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Voorzaat BM, Janmaat CJ, Wilschut ED, Van Der Bogt KEA, Dekker FW, Rotmans JI. No consensus on physicians' preferences on vascular access management after kidney transplantation: Results of a multi-national survey. J Vasc Access 2019; 20:52-59. [PMID: 29843559 PMCID: PMC6305957 DOI: 10.1177/1129729818776905] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/26/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE: Arteriovenous fistulas for hemodialysis vascular access are a burden for the cardiovascular system. After successful kidney transplantation, prophylactic arteriovenous fistula ligation may improve cardiac outcomes; however, evidence is scarce. This survey investigates physicians' preference for management of arteriovenous fistulas and identifies the factors associated with preference for either arteriovenous fistula ligation or maintenance. MATERIALS AND METHODS: A survey was sent to members of eight national and international Nephrology and Vascular Surgery societies. The survey comprised eight case vignettes of asymptomatic patients with a functioning arteriovenous fistula after kidney transplantation. Characteristics possibly associated with treatment preferences were arteriovenous fistula flow, left ventricular ejection fraction, and patient age. Respondents were asked to state preference to maintain or ligate the arteriovenous fistula. Linear mixed-effects models were used to investigate the association of treatment preference with case characteristics. RESULTS: A total of 585 surveys were returned. A reduced left ventricular ejection fraction of 30% (beta 0.60, 95% confidence interval 0.55; 0.65) and a high flow of 2500 mL/min (beta 0.46, 95% confidence interval 0.41; 0.51) were associated with a higher preference for arteriovenous fistula ligation. Disagreement among respondents was considerable, as in four out of eight cases less than 70% of respondents agreed on the arteriovenous fistula management strategy. CONCLUSION: Although respondents recognize a reduced left ventricular ejection fraction and a high flow as the risk factors, the high disagreement on management preferences suggests that evidence is inconclusive to recommend arteriovenous fistula ligation or maintenance after kidney transplantation. More research is needed to determine optimal arteriovenous fistula management after successful kidney transplantation.
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Affiliation(s)
- Bram M Voorzaat
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Cynthia J Janmaat
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther D Wilschut
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koen EA Van Der Bogt
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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2
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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: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Lee HS, Ju YS, Song YR, Kim JK, Choi SR, Joo N, Kim HJ, Park P, Kim SG. Current treatment status and medical costs for hemodialysis vascular access based on analysis of the Korean Health Insurance Database. Korean J Intern Med 2018; 33:1160-1168. [PMID: 30396254 PMCID: PMC6234403 DOI: 10.3904/kjim.2018.170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 07/24/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The Republic of Korea is a country where the hemodialysis population is growing rapidly. It is believed that the numbers of treatments related to vascular access-related complications are also increasing. This study investigated the current status of treatment and medical expenses for vascular access in Korean patients on hemodialysis. METHODS This was a descriptive observational study. We inspected the insurance claims of patients with chronic kidney disease who underwent hemodialysis between January 2008 and December 2016. We calculated descriptive statistics of the frequencies and medical expenses of procedures for vascular access. RESULTS The national medical expenses for access-related treatment were 7.12 billion KRW (equivalent to 6.36 million USD) in 2008, and these expenses increased to 42.12 billion KRW (equivalent to 37.67 million USD) in 2016. The population of hemodialysis patients, the annual frequency of access-related procedures, and the total medical cost for access-related procedures increased by 1.6-, 2.6-, and 5.9-fold, respectively, over the past 9 years. The frequency and costs of access care increased as the number of patients on hemodialysis increased. The increase in vascular access-related costs has largely been driven by increased numbers of percutaneous angioplasty. CONCLUSION The increasing proportion of medical costs for percutaneous angioplasty represents a challenge in the management of end-stage renal disease in Korea. It is essential to identify the clinical and physiological aspects as well as anatomical abnormalities before planning angioplasty. A timely surgical correction could be a viable option to control the rapid growth of access-related medical expenses.
