Late Creation of Vascular Access for Hemodialysis and Increased Risk of Sepsis

Clinical presentation and outcome of hemodialysis tunneled catheter-related bloodstream infection in older persons

BACKGROUND

The use of a tunneled catheter as the primary vascular access among old hemodialysis patients is frequent. Catheter-related bloodstream infection (CRBSI) is a common complication, associated with increased mortality. Data regarding the clinical presentation and outcomes of CRBSI among old hemodialysis patients is limited.

METHODS

All chronic hemodialysis patients hospitalized between 2010 and 2022 with CRBSI were included. Patients were classified into two groups: old adults (≥ 75) and younger patients. Clinical, microbiological, and outcome data were collected and analyzed.

RESULTS

One hundred and fifty-four patients with CRBSI were identified. Fifty-seven were aged ≥ 75 years. Mean age in the older and younger groups was 81.2 ± 5 and 59.7 ± 12.7, respectively. Male gender was predominant (64%). Charlson comorbidity score and Pitt bacteremia score were comparable among both groups. Norton score < 14 was more common among old persons (n = 24, 67% versus n = 21, 31%, p < 0.001), as well as nursing-home residence. Gram-negative pathogens and Staphylococcus aureus were common in both groups. The frequency of inappropriate empirical antimicrobial treatment was higher among older persons. Overall, in-hospital and 90-day mortality was high (age ≥ 75, 36.8%, age < 75, 24.7%, p = 0.14). Age was not significantly associated with mortality after adjustment for low Norton score, residence, and inappropriate antimicrobial therapy as well as resistance patterns of bloodstream isolates [OR = 1.2 (95% CI 0.4-3.3), p = 0.76].

CONCLUSIONS

Clinical characteristics and outcomes of CRBSI were comparable among old and young hemodialysis patients. However, the high mortality rate in this cohort suggests that the use of tunneled catheters as a permanent vascular access should be discouraged in both patient groups.

The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants

The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.

Initiation of hemodialysis at one month following fistulogram in patients with advanced kidney disease

OBJECTIVE

Previous studies have demonstrated that low contrast volume used in access-related interventions had limited effects on the progression of chronic kidney disease (CKD) after fistulography, but studies are limited and heterogeneous. We sought to evaluate the rate of and factors associated with progression to dialysis (HD) within 1 month after fistulography for patients with advanced CKD.

METHODS

A single-institution retrospective cohort analysis of patients with CKD stage IV and V, not yet on HD, undergoing fistulography from 1 January 2014 to 31 December 2018 was performed. The primary outcome was progression to HD within 1 month. Additional variables and the association with the primary outcome such as medical comorbidities, contrast type or volume were assessed.

RESULTS

A total of 34 patients underwent 41 fistulograms prior to HD initiation. Progression to HD within 1 month of fistulogram occurred in seven patients (all CKD V). The mean time between fistulogram and HD was 271 days for 31 of 34 patients who ultimately progressed to HD. Those with CKD IV began HD in 549 days on average, while those with CKD V began HD in 190 days on average. Three patients had not initiated HD at a mean of 539 days of follow-up. The only factors associated with progression to HD within 1 month included use of isovue (p = .005) and elevated contrast volume, with a mean of 40 mL (p = .027).

CONCLUSION

Although none of the patients with CKD IV required HD within 1 month after fistulogram, the use of larger iodinated contrast volume was associated with progression to HD within 1 month of fistulography for patients with CKD V. Further studies should investigate the safety of iodinated and alternative (e.g., carbon dioxide) contrast media in fistulography or duplex-based HD access procedures for CKD patients, especially CKD V, not yet on HD.

The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula

Introduction:

When created in appropriately selected patients, arteriovenous fistula requires fewer interventions and costs compared to arteriovenous graft. The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula is not studied well in the literature, and this study highlights the outcome of these arteriovenous fistulae.

Methods:

The retrospective, single-center study, based on patient record analysis of 1040 arteriovenous fistula, was created between January 2017 and October 2021. Thirty-nine (3.37%) patients met the inclusion criteria for radiocephalic after brachiocephalic arteriovenous fistula group, and 42 (4.04%) met the inclusion criteria for the redo arteriovenous fistula group. Preoperative Doppler ultrasound was performed by the operating surgeon in all patients. All patients were scheduled for a visit 2 months after surgery for assessment—only 34 of radiocephalic after brachiocephalic arteriovenous fistula and 35 of redo arteriovenous fistula patients presented for follow-up. The arteriovenous fistula was assessed for patency, maturation, and complications. SPSS version 22 (Chicago, USA) was used for data entry and analysis.

Results:

The redo arteriovenous fistula has a significantly lower maturation rate at 2 months of follow-up (62.85%) when compared to other brachiocephalic arteriovenous fistula (79.18%) ( p-value = 0.0245). The radiocephalic after brachiocephalic arteriovenous fistula has no significant difference in maturation rate at 2 months of follow-up (61.67%) when compared to other distal forearms radiocephalic arteriovenous fistula (68.18%) ( p-value = 0.5173). The incidence of some early complications was higher in the redo group.

Conclusion:

The feasibility of doing radiocephalic arteriovenous fistula after failed brachiocephalic arteriovenous fistula is generally overlooked. The redo arteriovenous fistula is more technically challenging, associated with higher complications, but it provides reliable access in a specific group of patients.

Age Based Outcomes of Autogenous Fistulas for Hemodialysis Access

INTRODUCTION

Hemodialysis (HD) dependence and autogenous fistula use for HD span the spectrum of age. This study examines age related outcomes of autogenous fistulas for hemodialysis access in a large population-based cohort of patients.

METHODS

A retrospective cohort study of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). Chi-square, T-tests, Kaplan-Meier, log-rank tests, multivariable logistic and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality.

RESULTS

Of the 303281 patients studied, 48892 (16.1%) were younger than 50 years, 55817 (18.4%) were 50-59 years, 79138 (26.1%) were 60-69 years, 75200 (24.8%) were 70-79 years and 44234 (14.6%) were 80 years or older. There was a decrease in autogenous fistula maturation with increasing age. Primary patency at 5 years comparing patients <50 vs. 50-59 vs. 60-69 vs. 70-79 vs. 80+ was 24 vs. 23 vs. 21 vs. 20 vs. 18% (p<0.001). Primary assisted patency at 5 years was 38 vs. 40 vs. 37 vs. 35 vs. 33% (p<0.001). Secondary patency at 5 years was 48 vs. 50 vs. 47 vs. 45 vs. 42% (p<0.001). The risk adjusted analyses revealed a progressive decrease in primary, primary assisted and secondary patency with increasing age. As expected, patient survival decreased with increasing age.

