The effects of vascular access types on the survival and quality of life and depression in the incident hemodialysis patients.
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SUBMITTER: Kim DH
PROVIDER: S-EPMC6968432 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Vascular access (VA) is the cornerstone for carrying out hemodialysis, yet it may bring in complications and leads to hemodialysis quality decline. This study aimed to explore the impact of vascular access types, including arteriovenous shunts and central venous catheter on all-cause mortality after adjustment of other risk factors. Total 738 ESRD patients aged over 40 year old receiving regular hemodialysis therapies were recruited between January 2001 and December 2010 from a single hemodialysis center in northern Taiwan. We ascertained the causes and date of death by linking our hospital database with Nationwide Mortality Registry Database. VA types and biochemistry parameters were extracted from the electronic hospital records. Patients were categorized into three groups, including (1)arteriovenous shunts (AVF)/arteriovenous shunts with Gortex®(AVG); (2)AVF/AVG combined central venous catheter; (3)catheter only. The time-dependent influence of vascular types i.e. initiation and follow-up period was also assessed. The mean follow-up time was 4.5 years. In patients using central venous catheter for initiation of hemodialysis, the adjusted hazard ratio (HR) for all-cause mortality was 1.55(95%CI: 1.09, 2.21), when compared with AVF/AVG. In the follow-up period, after adjustment for other risk factors, the multivariable analysis showed that the adjusted HRs were 3.23(95%CI: 1.85, 5.64) and 1.45(95%CI: 1.11, 1.91) for catheter only and AVF/AVG plus catheter, respectively. Our results showed that vascular accesses used for hemodialysis had different and time-dependent impact on patients' long-term survival. Patients who started hemodialysis with central venous catheter had significantly higher all-cause mortality rate. Furthermore, in the follow-up period, patients both in the catheter only and AVF/AVG plus catheter groups also had the significant all-cause mortality rates. Our results support the early establishment of arteriovenous shunt for the chronic kidney disease patients.
| S-EPMC6656721 | biostudies-literature
Project description:BACKGROUND:End stage kidney disease and hemodialysis dependence are associated with impairments in health-related quality of life (HRQOL), which may be related to vascular access (VA). Few HRQOL measures are VA-specific and none differentiate HRQOL impact by VA type. We developed a VA-targeted HRQOL measure to distinguish the impact of fistulas, grafts and catheters. METHODS:We created an initial item pool based on literature review and then conducted focus groups at 4 US sites with 37 adults and interviews with nine dialysis clinicians about VA's impact on HRQOL. We then drafted the Hemodialysis Access-Related Quality of Life (HARQ) measure and cognitively tested it with 17 hemodialysis patients. Focus group and cognitive interview participants were diverse in age, gender, years on dialysis, and VA. RESULTS:We identified six domains for the HARQ: symptoms, physical functioning, emotional impacts, social and role functioning, sleep, and care-related burdens. Cognitive interviews indicated that items were easily understood and supported content validity. Attributing HRQOL impact to VA as opposed to other hemodialysis burden was challenging for some items. Some items were dropped that were considered redundant by patients, limitations while dressing was added, and reference to VA-specific impact was included for each item. The average Flesch-Kincaid reading grade level for the revised 47-item HARQ was 5.3. CONCLUSIONS:The HARQ features VA-specific content not addressed in other HRQOL measures, making it ideal for comparisons of different VA types and new VA technologies. The psychometric properties of the HARQ will be evaluated in future research.
| S-EPMC6958666 | biostudies-literature
Project description:BACKGROUND:Arteriovenous fistulas (AVFs) are the preferred vascular access type in most hemodialysis patients. However, the optimal vascular access type in octogenarians and older (?80?years) hemodialysis patients remains widely debated given their limited life expectancy and lower AVF maturation rates. METHODS:Among incident hemodialysis patients receiving care in a large national dialysis organization during 2007-2011, we examined patterns of vascular access type conversion in 1 year following dialysis initiation in patients <80 versus ?80 years of age. Among a subcohort of patients ?80?years of age, we examined the association between vascular access type conversion and mortality using multivariable survival models. RESULTS:In the overall cohort of 100?804 patients, the prevalence of AVF/arteriovenous graft (AVG) as the primary vascular access type increased during the first year of hemodialysis, but plateaued thereafter. Among 8356 patients ?80?years of age and treated for >1 year, those with initial AVF/AVG use and placement of AVF from a central venous catheter (CVC) had lower mortality compared with patients with persistent CVC use. When the reference group was changed to patients who had AVF placement from a CVC in the first year of dialysis, those with initial AVF use had similar mortality. A longer duration of CVC use was associated with incrementally worse survival. CONCLUSIONS:Among incident hemodialysis patients ?80?years of age, placement of an AVF from a CVC within the first year of dialysis had similar mortality compared with initial AVF use. Our data suggest that initial CVC use with later placement of an AVF may be an acceptable option among elderly hemodialysis patients.