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Affiliation(s)
- Hyung Seok Lee
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young-Su Ju
- Department of Occupational and Environmental Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young Rim Song
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jwa Kyung Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sun Ryoung Choi
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Narae Joo
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyung Jik Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Pyoungju Park
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Korea
- Correspondence to Sung Gyun Kim, M.D. Department of Internal Medicine, Kidney Research Institute, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel: +82-31-380-1942 Fax: +82-31-386-2269 E-mail:
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Gill S, Quinn R, Oliver M, Kamar F, Kabani R, Devoe D, Mysore P, Pannu N, MacRae J, Manns B, Hemmelgarn B, James M, Tonelli M, Lewin A, Liu P, Ravani P. Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy. Clin J Am Soc Nephrol 2017; 12:1991-1999. [PMID: 28912248 PMCID: PMC5718268 DOI: 10.2215/cjn.03430317] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/19/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. RESULTS We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. CONCLUSION Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.
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Affiliation(s)
| | - Robert Quinn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | | | | | - Daniel Devoe
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Priyanka Mysore
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Neesh Pannu
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew James
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adriane Lewin
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ping Liu
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Beathard GA, Urbanes A, Litchfield T. Changes in the Profile of Endovascular Procedures Performed in Freestanding Dialysis Access Centers over 15 Years. Clin J Am Soc Nephrol 2017; 12:779-786. [PMID: 28420654 PMCID: PMC5477215 DOI: 10.2215/cjn.09730916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 02/10/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Marked changes occurred in the vascular access profile of patients receiving hemodialysis in the United States over the 15-year period of 2001-2015. This study was undertaken to evaluate how these changes have affected dialysis access maintenance and salvage procedures performed in freestanding dialysis access centers and to examine the effectiveness, efficiency, and safety of these procedures in this setting. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were collected from freestanding, dedicated dialysis access centers operating under a common system of management. Data were available on 689,676 dialysis access procedures. Data relating to case mix, procedure outcome, procedural time, and intraprocedural and immediate postprocedural complications were analyzed. RESULTS The arteriovenous procedure profile changed from one characterized by approximately equal numbers of angioplasties and thrombectomies performed on arteriovenous grafts (AVGs) to one characterized primarily by angioplasties performed on arteriovenous fistulas. The percentage of angioplasties performed throughout the study was significantly greater than thrombectomies, with a mean of 67.9% versus 32.1% (P<0.001). Interventional procedures did not decrease with increasing arteriovenous fistula utilization in prevalent patients receiving dialysis. The incidence roughly paralleled the increasing prevalence of this type of access. A decreasing percentage of AVG utilization resulted in a progressive, roughly parallel, but disproportionately higher, decrease in the percentage of AVG procedures (P<0.001). A progressive improvement in procedure outcomes and a decrease in complication rates and procedure times were observed (P<0.001 for each). A progressive decrease in tunneled dialysis catheter placement was also observed. CONCLUSIONS The procedure profile treated in freestanding, dedicated dialysis access centers changed significantly over 15 years, reflecting the changes that have occurred in the vascular access profile of the dialysis population.
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Affiliation(s)
- Gerald A. Beathard
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
- Department of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Aris Urbanes
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
| | - Terry Litchfield
- Lifeline Vascular Access a division of DaVita Healthcare, Denver, Colorado; and
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Abstract
Hypertension management poses a major challenge to clinicians globally once non-drug (lifestyle) measures have failed to control blood pressure (BP). Although drug treatment strategies to lower BP are well described, poor control rates of hypertension, even in the first world, suggest that more needs to be done to surmount the problem. A major issue is non-adherence to antihypertensive drugs, which is caused in part by drug intolerance due to side effects. More effective antihypertensive drugs are therefore required which have excellent tolerability and safety profiles in addition to being efficacious. For those patients who either do not tolerate or wish to take medication for hypertension or in whom BP control is not attained despite multiple antihypertensives, a novel class of interventional procedures to manage hypertension has emerged. While most of these target various aspects of the sympathetic nervous system regulation of BP, an additional procedure is now available, which addresses mechanical aspects of the circulation. Most of these new devices are supported by early and encouraging evidence for both safety and efficacy, although it is clear that more rigorous randomized controlled trial data will be essential before any of the technologies can be adopted as a standard of care.
