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Napoli M, Guzzi F, Morale W, Lomonte C, Galli F, Lodi M, Bonforte G, Bonucchi D, Brunori G, Buzzi L, Forneris G, Gallieni M, Meola M, Pirozzi N, Sessa C, Spina M, Tazza L. Vascular access for hemodialysis in Italy: What a national survey reveals. J Vasc Access 2024:11297298231217318. [PMID: 38235699 DOI: 10.1177/11297298231217318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey. METHODS A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation. RESULT The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients. CONCLUSIONS Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.
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Affiliation(s)
| | | | | | - Carlo Lomonte
- Nephrology Unit, General Hospital, Acquaviva delle Fonti, Italy
| | - Franco Galli
- Vascular Access Project Group of Italian Society of Nephrology, Rome, Italy
| | - Massimo Lodi
- Nephrology Unit, Pescara Hospital, Pescara, Abruzzo, Italy
| | - Giuseppe Bonforte
- Vascular Access Project Group of Italian Society of Nephrology, Rome, Italy
| | | | | | - Laura Buzzi
- Nephrology Unit, Cinisello Balsamo Hospital, Cinisello Balsamo, Italy
| | | | - Maurizio Gallieni
- "L. Sacco" Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Mario Meola
- Sant'Anna School of Advanced Studies, Institute of Life Sciences, Pisa, Italy
| | - Nicola Pirozzi
- Department of Clinical and Molecular Medicine, Nephrology Unit, Sant'Andrea Hospital, Universita of Rome La Sapienza, Rome, Italy
| | | | - Monica Spina
- Nephrology Unit, S. Gavino Hospital, S. Gavino, Italy
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Staaf K, Fernström A, Uhlin F. Preconditions that facilitate cannulation in arteriovenous fistula: A mixed-methods study. J Ren Care 2023; 49:264-277. [PMID: 36394202 DOI: 10.1111/jorc.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nurses have a great responsibility in the daily care of arteriovenous fistulae, which entails the potential to affect patency. However, good cannulation technique involves more than placing a needle in the vessel and relies on different skills to facilitate needling. OBJECTIVES To describe the preconditions for cannulation in arteriovenous fistulas. DESIGN Descriptive statistics and qualitative content analysis were used in a mixed-methods design. PARTICIPANTS Haemodialysis units in Sweden. MEASUREMENTS Local guidelines regarding arteriovenous fistula cannulation were analysed in parallel with responses to a questionnaire that contained open-ended and closed-ended questions on cannulation technique. RESULTS Preconditions that facilitate cannulation fall into five stages, each with relevant factors in relation to the cannulation, as follows: planning cannulation-maturation and planning the cannulation, patient record, education and experience, and patient information; precannulation-physical examination, hygiene routines, arm position, tourniquet, choosing the cannulation site, and preventing pain; during cannulation-how to needle, type of needle, angle during cannulation, fixation, and adjusting; evaluating cannulation-blood flow rate and arterial and venous pressure; and postcannulation-needle withdrawal and haemostasis. The majority of dialysis units identified implementation of most of these preconditions, but the units handle several practical aspects differently. CONCLUSIONS Tracing the chain of cannulation led to identification of necessary preconditions for facilitating good cannulation technique. The findings also show the need for a better understanding of how different preconditions affect arteriovenous fistula and patency.
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Affiliation(s)
- Karin Staaf
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Nephrology, Linköping University Hospital, Linköping, Sweden
| | - Anders Fernström
- Department of Nephrology, Linköping University Hospital, Linköping, Sweden
| | - Fredrik Uhlin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Nephrology, Linköping University Hospital, Linköping, Sweden
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
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3
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Alindogan NG, Yuo TH. Challenges to Performance of Clinical Trials on Vascular Access. KIDNEY360 2023; 4:1632-1636. [PMID: 37856685 PMCID: PMC10695645 DOI: 10.34067/kid.0000000000000251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 08/19/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Nicole G Alindogan
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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4
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Lomonte C, Corciulo S, Cortese D, Libutti P, Montinaro V, Gesualdo L. Rethinking an effective AV fistula-graft screening program. An "A B C". J Nephrol 2023; 36:1861-1865. [PMID: 37458910 DOI: 10.1007/s40620-023-01669-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/29/2023] [Indexed: 10/01/2023]
Abstract
The goal of a vascular access screening program is to detect and preemptively correct hemodynamically significant stenosis, however, a practice pattern allowing to implement such a program still remains to be defined. Achieving balance between the increase in access-related procedures by adopting an aggressive screening program, and the risks associated with the absence of any screening program, i.e., failure or abandonment of the arterio-venous access with need for central venous catheter placement, can be extremely challenging. All major guidelines agree about the role of arterio-venous access monitoring, but the way surveillance should be managed is still a controversial issue. Preserving long-term vascular access function should be a goal for all hemodialysis teams, yet it ideally requires a multidisciplinary effort with a monitoring program, calling for a great deal of involvement by hemodialysis health professionals. In this context, the engagement of skilled nurses and the role of patient empowerment with collaborative decision-making may be the key to a successful vascular access screening program. Screening programs should be personalized, shared with the patients, and tailored according to vascular access type and site. In the near future, new devices and the use of artificial intelligence may allow to support interpretation of complex data and lead to the development of prediction models for vascular access failure.