| S-EPMC7057539 | biostudies-literature
Project description:Hemodialysis vascular access recommendations promote arteriovenous (AV) fistulas first; however, it may not be the best approach for all hemodialysis patients, because likelihood of successful fistula placement, procedure-related and subsequent costs, and patient survival modify the optimal access choice. We performed a decision analysis evaluating AV fistula, AV graft, and central venous catheter (CVC) strategies for patients initiating hemodialysis with a CVC, a scenario occurring in over 70% of United States dialysis patients. A decision tree model was constructed to reflect progression from hemodialysis initiation. Patients were classified into one of three vascular access choices: maintain CVC, attempt fistula, or attempt graft. We explicitly modeled probabilities of primary and secondary patency for each access type, with success modified by age, sex, and diabetes. Access-specific mortality was incorporated using preexisting cohort data, including terms for age, sex, and diabetes. Costs were ascertained from the 2010 USRDS report and Medicare for procedure costs. An AV fistula attempt strategy was found to be superior to AV grafts and CVCs in regard to mortality and cost for the majority of patient characteristic combinations, especially younger men without diabetes. Women with diabetes and elderly men with diabetes had similar outcomes, regardless of access type. Overall, the advantages of an AV fistula attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the effect of lower AV fistula success rates and lower life expectancy. These results suggest that vascular access-related outcomes may be optimized by considering individual patient characteristics.
| S-EPMC4279737 | biostudies-literature
Project description:BackgroundCommencing hemodialysis (HD) with an arteriovenous access is associated with superior patient outcomes compared with a catheter, but the majority of patients in Australia and New Zealand initiate HD with a central venous catheter. This study examined patient and center factors associated with arteriovenous fistula/graft access use at HD commencement.MethodsWe included all adult patients starting chronic HD in Australia and New Zealand between 2004 and 2015. Access type at HD initiation was analyzed using logistic regression. Patient-level factors included sex, age, race, body mass index (BMI), smoking status, primary kidney disease, late nephrologist referral, comorbidities, and prior RRT. Center-level factors included size; transplant capability; home HD proportion; incident peritoneal dialysis (average number of patients commencing RRT with peritoneal dialysis per year); mean weekly HD hours; average blood flow; and achievement of phosphate, hemoglobin, and weekly Kt/V targets. The study included 27,123 patients from 61 centers.ResultsArteriovenous access use at HD commencement varied four-fold from 15% to 62% (median 39%) across centers. Incident arteriovenous access use was more likely in patients aged 51-72 years, males, and patients with a BMI of >25 kg/m2 and polycystic kidney disease; but use was less likely in patients with a BMI of <18.5 kg/m2, late nephrologist referral, diabetes mellitus, cardiovascular disease, chronic lung disease, and prior RRT. Starting HD with an arteriovenous access was less likely in centers with the highest proportion of home HD, and no center factor was associated with higher arteriovenous access use. Adjustment for center-level characteristics resulted in a 25% reduction in observed intercenter variability of arteriovenous access use at HD initiation compared with the model adjusted for only patient-level characteristics.ConclusionsThis study identified several patient and center factors associated with incident HD access use, yet these factors did not fully explain the substantial variability in arteriovenous access use across centers.
| S-EPMC8791318 | biostudies-literature
Project description:Rationale & objectiveAs the proportion of arteriovenous fistulas (AVFs) compared with arteriovenous grafts (AVGs) in the United States has increased, there has been a concurrent increase in interventions. We explored AVF and AVG maturation and maintenance procedural burden in the first year of hemodialysis.Study designObservational cohort study.Setting & participantsPatients initiating hemodialysis from July 1, 2012, to December 31, 2014, and having a first-time AVF or AVG placement between dialysis initiation and 1 year (N = 73,027), identified using the US Renal Data System (USRDS).PredictorsPatient characteristics.OutcomeSuccessful AVF/AVG use and intervention procedure burden.Analytical approachFor each group, we analyzed interventional procedure rates during maturation maintenance phases using Poisson regression. We used proportional rate modeling for covariate-adjusted analysis of interventional procedure rates during the maintenance phase.ResultsDuring the maturation phase, 13,989 of 57,275 patients (24.4%) in the AVF group required intervention, with therapeutic interventional requirements of 0.36 per person. In the AVG group 2,904 of 15,572 patients (18.4%) required intervention during maturation, with therapeutic interventional requirements of 0.28 per person. During the maintenance phase, in the AVF group 12,732 of 32,115 patients (39.6%) required intervention, with a therapeutic intervention rate of 0.93 per person-year. During maintenance phase, in the AVG group 5,928 of 10,271 patients (57.7%) required intervention, with a therapeutic intervention rate of 1.87 per person-year. For both phases, the intervention rates for AVF tended to be higher on the East Coast while those for AVG were more uniform geographically.LimitationsThis study relies on administrative data, with monthly recording of access use.ConclusionsDuring maturation, interventions for both AVFs and AVGs were relatively common. Once successfully matured, AVFs had lower maintenance interventional requirements. During the maturation and maintenance phases, there were geographic variations in AVF intervention rates that warrant additional study.
