Dataset Information

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation.

ABSTRACT: In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) were included and analyzed retrospectively. The study outcome was defined as AVF patency and all-cause mortality (time to death). On Kaplan-Meier survival analysis, primary and secondary AVF patency rates did not differ significantly between the two groups (P = 0.812 and P = 0.586, respectively), although the overall survival rate was significantly higher in the pre-HD group compared with the on-HD group (P = 0.013). On multivariate analysis, well-known patient factors were associated with decreased primary (older age and diabetes mellitus [DM]) and secondary (DM and peripheral arterial occlusive disease) AVF patency, whereas use of a CVC as the initial predialysis access (hazard ratios, 1.84; 95% confidence intervals, 1.20-2.75; P = 0.005) was significantly associated with worse survival in addition to well-known patient factors (older age, diabetes mellitus, and peripheral arterial occlusive disease). Worse survival in the on-HD group was likely confounded by selection bias because of the retrospective nature of our study. Therefore, the observed lower mortality associated with AVF creation before HD initiation is not fully attributable to CVC use, but rather, affected by other patient-level prognostic factors. There were no CVC-related complications in the pre-HD group, whereas 10.2% of CVC-related complications were noted in the on-HD group. In conclusion, among incident HD patients, compared with patients who underwent creation of an AVF from a CVC, initial AVF creation showed similar primary and secondary AVF patency rates, but lower mortality risk. We also observed that an initial CVC use was an independent risk factor associated with worse survival. A fistula-first strategy might be the best option for incident HD patients who are good candidates for AVF creation.

SUBMITTER: Jeong S

PROVIDER: S-EPMC6349337 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation.

Jeong Seonjeong S Kwon Hyunwook H Chang Jai Won JW Kim Min-Ju MJ Ganbold Khaliun K Han Youngjin Y Kwon Tae-Won TW Cho Yong-Pil YP

PloS one 20190128 1

In an incident hemodialysis (HD) population, we aimed to investigate whether arteriovenous fistula (AVF) creation before HD initiation was associated with improved AVF patency compared with AVF creation from a central venous catheter (CVC), and also to compare patient survival between these patients. Between January 2011 and December 2013, 524 incident HD patients with identified first predialysis vascular access with an AVF (pre-HD group, n = 191) or an AVF from a CVC (on-HD group, n = 333) wer ...[more]

PMID: 30689672

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Project description:ObjectiveThis study analyzed the long-term arteriovenous fistula (AVF) patency rate and its determinants in patients undergoing maintenance hemodialysis.MethodsGeneral data and laboratory examinations of hemodialysis patients were collected retrospectively. The primary patency time, primary functional patency time, cumulative patency time, cumulative functional patency time, and temporary central venous catheterization (CVC) time were counted. Cox regression was used to analyze the relationships between different factors and AVF survival time. Kaplan-Meier survival analysis was used to analyze the primary patency, primary functional patency, cumulative patency, and cumulative functional patency rates between different groups.ResultsA total of 174 patients were included (mean age 58.38 ± 15.35 years), 57 women (32.76%) and 68 diabetics (39.08%). Univariate and multivariate Cox regression showed a correlation between UCR and AVF primary patency time, primary functional patency time, cumulative patency time, and cumulative functional patency time (HR 1.127, 1.116, 1.127, 1.115, 1.088, 1.075, 1.087, 1.013; 95%CI 1.055-1.204, 1.043-1.194, 1.055-1.204, 1.042-1.194, 1.022-1.158, 1.006-1.149, 1.021-1.157, 1.004-1.147; p < 0.001, 0.001, <0.001, 0.002, 0.008, 0.033, 0.009, 0.039, respectively). Duration of temporary CVC was also correlated (HR 1.013, 1.013, 1.013, 1.014, 1.008, 1.008, 1.008, 1.008; 95%CI 1.007-1.018, 1.008-1.019, 1.008-1.019, 1.009-1.020, 1.004-1.012, 1.004-1.012, 1.004-1.012, 1.004-1.012; p < 0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, <0.001, respectively). Female sex was correlated with the primary patency time and the primary functional patency time (HR 1.755, 1.765, 1.767; 95%CI 1.028-2.997, 1.034-3.014, 1.021-3.057; p = 0.039, 0.037, 0.042, respectively), but not with the cumulative patency time and the cumulative functional patency time, the primary patency rate and primary functional patency rate of AVF were higher in male than in female patients (χ2 = 4.439, 4.531; p = 0.035, 0.033, respectively). The primary patency rate, primary functional patency rate, cumulative patency rate, and cumulative functional patency rate of AVF with UCR > 10.11 group are lower than those with UCR ≤ 10.11 (χ2 = 10.745, 10.712, 4.605, 4.472; p = 0.001, 0.001, 0.032, 0.034, respectively). The group of DTCP ≤ 42 days is better than DTCP > 42 days (χ2 = 6.014, 6.055, 8.572, 8.461; p = 0.014, 0.014, 0.003, 0.004, respectively).ConclusionWomen with high UCR values at the beginning of dialysis and a long duration of temporary CVC have a poor long-term survival rate of AVF. Therefore, UCR can be used as an indicator to predict the long-term survival rate of AVF. Simultaneously, clinicians should remove the temporary catheter as early as possible if conditions permit it.