CONCLUSIONS

In this population-based cohort of hemodialysis patients, there was a decrease in autogenous fistula maturation, primary patency, primary assisted patency, secondary patency and patient survival with increasing age. Despite the relative decline in outcomes associated with older age, decisions about AV access creation in older patients should be individualized taking overall clinical status and outcomes of alternatives modes of access into consideration.

Evolution of Vascular Access Use among Incident Patients during the First Year on Hemodialysis: A National Cohort Study

Background

Although the arteriovenous fistula (AVF) confers superior benefits over central venous catheters (CVCs), utilization rates remain low among prevalent patients on hemodialysis (HD). The goal of this study was to determine the evolution of vascular access type in the first year of dialysis and identify factors associated with conversion from CVC to a functioning AVF.

Methods

We studiedadult patients (n=610) who began HD between the January 1, 2015 and December 31, 2016 and were treated for at least 90 days, using data from the National Kidney Disease Clinical Patient Management System in the Irish health system. Prevalence of vascular access type was determined at days 90 and 360 after dialysis initiation and at 30-day intervals. Multivariable logistic regression explored factors associated with CVC at day 90, and Cox regression evaluated predictors of conversion from CVC to AVF on day 360.

Results

CVC use was present in 77% of incident patients at day 90, with significant variation across HD centers (from 63% to 91%, P<0.001), which persisted after case-mix adjustment. From day 90 to day 360, AVF use increased modestly from 23% to 41%. Conversion from CVC to AVF increased over time, but the likelihood was lower for older patients (for age >77 years versus referent, adjusted hazard ratio [HR], 0.43; 95% CI, 0.19 to 0.96), for patients with a lower BMI (per unit decrease in BMI, HR, 0.95; 95% CI, 0.93 to 0.98), and varied significantly across HD centers (from an HR of 0.25 [95% CI, 0.08 to 0.74] to 2.09 [95% CI, 1.04 to 4.18]).

Conclusion

CVCs are the predominant type of vascular access observed during the first year of dialysis, with low conversion rates from CVC to AVF. There is substantial center variation in the Irish health system that is not explained by patient-related factors alone.

Incidence and risk factors of sepsis in hemodialysis patients in the United States

BACKGROUND

Sepsis is one the most serious and life-threatening complication in patients with chronic hemodialysis (HD) access. Arteriovenous fistula (AVF) use is associated with a lower risk of infection. However, several prior studies identified significantly higher number of patients initiating HD using a catheter (HC) or arteriovenous graft (AVG). The aim of this study was to use a large national renal database to report the incidence and risk factors of sepsis in patients with end-stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the United States.

METHODS

All patients with ESRD initiating HD access (AVF, AVG, HC) between January 1, 2006, and December 31, 2014, in United States Renal Data System were included. International Classification of Diseases, 9th edition-Clinical Modification diagnosis code (038x, 790.7) was used to identify patients who developed first onset of sepsis during follow-up. Standard univariate (Students t-test, χ², and Kaplan-Meier) and multivariable (logistic/Cox regression) analyses were performed as appropriate.

RESULTS

A total of 870,571 patients were identified, of whom, 29.8% (n = 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated with a higher number of septic cases compared with AVF (22.9%; P < .001). The incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years). Patients with sepsis were slightly older (mean age 65.09 ± 14.49 years vs 63.24 ± 15.17 years) and had higher number of comorbidities including obesity (40.7% vs 37.7%), congestive heart failure (36.6% vs 30.8%), peripheral arterial disease (15.6% vs 12.4%), and diabetes (59.6% vs 53.5%) (all P < .001). After adjusting for potential confounders, compared with AVF, patients with AVG (hazard ratio [HR], 1.35 [95% confidence interval [CI], 1.31-1.40) and HC (HR, 1.80 [95% CI, 1.77-1.84) were more likely to develop sepsis at 3 years (both P < .001). Compared with patients with no sepsis, sepsis was associated with a three-fold increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11-3.21; P < .001). Additionally, in patients who developed sepsis, AVF use was associated with significantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%; P < .001). After adjusting for significant covariates, compared with AVF, mortality at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15-1.28; P < .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88-2.00; P < .001).

CONCLUSIONS

Sepsis risk in HD patients is clearly related to access type and is associated with dramatic increase in mortality. Initiating HD access with AVF to meet the National Kidney Foundation Kidney Disease Outcomes Quality recommendations should be implemented to reduce the incidence of sepsis and improve survival in patients with ESRD.

The effects of vascular access types on the survival and quality of life and depression in the incident hemodialysis patients

Background

Although arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD), the association between vascular access types and quality of life is not well-known. We investigated the relationships between HD vascular access types and all-cause mortality, health-related quality of life (HRQOL) and the degree of depression in a large prospective cohort.

Methods

A total of 1461 patients who newly initiated HD were included. The initial vascular access types were classified into AVF, arteriovenous graft (AVG), and central venous catheter (CVC). The primary outcomes were all-cause mortality and HRQOL and depression. The secondary outcome was all-cause hospitalization. Kidney Disease Quality of Life Short Form 36 (KDQOL-36) and Beck’s depression inventory (BDI) scores were measured to assess HRQOL and depression.

Results

Among 1461 patients, we identified 314 patients who started HD via AVF, 76 via AVG, and 1071 via CVC. In the survival analysis, patients with AVF showed significantly better survival compared with patients with other accesses (p < .001). The AVF and AVG group had higher KDQOL-36 score and lower BDI score than CVC group at 3 months and 12 months after the initiation of HD. The frequency of hospitalization was higher in patients with AVG compared to those with AVF (AVF 0.7 vs. AVG 1.1 times per year) (p = .024).

Conclusions

The patients with AVF had better survival rate and low hospitalization rate, and the patients with AVF or AVG showed both higher HRQOL and lower depression scores than those with CVC.

Outcomes of arteriovenous fistula creation: A Jordanian experience

Objective:

The arteriovenous fistula is considered the preferred hemodialysis access due to its lower complication rate and longer patency. The aim of this study is to report the outcomes of arteriovenous fistula creation and to study the predictive factors for these outcomes.

Study design and method:

This is a retrospective study of all patients who underwent autogenous arteriovenous fistula creation procedure by a single surgeon during the period from October 2011 till December 2017.

Material:

All the procedures were performed at an academic referral center by a single surgeon. All patients who underwent arteriovenous fistula creation in the upper limb during the study period were included. All patients were diagnosed with end-stage renal disease and referred for arteriovenous fistula creation either before or after initiating hemodialysis.