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Affiliation(s)
- Melvin D. Lobo
- Barts BP Centre of Excellence, Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Paul A. Sobotka
- The Ohio State University, Columbus, OH, USA
- ROX Medical, San Clemente, CA, USA
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension and Heart Failure Unit, Health Innovation Lab (Hi-Lab) Clinique Pasteur, Toulouse, France
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7
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Kadan M, Erol G, Karabacak K, Kaya E, Özkan G, Doğanci S, Yildirim V, Demirkiliç U. New probing and warm-wash-out technique improves early patency rates in arteriovenous fistula surgery. Eur Rev Med Pharmacol Sci 2015; 19:3917-3921. [PMID: 26531279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Arteriovenous fistulas (AVFs) are commonly used during hemodialysis. Early failure of AVFs is quite common with incidence of 43% to 63%. In this study we aimed to describe a novel approach to AVF surgery for improving early patency rates. PATIENTS AND METHODS Patients were divided into two groups according to use of probing and warm-wash-out technique. Group I consisted of 31 patients with additional probing technique. Group II consisted of 32 patients without additional maneuver. End-to-side anastomosis were used to all patients. Technical success was defined as having palpation of a thrill on fistula. Flow rates of draining vein was measured at 1st hour, 24th hour, 1st week and 3rd week of surgery. SURGICAL TECHNIQUE Classical maneuvers were performed until end of the anastomosis. At this time, vein lumen was washed by low-dosed heparinized warm fluid, with assistance of a simple catheter. RESULTS Technical success was similar in both groups at 1st hour and 24th hour, while there were significantly differences between groups at 1st week (p = 0.042) and 3rd week (p = 0.05) assessments. Flow rates were also measured significantly higher in Group I at 1st hour (p = 0.011) and 24th hour (p = 0.016). Flow rates were almost similar in two groups at 1st and 3rd weeks but overall success rate was higher in Group I comparing with Group II (96.8% vs. 81.3%, respectively, p = 0.05). CONCLUSIONS Probing and warm-wash out technique will simply increase the surgical success and flow rate of draining vein.
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Affiliation(s)
- M Kadan
- Department of Cardiovascular Surgery, and Department of Cardiovascular Anesthesiology, Gulhane Military Academy of Medicine, Etlik, Ankara, Turkey.
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Al-Jaishi AA, Lok CE, Garg AX, Zhang JC, Moist LM. Vascular access creation before hemodialysis initiation and use: a population-based cohort study. Clin J Am Soc Nephrol 2015; 10:418-27. [PMID: 25568219 PMCID: PMC4348683 DOI: 10.2215/cjn.06220614] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/20/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In Canada, approximately 17% of patients use an arteriovenous access (fistula or arteriovenous graft) at commencement of hemodialysis, despite guideline recommendations promoting its timely creation and use. It is unclear if this low pattern of use is attributable to the lack of surgical creation or a high nonuse rate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using large health care databases in Ontario, Canada, a population-based cohort of adult patients (≥18 years old) who initiated hemodialysis as their first form of RRT between 2001 and 2010 was studied. The aims were to (1) estimate the proportion of patients who had an arteriovenous access created before starting hemodialysis and the proportion who successfully used it at hemodialysis start, (2) test for secular trends in arteriovenous access creation, and (3) estimate the effect of late nephrology referral and patient characteristics on arteriovenous access creation. RESULTS There were 17,183 patients on incident hemodialysis. The mean age was 65.8 years, 60% were men, and 40% were referred late to a nephrologist; 27% of patients (4556 of 17,183) had one or more arteriovenous accesses created, and the median time between arteriovenous access creation and hemodialysis start was 184 days. When late referrals were excluded, 39% of patients (4007 of 10,291) had one or more arteriovenous accesses created, and 27% of patients (2724 of 10,291) used the arteriovenous access. Since 2001, there has been a decline in arteriovenous access creation before hemodialysis initiation. Women, higher numbers of comorbidities, and rural residence were consistently associated with lower rates of arteriovenous access creation. These results persisted even after removing patients with <6 months nephrology care or who had AKI 6 months before starting hemodialysis. CONCLUSIONS In Canada, arteriovenous access creation before hemodialysis initiation is low, even among patients followed by a nephrologist. Better understanding of the barriers and influencers of arteriovenous access creation is needed to inform both clinical care and guidelines.