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Affiliation(s)
- Carlo Lomonte
- Nephrology Unit, Miulli General Hospital, Acquaviva delle Fonti (Ba), Bari, Italy.
| | - Simone Corciulo
- Nephrology Unit, Miulli General Hospital, Acquaviva delle Fonti (Ba), Bari, Italy
| | - Denni Cortese
- Nephrology Department, University of Bari, Bari, Italy
| | - Pasquale Libutti
- Nephrology Unit, Miulli General Hospital, Acquaviva delle Fonti (Ba), Bari, Italy
| | - Vincenzo Montinaro
- Nephrology Unit, Miulli General Hospital, Acquaviva delle Fonti (Ba), Bari, Italy
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5
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Richarz S, Greenwood S, Kingsmore DB, Thomson PC, Dunlop M, Bouamrane MM, Meiklem R, Stevenson K. Validation of a vascular access specific quality of life measure (VASQoL). J Vasc Access 2023; 24:702-714. [PMID: 34608832 DOI: 10.1177/11297298211046746] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A self-administered 11 item vascular access specific quality of life measure (VASQoL) was previously derived from detailed qualitative interviews with adult patients with kidney failure who have experienced vascular access using the Capabilities Approach as a theoretical base. This study reports the psychometric validation of the VASQoL measure including its reliability, content validity and responsiveness to change. METHODS Cognitive interviews were conducted with 23 adult patients with kidney failure after completion of the VASQoL measure. Focus group discussion with a vascular access professional multidisciplinary team was undertaken (n = 8) and subsequently a further 101 adult kidney failure patients with vascular access (TCVC, AVF or AVG) completed the digital VASQoL measure, EQ-5D and SF-36 questionnaires in a longitudinal study with prospectively recorded vascular access events. RESULTS Transcript analysis of cognitive interviews after VASQoL completion indicated that the content was comprehensive and well understood by participants. Assessment of Internal reliability for the VASQoL measure was high (Cronbach's alpha 0.858). Test-retest reliability of the overall VASQoL measure was high (intra class correlation coefficient 0.916). In those patients who experienced a vascular access event, significant differences were observed in paired analysis of the VASQoL physical domain questions and vascular access function domain questions and in the EQ-5D usual activities, pain and anxiety domains. In those with no vascular access event, variation was observed in longitudinal analysis in VASQoL questions relating to worry about VA function and capability domains, whilst no variation was observed in the EQ5D measure. CONCLUSION The VASQoL measure has good internal consistency, test-retest reliability, convergent validity and responsiveness to change for clinically relevant vascular access outcomes. This provides a validated, vascular access specific quality of life measure that can be used in future trials of vascular access, evaluation of new technologies and routine use as a patient reported outcome measure (PROM).
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Affiliation(s)
- Sabine Richarz
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Department of Vascular Surgery and Renal Transplantation, University Hospital Basel, Basel, Switzerland
| | - Sharon Greenwood
- Graduate School, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - David B Kingsmore
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mark Dunlop
- Department of Computer and Information Sciences, University of Strathclyde, Glasgow, UK
| | - Matt-Mouley Bouamrane
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Ramsey Meiklem
- Department of Computer and Information Sciences, University of Strathclyde, Glasgow, UK
| | - Karen Stevenson
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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6
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Viecelli AK, Teixeira-Pinto A, Valks A, Baer R, Cherian R, Cippà PE, Craig JC, DeSilva R, Jaure A, Johnson DW, Kiriwandeniya C, Kopperschmidt P, Liu WJ, Lee T, Lok C, Madhan K, Mallard AR, Oliver V, Polkinghorne KR, Quinn RR, Reidlinger D, Roberts M, Sautenet B, Hooi LS, Smith R, Snoeijs M, Tordoir J, Vachharajani TJ, Vanholder R, Vergara LA, Wilkie M, Yang B, Yuo TH, Zou L, Hawley CM. Study protocol for Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID). BMC Nephrol 2022; 23:372. [PMCID: PMC9675211 DOI: 10.1186/s12882-022-02987-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background A functioning vascular access (VA) is crucial to providing adequate hemodialysis (HD) and considered a critically important outcome by patients and healthcare professionals. A validated, patient-important outcome measure for VA function that can be easily measured in research and practice to harvest reliable and relevant evidence for informing patient-centered HD care is lacking. Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID) aims to assess the accuracy and feasibility of measuring a core outcome for VA function established by the international Standardized Outcomes in Nephrology (SONG) initiative. Methods VALID is a prospective, multi-center, multinational validation study that will assess the accuracy and feasibility of measuring VA function, defined as the need for interventions to enable and maintain the use of a VA for HD. The primary objective is to determine whether VA function can be measured accurately by clinical staff as part of routine clinical practice (Assessor 1) compared to the reference standard of documented VA procedures collected by a VA expert (Assessor 2) during a 6-month follow-up period. Secondary outcomes include feasibility and acceptability of measuring VA function and the time to, rate of, and type of VA interventions. An estimated 612 participants will be recruited from approximately 10 dialysis units of different size, type (home-, in-center and satellite), governance (private