Method:

Data were collected from the patients’ charts. The primary outcomes were the primary failure and secondary patency rates. Secondary outcome was to find the factors associated with decreased patency. The Kaplan–Meier curve with the log-rank test was used to describe the patency while univariate and multivariate analyses were done to the factors considered relevant to the patency.

Results:

The total number of procedures was 291; of which, 18 were lost to follow-up. The primary failure rate was 12%. Secondary patency rate at 1 and 5 years was 79% and 53%, respectively. Diabetes mellitus and fistulae placed on right side were associated with decreased patency.

Conclusion:

The primary failure rate was relatively low in this study but the long-term functionality of the arteriovenous fistulae needs to be improved.

Hemodialysis care for undocumented immigrants with end-stage renal disease in the United States

PURPOSE OF REVIEW

Across the United States, significant variation exists in the provision of care of undocumented immigrants with end-stage renal disease (ESRD), with some states providing standard dialysis, and other states providing emergency-only hemodialysis (EoHD).

RECENT FINDINGS

EoHD is associated with higher morbidity and mortality compared with standard hemodialysis. EoHD is also associated with higher healthcare utilization, resulting in more emergency department visits, more days spent in the hospital, and higher healthcare costs. Undocumented immigrants with ESRD who rely on EoHD also experience crippling and potentially fatal physical symptoms as well as psychosocial suffering, with some patients describing recurrent near-death experiences. Clinicians who provide EoHD to undocumented patients report experiencing moral distress and symptoms of professional burnout because of providing care that they perceive as unethical and far below the standard of care.

SUMMARY

Undocumented immigrants with ESRD who rely on EoHD have worse health outcomes and quality of life compared with patients who receive standard hemodialysis. EoHD is also more costly to the healthcare system. Healthcare policy reform is critical as more research demonstrates the worse clinical outcomes and higher costs of EoHD.

Vascular Access and Risk of Bloodstream Infection Among Older Incident Hemodialysis Patients

Rationale & Objective

Most new patients with end-stage renal disease (ESRD) initiate hemodialysis (HD) with a central venous catheter (CVC) and later transition to a permanent vascular access with lower infection risk. The benefit of early fistula use in preventing severe infections is incompletely understood. We examined patients' first access and subsequent transitions between accesses during the first year of HD to estimate the risk for bloodstream infection (BSI) associated with incident and time-dependent use of HD access.

Study Design

A retrospective cohort study using enhanced 5% Medicare claims data.

Setting & Participants

New patients with ESRD initiating HD between January 1, 2011, and December 31, 2012, and having complete pre-ESRD Medicare fee-for-service coverage for 2 years.

Exposure

The incident and prevalent use of CVC, graft, or fistula as determined from monthly reports to the Centers for Medicare & Medicaid Services by HD providers.

Outcome

Incident hospitalization with a primary/secondary diagnosis of BSI (International Classification of Diseases, Ninth Revision, Clinical Modification code 038.xx or 790.7).

Analytical Approach

Extended survival analysis accounting for patient confounders.

Results

Of 2,352 study participants, 1,870 (79.5%), 77 (3.3%), and 405 (17.2%) initiated HD with a CVC, graft, and fistula, respectively. During the first year, the incident BSI hospitalization rates per 1,000 person-days were 1.3, 0.8, and 0.3 (P<0.001) in patients initiating with a CVC, graft, and fistula, respectively. After adjusting for confounders, incident fistula use was associated with 61% lower risk for BSI (HR, 0.39; 95% CI, 0.28-0.54; P<0.001) compared with incident CVC or graft use. The prevalent fistula or graft use was associated with lower risk for BSI compared with prevalent CVC use (HRs of 0.30 [95% CI, 0.22-0.42] and 0.47 [95% CI, 0.31-0.73], respectively).

Limitations

Restricted to an elderly population; potential residual confounding.

Conclusions

Incident fistula use was associated with lowest rates of BSI, but the majority of beneficiaries with pre-ESRD insurance initiated HD with a CVC. Strategies are needed to improve pre-ESRD fistula placement.

Early Initiation of Dialysis and Late Implantation of Catheters Adversely Affect Outcomes of Patients on Chronic Peritoneal Dialysis

Objectives

Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD).

Design

Retrospective cohort.

Setting and Participants

275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (≥ 6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) ≥ 5 or <5 mL/minute/1.73 m2].

Main Outcome Measures

All-cause mortality and hospitalization.

Results

During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization.

Conclusions

Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Prediction model for successful radiocephalic arteriovenous fistula creation in patients with diabetic nephropathy

Arteriovenous fistula (AVF) is the most appropriate vascular access for all chronic kidney disease patients for hemodialysis. However, patients with diabetic nephropathy are at increased risk for primary failure after AVF creation, mainly due to atherosclerosis and calcification of blood vessels. We conducted this study to find out the risk factors for primary failure of radiocephalic AVF in end-stage renal disease (ESRD) patients due to diabetic nephropathy and develop a risk predicting model. This study was conducted at a tertiary care teaching hospital of South India. Patients with ESRD due to diabetic nephropathy whom underwent left radiocephalic AVF at wrist were enrolled. Risk factors for primary failure were analyzed by univariate and multivariate logistic regression models. Sixty-six patients were included in the study. Thirty-one patients had a primary failure. Independent risk factors for primary failure were palpable vessel wall of the radial artery (P = 0.003, odds ratio [OR] = 15.317), smaller radial artery diameter (P = 0.001, OR = 16.526), radial artery peak systolic velocity (PSV) <45 cm/s (P = 0.005, OR = 8.494), and linear radial artery calcification (P = 0.006, OR = 7.942). The risk predicting model obtained by adding the score given for each risk factors (vessel wall not palpable = 0, palpable = 1, no linear calcification in digital X-ray = 0, linear calcification = 1, PSV ≥45 cm/s = 0, <45 cm/s = 1 and 2.5 - radial artery diameter in mm) had an area under receiver-operating characteristic curve of 0.886. Cutoff score of 1.5 had sensitivity of 83.9% and specificity of 80.0% for primary failure. Risk predicting model for primary failure based on condition of the vessel wall on palpation, radial artery diameter, flow velocity, and calcification may be helpful for suitable patient selection.

Association between initial vascular access and survival in hemodialysis according to age

BACKGROUND/AIMS

This study aims to demonstrate whether the association between initial vascular access and mortality among hemodialysis patients varies by age.

METHODS

We conducted a retrospective study that included 2,552 patients who started hemodialysis. Vascular access was divided into three categories: percutaneous catheter, tunneled cuffed catheter, and arteriovenous (AV) access.