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Affiliation(s)
- Ahmed A Al-Jaishi
- Institute for Clinical Evaluative Sciences, Kidney Dialysis Transplantation Program, Toronto, Ontario, Canada; Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Charmaine E Lok
- Institute for Clinical Evaluative Sciences, Kidney Dialysis Transplantation Program, Toronto, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology, Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Kidney Dialysis Transplantation Program, Toronto, Ontario, Canada; Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
| | - Joyce C Zhang
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
| | - Louise M Moist
- Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
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9
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Takemoto Y, Naganuma T. [The progression and change of the vascular access]. Nihon Jinzo Gakkai Shi 2013; 55:489-492. [PMID: 23819373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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10
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Nuemann ME. Paper calls for incentivizing AVF placement. Nephrol News Issues 2011; 25:30-31. [PMID: 21608457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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11
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Wilson B, Harwood L, Oudshoorn A, Thompson B. The culture of vascular access cannulation among nurses in a chronic hemodialysis unit. CANNT J 2010; 20:35-42. [PMID: 21038828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The native arteriovenous fistula (AVF) is the vascular access of choice for patients on chronic hemodialysis (HD) because of its longevity and lower complication rate. Yet from 2001 to 2004 in Canada, there has been a notable increase in both incident and prevalent central venous catheter (CVC) use with a corresponding decrease in AVF use over the same time period (Moist, Trpeski, Na, & Lok, 2008). A similar trend has been found in other countries (Moist, Chang, Polkinghorne, & McDonald, 2007). There are a number of contributing factors to low AVF use in patients on chronic hemodialysis. While some of these factors may be patient-related, nursing interventions specific to cannulation may be a contributor. To date, little is known about HD nurses' attitudes and experiences regarding cannulation. The purpose of this study was to describe the culture and everyday practices of vascular access cannulation of the AVF from the perspective of the HD nurse. An ethnographic research design was employed, utilizing qualitative methods. Ten HD nurses were interviewed using a semi-structured interview tool, and a number of themes were generated from the interviews. One overarching theme of "perpetual novice" was evident, acknowledging the failure to transition from novice to expert cannulator despite working in HD for a number of years. Other common themes that emerged from the interviews were a) the lack of fistulas, b) the fistula as a "hard sell" to patients, c) the skill of cannulation, and d) the assembly-line approach to care. As a result of a number of factors, HD nurses were unable to acquire the skills necessary to become an expert cannulator. Moreover, the decrease in opportunities to practise cannulation has resulted in wide variation in skill level among HD nurses. To improve cannulation skills and achieve successful cannulation of AV fistulas, HD nurses identified a number of educational strategies that should take place. They also identified the need for an improved documentation system in order to track cannulation-related problems. Results of this study may be helpful in understanding the culture of cannulation in a chronic HD unit and in directing future educational, supportive, and practice interventions for HD nurses.
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MESH Headings
- Arteriovenous Shunt, Surgical/nursing
- Arteriovenous Shunt, Surgical/trends
- Attitude of Health Personnel
- Blood Vessel Prosthesis/trends
- Canada
- Catheterization, Central Venous/nursing
- Catheterization, Central Venous/trends
- Clinical Competence
- Ethnology
- Female
- Health Knowledge, Attitudes, Practice
- Humans
- Nursing Methodology Research
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/organization & administration
- Nursing Staff, Hospital/psychology
- Organizational Culture
- Practice Patterns, Nurses'/organization & administration
- Qualitative Research
- Renal Dialysis/instrumentation
- Renal Dialysis/nursing
- Renal Dialysis/trends
- Self Efficacy
- Surveys and Questionnaires
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Affiliation(s)
- Barbara Wilson
- London Health Sciences Centre, Victoria Hospital, London, Ontario.
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12
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Moist LM, Trpeski L, Na Y, Lok CE. Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001-2004. Clin J Am Soc Nephrol 2008; 3:1726-32. [PMID: 18922993 PMCID: PMC2572294 DOI: 10.2215/cjn.01240308] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 07/31/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The 1999 Canadian vascular access guidelines recommend the fistula as the access of choice. The study describes the trends in hemodialysis access use, variation among provinces, and the association with mortality from 2001 to 2004. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS An observational study of adult patients registered in Canadian Organ Replacement Registry on hemodialysis. Access trends were examined among incident and prevalent hemodialysis patients adjusted for age, sex, body mass index, late referral, race, smoking status, province, etiology of end-stage renal disease, and comorbidities. Cox proportional hazard regression analysis was used to analyze risk for death for patients followed to December 31, 2005. RESULTS From 2001 to 2004, incident catheter use increased from 76.8% to 79.1%, fistulas decreased from 21.6% to 18.6%, and grafts remained between 2.1% to 2.6%. Prevalent catheter use increased from 41.8% to 51.7%, and fistulas and grafts decreased from 46.8% to 41.6% and 11.4% to 6.7%, respectively. There was significant variation in incident and prevalent fistulae use among the provinces. Adjustment for differences in patient characteristics did not change these trends. Incident catheter use was associated with a 6 times greater risk of death compared with fistula or graft use combined. CONCLUSIONS In Canada there has been a decrease in fistulae and grafts with a subsequent increase in catheters that is not explained by changes in patient characteristics. Vascular access use varied by province, suggesting differences in practice patterns. Because incident catheter use was associated with increased mortality, urgent measures are needed to develop strategies to decrease catheter use.