versus public), and location (rural versus urban) across Australia, Canada, Europe, and Malaysia. Validity will be measured by the sensitivity and specificity of the data acquisition process. The sensitivity corresponds to the proportion of correctly identified interventions by Assessor 1, among the interventions identified by Assessor 2 (reference standard). The feasibility of measuring VA function will be assessed by the average data collection time, data completeness, feasibility questionnaires and semi-structured interviews on key feasibility aspects with the assessors. Discussion Accuracy, acceptability, and feasibility of measuring VA function as part of routine clinical practice are required to facilitate global implementation of this core outcome across all HD trials. Global use of a standardized, patient-centered outcome measure for VA function in HD research will enhance the consistency and relevance of trial evidence to guide patient-centered care. Trial registration Clinicaltrials.gov: NCT03969225. Registered on 31st May 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02987-1.
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Affiliation(s)
- Andrea K. Viecelli
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Armando Teixeira-Pinto
- grid.1013.30000 0004 1936 834XCentre for Kidney Research, School of Public Health, The University of Sydney, Sydney, Australia
| | - Andrea Valks
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Richard Baer
- grid.416528.c0000 0004 0637 701XMater Hospital Brisbane, Brisbane, Queensland Australia
| | - Roy Cherian
- grid.460765.60000 0004 0430 0107Mackay Base Hospital, Mackay, Australia
| | - Pietro E. Cippà
- grid.469433.f0000 0004 0514 7845Division of Nephrology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Jonathan C. Craig
- grid.1014.40000 0004 0367 2697Flinders University, Adelaide, Australia
| | - Ranil DeSilva
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, PA USA
| | - Allison Jaure
- grid.1013.30000 0004 1936 834XThe University of Sydney, Sydney, Australia
| | - David W. Johnson
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Charani Kiriwandeniya
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | | | - Wen-J Liu
- grid.413461.50000 0004 0621 7083Sultanah Aminah, Johor Bahru, Malaysia
| | - Timmy Lee
- grid.280808.a0000 0004 0419 1326Veterans Affairs Medical Center, Birmingham, AL USA
| | - Charmaine Lok
- grid.17063.330000 0001 2157 2938University of Toronto, Toronto, Ontario Canada
| | | | - Alistair R. Mallard
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Veronica Oliver
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia
| | - Kevan R. Polkinghorne
- grid.416060.50000 0004 0390 1496Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Medicine, Monash University, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology & Preventive Medicine, Monash University, Clayton, VIC Australia
| | - Rob R. Quinn
- grid.22072.350000 0004 1936 7697Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Donna Reidlinger
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Matthew Roberts
- grid.1002.30000 0004 1936 7857Eastern Health Clinical School, Monash University, Melbourne, Australia
| | | | - Lai Seong Hooi
- grid.413461.50000 0004 0621 7083Sultanah Aminah, Johor Bahru, Malaysia
| | - Rob Smith
- grid.240634.70000 0000 8966 2764Patient Partner, Royal Darwin Hospital, Darwin, Australia
| | - Maarten Snoeijs
- grid.412966.e0000 0004 0480 1382Maastricht University Medical Center, Maastricht, Netherlands
| | - Jan Tordoir
- grid.412966.e0000 0004 0480 1382Maastricht University Medical Center, Maastricht, Netherlands
| | - Tushar J. Vachharajani
- grid.239578.20000 0001 0675 4725Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, USA ,grid.254293.b0000 0004 0435 0569Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | | | - Liza A. Vergara
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Martin Wilkie
- grid.31410.370000 0000 9422 8284Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Bing Yang
- grid.411634.50000 0004 0632 4559Peking University People’s Hospital, Beijing, China
| | - Theodore H. Yuo
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, PA USA
| | - Li Zou
- grid.411634.50000 0004 0632 4559Peking University People’s Hospital, Beijing, China
| | - Carmel M. Hawley
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
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Staaf K, Fernström A, Uhlin F. How to needle: A mixed methods study on choice of cannulation technique for arteriovenous fistula. J Clin Nurs 2022. [PMID: 35811391 DOI: 10.1111/jocn.16454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/31/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to describe the basis for choosing a cannulation technique for arteriovenous fistula. BACKGROUND Four cannulation techniques are relevant to cannulating an arteriovenous fistula: rope ladder, area puncture and buttonhole using blunt or sharp needles. The chosen technique may affect both the patency and number of complications. DESIGN The study used a convergent mixed methods design and inductive approach. METHODS A questionnaire and an inquiry of local guidelines were sent to nurses in all dialysis units in Sweden. Questionnaires were answered by nurses from 37 units, and 29 units included their local guidelines. The questionnaires were analysed using descriptive statistics and qualitative content analysis, and the guidelines were analysed using qualitative content analysis. The different analyses were combined in a final result. The study is based on GRAMMS guidelines. RESULTS Local guidelines, patients' and nurses' own judgement, and consultation with colleagues were found to greatly influence the choice of cannulation technique. Buttonhole was the most preferred cannulation technique in the participating units and was favoured by nurses when choosing a cannulation technique. The process of choosing a cannulation technique was found to be influenced by the dedication to good cannulation technique and healthy arteriovenous fistulas, whether the technique is perceived as being easy to use and is expected to prevent complications and based on the experienced-based knowledge of each dialysis unit. CONCLUSIONS Choosing a cannulation technique is a process based on the nurse, local guidelines and the patient. Most dialysis nurses and units in Sweden consider buttonhole to be a good cannulation technique and use it as their standard technique. RELEVANCE TO CLINICAL PRACTICE The results provide insight into why cannulation techniques are chosen differently in different units. The results also show the importance of evidence in making decisions on cannulation technique.