| S-EPMC8384666 | biostudies-literature
Project description:INTRODUCTION:Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. METHODS:Retrospective cohort of patients initiating HD with CVC in 2010-2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time-dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. FINDINGS:Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR?=?1.45 [95% confidence interval [CI] 1.36, 1.55], P?<?0.001]), any AVF or AVG (HR?=?1.63 [1.58, 1.69], P?>?0.001), and less likely to die (HR?=?0.88 [0.83-0.94], P?<?0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02-1.16, P?=?0.008). DISCUSSION:Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.
| S-EPMC5438785 | biostudies-literature
Project description:The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m2, with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = - 0.182, P < 0.001). The fastest eGFR slope patients (the first quartile or < - 10 min/ml/1.73 m2/year) had the lowest percentage of vascular access created timely. In the multivariable logistic regression analysis, only higher eGFR upon vascular access creation (P = 0.001) and eGFR slope (P = 0.009) were significantly associated with vascular access created timely. The adjusted odds ratios of each quartile of eGFR slopes for vascular access created timely were 0.46 (95% confidence interval 0.27-0.86), 1.30 (0.62, 2.72), 1.00 (reference), and 0.95 (0.48-1.87), respectively. eGFR slope is associated with the timely creation of vascular access for the initiation of hemodialysis in a reverse-J-shaped pattern and may help determine the time of vascular access creation.
| S-EPMC8222220 | biostudies-literature
Project description:BACKGROUND:In this single-center, retrospective observational study, we assessed the long-term patency of vascular access (VA) after first VA placement to uncover independent risk factors associated with VA patency in Asian hemodialysis (HD) patients stratified by age. We also investigated factors associated with VA patency among older HD patients according to the type of VA in the overall study population. METHODS:The study period was from January 2011 to December 2013. A total of 651 chronic HD patients with confirmed first upper-extremity VA placement were enrolled, and their records were analyzed retrospectively. A total of 445 patients (68.4%) made up the nonelderly group (<?65?years), and 206 patients (31.6%) were in the elderly group (? 65?years). Study outcomes were defined as primary or secondary VA patency. RESULTS:Autologous arteriovenous fistula (AVF) was more common in the nonelderly group (P?<? 0.01). Kaplan-Meier curve survival analysis indicated that primary patency was longer in the nonelderly group (P?<? 0.01); secondary patency, however, was similar between groups (P?=?0.37). The multivariate analysis of factors associated with primary VA patency revealed that increased age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P?<? 0.01) was associated with shorter primary patency, and AVF (HR, 0.38; 95% CI, 0.28-0.51; P?<? 0.01) was associated with longer primary patency. AVF (HR, 0.57; 95% CI, 0.37-0.87; P?=?0.010) and diabetes mellitus (HR, 1.56; 95% CI, 1.07-2.29; P?=?0.02) were independently associated with longer and shorter secondary patency periods, respectively; however, increased age was not a risk factor for decreased secondary patency. CONCLUSIONS:Increased age was associated with shorter primary patency but not secondary patency, whereas AVF placement was associated with longer primary and secondary patency. Considering the similar rates of secondary patency between groups and the superior patency of AVF compared to arteriovenous graft, a fistula-first strategy should be applied to appropriate older patients.
| S-EPMC6873763 | biostudies-literature
Project description:Most arteriovenous grafts fail due to irreversible thrombosis, and most clotted grafts have an underlying stenotic lesion. These observations raise the plausible hypothesis that early detection of graft stenosis with preemptive angioplasty will reduce the likelihood of graft thrombosis. A number of noninvasive methods can be used to detect hemodynamically significant graft stenosis with a high positive predictive value. These tests include clinical monitoring, as well as surveillance by static dialysis venous pressures, flow monitoring, or duplex ultrasound. However, these surveillance tests have a much lower positive predictive value for graft thrombosis in the absence of preemptive angioplasty. In other words, none of the currently available surveillance tests can reliably distinguish between stenosed grafts destined to clot, and those that will remain patent without intervention. As a consequence, any program of graft surveillance necessarily results in a substantial proportion of unnecessary angioplasties. Moreover, a substantial proportion of grafts thrombose despite a normal antecedent surveillance test. Numerous observational studies have found an impressive reduction of graft thrombosis after implementation of a stenosis surveillance program. In contrast, 5 of 6 randomized clinical trials failed to show a reduction of graft thrombosis in patients undergoing graft surveillance, as compared with those receiving only clinical monitoring. The lack of benefit of surveillance is largely attributable to the rapid recurrence of stenosis after angioplasty. Thus, routine surveillance for graft stenosis, with preemptive angioplasty, cannot be recommended for reduction of graft thrombosis. Future research should be directed at pharmacologic interventions to prevent graft stenosis.
| S-EPMC4017945 | biostudies-literature