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Affiliation(s)
- Louise M Moist
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada.
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Ethier J, Mendelssohn DC, Elder SJ, Hasegawa T, Akizawa T, Akiba T, Canaud BJ, Pisoni RL. Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study. Nephrol Dial Transplant 2008; 23:3219-26. [PMID: 18511606 PMCID: PMC2542410 DOI: 10.1093/ndt/gfn261] [Citation(s) in RCA: 399] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 04/15/2008] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A well-functioning vascular access (VA) is essential to efficient dialysis therapy. Guidelines have been implemented improving care, yet access use varies widely across countries and VA complications remain a problem. This study took advantage of the unique opportunity to utilize data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to examine international trends in VA use and trends in patient characteristics and practices associated with VA use from 1996 to 2007. DOPPS is a prospective, observational study of haemodialysis (HD) practices and patient outcomes at >300 HD units from 12 countries and has collected data thus far from >35,000 randomly selected patients. METHODS VA data were collected for each patient at study entry (1996-2007). Practice pattern data from the facility medical director, nurse manager and VA surgeon were also analysed. RESULTS Since 2005, a native arteriovenous fistula (AVF) was used by 67-91% of prevalent patients in Japan, Italy, Germany, France, Spain, the UK, Australia and New Zealand, and 50-59% in Belgium, Sweden and Canada. From 1996 to 2007, AVF use rose from 24% to 47% in the USA but declined in Italy, Germany and Spain. Moreover, graft use fell by 50% in the USA from 58% use in 1996 to 28% by 2007. Across three phases of data collection, patients consistently were less likely to use an AVF versus other VA types if female, of older age, having greater body mass index, diabetes, peripheral vascular disease or recurrent cellulitis/gangrene. In addition, countries with a greater prevalence of diabetes in HD patients had a significantly lower percentage of patients using an AVF. Despite poorer outcomes for central vein catheters, catheter use rose 1.5- to 3-fold among prevalent patients in many countries from 1996 to 2007, even among non-diabetic patients 18-70 years old. Furthermore, 58-73% of patients new to end-stage renal disease (ESRD) used a catheter for the initiation of HD in five countries despite 60-79% of patients having been seen by a nephrologist >4 months prior to ESRD. Patients were significantly (P < 0.05) less likely to start dialysis with a permanent VA if treated in a faciity that (1) had a longer time from referral to access surgery evaluation or from evaluation to access creation and (2) had longer time from access creation until first AVF cannulation. The median time from referral until access creation varied from 5-6 days in Italy, Japan and Germany to 40-43 days in the UK and Canada. Compared to patients using an AVF, patients with a catheter displayed significantly lower mean Kt/V levels. CONCLUSIONS Most countries meet the contemporary National Kidney Foundation's Kidney Disease Outcomes Quality Initiative goal for AVF use; however, there is still a wide variation in VA preference. Delays between the creation and cannulation must be improved to enhance the chances of a future permanent VA. Native arteriovenous fistula is the VA of choice ensuring dialysis adequacy and better patient outcomes. Graft is, however, a better alternative than catheter for patients where the creation of an attempted AVF failed or could not be created for different reasons.