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Affiliation(s)
- Karin Staaf
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Anders Fernström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden
| | - Fredrik Uhlin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nephrology, Linköping University Hospital, Region Östergötland, Linköping, Sweden.,Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
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8
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Using an international online forum to explore perspectives of caregivers of patients with chronic kidney disease. J Nephrol 2022; 35:267-277. [PMID: 35000136 DOI: 10.1007/s40620-021-01216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Caregivers of patients with chronic kidney disease (CKD) experience significant burden of care. Online forums provide an important platform for peer connection and expression of perspectives and concerns, but have not been used to capture consumer experiences in CKD research. Social support can improve caregivers' quality of life, with emerging research exploring online social support. METHOD This study employed qualitative content analysis to examine 159 posts on an online international forum: Caregivers of Patients with Kidney Disease to examine the experiences and concerns raised by caregivers of patients with CKD. Posts were coded using verbatim words and phrases, then arranged into three overarching themes, 12 categories and 71 sub-categories. RESULTS The overarching themes were Impact to Carer Wellbeing; Use of Online Social Support; Caregiver Knowledge. Online posts highlighted the psychological and physical challenges for caregivers of patients with CKD including social isolation, helplessness and the impact to paid employment. Participants used online social support to connect with peers and seek advice from the forum community on topics including: the patient's diet; clinical management; CKD symptoms; and how to support the patient to adhere to diet and medications. CONCLUSION This study provides valuable insight into gaps in caregiver knowledge and their need to seek online peer support. Caregiver forums can inform support strategies from healthcare professionals to increase caregiver involvement in treatment and education options, as well as tangible assistance to support caregivers' and patients' needs, such as transportation services for dialysis patients.
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Musgrove E, Gasparini L, McBain K, Clifford SA, Carter SA, Teede H, Wake M. Synthesizing Core Outcome Sets for outcomes research in cohort studies: a systematic review. Pediatr Res 2022; 92:936-945. [PMID: 34921214 PMCID: PMC8678579 DOI: 10.1038/s41390-021-01801-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/10/2021] [Accepted: 10/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Life course studies are designed to "collect once, use multiple times" for observational and, increasingly, interventional research. Core Outcome Sets (COS) are minimum sets developed for clinical trials by multi-stakeholder consensus methodologies. We aimed to synthesize published COS that might guide outcomes selection for early life cohorts with an interventional focus. METHODS We searched PubMed, Medline, COMET, and CROWN for COS published before January 2021 relevant to four life stages (pregnancy, newborns, children <8 years, and parents (adults aged 18-50 years)). We synthesized core outcomes into overarching constructs. RESULTS From 46 COS we synthesized 414 core outcomes into 118 constructs. "Quality of life", "adverse events", "medication use", "hospitalization", and "mortality" were consistent across all stages. For pregnancy, common constructs included "preterm birth", "delivery mode", "pre-eclampsia", "gestational weight gain", "gestational diabetes", and "hemorrhage"; for newborns, "birthweight", "small for gestational age", "neurological damage", and "morbidity" and "infection/sepsis"; for pediatrics, "pain", "gastrointestinal morbidity", "growth/weight", "breastfeeding", "feeding problems", "hearing", "neurodevelopmental morbidity", and "social development"; and for adults, "disease burden", "mental health", "neurological function/stroke", and "cardiovascular health/morbidity". CONCLUSION This COS synthesis generated outcome constructs that are of high value to stakeholders (participants, health providers, services), relevant to life course research, and could position cohorts for trial capabilities. IMPACT We synthesized existing Core Outcome Sets as a transparent methodology that could prioritize outcomes for lifecourse cohorts with an interventional focus. "Quality of life", "adverse events", "medication use", "hospitalization", and "mortality" are important outcomes across pregnancy, newborns, childhood, and early-to-mid-adulthood (the age range relevant to parents). Other common outcomes (such as "birthweight", "cognitive function/ability", "psychological health") are also highly relevant to lifecourse research. This synthesis could assist new early life cohorts to pre-select outcomes that are of high value to stakeholders (participants, health providers, services), are relevant to lifecourse research, and could position them for future trials and interventional capability.
