialysis. Despite regular duplex ultrasound (DUS) a significant number of AVFs fail. Tomographic 3D ultrasound (tUS) creates a 3D image of the AVF that can be interpreted by the clinician. DUS, tUS, and fistulograms were compared for the identification and measurement of flow limiting stenosis. METHODS Patients with AVF dysfunction on routine Transonic surveillance, defined as (1) > 15% reduction in flow on two consecutive occasions, (2) > 30% reduction in flow on one occasion, (3) flow of < 600 mL/sec, (4) presence of recirculation, underwent DUS. AVF tUS imaging was performed prior to fistulography. All fistulograms were reported by the same consultant radiologist and tUS images by the same vascular scientist blinded to the fistulogram results. Maximum diameter reduction in all stenoses were measured using all three imaging techniques. RESULTS In 97 patients with 101 stenoses, the mean (± standard deviation [SD]) severity of stenosis was 63.0 ± 13.9%, 65.0 ± 11.6%, and 64.8 ± 11.7% for the fistulograms, DUS, and tUS respectively. The mean (± SD) time between ultrasound and fistulography imaging was 15.0 ± 14.5 days. Assuming the fistulogram as the "gold standard", Bland-Altman agreement for DUS was -1.9 ± 15.5% (limit of agreement [LOA] -32.2 - 28.4) compared with -1.7 ± 15.4% (LOA -31.9 - 28.4) for tUS. Median (± interquartile range) time to complete the investigation was 09:00 ± 03:19 minutes for DUS and 03:13 ± 01:56 minutes for tUS (p < .001). CONCLUSION DUS and tUS were equally accurate at detecting AVF complications but tUS investigation requires less skill and was significantly quicker than DUS.
Collapse
Affiliation(s)
- Steven Rogers
- Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, Wythenshawe Hospital, Manchester, UK; Independent Vascular Services Ltd, Arrowe Park Hospital, Arrowe Park, UK.
| | - Katie Simm
- Independent Vascular Services Ltd, Arrowe Park Hospital, Arrowe Park, UK
| | - Charles McCollum
- Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, Wythenshawe Hospital, Manchester, UK
| | - Sharifah Kiyegga
- Independent Vascular Services Ltd, Arrowe Park Hospital, Arrowe Park, UK
| | - Adam Haque
- Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, Wythenshawe Hospital, Manchester, UK
| | - Simon Lea
- Department of Vascular and Endovascular Surgery, Arrowe Park Hospital, Arrowe Park, UK
| | | |
Collapse
|
10
|
Manov JJ, Mohan PP, Vazquez-Padron R. Arteriovenous fistulas for hemodialysis: Brief review and current problems. J Vasc Access 2021; 23:839-846. [PMID: 33818180 DOI: 10.1177/11297298211007720] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.
Collapse
Affiliation(s)
- John J Manov
- Department of Radiology, University of Miami, Miami, FL, USA
| | - Prasoon P Mohan
- Department of Interventional Radiology, University of Miami, Miami, FL, USA
| | | |
Collapse
|
11
|
Anvari E, Vachharajani TJ. The Hemodialysis Access Surveillance Controversy Continues. Kidney Int Rep 2020; 5:1848-1850. [PMID: 33027316 PMCID: PMC7529591 DOI: 10.1016/j.ekir.2020.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Evamaria Anvari
- Department of Hypertension and Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Tushar J. Vachharajani
- Department of Hypertension and Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
12
|
Getting the basics right: the monitoring of arteriovenous fistulae, a review of the evidence. Curr Opin Nephrol Hypertens 2020; 29:564-571. [PMID: 32889977 DOI: 10.1097/mnh.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite being the preferred vascular access for haemodialysis, the arteriovenous fistula (AVF) remains prone to a number of complications, the most common of these being thrombosis secondary to stenosis. This has resulted in the widespread use of monitoring and surveillance programmes. Surveillance uses more resources than monitoring and has not been convincingly shown to improve outcomes. The evidence supporting the use of the various monitoring tools has been relatively neglected and has not been the focus of literature review. This narrative review is the first to appraise the evidence for the use of physical examination, access recirculation, Kt/V and dynamic venous pressures (DVP) as monitoring tools in mature AVF. RECENT FINDINGS The vastly increased number of data points for access recirculation, Kt/V and DVP produced as standard by online clearance monitoring (OCM) on modern dialysis machines is likely to have significantly changed the utility of these metrics in the prediction of AVF failure. Algorithms have been developed to highlight those of highest risk of failure. SUMMARY The evidence supporting the use of monitoring in the prediction of AVF failure is predominantly observational, underpowered and more than 20 years old. Access recirculation and Kt/V appears to have higher utility in AVF than in arteriovenous grafts. We suggest that the development of OCM necessitates the reevaluation of these tools.