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Affiliation(s)
- Jean Ethier
- Department of Nephrology, Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - David C. Mendelssohn
- Department of Nephrology, University of Toronto/Humber River Regional Hospital, Weston, Ontario, Canada
| | | | | | - Tadao Akizawa
- Division of Nephrology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Takashi Akiba
- Department of Blood Purification and Internal Medicine, Kidney Center, Tokyo, Japan
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14
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Abstract
Gaining access to blood circulation has been a major breakthrough of modern medical care and, despite the evolution of dialysis technology, vascular access (VA) remains the main impediment in providing quantity as well as quality of life to the end-stage renal disease (ESRD) patient. The external Scribner shunt and the internal Brescia/Cimino arteriovenous fistula (AVF) opened the way for further advancements such as graft angioaccess and other sophisticated devices. Forty years later, the radio-cephalic fistula remains the VA with the longest patency and the lowest complications. Although various technical solutions can be adopted for constructing access to the patient's vessels, the nephrologist must bear in mind that every VA in the upper limb, lower limb or body wall needs a run-in and a run-off: currently, thrombosis of the central vessels due to the excessive widespread use of central venous catheters (CVCs) emerge as a substantial cause of hemodialysis (HD) morbidity and mortality. Moreover, as there is a risk of central vein stenosis, even 2 weeks after catheter placement, and an impaired venous outflow precludes the creation of any VA and sometimes the placement of a kidney transplant in the iliac fossa for many years, we agree with McGill et al, who in 2005 said that ''expansion of catheter access may contribute to the reduced survival of hemodialysis patients in the United States''.
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MESH Headings
- Arteriovenous Shunt, Surgical/adverse effects
- Arteriovenous Shunt, Surgical/instrumentation
- Arteriovenous Shunt, Surgical/methods
- Arteriovenous Shunt, Surgical/trends
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/methods
- Catheterization, Central Venous/trends
- Catheters, Indwelling/adverse effects
- Catheters, Indwelling/trends
- Equipment Design
- Extremities/blood supply
- Humans
- Kidney Failure, Chronic/therapy
- Renal Dialysis/instrumentation
- Renal Dialysis/methods
- Renal Dialysis/trends
- Vascular Patency
- Venous Thrombosis/etiology
- Venous Thrombosis/physiopathology
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Affiliation(s)
- L Berardinelli
- Division of Vascular Surgery and Kidney Transplantation, Policlinico University Hospital Foundation, IRCCS, Milan, Italy.
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15
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Abstract
The native arterio-venous fistula provides the best access for haemodialysis. The dialysis population is growing in number, becoming more elderly, and has increasingly complex medical co-morbidity. The ability to establish and maintain optimal haemodialysis access in this population requires the planning and commissioning of operating and diagnostic facilities and the training of sufficient suitable surgical specialists. This article outlines the major factors that influence the demand for and requirements of a vascular access service for the renal failure population.
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Affiliation(s)
- K Donovan
- University Hospital of Wales, Cardiff, UK
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16
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Brouwer DJ. . . . the road to improvement? Part 2. The care and feeding of the AV fistula. Nephrol News Issues 2003; 17:48-51. [PMID: 12847962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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17
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Pisoni RL, Young EW, Mapes DL, Keen ML, Port FK. Vascular access use and outcomes in the U.S., Europe, and Japan: results from the Dialysis Outcomes and Practice Patterns Study. Nephrol News Issues 2003; 17:38-43, 47. [PMID: 12778616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Ronald L Pisoni
- University Renal Research and Education Association (URREA), Ann Arbor, Mich., USA
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18
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19
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Rezabek MS, Balwit JM. Trends in access selection and placement. Nephrol News Issues 2002; 16:57-9, 62, 64. [PMID: 12035628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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20
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Hingorani A, Ascher E, Kallakuri S, Greenberg S, Khanimov Y. Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis. J Vasc Surg 2001; 34:1004-9. [PMID: 11743552 DOI: 10.1067/mva.2001.119750] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Although large published series have described their experience with the management of failed or failing prosthetic arteriovenous grafts for hemodialysis, there are scant data regarding failing arteriovenous fistulae (AVFs). To analyze the management of nonfunctioning or nonmaturing AVFs, we reviewed our experience with salvage procedures for these AVFs. MATERIALS AND METHODS Of the 474 AVFs placed at our institution in 380 patients between June 1997 and March 2001, 75 revisions were performed in 46 patients (49 AVFs). Ages of these patients ranged from 29 to 94 years (mean, 68 +/- 1.4 years). Diabetic patients comprised 51%, and hypertensive patients comprised 75%. Twenty patients underwent 26 vein patch angioplasties, and 17 patients underwent 24 balloon angioplasties. Four patients required four vein interpositions, and 12 patients underwent 12 revisions of the fistula to a more proximal level. Extended salvage procedures consisted of four turn-downs