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Affiliation(s)
- Erica Musgrove
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville VIC, Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, The University of Melbourne, Parkville, VIC Australia
| | - Loretta Gasparini
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville VIC, Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, The University of Melbourne, Parkville, VIC Australia
| | - Katie McBain
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville VIC, Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, The University of Melbourne, Parkville, VIC Australia
| | - Susan A. Clifford
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville VIC, Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, The University of Melbourne, Parkville, VIC Australia
| | - Simon A. Carter
- grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville VIC, Australia ,grid.1013.30000 0004 1936 834XSydney School of Public Health, The University of Sydney, NSW, Australia
| | - Helena Teede
- grid.1002.30000 0004 1936 7857Monash Centre of Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, VIC Australia ,grid.419789.a0000 0000 9295 3933Monash Endocrinology and Diabetes Units, Monash Health, Clayton, VIC Australia
| | - Melissa Wake
- Murdoch Children's Research Institute, Parkville, VIC, Australia. .,Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia. .,Liggins Institute, The University of Auckland, Grafton, Auckland, New Zealand.
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Diep J, Makris A, De Guzman I, Wong J, Aravindan A, Nandakoban H, Narayanan G. Impact of Previous Tunneled Vascular Catheters and their Location on Upper Limb Arteriovenous Fistula Function. KIDNEY360 2021; 2:1953-1959. [PMID: 35419532 PMCID: PMC8986056 DOI: 10.34067/kid.0003362021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/07/2021] [Indexed: 05/23/2023]
Abstract
BACKGROUND Long-term arteriovenous fistula (AVF) survival has been shown to be adversely affected by the presence of previous tunneled vascular catheters (TVC). We analyzed the effect of previous TVCs and their location (ipsilateral versus contralateral) on the successful function of upper-limb AVFs in the first 12 months after creation. METHODS We retrospectively reviewed clinical data on patients' first upper-limb AVFs, created between January 2013 and December 2017. We analyzed the rates of successful AVF function (successful cannulation using two needles for ≥50% sessions over a 2-week period) at 6 and 12 months after creation, time to AVF maturation, and rates of assisted maturation. RESULTS In total, 287 patients with first AVFs were identified, of which 142 patients had a previous TVC (102 contralateral, 40 ipsilateral) and 145 had no previous TVC. The no TVC group had higher rates of AVF function at both 6 months (69% versus 54%, OR, 1.84; 95% CI, 1.00 to 3.39, P=0.05) and 12 months (84% versus 64%, OR, 3.10; 95% CI, 1.53 to 6.26, P=0.002) compared with the TVC group. The contralateral TVC group had higher rates of AVF function at 6 months (60% versus 40%, OR, 2.21; 95% CI, 1.01 to 4.88, P=0.05), but not at 12 months (66% versus 58%, OR, 1.42; 95% CI, 0.62 to 3.25, P=0.40) compared with the ipsilateral TVC group. The median time to AVF maturation in the contralateral and ipsilateral TVC groups were 121.5 and 146 days respectively (P=0.07). Assisted maturation rates were lower in no TVC group compared with the TVC group (12% versus 28%, P=0.007), but similar between the contralateral and ipsilateral TVC groups (29% versus 26%, P=0.74). CONCLUSIONS Previous TVC use was associated with poorer AVF function at 6 and 12 months, with a higher rate of assisted maturation. The presence of an ipsilateral TVC was associated with lower successful AVF use at 6 months, compared with contralateral TVC.