Collapse
|
13
|
Gjorgjievski N, Dzekova-Vidimliski P, Trajcheska L, Stojanoska A, Selim G, Rambabova-Bushljetik I, Nikolov I, Gjorgievska J, Janevski Z, Muharremi S, Dejanov P, Spasovski G, Sikole A, Ivanovski N. Impact of preoperative arterial and venous diameter on achievement of the adequate blood flow in arteriovenous fistula for hemodialysis. Ther Apher Dial 2020; 25:273-281. [PMID: 32749076 DOI: 10.1111/1744-9987.13570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of the study was to determine the factors associated with the achievement of adequate blood flow (BF) of AVFs at the 4th week after creation. Created AVFs in 63 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on hemodialysis (CKD5D) were analyzed in a prospective study. Doppler ultrasound (DUS) was used for measuring the diameter of the radial artery, the brachial artery and the cephalic vein before AVF creation. The BF of AVF was calculated by DUS at the 4th week after creation and adequate BF was defined as ≥ 600 mL/min. The average age of patients was 61.31 ± 12.9 years. An adequate BF of AVF at the 4th week after creation was achieved in 43.54% of patients. The BF of AVF measured in male patients was significantly higher compared to the BF of AVF obtained in females (576.03 mL/min vs 375.12 mL/min, P = 0.004). The diameter of the blood vessels with achieved adequate BF was significantly larger compared to the diameter of the blood vessels without adequate BF (radial artery: 2.45 mm vs 2.03 mm, P = 0.000; brachial artery: 4.78 mm vs 4.06 mm, P = 0.001 and cephalic vein: 3.12 mm vs 2.83 mm P = 0.018). The gender and the diameter of the blood vessels before AVF creation were significantly associated with achievement of adequate BF of AVF at the 4th week of creation.
Collapse
Affiliation(s)
- Nikola Gjorgjievski
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | | | - Lada Trajcheska
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Ana Stojanoska
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Gjulshen Selim
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | | | - Igor Nikolov
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Juija Gjorgievska
- University Hospital for Pediatric Disease, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Zoran Janevski
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | | | - Petar Dejanov
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Goce Spasovski
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | - Aleksandar Sikole
- University Hospital of Nephrology, University SS "Cyril and Methodius", Skopje, Macedonia
| | | |
Collapse
|
14
|
A Multicenter Randomized Clinical Trial of Hemodialysis Access Blood Flow Surveillance Compared to Standard of Care: The Hemodialysis Access Surveillance Evaluation (HASE) Study. Kidney Int Rep 2020; 5:1937-1944. [PMID: 33163714 PMCID: PMC7609971 DOI: 10.1016/j.ekir.2020.07.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Arteriovenous (AV) access thrombosis remains 1 of the most troubling AV access–related complications affecting hemodialysis patients. It necessitates an urgent and occasionally complicated thrombectomy procedure and increases the risk of AV access loss. AV access stenosis is found in the majority of thrombosed AV accesses. The routine use of AV access surveillance for the early detection and management of stenosis to reduce the thrombosis rate remains controversial. Methods We have conducted a multicenter, prospective, randomized clinical trial comparing the standard of care coupled with ultrasound dilution technique (UDT) flow measurement monthly surveillance with the standard of care alone. Results We prospectively randomized 436 patients with end-stage renal disease on hemodialysis with arteriovenous fistula (AVF) or arteriovenous graft (AVG) using cluster (shift) randomization to surveillance and control groups. There were no significant differences in the baseline demographic data between the 2 groups, except for ethnicity (P = 0.017). Patients were followed on average for 15.2 months. There were significantly