to the basilic vein for proximal cephalic vein thrombosis or stenosis and five extension bypasses to the axillary or jugular vein for subclavian vein thrombosis. RESULTS Follow-up ranged from 1 to 31 months (mean, 10 months). The patients who underwent open revisions tended to need fewer subsequent procedures. However, primary patency of the vein patch angioplasty was not significantly better as compared with balloon angioplasty (P = .8) by life table analysis. Patency after revision of a radial cephalic fistula and brachial cephalic fistula were not statistically different. One interposition failed during the follow-up, and one revision to a more proximal level thrombosed during the follow-up. Two of the turn-down procedures had thrombosed at 2 and 11 months. The remaining two turn-down procedures have remained functional at 1 and 24 months. One of the extensions thrombosed at 8 months whereas the other four have remained functional at 1, 6, and 8 months. CONCLUSIONS Despite the limited follow-up data, this review suggests that simple and extended salvage procedures may allow maturation and add to the life span of AVFs for hemodialysis. In addition, these data suggest an advantage for open techniques as compared with percutaneous techniques but only in terms of requiring fewer subsequent procedures.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Angioplasty/instrumentation
- Angioplasty/methods
- Angioplasty/statistics & numerical data
- Angioplasty, Balloon/instrumentation
- Angioplasty, Balloon/methods
- Angioplasty, Balloon/statistics & numerical data
- Arteriovenous Shunt, Surgical/adverse effects
- Arteriovenous Shunt, Surgical/statistics & numerical data
- Arteriovenous Shunt, Surgical/trends
- Diabetic Nephropathies/complications
- Embolism/etiology
- Embolism/surgery
- Female
- Follow-Up Studies
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/surgery
- Graft Survival
- Humans
- Hypertension/complications
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/therapy
- Male
- Middle Aged
- Renal Dialysis/instrumentation
- Reoperation/instrumentation
- Reoperation/methods
- Reoperation/statistics & numerical data
- Salvage Therapy/instrumentation
- Salvage Therapy/methods
- Salvage Therapy/statistics & numerical data
- Survival Analysis
- Thrombosis/etiology
- Thrombosis/surgery
- Treatment Outcome
- Vascular Patency
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Affiliation(s)
- A Hingorani
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, New York 11219, USA
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21
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Glazer S, Crooks P, Shapiro M, Diesto J. Using CQI and the DOQI guidelines to improve vascular access outcomes: the Southern California Kaiser Permanente experience. Nephrol News Issues 2000; 14:21-6; discussion 27. [PMID: 11111537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- S Glazer
- Southern California Kaiser Permanente Medical Group, USA
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22
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23
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Neumann ME. Moving toward the future in access management. Nephrol News Issues 1999; 13:27-8. [PMID: 10578818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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24
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Quarello F, Forneris G, Boero R, Iadarola GM, Borca M, Salomone M. [Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]. MINERVA UROL NEFROL 1998; 50:9-15. [PMID: 9578651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.
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MESH Headings
- Adult
- Aged
- Animals
- Arteriovenous Shunt, Surgical/adverse effects
- Arteriovenous Shunt, Surgical/classification
- Arteriovenous Shunt, Surgical/statistics & numerical data
- Arteriovenous Shunt, Surgical/trends
- Bioprosthesis
- Blood Vessel Prosthesis
- Brachiocephalic Veins
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/methods
- Catheterization, Central Venous/statistics & numerical data
- Catheterization, Central Venous/trends
- Catheters, Indwelling/adverse effects
- Catheters, Indwelling/statistics & numerical data
- Catheters, Indwelling/trends
- Cattle
- Equipment Design
- Femoral Vein
- Humans
- Infections/etiology
- Italy
- Jugular Veins
- Middle Aged
- Peritoneal Dialysis/methods
- Polytetrafluoroethylene
- Radial Artery
- Renal Dialysis/methods
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Affiliation(s)
- F Quarello
- Divisione di Nefrologia e Dialisi, Azienda Regionale USL 4, Ospedale G. Bosco, Torino
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Sands J, Miranda CL. Increasing numbers of AV fistulas for hemodialysis access. Clin Nephrol 1997; 48:114-7. [PMID: 9285149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
As part of our CQI program, we initiated an effort to see if we could successfully increase the total number of native arterio-venous (AV) fistulas relative to synthetic PTFE grafts in our dialysis population. This was a combined effort of the nephrology and surgery departments. The program emphasized placement of brachial fistulas in elderly patients and diabetics. Permcaths were placed in the internal jugular position to allow adequate time for maturation of fistulas. The percentage of AV fistulas in our total dialysis population increased from 28% (93 of 328) in the base period 1990 through 1992 to 44% (170 of 386) in the period from 1993 through 1995 (p < 0.0001). Initial AV fistula insertions increased from 38% (52 of 137) in 1990-1992 to 71.8% (102 of 142) in the years 1993 through 1995 (p < 0.0001). 86.5% (45 of 52) of initial fistulas placed in 1990-1992 were useable compared to 63.7% (65 of 102) in 1993-1995 (p < 0.01). Patient demographics were unchanged throughout the study. In conclusion, the number and percentage of AV fistulas in our dialysis population was significantly increased through a coordinated CQI initiative. We expect that this will have a positive impact on decreasing future thrombosis rates and decreasing the cost of access management.