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Affiliation(s)
- Jason Diep
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
| | - Imelda De Guzman
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
| | - Jeffery Wong
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
| | | | - Hareeshan Nandakoban
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Govind Narayanan
- Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia
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11
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Rønning MI, Benschop WP, Øvrehus MA, Hultstrøm M, Hallan SI. Direction- and Angle-Assisted Buttonhole Cannulation of Arteriovenous Fistula in Hemodialysis Patients: A Multicenter Randomized Controlled Trial. Kidney Med 2021; 4:100393. [PMID: 35243305 PMCID: PMC8861953 DOI: 10.1016/j.xkme.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Rationale & Objective Arteriovenous fistula cannulation with the buttonhole technique is often preferred by patients but has been associated with an increased infection risk. Guidelines disagree on whether it should be abandoned, thus we assessed a technologically simple method to facilitate gentler arteriovenous fistula cannulation with potentially less discomfort and damage to the epithelial lining of the buttonhole tract. Study Design 8-week, prospective, open-label, randomized controlled trial. Setting & Participants Patients with buttonhole tracts receiving hemodialysis at 7 dialysis centers in Norway were randomized to the intervention group (43 patients, 658 cannulations) or control group (40 patients, 611 cannulations). Intervention Direction and angle of the established buttonhole tract were marked on the forearm skin in the intervention group, whereas the control group had no structured cannulation information system. Outcomes The primary outcome was successful cannulation, defined as correct placement of both blunt needles at the first attempt without needing to change needles, perform extra perforations, or reposition the needle. The secondary outcomes were patient-reported difficulty of cannulation (verbal rating scale: 1 = very easy, 6 = impossible) and intensity of pain (numeric rating scale: 0 = no pain, 10 = unbearable pain). Results After a 2-week run-in period, successful cannulation was achieved in 73.9% and 74.8% of the patients in the intervention and control groups, respectively (relative risk [RR], 0.99; 95% CI, 0.87-1.12; P = 0.85). However, the probability of a difficult arterial cannulation (verbal rating scale, 3-6) was significantly lower in the intervention group (RR, 0.69; 95% CI, 0.55-0.85; P = 0.001). There were no improvements for venous cannulations. Furthermore, the probability of a painful cannulation (numeric rating scale, 3-10) was lower in the intervention group (RR, 0.72; 95% CI, 0.51-1.02; P = 0.06). Limitations Unable to evaluate hard end points such as infections and thrombosis owing to the small sample size. Conclusions Marking direction and angle of cannulation did not improve cannulation success rates; however, patients more often reported an unproblematic procedure and less pain. Funding None. Trial Registration ClinicalTrials.gov (NCT01536548).
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Affiliation(s)
| | | | | | - Maria Hultstrøm
- Department of Nephrology, St. Olav Hospital, Trondheim, Norway
| | - Stein I. Hallan
- Department of Nephrology, St. Olav Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Address for Correspondence: Stein I. Hallan, MD, PhD, Department of Nephrology, St. Olav Hospital, Prinsesse Kristinas gate 1, 7030 Trondheim, Norway.
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12
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Murea M, Grey CR, Lok CE. Shared decision-making in hemodialysis vascular access practice. Kidney Int 2021; 100:799-808. [PMID: 34246655 PMCID: PMC8463450 DOI: 10.1016/j.kint.2021.05.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | - Carl R Grey
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Charmaine E Lok
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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13
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Staaf K, Fernström A, Uhlin F. Cannulation technique and complications in arteriovenous fistulas: a Swedish Renal Registry-based cohort study. BMC Nephrol 2021; 22:256. [PMID: 34233650 PMCID: PMC8265150 DOI: 10.1186/s12882-021-02458-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The four cannulation techniques, rope ladder (RL), area puncture (AP), buttonhole with blunt needles (BHb), and buttonhole with sharp needles (BHs), affects the arteriovenous fistula (AVF) in different ways. The aim of this study was to describe the relationship between the different cannulation techniques and the occurrence of AVF complications. METHODS The study was performed as a national registry-based cohort study using data from the Swedish Renal Registry (SRR). Data were collected from January 2014 to October 2019. Seventy of Sweden's dialysis units participate in the registry. We analyzed a total of 1328 AVFs in this study. The risk of complications was compared between the four different cannulation techniques. The risk of AVF complications was measured by the incidence and incidence rate ratio (IRR). We compared the IRRs of complications between different cannulation techniques. RESULTS BHs is the most common cannulation technique in Sweden. It has been used in 55% of the AVFs at some point during their functional patency. BHb (29%), RL (13%), and AP (3%) has been used less. BHb had the lowest risk of complications compared to the other techniques, and a significantly lower risk of stenosis, infiltration, cannulation difficulties, compared to RL and BHs. Cannulation difficulties were significantly more common using AP compared to BHs, and BHb. Infections were not significantly increased using the buttonhole technique. CONCLUSIONS BHb had the lowest risk of complications. Infections were not significantly increased using the buttonhole technique. Dialysis units with a low infection rate may continue to use the buttonhole technique, as the risk of complications is lower.