less per-patient thrombotic events (Poisson rate) in the surveillance group (0.12/patient) compared with the control group (0.23/patient) (P = 0.012). There was no statistically significant difference in the total number of procedures between the 2 groups, irrespective of whether thrombectomy procedures were included or excluded, and no statistically significant differences in the rate of or time to the first thrombotic event or the number of catheters placed due to thrombosis. Conclusion The use of UDT flow measurement monthly AV access surveillance in this multicenter randomized controlled trial reduced the per-patient thrombotic events without significantly increasing the total number of angiographic procedures. Even though there is a trend, surveillance did not reduce the first thrombotic event rate.
Collapse
|
15
|
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.
Collapse
|
16
|
Gallieni M, Hollenbeck M, Inston N, Kumwenda M, Powell S, Tordoir J, Al Shakarchi J, Berger P, Bolignano D, Cassidy D, Chan TY, Dhondt A, Drechsler C, Ecder T, Finocchiaro P, Haller M, Hanko J, Heye S, Ibeas J, Jemcov T, Kershaw S, Khawaja A, Labriola L, Lomonte C, Malovrh M, Marti I Monros A, Matthew S, McGrogan D, Meyer T, Mikros S, Nistor I, Planken N, Roca-Tey R, Ross R, Troxler M, van der Veer S, Vanholder R, Vermassen F, Welander G, Wilmink T, Koobasi M, Fox J, Van Biesen W, Nagler E. Clinical practice guideline on peri- and postoperative care of arteriovenous fistulas and grafts for haemodialysis in adults. Nephrol Dial Transplant 2019; 34:ii1-ii42. [PMID: 31192372 DOI: 10.1093/ndt/gfz072] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | | | | | | | - Jan Tordoir
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Davide Bolignano
- Institute of Clinical Physiology of the Italian National Council of Research, Reggio Calabria, Italy.,ERBP, guideline development body of ERA-EDTA, London, UK
| | | | | | | | - Christiane Drechsler
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Würzburg, Würzburg, Germany
| | - Tevfik Ecder
- Istanbul Bilim University School of Medicine, Istanbul, Turkey
| | | | - Maria Haller
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ordensklinikum Linz Elisabethinen, Linz, Austria
| | | | - Sam Heye
- Jessa Hospital, Hasselt, Belgium
| | - Jose Ibeas
- Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Aurangzaib Khawaja
- Queen Elisabeth Hospital, University Hospitals Birmingham, West Midlands Deanery, Birmingham, UK
| | | | - Carlo Lomonte
- Miulli General Hospital, Acquaviva delle Fonti, Italy
| | | | | | | | | | | | | | - Ionut Nistor
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Medicine and Pharmacy, Iasi, Romania
| | - Nils Planken
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ramon Roca-Tey
- Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Rose Ross
- Ninewells Hospital Scotland, Dundee, UK
| | | | | | | | | | | | - Teun Wilmink
- Heart of England NHS foundation Trust, Birmingham, UK
| | - Muguet Koobasi
- ERBP, guideline development body of ERA-EDTA, London, UK
| | - Jonathan Fox
- ERBP, guideline development body of ERA-EDTA, London, UK.,University of Glasgow, UK
| | - Wim Van Biesen
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
| | - Evi Nagler
- ERBP, guideline development body of ERA-EDTA, London, UK.,Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
17
|
Smyth B, Kotwal S, Gallagher M, Gray NA, Polkinghorne KR. Arteriovenous access practices in Australian and New Zealand dialysis units. J Vasc Access 2019; 20:740-745. [PMID: 31144566 DOI: 10.1177/1129729819851061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The creation and maintenance of dialysis vascular access is associated with significant morbidity. Structured management pathways can reduce this morbidity, yet practice patterns in Australia and New Zealand are not known. We aimed to describe the arteriovenous access practices in dialysis units in Australia and New Zealand. METHODS An online survey comprising 51 questions was completed by representatives from