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Affiliation(s)
- J Sands
- Renal Consultants of Wyoming Valley, Wilkes-Barre, Pennsylvania 18702, USA
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Kapoian T, Sherman RA. A brief history of vascular access for hemodialysis: an unfinished story. Semin Nephrol 1997; 17:239-45. [PMID: 9165653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Progress in the development of permanent vascular access for hemodialysis has been much slower than progress in other areas of end-stage renal disease (ESRD) patient care. This article provides a brief historical overview of the major means used for vascular access since the start of chronic hemodialysis. These access modalities include external shunts, arteriovenous fistulae, prosthetic arteriovenous grafts, needle-less access devices, and tunneled central venous catheters. Despite the evolution of access methodology, vascular access complications remain a major impediment to the full rehabilitation of the chronic hemodialysis patient.
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Affiliation(s)
- T Kapoian
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick 08903, USA
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Hirth RA, Turenne MN, Woods JD, Young EW, Port FK, Pauly MV, Held PJ. Predictors of type of vascular access in hemodialysis patients. JAMA 1996; 276:1303-8. [PMID: 8861988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Complications from vascular access account for 15% of hospital admissions among US hemodialysis patients. Complications are less frequent with arteriovenous fistulas than with synthetic grafts. We assessed clinical and nonclinical predictors of whether patients with end-stage renal disease (ESRD) starting hemodialysis receive a fistula or graft. We also investigated changes in practice between 1986-1987 and 1990. DESIGN Cross-sectional study. SETTING United States hemodialysis population. PATIENTS Random, national samples of ESRD patients who started hemodialysis in 1986-1987 (n=2741) or 1990 (n=1409) from United States Renal Data System Special Studies. MAIN OUTCOME MEASURE Type of permanent vascular access (arteriovenous fistula vs synthetic graft), analyzed using multivariate logistic regression. RESULTS Clinical and demographic factors as well as socioeconomic status, region of residence, and year starting hemodialysis predicted the type of vascular access. Overall, 56% of patients had grafts 30 days after starting dialysis, but graft use increased from 51% in 1986-1987 to 65% in 1990 (adjusted odds ratio [AOR], 1.67 for 1990 vs 1986-1987; 95% confidence interval [CI], 1.43-1.95; P<.001). Graft use (relative to fistula) varied by region of residence (ranging from AOR, 0.20; 95% CI, 0.14-0.28; P<.001 [New England], to AOR, 2.69; 95% CI, 2.03-3.58; P<.001 [East South Central]; both relative to the national average). CONCLUSIONS This national study documents large variations in the relative use of fistulas and grafts and a trend away from fistulas. The prevalence of comorbid conditions fails to explain these findings. Presentation and referral of patients early in the process of their ESRD, teaching surgeons to place fistulas, and training dialysis nurses to access fistulas may increase their use.
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Affiliation(s)
- R A Hirth
- Department of Health Management and Policy, University of Michigan, Ann Arbor 48109-2029, USA
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Chertow GM. Grafts vs fistulas for hemodialysis patients: equal access for all? JAMA 1996; 276:1343-4. [PMID: 8861996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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29
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Giacchino JL, Geis WP, Wittenstein BH, Gandhi VC. Recent trends in vascular access. Am Surg 1982; 48:501-4. [PMID: 7137712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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