RESULTS

Survival rates for patients who received a central venous catheter, such as percutaneous or tunneled cuffed catheter, aged 65 to 74 years and those ≥ 75 years were reduced, but not for those aged < 65 years (log-rank test; p < 0.001, p = 0.007, and p = 0.278). After fully adjusting for potential confounding factors in the patients aged < 65 years, percutaneous and tunneled cuffed catheter were not associated with 5-year mortality. On the other hand, for patients aged 65 to 74 or ≥ 75 years, percutaneous catheter and tunneled cuffed catheter were associated with higher 5-year mortality rates. As age increased, the conversion rate from central venous catheter, including percutaneous catheter and tunneled cuffed catheter, to AV access decreased (94.1%, 90.5%, and 80.3% for patients aged < 65, 65 to 74, and ≥ 75 years, respectively; p < 0.001).

CONCLUSION

In patients aged ≥ 65 years, initial vascular access was associated with long-term mortality. We suggest that a "fistula first" strategy is superior for elderly patients and demonstrates that it is desirable to change to AV access, and not maintain an initial central vascular catheter.

Prehemodialysis arteriovenous access creation is associated with better cardiovascular outcomes in patients receiving hemodialysis: a population-based cohort study

Background

Cardiovascular (CV) disease contributes to nearly half of the mortalities in patients with end-stage renal disease. Patients who received prehemodialysis arteriovenous access (pre-HD AVA) creation had divergent CV outcomes.

Methods

We conducted a population-based cohort study by recruiting incident patients receiving HD from 2001 to 2012 from the Taiwan National Health Insurance Research Database. Patients’ characteristics, comorbidities, and medicines were analyzed. The primary outcome of interest was major adverse cardiovascular events (MACEs), defined as hospitalization due to acute myocardial infarction, stroke, or congestive heart failure (CHF) occurring within the first year of HD. Secondary outcomes included MACE-related mortality and all-cause mortality in the same follow-up period.

Results

The patients in the pre-HD AVA group were younger, had a lower burden of underlying diseases, were more likely to use erythropoiesis-stimulating agents but less likely to use renin–angiotensin–aldosterone system blockers. The patients with pre-HD AVA creation had a marginally lower rate of MACEs but a significant 35% lower rate of CHF hospitalization than those without creation (adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) [0.48–0.88]). In addition, the pre-HD AVA group exhibited an insignificantly lower rate of MACE-related mortality but a significantly 52% lower rate of all-cause mortality than the non-pre-HD AVA group (adjusted HR 0.48, 95% CI [0.39–0.59]). Sensitivity analyses obtained consistent results.

Conclusions

Pre-HD AVA creation is associated with a lower rate of CHF hospitalization and overall death in the first year of dialysis.

Timing of referral for vascular access for hemodialysis: Analysis of the current status and the barriers to timely referral

Introduction:

Current guidelines recommend the placement of vascular access 6 months before the anticipated start of hemodialysis therapy; however, many patients start hemodialysis using a central venous catheter. We investigated the timing of referral for vascular access, the vascular access type at hemodialysis initiation, and the barriers to a timely referral.

Methods:

The study involved a retrospective review of 237 patients for whom the first vascular access for hemodialysis was created between January and November 2017.

Results:

Among the 237 patients, 58.2% were referred before hemodialysis initiation, while 41.8% were referred after hemodialysis initiation. Among the 138 patients, 55, 59, and 24 patients were referred more than 6 months, between 2 and 6 months, and within 2 months before hemodialysis initiation, respectively. Within these subgroups, 3.6%, 10.2%, and 75.0% patients underwent hemodialysis initiation with a central venous catheter, respectively. Among the 99 patients referred after hemodialysis initiation, the reasons for late referral were as follows: unexpected rapid progression of kidney disease (n = 23), noncompliance (n = 21), late visit to the nephrologist (initial visit within 2 months of hemodialysis initiation; n = 14), change of treatment strategy from peritoneal dialysis or transplants (n = 9), and unknown reasons (n = 32).

Conclusion:

Only 23% of patients were referred for vascular access 6 months before the anticipated hemodialysis therapy. In addition, 53% of patients initiated hemodialysis with a central venous catheter. Avoidance of catheter insertion was mostly successful in patients referred 2 months before hemodialysis initiation. The most common modifiable barrier to the timely referral was noncompliance.

The Prognostic Significance of Puncture Timing to Survival of Arteriovenous Fistulas in Hemodialysis Patients: A Multicenter Retrospective Cohort Study

(1) Background: A functional shunt is critical to hemodialysis, but the ideal timing of shunt cannulation is still not established. In this study, we assessed the association between ideal puncture timing and shunt survival. (2) Methods: This retrospective cohort study using data from the Taiwan Health and Welfare database, which included 26885 hemodialysis patients with arteriovenous fistulas from 1 July 2008 to 30 June 2012. Fistulas were categorized by functional maturation time, defined as the time from the date of shunt construction to the first successful cannulation. Functional cumulative survival, measured as the duration from the first puncture to shunt abandonment, was mainly regarded. (3) Results: The fistulas created between 91 and 180 days prior to the first cannulation had significantly greater cumulative functional survival (HR 0.883; 95% CI 0.792–0.984), and there was no more benefit on their survival from waiting more than 180 days (HR 0.957; 95% CI 0.853–1.073) for shunt maturity. (4) Conclusions: Our results showed that to achieve better long-term shunt survivals, fistulas should be constructed at least 90 days before starting hemodialysis. Notably, there was no additional benefit on waiting more than 180 days prior to cannulation.

Clinical and Regulatory Considerations for Central Venous Catheters for Hemodialysis

Central venous catheters remain a vital option for access for patients receiving maintenance hemodialysis. There are many important and evolving clinical and regulatory considerations for all stakeholders for these devices. Innovation and transparent and comprehensive regulatory review of these devices is essential to stimulate innovation to help promote better outcomes for patients receiving maintenance hemodialysis. A workgroup that included representatives from academia, industry, and the US Food and Drug Administration was convened to identify the major design considerations and clinical and regulatory challenges of central venous catheters for hemodialysis. Our intent is to foster improved understanding of these devices and provide the foundation for strategies to foster innovation of these devices.

Medicare Costs Associated With Arteriovenous Fistulas Among US Hemodialysis Patients

BACKGROUND

An arteriovenous fistula (AVF) is the recommended vascular access for hemodialysis (HD). Previous studies have not examined the resources and costs associated with creating and maintaining AVFs.

STUDY DESIGN

Retrospective observational study.