dialysis units from both countries. In addition to descriptive analysis, responses were compared between units inside and outside of major cities. RESULTS Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 38% of dialysis units in Australia and New Zealand. While 94% of units provided pre-dialysis education, only 60% reported a structured pre-dialysis pathway and 69% had a dedicated vascular access nurse. Most units routinely monitored fistula/graft function using flow rate measurement (73%) or recirculation studies (63%). A minority used routine ultrasound (35%). Thrombectomy, fistuloplasty and peritoneal dialysis catheter insertion were rarely performed by nephrologists (4%, 4% and 17% of units, respectively). Units outside of a major city were less likely to have access to a local vascular access surgeon (6/13 (46%) vs 35/35 (100%), P < 0.001). There were no other significant differences between units on the basis of location. CONCLUSION Much variation exists in unit management of arteriovenous access. Structured pre-dialysis pathways and dedicated vascular access nurses may be underutilised in Australia and New Zealand. The use of regular access blood flow measurement and ultrasound is common in both countries despite a lack of data supporting its effectiveness. There is room for both practice improvement and a need for further evidence to ensure optimal arteriovenous access care.
Collapse
Affiliation(s)
- Brendan Smyth
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Sradha Kotwal
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Department of Nephrology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Martin Gallagher
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Nicholas A Gray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia.,Sunshine Coast Clinical School, University of Queensland, Brisbane QLD, Australia
| | - Kevan R Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, VIC, Australia.,Departments of Nephrology & Medicine, Monash Medical Centre, Monash University, Clayton, VIC, Australia
| |
Collapse
|
18
|
Moist L, Lok CE. Con: Vascular access surveillance in mature fistulas: is it worthwhile? Nephrol Dial Transplant 2019; 34:1106-1111. [DOI: 10.1093/ndt/gfz004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
The risks and benefits of hemodialysis arteriovenous (AV) access surveillance have been debated since the introduction of AV access surveillance techniques. The debate is fuelled by the lack of robust, high-quality evidence with consistent and comparable patient-important outcomes. Additionally, there is a lack of clarity regarding the diagnostic cut points for AV access stenosis using the various surveillance techniques, questions about the appropriateness of the ‘knee-jerk’ response to intervention on a stenosis >50% regardless of the presence of clinical indicators and whether the intervention results in desired patient-important outcomes. The physiology of the AV access is complex considering the different hemodynamics within an AV fistula, which vary by time of dialysis, location, size of vessels and location of the stenosis. The current evidence suggests that the use of AV access surveillance in an AV fistula does detect more stenosis compared with clinical monitoring alone and leads to an increased number of procedures. It remains uncertain if that leads to improved patient-important outcomes such as prolonged AV fistula patency. Vascular access is an essential component of hemodialysis and further study is needed to clarify this long-standing debate. There needs to be better distinction between the strategies of vascular access surveillance, clinical monitoring with clinical indictors and preemptive intervention and their respective impacts on patient-important outcomes. Randomized controlled studies must be conducted with defined indications for intervention, reproducible methods of intervention and clinically important AV fistula and patient outcomes. The current guidelines need to be challenged and revised to permit these necessary studies to be done.
Collapse
Affiliation(s)
- Louise Moist
- Division of Nephrology, Department of Medicine, Schulich School of Medicine, University of Western Ontario, London, ON, Canada
- Kidney Clinical Research Unit, London Health Sciences Center, London, ON, Canada
| | - Charmaine E Lok
- Department of Medicine, Division of Nephrology, University Health Network-Toronto General Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| |
Collapse
|
19
|
Ren C, Chen J, Wang Y, Huang B, Lu W, Cao Y, Yang X. Application of ultrasonography in monitoring the complications of autologous arteriovenous fistula in hemodialysis patients. Medicine (Baltimore) 2018; 97:e12994. [PMID: 30383654 PMCID: PMC6221746 DOI: 10.1097/md.0000000000012994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This study aims to evaluate the application of color Doppler ultrasound in monitoring the complications of autologous arteriovenous fistula in hemodialysis patients.Patients with maintenance hemodialysis who underwent autologous arteriovenous fistula were enrolled in this cross-sectional study. Ultrasound was used to detect fistula complications (stenosis and thrombosis), brachial artery diameter, and hemodynamic parameters. The ultrasound parameters were analyzed and screened to identify the most important indicator for monitoring complications.In all, 89 patients were included. Ultrasound showed 72 cases (80.90%) had normal fistula structure, and 17 cases (19.10%) had complications. The diameter, time-averaged mean velocity, flow volume, and diastolic peak velocity of brachial artery in complication group were significantly lower than those of noncomplication group (P < .05). The brachial artery pulsatility index and resistance index of complication group were significantly higher than those of noncomplication group (P < .05). There was no significant difference in peak flow velocity between complication and noncomplication group (P > .05). Indicators showed statistical significance were grouped based on quantiles. The incidence of complications was higher when the brachial artery diameter was ≤5.40 mm, or brachial artery flow was ≤460 mL/ min, or brachial artery pulsatility index was >1.04, or brachial artery resistance index was >0.60.Ultrasound monitoring of brachial artery diameter and hemodynamic parameters can help early detection of fistula complications. When the brachial artery diameter was ≤5.40 mm, or brachial artery flow was ≤460 mL/min, or brachial artery pulsatility index was >1.04, or brachial artery resistance index >0.60, stenosis or thrombosis should be checked to prevent fistula failure.
Collapse
Affiliation(s)
- Chong Ren
- Department of Nursing, Huashan Hospital
| | | | - Yong Wang
- Department of Ultrasound, Fudan University, Shanghai, China
| | | | - Wenwen Lu
- Department of Nursing, Huashan Hospital
| | | | | |
Collapse
|
20
|
Spanish Clinical Guidelines on Vascular Access for Haemodialysis. Nefrologia 2018; 37 Suppl 1:1-191. [PMID: 29248052 DOI: 10.1016/j.nefro.2017.11.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 12/26/2022] Open
Abstract
Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.
Collapse
|
21
|
Hwang SD, Lee JH, Lee SW, Kim JK, Kim MJ, Song JH. Comparison of ultrasound scan blood flow measurement versus other forms of surveillance in the thrombosis rate of hemodialysis access: A systemic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11194. [PMID: 30045249 PMCID: PMC6078674 DOI: 10.1097/md.0000000000011194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The benefit of access flow surveillance in preventing vascular access thrombosis and failure remains controversial, as many randomized clinical trials (RCTs) have failed to demonstrate consistent results. The aim of this study was to perform a meta-analysis including newly published RCTs with a subgroup analysis for arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs). METHODS A systematic review of the available literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An electronic search was conducted using the MEDLINE, EMBASE, and Cochrane Library databases of RCTs conducted from 1970 to 2017 that involved access flow surveillance. As a result, 9 RCTs met our criteria. The control group was defined by indirect and various surveillance methods such as dynamic venous pressure measurement and physical examination. Conversely, the interventional group was defined as a noninvasive duplex ultrasound scan (USS) or ultrasound dilution that directly measured the flow of vascular access. RESULTS The studies included 990 patients comprising 658 native AVFs and 332 AVGs. The prevalence of diabetes was 29.3%and 30.5% in the interventional and control groups, respectively. The estimated overall pooled risk ratio (RR) of thrombosis was 0.782 [95% confidence interval (95% CI), 0.553-1.107; P = .17], favoring interventional group, although this was not statistically significant. In the subgroup analysis, the pooled RR of thrombosis was .562 (95% CI, 0.346-0.915; P = .02) for AVFs, which significantly favored the interventional group. Conversely, the pooled RR for AVGs was 1.104 (95% CI, 0.672-1.816; P = .70). CONCLUSION The surveillance method to measure access flow through USS showed a significant benefit for reducing thrombosis in AVFs. The result encourages adherence to the current guidelines for AVFs. However, no benefit was found regarding AVGs. Recent guidelines with a "one-size-fits-all" approach may be revised to a "tailored-to-risk" approach.