Project description:Rationale & objectiveThe current clinical guidelines for vascular access do not have specific recommendations for older hemodialysis patients. Our study aimed to determine the association of age with arteriovenous fistula (AVF) placement, maturation, and primary and secondary patency loss among older hemodialysis recipients.Study designRetrospective cohort study.Setting & participantsA US national cohort of incident hemodialysis patients 67 years or older (N = 43,851) assembled from the US Renal Data System.ExposureAge at dialysis initiation.OutcomesAVF placement, maturation, primary patency loss, and abandonment.Analytical approachCause-specific and subdistribution proportional hazards models were used to examine the association of age and AVF outcomes, with kidney transplantation, peritoneal dialysis, and death treated as competing events. Age cutoff was identified by restricted cubic splines. We compared crude and inverse probability-weighted cumulative incidence functions using Gray's test.ResultsAs compared with those aged 67-<77 years, patients 77 years or older had significantly lower probabilities of AVF placement (adjusted cause-specific HR [cHR], 0.96 [95% CI, 0.92-0.99]; adjusted subdistribution HR [sHR], 0.92 [95% CI, 0.89-0.95]; Gray's test P < 0.001) and maturation (adjusted cHR, 0.95 [95% CI, 0.91-0.99]; adjusted sHR, 0.93 [95% CI, 0.90-0.97]; P < 0.001). However, age was not associated with AVF primary (adjusted cHR, 1.05 [95% CI, 1.00-1.11]; adjusted sHR, 1.04 [95% CI, 0.99-1.09]; P = 0.09) or secondary (adjusted cHR, 1.06 [95% CI, 0.94-1.20]; adjusted sHR, 1.05 [95% CI, 0.93-1.18]; P = 0.4) patency loss.LimitationsReliance on administrative claims to ascertain AVF outcomes.ConclusionsThe likelihood of AVF maturation is an important consideration for vascular access planning. Age alone should not be the basis for excluding older dialysis patients from AVF creation because maintenance of fistula patency was not reduced with older age despite a modest reduction in fistula maturation.

Project description:Background and purposeA minority of intracranial dural arteriovenous fistulas progress with time. We sought to determine features that predict progression and define outcomes of patients with progressive dural arteriovenous fistulas.Materials and methodsWe performed a retrospective imaging and clinical record review of patients with intracranial dural arteriovenous fistula evaluated at our hospital.ResultsOf 579 patients with intracranial dural arteriovenous fistulas, 545 had 1 fistula (mean age, 45 ± 23 years) and 34 (5.9%) had enlarging, de novo, multiple, or recurrent fistulas (mean age, 53 ± 20 years; P = .11). Among these 34 patients, 19 had progressive dural arteriovenous fistulas with de novo fistulas or fistula enlargement with time (mean age, 36 ± 25 years; progressive group) and 15 had multiple or recurrent but nonprogressive fistulas (mean age, 57 ± 13 years; P = .0059, nonprogressive group). Whereas all 6 children had fistula progression, only 13/28 adults (P = .020) progressed. Angioarchitectural correlates to chronically elevated intracranial venous pressures, including venous sinus dilation (41% versus 7%, P = .045) and pseudophlebitic cortical venous pattern (P = .048), were more common in patients with progressive disease than in those without progression. Patients with progressive disease received more treatments than those without progression (median, 5 versus 3; P = .0068), but as a group, they did not demonstrate worse clinical outcomes (median mRS, 1 and 1; P = .39). However, 3 young patients died from intracranial venous hypertension and intracranial hemorrhage related to progression of their fistulas despite extensive endovascular, surgical, and radiosurgical treatments.ConclusionsFew patients with dural arteriovenous fistulas follow an aggressive, progressive clinical course despite treatment. Younger age at initial presentation and angioarchitectural correlates to venous hypertension may help identify these patients prospectively.

Project description:ContextThe arteriovenous fistula is the preferred type of vascular access for hemodialysis because of lower thrombosis and infection rates and lower health care expenditures compared with synthetic grafts or central venous catheters. Early failure of fistulas due to thrombosis or inadequate maturation is a barrier to increasing the prevalence of fistulas among patients treated with hemodialysis. Small, inconclusive trials have suggested that antiplatelet agents may reduce thrombosis of new fistulas.ObjectiveTo determine whether clopidogrel reduces early failure of hemodialysis fistulas.Design, setting, and participantsRandomized, double-blind, placebo-controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007. Eight hundred seventy-seven participants with end-stage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later.InterventionParticipants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n = 441) or placebo (n = 436) for 6 weeks starting within 1 day after fistula creation.Main outcome measuresThe primary outcome was fistula thrombosis, determined by physical examination at 6 weeks. The secondary outcome was failure of the fistula to become suitable for dialysis. Suitability was defined as use of the fistula at a dialysis machine blood pump rate of 300 mL/min or more during 8 of 12 dialysis sessions.ResultsEnrollment was stopped after 877 participants were randomized based on a stopping rule for intervention efficacy. Fistula thrombosis occurred in 53 (12.2%) participants assigned to clopidogrel compared with 84 (19.5%) participants assigned to placebo (relative risk, 0.63; 95% confidence interval, 0.46-0.97; P = .018). Failure to attain suitability for dialysis did not differ between the clopidogrel and placebo groups (61.8% vs 59.5%, respectively; relative risk, 1.05; 95% confidence interval, 0.94-1.17; P = .40).ConclusionClopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis. Trial Registration clinicaltrials.gov Identifier: NCT00067119.

Dataset Information

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation.

Publications

Patency rates of arteriovenous fistulas created before versus after hemodialysis initiation.

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