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Vasodilator agents improve hemodialysis vascular access patency: A population-based study from Korea.

ABSTRACT:

Abstract

Vascular access (VA) failure is an important problem for patients undergoing hemodialysis, and maintaining VA patency is challenging. In this study, we used a nationwide database to investigate the effects of nitrate, as a vasodilator, on VA failure in hemodialysis patients.We investigated the Korean insurance claims data of hemodialysis patients who underwent angioplasty for VA failure between January 2012 and December 2017. The patients were divided into 2 groups: those not receiving vasodilator therapy (controls) and those receiving any vasodilator administration (vasodilator treatment, VDT). The primary endpoint was VA primary patency, defined as the time between arteriovenous dialysis access creation and the first percutaneous transluminal angioplasty (PTA).During the study period, a total of 6350 patients were recruited, 409 (6.4%) patients assigned to the VDT group and 5941 (93.6%) controls. PTA was performed in 998 patients (15.7%), including 8 in the VDT group and 990 controls. The VA site PTA rate was significantly lower in the VDT group (2.0%) than in the control group (16.7%, P < .001). In the subgroup analysis, the patency rates associated with the different vasodilators were similar (P = .736). All vasodilators, except molsidomine, improved the patency rate by approximately 20%.In this large national database study, vasodilator administration was associated with higher VA primary patency, compared with controls, in hemodialysis patients. VDT may have a beneficial effect on maintaining VA patency in patients undergoing hemodialysis.

SUBMITTER: Kim DH

PROVIDER: S-EPMC8500602 | biostudies-literature | 2021 Oct

REPOSITORIES: biostudies-literature

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Vasodilator agents improve hemodialysis vascular access patency: A population-based study from Korea.

Kim Do Hyoung DH Han Donghoon D Kim Jaehwan J Park Hayne Cho HC Lee Young-Ki YK Shin Dong Geum DG Kang Min-Kyung MK Cho Jung Rae JR Choi Seonghoon S Lee Namho N

Medicine 20211001 40

<h4>Abstract</h4>Vascular access (VA) failure is an important problem for patients undergoing hemodialysis, and maintaining VA patency is challenging. In this study, we used a nationwide database to investigate the effects of nitrate, as a vasodilator, on VA failure in hemodialysis patients.We investigated the Korean insurance claims data of hemodialysis patients who underwent angioplasty for VA failure between January 2012 and December 2017. The patients were divided into 2 groups: those not re ...[more]

PMID: 34622859

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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.

Project description:Rationale & objectiveAccess patency outcomes for arteriovenous fistulas (AVFs) as compared with arteriovenous grafts (AVGs) in patients receiving hemodialysis (HD) who have achieved a functioning permanent access are not fully explored.Study designObservational cohort study.Setting & populationFee-for-service Medicare beneficiaries aged ≥18 years with kidney failure who were newly using a permanent access for maintenance HD from the United States Renal Data System (2010-2015). Patients using an oral anticoagulant were excluded.ExposureAVG or AVF.OutcomesLoss of primary unassisted, primary assisted, and secondary patency.Analytical approachOutcomes were characterized using cumulative incidence curves, and HRs adjusted for sociodemographic and clinical factors were estimated for the comparison of AVF versus AVG.ResultsThe cohort included 60,329 and 17,763 patients newly using an AVF and AVG, respectively, for HD. Over 3 years of follow-up, AVG users, compared to AVF users, had a higher cumulative incidence of loss of primary unassisted patency (87% vs 69%; HR, 1.56; 95% CI, 1.52-1.60), loss of primary assisted patency (69% vs 25%; HR, 3.79; 95% CI, 3.67-3.92), and loss of secondary patency (22% vs 10%; HR, 2.03; 95% CI, 1.92-2.16). Stratified analyses revealed differences by subgroups; in particular, incidence of patency loss was higher among patients who underwent prior interventions to maintain prefunctional access patency and Black patients.LimitationsThis analysis focused on outcomes occurring after first successful use of a permanent access and thus does not inform about risk of patency loss during access maturation.ConclusionsAmong patients with kidney failure who successfully used a permanent access for HD, patency loss was consistently substantially higher in those using AVGs compared with AVFs. New interventions, such as prophylactic drugs, are needed to improve access longevity and reduce the need for invasive interventions, particularly among patients unable to receive a fistula.

Project description:Background and objectivesIn 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, & measurementsUsing 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.ResultsThere 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.ConclusionsIn 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.

Dataset Information

Vasodilator agents improve hemodialysis vascular access patency: A population-based study from Korea.

Abstract

Publications

Vasodilator agents improve hemodialysis vascular access patency: A population-based study from Korea.

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