Collapse
Affiliation(s)
- Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Bongseng-Memorial Hospital, Busan, Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Joong kyung Kim
- Division of Nephrology, Department of Internal Medicine, Bongseng-Memorial Hospital, Busan, Korea
| | - Moon-Jae Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon
| |
Collapse
|
22
|
Roca-Tey R, Ibeas J, Moreno T, Gruss E, Merino JL, Vallespín J, Hernán D, Arribas P. Dialysis arteriovenous access monitoring and surveillance according to the 2017 Spanish Guidelines. J Vasc Access 2018; 19:422-429. [PMID: 29544403 DOI: 10.1177/1129729818761307] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology (S.E.N.), vascular surgery (SEACV), interventional radiology (SERAM-SERVEI), infectious diseases (SEIMC), and nephrology nursing (SEDEN)), along with the methodological support of the Iberoamerican Cochrane Centre, has developed the Spanish Clinical Guidelines on Vascular Access for Hemodialysis. This article summarizes the main issues from the guideline's chapter entitled "Monitoring and surveillance of arteriovenous access." We will analyze the current evidence on conflicting topics such as the value of the flow-based screening methods for the arteriovenous access surveillance or the role of Doppler ultrasound as the imaging exploration to confirm suspected stenosis. In addition, the concept of significant stenosis and the criteria to perform the elective intervention for stenosis were reviewed. The adoption of these guidelines will hopefully translate into a reduced risk of thrombosis and increased patency rates for both arteriovenous fistulas and grafts.
Collapse
Affiliation(s)
- Ramon Roca-Tey
- 1 Department of Nephrology, Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - José Ibeas
- 2 Department of Nephrology, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Moreno
- 3 Department of Radiology, Hospital Juan Ramón Jiménez, Complejo Hospitalario Universitario de Huelva, Huelva, Spain
| | - Enrique Gruss
- 4 Department of Nephrology, Hospital Universitario Fundación de Alcorcón, Alcorcón, Spain
| | - José Luis Merino
- 5 Department of Nephrology, Hospital Universitario del Henares, Coslada, Spain
| | - Joaquín Vallespín
- 6 Department of Vascular Surgery, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernán
- 7 Fundación Renal Íñigo Álvarez de Toledo, Madrid, Spain
| | - Patricia Arribas
- 8 Department of Nephrology, Hospital Infanta Leonor, Madrid, Spain
| | | |
Collapse
|
23
|
Vega A, Abad S, Aragoncillo I, Galán I, Macías N, Cedeño S, Santos A, García A, Linares T, Martínez-Villaescusa M, López-Gómez JM. Comparison of urea recirculation and thermodilution for monitoring of vascular access in patients undergoing hemodialysis. J Vasc Access 2018. [DOI: 10.1177/1129729817747536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction It is important to monitor vascular access in patients with stage 5 chronic kidney disease receiving hemodialysis. Access recirculation can help to detect a need for intervention. Objectives: To compare urea recirculation with recirculation by thermodilution using blood temperature monitoring to predict a need for intervention of vascular access over a 6-month period. Methods: We analyzed urea recirculation and blood temperature monitoring simultaneously in 61 patients undergoing hemodialysis. During the 6-month follow-up, we recorded all cases of angioplasty or surgery (thrombectomy or reanastomosis). In line with previous studies, we considered a value to be positive when urea recirculation was >10% and blood temperature monitoring >15%. Receiver operating characteristic curves were constructed. Results: Mean urea recirculation was 9.5% ± 6.6% and mean blood temperature monitoring 12.9% ± 4.3% (p = 0.001). Urea recirculation >10% had a sensitivity of 80% and specificity of 78%. Blood temperature monitoring >15% had a sensitivity of 33% and specificity of 85%. During follow-up, 25% of patients developed need for intervention of vascular access. We found an association between vascular access dysfunction and urea recirculation. The Kaplan–Meier analysis confirmed an association between urea recirculation and risk of vascular access dysfunction (log rank = 17.2; p = 0.001). We were unable to confirm this association with blood temperature monitoring (log rank = 0.879; p = 0.656). Conclusion: Urea recirculation is better predictor of vascular access dysfunction than thermodilution.