SETTING & PARTICIPANTS

Elderly US Medicare patients initiating hemodialysis therapy during 2010 to 2011.

PREDICTOR

AVF primary and secondary patency and nonuse in the first year following AVF creation.

OUTCOMES

Annualized vascular access costs per patient per year.

RESULTS

Among patients with only a catheter at HD therapy initiation, only 54% of AVFs were successfully used for HD, 10% were used but experienced secondary patency loss within 1 year of creation, and 83% experienced primary patency loss within 1 year of creation. Mean vascular access costs per patient per year in the 2.5 years after AVF creation were $7,871 for AVFs that maintained primary patency in year 1, $13,282 for AVFs that experienced primary patency loss in year 1, $17,808 for AVFs that experienced secondary patency loss in year 1, and $31,630 for AVFs that were not used. Similar patterns were seen among patients with a mature AVF at HD therapy initiation and patients with a catheter and maturing AVF at HD therapy initiation. Overall, in 2013, fee-for-service Medicare paid $2.8 billion for dialysis vascular access-related services, ∼12% of all end-stage renal disease payments.

LIMITATIONS

Lack of granularity with certain billing codes.

CONCLUSIONS

AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.

Association of Proteinuria with Central Venous Catheter Use at Initial Hemodialysis

CONTEXT

Central venous catheter (CVC) use is associated with increased mortality and complications in hemodialysis recipients. Although prevalent CVC use has decreased, incident use remains high.

OBJECTIVE

To examine characteristics associated with CVC use at initial dialysis, specifically looking at proteinuria as a predictor of interest.

DESIGN

Retrospective cohort of 918 hemodialysis recipients from Kaiser Permanente Northwest who started hemodialysis from January 1, 2004, to January 1, 2014.

MAIN OUTCOME MEASURES

Multivariable logistic regression was used to examine an association of proteinuria with the primary outcome of CVC use.

RESULTS

More than one-third (36%) of patients in our cohort started hemodialysis with an arteriovenous fistula, and 64% started with a CVC. Proteinuria was associated with starting hemodialysis with a CVC (likelihood ratio test, p < 0.001) after adjustment for age, peripheral vascular disease, congestive heart failure, diabetes, sex, race, and length of predialysis care. However, on pairwise comparison, only patients with midgrade proteinuria (0.5-3.5 g) had lower odds of starting hemodialysis with a CVC (odds ratio = 0.39, 95% confidence interval = 0.24-0.65).

CONCLUSION

Proteinuria was associated with use of CVC at initial hemodialysis. However, a graded association did not exist, and only patients with midgrade proteinuria had significantly lower odds of CVC use. Our findings suggest that proteinuria is an explanatory finding for CVC use but may not have pragmatic value for decision making. Patients with lower levels of proteinuria may have a higher risk of starting dialysis with a CVC.

The Type of Vascular Access and the Incidence of Mortality in Japanese Dialysis Patients

Objective The National Kidney Foundation (NKF) Kidney Disease Outcome Quality Initiative (KDOQI) guidelines have recommended the use of arteriovenous fistula (AVF) at the initiation of dialysis. However, there are significant differences in the dialysis environments of Japan and the United States, and there are few people who receive hemodialysis via a central venous catheter (CVC) in Japan. The aim of the present study was to examine the association between the type of vascular access at the initiation of dialysis and the incidence of mortality in Japan. Methods This study was a prospective, multicenter, cohort study. The data was collected by the Aichi Cohort study of Prognosis in Patients newly initiated into dialysis (AICOPP) in which 18 Japanese tertiary care centers participated. The present study enrolled 1,524 patients who were newly introduced to dialysis (the patients started maintenance dialysis between October 2011 and September 2013). After excluding 183 patients with missing data, 1,341 patients were enrolled. The Cox proportional hazards model was used to evaluate mortality based on the type of vascular access. The types of vascular access were divided into four categories: AVF, arteriovenous graft (AVG), CVC changed to AVF during the course (CAVF), CVC changed to AVG during the course (CAVG). Results A multivariate analysis revealed that AVG, CAVF and CAVG were associated with a higher risk of mortality in comparison to AVF [hazard ratio (HR), 1.60; p=0.048; HR, 2.26; p=0.003; and HR, 2.45; p=0.001, respectively]. Conclusion The research proved that the survival rate among patients in whom hemodialysis was initiated with AVF was significantly higher than that in patients in whom hemodialysis was initiated with AVG or CVC.

Hemodialysis vascular access and clinical outcomes: an observational multicenter study

Background

Arteriovenous fistula (AVF) is the optimal vascular access in hemodialysis (HD) patients because of its lower complication rates and better longevity compared to arteriovenous graft (AVG) and central venous catheter (CVC).

Methods

A cohort of 532 HD patients from nine HD facilities were recruited in September 2012 and prospectively followed for a median of 28 months. Unadjusted and fully adjusted hazard ratios (HR) of mortality for vascular access were calculated using Cox proportional hazards model.

Results

Seventy-two percent of patients had AVF, 7% AVG, 21% CVC. Overall, AVF failure was 43 per 1000 patient-years and AVF creation 19 per 1000 patient-years. In logistic regression analysis, odds ratio of having non-AVF access for age was 1.02 (95% CI: 1.01-1.03), female gender 1.97 (95% CI: 1.30-3.01), and Charlson comorbidity index (CCI) 1.17 (95% CI: 1.02-1.36). Total number of deaths was 17 per 100 patient-years. Two percent of death was because of pure catheter infection and 10.5% more mortality happened due to catheter infection complicated by underlying cardiovascular diseases. In unadjusted and full adjustment Cox models, HR of death for patients with CVC (reference: AVF patients) was, respectively, 2.17 (95% CI: 1.51-3.11) and 1.58 (95% CI: 1.01-2.51). Access problems of insertion-repair accounted for 24% of hospitalization, and catheter infection explained 10% of total admissions.

Conclusions

Catheter use in HD patients was associated with higher mortality and morbidity despite extensive adjustment for covariates. Risk factors for higher usage of non-AVF access are older age, female gender, and underlying comorbidities.

Preparation of the Dialysis Access in Stages 4 and 5 CKD

Patients with Stages 4 and 5 CKD are optimally managed within a multidisciplinary care setting. This provides an opportunity to create a "patient centered" approach to renal replacement modality options and conservative care. The care team engages with the patient and caregivers to assist with the understanding of their health status, modality and vascular access selection, and overall living with the comorbidity of chronic illness. A systematic approach to provision of education, modality, and access selection, are in part, driven by the patient's expected survival and need for dialysis, the risks and benefits with different modalities, and access and adaptation to their preferences and home situations. Dialysis access education should be included in all education programs so that patients can consider risks and benefits of all modalities. Decision support interventions have been effective in reducing decisional conflict and informed values-based decision-making. For both hemodialysis and peritoneal dialysis, timing of the surgical referral and access creation should be individualized based on the rate of CKD progression, risk of complications, and ease of access to surgical services. The health care team should support the patients' decision balancing risks and benefits, as well as their lifestyle, values, beliefs, and preferences.