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Affiliation(s)
- Karin Staaf
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.
| | - Anders Fernström
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Fredrik Uhlin
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
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14
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Range and Consistency of Infection Outcomes Reported in Trials Conducted in Kidney Transplant Recipients: a Systematic Review. Transplantation 2021; 105:2632-2638. [PMID: 33653998 DOI: 10.1097/tp.0000000000003723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infection remains a leading cause of death in kidney transplant recipients. This study aimed to assess the scope and consistency of infection outcomes reported in contemporary trials conducted in kidney transplant recipients. METHODS A literature review of all randomized trials and trial protocols reporting infection outcomes in adult kidney transplant recipients were identified in the Cochrane Kidney and Transplant Specialized Register from January 2014 to July 2019. Characteristics and infection outcomes from the trials were analyzed. RESULTS From 102 included trials, 772 outcome measures were extracted and categorized into 216 unique measures with a median of 3.2 outcome measures per trial (range: 1 to 9). Measures were further grouped into 32 outcomes based on site of infection (14 outcomes) and organism (18 outcomes). The most commonly reported site-specific outcome and organism-specific outcome was systemic infection (71% trials) and cytomegalovirus infection (62% trials), respectively. Outcome metric and methods of aggregation included mean, median, proportion, proportional change and number of patients with at least 1 episode. Across all trials, measures were assessed at 55 different time points with a range of 1 to 11 time points per trial. CONCLUSIONS Infection outcomes in kidney transplant recipients were frequently reported by site and organism but varied widely in terms of outcome, metrics, method of aggregation and time point of measurement. Establishment of core outcomes for infection based on the shared priorities of patients/caregivers and health professionals may improve the consistency, comparability and usefulness of trial evidence.Supplemental Visual Abstract; http://links.lww.com/TP/C169.
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15
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Sylvestre R, Alencar de Pinho N, Massy ZA, Jacquelinet C, Prezelin-Reydit M, Galland R, Stengel B, Coscas R. Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation. BMC Nephrol 2020; 21:422. [PMID: 33008322 PMCID: PMC7532567 DOI: 10.1186/s12882-020-02080-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early kidney transplantation (KT) is the best option for patients with end-stage kidney disease, but little is known about dialysis access strategy in this context. We studied practice patterns of dialysis access and how they relate with outcomes in adults wait-listed early for KT according to the intended donor source. METHODS This study from the REIN registry (2002-2014) included 9331 incident dialysis patients (age 18-69) wait-listed for KT before or by 6 months after starting dialysis: 8342 candidates for deceased-donor KT and 989 for living-donor KT. Subdistribution hazard ratios (SHR) of KT and death associated with hemodialysis by catheter or peritoneal dialysis compared with arteriovenous (AV) access were estimated with Fine and Gray models. RESULTS Living-donor candidates used pretransplant peritoneal dialysis at rates similar to deceased-donor KT candidates, but had significantly more frequent catheter than AV access for hemodialysis (adjusted OR 1.25; 95%CI 1.09-1.43). Over a median follow-up of 43 (IQR: 23-67) months, 6063 patients received transplants and 305 died before KT. Median duration of pretransplant dialysis was 15 (7-27) months for deceased-donor recipients and 9 (5-15) for living-donor recipients. Catheter use in deceased-donor candidates was associated with a lower SHR for KT (0.88, 95%CI 0.82-0.94) and a higher SHR for death (1.53, 95%CI 1.14-2.04). Only five deaths occurred in living-donor candidates, three of them with catheter use. CONCLUSIONS Pretransplant dialysis duration may be quite long even when planned with a living donor. Advantages from protecting these patients from AV fistula creation must be carefully evaluated against catheter-related risks.
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Affiliation(s)
- Raphaëlle Sylvestre
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Vascular Surgery, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
| | - Natalia Alencar de Pinho
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.