Collapse
Affiliation(s)
- Almudena Vega
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Soraya Abad
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Inés Aragoncillo
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Galán
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nicolás Macías
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Santiago Cedeño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alba Santos
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana García
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tania Linares
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Juan M López-Gómez
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| |
Collapse
|
24
|
Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized controlled trial. J Vasc Access 2017; 18:352-358. [DOI: 10.5301/jva.5000700] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 02/03/2023] Open
Abstract
Purpose Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity. Methods We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [ M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103). The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3). Results At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935). There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029). Total vascular access-related costs were higher in the control group (€227.194 vs. €133.807; p = 0.029). Conclusions QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.
Collapse
|
25
|
Quencer KB, Kidd J, Kinney T. Preprocedure Evaluation of a Dysfunctional Dialysis Access. Tech Vasc Interv Radiol 2017; 20:20-30. [DOI: 10.1053/j.tvir.2016.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
26
|
Duplex Ultrasound for the Prediction of Vascular Events Associated with Arteriovenous Fistulas in Hemodialysis Patients. J Vasc Access 2016; 17:499-505. [DOI: 10.5301/jva.5000595] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2016] [Indexed: 11/20/2022] Open
Abstract
Objective To determine if duplex ultrasound (US) for arteriovenous fistulas (AVFs) can predict vascular events (VEs; thrombosis and stenosis). Methods Duplex US was performed for vascular access evaluation in 2557 maintenance hemodialysis (HD) patients between October 1, 2013 and March 31, 2016. Of these patients, 2184 patients were finally included in this study. AVF dysfunction was assessed using the brachial artery blood flow volume (Qa; mL/min), arterial blood flow resistance index (RI), and residual diameter of the fistula vein (RD; mm). Proximal, midpoint, and distal aspects of the fistulas were measured. The baseline measurements were the US assessments, and the endpoint was VEs requiring vascular access intervention therapy or vascular surgery. Associations of US findings and VEs were assessed with receiver operating characteristic curve analysis, log-rank analysis, and multivariate Cox hazard models. Results The mean Qa was 772.8 ± 441.4 mL/min; RI, 0.56 ± 0.1; and RD, 2.37 ± 1.0 mm. The optimal Qa cut-off point was calculated as 581.5 mL/min, RI cut-off as 0.56, and RD cut-off as 1.85 mm. VEs were more frequent in patients with a Qa <581.5 mL/min than in those with a Qa >581.5 mL/min (p<0.001). In multivariate analysis, Qa, ferritin, transferrin saturation, and warfarin use were significantly associated with VEs. Conclusions US evaluation of AVFs in HD patients is a simple method to predict the risks of thrombosis and fistula dysfunction. Qa, ferritin, transferrin saturation, and warfarin use might be associated with VEs.
Collapse
|