The importance of success prediction in angioaccess surgery

Access to the circulation is an "Achilles' heel" of chronic hemodialysis. According to the current guidelines, autologous arteriovenous fistula is the best choice available. However, the impossibility of immediate use and the high rate of non-matured fistulas place fistula far from an ideal hemodialysis vascular access. The first attempt at constructing an angioaccess should result in functional access as much as possible. After failed attempts, patients and nephrologists lose their patience and confidence, which results in high percentage of central venous catheter use. Predictive models could help, but clinical judgment still remains crucial. Early referral to the nephrologist and vascular access surgeon, careful preoperative examinations, preparation of patients and duplex sonography mapping of the vessels are very important in the preoperative stage. In the operative stage, it is crucial to understand that angioaccess procedures should not be considered as minor procedures and these operations must be performed by surgeons with demonstrable interest and experience. In the postoperative stage, appropriate surveillance of the maturation process is also important, as well as good cannulation skills of the dialysis staff. The purpose of this review article is to stress the importance of success prediction in order to avoid unsuccessful attempts in angioaccess surgery.

Outcomes of Elderly Patients after Predialysis Vascular Access Creation

Uniform vascular access guidelines for elderly patients may be inappropriate because of the competing risk of death, high rate of arteriovenous fistula (AVF) maturation failure, and poor vascular access outcomes in this population. However, the outcomes in elderly patients with advanced CKD who receive permanent vascular access before dialysis initiation are unclear. We identified a large nationally representative cohort of 3418 elderly patients (aged ≥ 70 years) with CKD undergoing predialysis AVF or arteriovenous graft (AVG) creation from 2004 to 2009, and assessed the frequencies of dialysis initiation, death before dialysis initiation, and dialysis-free survival for 2 years after vascular access creation. In all, 67% of patients with predialysis AVF and 71% of patients with predialysis AVG creation initiated dialysis within 2 years of access placement, but the overall risk of dialysis initiation was modified by patient age and race. Only one half of patients initiated dialysis with a functioning AVF or AVG; 46.8% of AVFs were created <90 days before dialysis initiation. Catheter dependence at dialysis initiation was more common in patients receiving predialysis AVF than in patients receiving AVG (46.0% versus 28.5%; P<0.001). In conclusion, most elderly patients with advanced CKD who received predialysis vascular access creation initiated dialysis within 2 years. As a consequence of late predialysis placement or maturation failure, almost one half of patients receiving AVFs initiated dialysis with a catheter. Insertion of an AVG closer to dialysis initiation may serve as a "catheter-sparing" approach and allow delay of permanent access placement in selected elderly patients with CKD.

Abdominal Wall Grafts: A Viable Addition to Arteriovenous Access Strategies

BACKGROUND

We seek to present our experience with innovative abdominal wall arteriovenous access grafts for patients who have run out of traditional dialysis access options.

METHODS

We retrospectively reviewed our cohort of patients who have undergone creation of abdominal wall grafts. In all patients, an iliac artery was used for inflow and either an iliac vein or the distal inferior vena cava (IVC) was use for the outflow. Ringed polytetrafluorethylene (PTFE), nonringed PTFE, and bovine carotid artery were used as access conduits.

RESULTS

Our 12-patient cohort had a mean primary patency of 17.4 months with mean secondary patency of 33 months. There were no operative deaths noted and 4 total graft infections.

CONCLUSIONS

Abdominal wall grafts with iliac vessel inflow and/or outflow represent viable alternatives for patients who have exhausted more traditional dialysis access options.

Renal replacement therapy in Brunei Darussalam: comparing standards with international renal registries

BACKGROUND AND AIM

Brunei Darussalam is a small South East Asian country with a high prevalence and incidence of end stage kidney disease (ESRD). This study aims to compare key performance indicators recorded in the Brunei Dialysis and Transplant Registry and department records against international practice. Registries from the USA (USRDS), UK (UK Renal Registry), Australasia (ANZDATA), Europe (ERA-EDTA Registry) and Malaysia (MDTR) were used for comparisons.

METHODS AND RESULTS

Haemodialysis (83%) and renal transplantation (6%) were the most and least favoured modality of renal replacement therapy in Brunei. Diabetes mellitus as a cause of ESRD (57%) was high in Brunei but on par with other South East Asian countries. Dialysis death rates (11%) and living-related transplant survival rates (5 year graft and patient survival 91% and 96% respectively) were favourable compared with other registries. Anaemia and mineral bone disease management were similar to Malaysia but slightly inferior to the others, but generally in keeping with KDOQI and KDIGO targets. Haemodialysis adequacy (48% achieving urea reduction ratio of >65%) was relatively poorer due to poor dialysis flow rates and low fistula usage (71%). Peritoneal dialysis peritonitis (24.5 patient-month/episode) and adequacy (78% achieving kt/v of 1.7) were in keeping with ISPD targets and international registries' results.

CONCLUSION

Brunei has achieved reasonable and commendable standards in many areas pertaining to the renal services. This report has identified several key areas for developments but this is to be expected for a service making its first foray into international benchmarked practice.

Impact of break-in period on the short-term outcomes of patients started on peritoneal dialysis

OBJECTIVES

Peritoneal dialysis (PD) is one of the first-line modalities of renal replacement therapy in patients with end-stage renal disease. Guidelines recommended a break-in period of at least 2 weeks before full PD start. However, the optimal duration of the break-in period is still unclear. In the present study, we investigated the effect of various break-in periods on short-term outcomes in patients on PD. ♢

METHODS

All patients who underwent Tenckhoff catheter implantation and initiated PD in Renji Hospital, Shanghai Jiao Tong University School of Medicine, between 1 January 2001 and 31 December 2010 were included. Patients were grouped according to the duration of their break-in period: 7 days or less (BI ≤ 7), 8 - 14 days (BI8-14), and more than 14 days (BI>14). Kaplan-Meier curves and log-rank tests were used to compare short-term outcomes in the various groups. ♢