| | - Ziad A Massy
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
| | - Christian Jacquelinet
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Agence de la Biomédecine, Direction Médicale et Scientifique, Boulogne-Billancourt, France
| | - Mathilde Prezelin-Reydit
- Aurad-Aquitaine, Service Hémodialyse, Saint Denis La Plaine, France.,Bordeaux Population Health Research Center, Clinical Investigation Center-Clinical Epidemiology-CIC-1401, University of Bordeaux, INSERM, UMR1219, Bordeaux, France
| | | | - Bénédicte Stengel
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France
| | - Raphael Coscas
- Clinical Epidemiology Team, Paris-Saclay University, Paris-Sud University, UVSQ, CESP, Inserm, Villejuif, France.,Division of Vascular Surgery, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
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16
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See YP, Cho Y, Pascoe EM, Cass A, Irish A, Voss D, Polkinghorne KR, Hooi LS, Ong LM, Paul-Brent PA, Kerr PG, Mori TA, Hawley CM, Johnson DW, Viecelli AK. Predictors of Arteriovenous Fistula Failure: A Post Hoc Analysis of the FAVOURED Study. ACTA ACUST UNITED AC 2020; 1:1259-1269. [DOI: 10.34067/kid.0002732020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/27/2020] [Indexed: 11/27/2022]
Abstract
BackgroundAn autologous arteriovenous fistula (AVF) is the preferred hemodialysis vascular access, but successful creation is hampered by high rates of AVF failure. This study aimed to evaluate patient and surgical factors associated with AVF failure to improve vascular access selection and outcomes.MethodsThis is a post hoc analysis of all participants of FAVOURED, a multicenter, double-blind, multinational, randomized, placebo-controlled trial evaluating the effect of fish oil and/or aspirin in preventing AVF failure in patients receiving hemodialysis. The primary outcome of AVF failure was a composite of fistula thrombosis and/or abandonment and/or cannulation failure at 12 months post-AVF creation, and secondary outcomes included individual outcome components. Patient data (demographics, comorbidities, medications, and laboratory data) and surgical factors (surgical expertise, anesthetic, intraoperative heparin use) were examined using multivariable logistic regression analyses to evaluate associations with AVF failure.ResultsOf 536 participants, 253 patients (47%) experienced AVF failure during the study period. The mean age was 55±14.4 years, 64% were male, 45% were diabetic, and 4% had peripheral vascular disease. Factors associated with AVF failure included female sex (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.20 to 2.68), lower diastolic BP (OR for higher DBP, 0.85; 95% CI, 0.74 to 0.99), presence of central venous catheter (OR, 1.49; 95% CI, 1.02 to 2.20; P=0.04), and aspirin requirement (OR, 1.60; 95% CI, 1.00 to 2.56).ConclusionsFemale sex, requirement for aspirin therapy, requiring hemodialysis via a central venous catheter, and lower diastolic BP were factors associated with higher odds of AVF failure. These associations have potential implications for vascular access planning and warrant further studies.
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17
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Getting the basics right: the monitoring of arteriovenous fistulae, a review of the evidence. Curr Opin Nephrol Hypertens 2020; 29:564-571. [PMID: 32889977 DOI: 10.1097/mnh.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite being the preferred vascular access for haemodialysis, the arteriovenous fistula (AVF) remains prone to a number of complications, the most common of these being thrombosis secondary to stenosis. This has resulted in the widespread use of monitoring and surveillance programmes. Surveillance uses more resources than monitoring and has not been convincingly shown to improve outcomes. The evidence supporting the use of the various monitoring tools has been relatively neglected and has not been the focus of literature review. This narrative review is the first to appraise the evidence for the use of physical examination, access recirculation, Kt/V and dynamic venous pressures (DVP) as monitoring tools in mature AVF. RECENT FINDINGS The vastly increased number of data points for access recirculation, Kt/V and DVP produced as standard by online clearance monitoring (OCM) on modern dialysis machines is likely to have significantly changed the utility of these metrics in the prediction of AVF failure. Algorithms have been developed to highlight those of highest risk of failure. SUMMARY The evidence supporting the use of monitoring in the prediction of AVF failure is predominantly observational, underpowered and more than 20 years old. Access recirculation and Kt/V appears to have higher utility in AVF than in arteriovenous grafts. We suggest that the development of OCM necessitates the reevaluation of these tools.
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Abstract
The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization. Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care. The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care. The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease. Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life. Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis. Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators). Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.
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Qian JZ, McAdams-DeMarco M, Ng DK, Lau B. Arteriovenous Fistula Placement, Maturation, and Patency Loss in Older Patients Initiating Hemodialysis. Am J Kidney Dis 2020; 76:480-489.e1. [PMID: 32654891 DOI: 10.1053/j.ajkd.2020.02.449] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/25/2020] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE The 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 DESIGN Retrospective cohort study. SETTING & PARTICIPANTS A US national cohort of incident hemodialysis patients 67 years or older (N = 43,851) assembled from the US Renal Data System. EXPOSURE Age at dialysis initiation. OUTCOMES AVF placement, maturation, primary patency loss, and abandonment. ANALYTICAL APPROACH Cause-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. RESULTS As 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. LIMITATIONS Reliance on administrative claims to ascertain AVF outcomes. CONCLUSIONS The 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.
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Affiliation(s)
- Joyce Z Qian
- Medical Technology and Practice Patterns Institute, Bethesda, MD; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.
| | - Mara McAdams-DeMarco
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Derek K Ng
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Bryan Lau
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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20
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Affiliation(s)
- Charmaine E Lok
- Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital and The University of Toronto, Toronto, Ontario, Canada
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21
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Vanholder R. Single needle hemodialysis: is the past the future? J Nephrol 2019; 33:49-58. [DOI: 10.1007/s40620-019-00644-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/31/2019] [Indexed: 01/12/2023]
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