RESULTS

Our study enrolled 657 patients (44.5% men), of whom 344, 137, and 176 patients were in the respective break-in groups. Compared with BI>14 patients, BI ≤ 7 patients had a lower estimated glomerular filtration rate (5.34 ± 1.86 mL/min/1.73 m(2) vs 6.55 ± 1.71 mL/min/1.73 m(2), p < 0.001) and lower serum albumin (33.29 ± 5.36 g/L vs 36.64 ± 5.40 g/L, p < 0.001). The incidence of mechanical complications during the first 6 months was significantly higher in BI ≤ 7 patients than in BI>14 patients (8.4% vs 1.7%, p = 0.004). However, we observed no significant differences between the three groups with respect to the prevalence of catheter dysfunction requiring surgical intervention (p > 0.05). Logistic regression analysis showed that BI ≤ 7 [relative risk: 4.322; 95% confidence interval (CI): 1.278 to 14.608; p = 0.019] was an independent predictor of catheter dysfunction, but not of catheter dysfunction requiring surgical intervention (p > 0.05). Catheter dysfunction [hazard ratio (HR): 20.087; 95% CI: 7.326 to 55.074; p < 0.001] and peritonitis (HR: 4.533; 95% CI: 1.748 to 11.751; p = 0.002) were risk factors for technique failure during the first 6 months, but BI ≤ 7 was not correlated with technique failure. ♢

CONCLUSIONS

Patients starting PD with a break-in period of less than 1 week might experience a minor increased risk of mechanical complications, but no major effect on technique survival.

Patients' perspectives on hemodialysis vascular access: a systematic review of qualitative studies

BACKGROUND

Delayed creation of vascular access may be due in part to patient refusal and is associated with adverse outcomes. Concerns about vascular access are prevailing treatment-related stressors for patients on hemodialysis therapy. This study aims to describe patients' perspectives on vascular access initiation and maintenance in hemodialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies.

SETTING & POPULATION

Patients with chronic kidney disease who express opinions about vascular access for hemodialysis.

SEARCH STRATEGY & SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October 2013.

ANALYTICAL APPROACH

Thematic synthesis was used to analyze the findings.

RESULTS

From 46 studies involving 1,034 patients, we identified 6 themes: heightened vulnerability (bodily intrusion, fear of cannulation, threat of complications and failure, unpreparedness, dependence on a lifeline, and wary of unfamiliar providers), disfigurement (preserving normal appearance, visual reminder of disease, and avoiding stigma), mechanization of the body (bonded to a machine, internal abnormality, and constant maintenance), impinging on way of life (physical incapacitation, instigating family tension, wasting time, and added expense), self-preservation and ownership (task-focused control, advocating for protection, and acceptance), and confronting decisions and consequences (imminence of dialysis therapy and existential thoughts).

LIMITATIONS

Non-English articles were excluded.

CONCLUSIONS

Vascular access is more than a surgical intervention. Initiation of vascular access signifies kidney failure and imminent dialysis, which is emotionally confronting. Patients strive to preserve their vascular access for survival, but at the same time describe it as an agonizing reminder of their body's failings and "abnormality" of being amalgamated with a machine disrupting their identity and lifestyle. Timely education and counseling about vascular access and building patients' trust in health care providers may improve the quality of dialysis and lead to better outcomes for patients with chronic kidney disease requiring hemodialysis.

Using Tunneled Femoral Vein Catheters for “Urgent Start” Dialysis Patients: A Preliminary Report

Background

Multiple benefits of arteriovenous fistulas (AVF) and arteriovenous grafts (AVGs) exist over catheters. As part of a strategy to preserve thoracic venous sites and reduce internal jugular (IJ) vein catheter use, we inserted tunneled femoral vein catheters in incident “urgent start” dialysis patients while facilitating a more appropriate definitive dialysis access.

Methods

“Urgent start” dialysis patients between January 15, 2013 and January 15, 2014 who required chronic dialysis, and did not have prior modality and vascular access plans, had tunneled femoral vein catheters inserted. We determined the femoral vein catheter associated infections rates, thrombosis, and subsequent dialysis access. Eligible patients were surveyed on their femoral vein catheter experience.

Results

Twenty-two femoral vein catheters were inserted without complications. Subsequently, one catheter required intraluminal thrombolytic locking, while all other catheters maintained blood flow greater than 300 ml/min. There were no catheter-related infections (exit site infection or bacteremia). Six patients continued to use their tunneled catheter at report end, one transitioned to peritoneal dialysis, thirteen to an arteriovenous graft, and two to a fistula. One patient received a tunneled IJ vein catheter. Of the patients who completed the vascular access survey, all indicated satisfaction with their access and that they had minimal complaints of bruising, bleeding, or swelling at their access sites. Pain/discomfort at the exit site was the primary complaint, but they did not find it interfered with activities of daily living.

Conclusions

Femoral vein tunneled catheters appear to be a safe, well tolerated, and effective temporary access in urgent start dialysis patients while they await more appropriate long-term access.

Initial hemodialysis with a temporary catheter is associated with complications of a later permanent vascular access

The aim was to identify the risk factors of long-term vascular access complications. The study cohort consisted of 239 incident hemodialysis (HD) patients from 1998 to 2010 in a single center. Among these patients, 59.8% had initially been dialyzing with a temporary catheter. Within 3 months after starting dialysis, all catheters had been converted into permanent accesses. 45 patients incurred long-term access complications after the first 2 years of dialysis, and 34 (75.6%) had used a temporary catheter starting HD. Complication occurrence was associated with age, initiation dialysis with a catheter and heart failure by logistic regression (odds ratios were 1.04, 2.77 and 2.23, respectively; p < 0.05). The 2-year primary patency rates of arteriovenous fistulae were significantly higher than those of arteriovenous grafts (79.5 vs. 50%, p = 0.002). We concluded that age, using a catheter and heart failure in HD initiation had a strong impact on long-term access complications.

The economics of hemodialysis catheter-related infection prophylaxis

Hemodialysis central venous catheter (CVC) use is associated with the highest morbidity, mortality, and cost of all types of hemodialysis vascular access. CVC-related infection drives much of the cost associated with CVC use. The magnitude of the cost associated with CVC-related infection varies depending on the type and severity of that infection; however, estimates of the total direct and indirect costs associated with hospitalizations due to hemodialysis CVC-related infections range from 17,000 USD to 32,000 USD per episode. Thus, it is critically important, to not only have effective strategies to limit CVC-related infection but also evaluate whether these strategies are an efficient use of resources. Prophylactic strategies can be considered economically efficient only if the value of its implementation and the corresponding drop in infection rate offer greater value than standard care. The optimal CVC-related infection prophylaxis strategy should work to limit infection risk with minimal risk, inconvenience, and discomfort to the patient, and at minimal cost. The aim of this review was to examine the clinical and economic impact of some commonly described interventions used for CVC infection prophylaxis.

Can peritoneal dialysis be applied for unplanned initiation of chronic dialysis?

Late referral of patients with chronic kidney disease (CKD) and unforeseeable deterioration of residual renal function in known CKD patients remain a major problem leading to the need of unplanned start on chronic dialysis without a mature access for dialysis. In most centres worldwide, these patients are started on haemodialysis (HD) using a temporary tunnelled central venous catheter (CVC) for access. However, during the last decade, increasing clinical experience with unplanned start on peritoneal dialysis (PD) right after PD catheter implantation has been published. Key studies are reviewed in the present paper, and the results seem to indicate that compared with patients starting PD in a planned setting with peritoneal resting after PD catheter implantation, patients starting unplanned PD have an increased risk of mechanical complications but apparently no increased risk of infectious complications. In contrast, patients starting unplanned HD using a temporary CVC have an increased risk of both mechanical and infectious complications when compared with patients starting planned HD using an arterio-venous fistula or a permanent CVC. Regarding clinical outcome in terms of survival, unplanned PD seems to be at least as safe as unplanned HD. Combining the unplanned PD programme with a nurse-assisted PD programme is crucial in order to offer the patient a real opportunity to choose a home-based dialysis option. In conclusion, unplanned start on PD seems to be a feasible, safe and efficient alternative to unplanned start on HD for the late referred patient with end-stage renal disease and urgent need for dialysis.

The transcription factor E26 transformation-specific sequence-1 mediates neointima formation in arteriovenous fistula

Hemodialysis vascular access dysfunction contributes to increased morbidity and mortality in hemodialysis patients. Arteriovenous fistula (AVF) is the preferred type of vascular access for hemodialysis but has high rates of dysfunction, in part because of excessive neointima formation. The transcription factor E26 transformation-specific sequence-1 (ETS-1) is a mediator of proinflammatory responses in hypertension and endovascular injury. We examined the role of ETS-1 in the formation of neointima in AVF. Right carotid artery to internal jugular vein fistulas were created in C57BL/6 mice and assigned to treatment with an ETS-1-dominant negative peptide (ETS-DN), an inactive mutant peptide (ETS-MU), or vehicle (n=6 per group). After 7 and 21 days, AVFs or contralateral internal jugular veins were processed for PCR, immunofluorescence, immunohistochemistry, and morphometry. In AVFs, ETS-1 mRNA increased 2.5-fold at 7 days and 4-fold at 21 days. By immunofluorescence, we confirmed increased expression of ETS-1 predominantly in the neointima and overlying endothelium. Similarly, ETS-1 expression increased in human AVFs compared with normal veins. In mice, ETS-DN, but not ETS-MU, reduced neointima formation at days 7 and 21 and reduced the expression of nitric oxide synthase 2, NADPH oxidase (NOX) 2, NOX4, E-selectin, and monocyte chemotactic protein-1. Shear stress increased ETS-1 phosphorylation in human umbilical vein cells in a NOX-dependent manner, demonstrating a role for reactive oxygen species in ETS-1 activation. These results unveil the role of ETS-1 as a mediator of neointima formation in AVF and may result in the development of novel strategies for the treatment of AVF dysfunction.

Is dialysis modality a factor in the survival of patients initiating dialysis after kidney transplant failure?

BACKGROUND

Kidney transplant failure (TF) is among the leading causes of dialysis initiation. Whether survival is similar for patients treated with peritoneal dialysis (PD) and with hemodialysis (HD) after TF is unclear and may inform decisions concerning dialysis modality selection.

METHODS

Between 1995 and 2007, 16 113 adult dialysis patients identified from the US Renal Data System initiated dialysis after TF. A multivariable Cox proportional hazards model was used to evaluate the impact of initial dialysis modality (1 865 PD, 14 248 HD) on early (1-year) and overall mortality in an intention-to-treat approach.

RESULTS

Compared with HD patients, PD patients were younger (46.1 years vs 49.4 years, p < 0.0001) with fewer comorbidities such as diabetes mellitus (23.1% vs 25.7%, p < 0.0001). After adjustment, survival among PD patients was greater within the first year after dialysis initiation [adjusted hazard ratio (AHR): 0.85; 95% confidence interval (CI): 0.74 to 0.97], but lower after 2 years (AHR: 1.15; 95% CI: 1.02 to 1.29). During the entire period of observation, survival in both groups was similar (AHR for PD compared with HD: 1.09; 95% CI: 1.0 to 1.20). In a sensitivity analysis restricted to a cohort of 1865 propensity-matched pairs of HD and PD patients, results were similar (AHR: 1.03; 95% CI: 0.93 to 1.14). Subgroups of patients with a body mass index exceeding 30 kg/m(2) [AHR: 1.26; 95% CI: 1.05 to 1.52) and with a baseline estimated glomerular filtration rate (eGFR) less than 5 mL/min/1.73 m(2) (AHR: 1.45; 95% CI: 1.05 to 1.98) experienced inferior overall survival when treated with PD.

CONCLUSIONS

Compared with HD, PD is associated with an early survival advantage, inferior late survival, and similar overall survival in patients initiating dialysis after TF. Those data suggest that increased initial use of PD among patients returning to dialysis after TF may be associated with improved outcomes, except among patients with a higher BMI and those who initiate dialysis at lower levels of eGFR. The reasons behind the inferior late survival seen in PD patients are unclear and require further study.

Temporal risk profile for infectious and noninfectious complications of hemodialysis access

Vascular access complications are a major cause of morbidity in patients undergoing hemodialysis, and determining how the risks of different complications vary over the life of an access may benefit the design of prevention strategies. We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to assess the temporal profiles of risks for infectious and noninfectious complications of fistulas, grafts, and tunneled catheters in incident hemodialysis patients. We used longitudinal data to model time from access placement or successful treatment of a previous complication to subsequent complication and considered multiple accesses per patient and repeated access complications using baseline and time-varying covariates to obtain adjusted estimates. Of the 7769 incident patients identified, 7140 received at least one permanent access. During a median follow-up of 14 months (interquartile range, 7-22 months), 10,452 noninfectious and 1131 infectious events (including 551 hospitalizations for sepsis) occurred in 112,085 patient-months. The hazards for both complication types declined over time in all access types: They were 5-10 times greater in the first 3-6 months than in later periods after access placement or a remedial access-related procedure. The hazards declined more quickly with fistulas than with grafts and catheters (P<0.001; Weibull regression). These data indicate that risks for noninfectious and infectious complications of the hemodialysis access decline over time with all access types and suggest that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure.