Arteriovenous fistula use is associated with lower cardiovascular mortality compared with catheter use among ESRD patients

Impact of prepared vascular access on mortality and medical expenses in elderly and non-elderly Japanese patients with chronic kidney disease stage G5: a retrospective cohort study

BACKGROUND

Patients with chronic kidney disease (CKD) stage 5 (CKDG5) have greater dialysis requirements that increase the risk of cardiovascular disease and mortality. The elevated costs associated with CKDG5 are a serious concern. The impact of prepared vascular access (VA) through planned VA creation on mortality and medical expenses remains unclear in Japanese patients with CKDG5.

METHODS

We conducted a retrospective cohort study including 157 patients with CKD who started hemodialysis (HD) at Shinshu University Hospital from April 2016 to March 2021 and assessed the relationship between the presence of a prepared VA and mortality and hospitalization expenses in elderly and non-elderly patients with CKDG5.

RESULTS

The presence of a prepared VA was associated with lower mortality in non-elderly patients but not in elderly patients. Medical expenses, emergency HD, and hospitalization duration were significantly lower in patients with a prepared VA in both age groups. The contribution of a prepared VA to mortality and medical expenses remained consistent after adjusting for sex, performance status, comorbidities, and nutritional status.

CONCLUSION

A prepared VA showed several benefits, including lower mortality rates and hospitalization costs; shorter hospital stays; and higher home discharge rates. Planned VA creation was significantly associated with lower hospitalization expenses, irrespective of age.

Associations between initial dialysis access types and death from dialysis withdrawal in incident patients with kidney failure

Background

Patients receiving haemodialysis via a central venous catheter (HD-CVC) have been shown to have an increased risk of all-cause mortality. It is unclear whether death from dialysis withdrawal is associated with the high mortality risk observed in patients initiated on HD-CVC.

Methods

Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the association between initial dialysis access [HD-CVC, haemodialysis via arteriovenous fistula (HD-AVF), and peritoneal dialysis (PD) via PD catheter (PD-PDC)] and death from dialysis withdrawal in adult patients starting dialysis in Australia between 2005 and 2022, analysed by time-stratified adjusted Cox regression with propensity score-matched cohorts.

Results

Of 47 412 incident patients followed for a median of 2.65 years (interquartile range 1.19-4.87), 8170 (17%) died from dialysis withdrawal. Compared with patients initiated on HD-AVF, patients initiated on HD-CVC were more likely to experience death from dialysis withdrawal in the first 3 years after dialysis initiation, but not after 3 years [adjusted hazard ratios 2.43 (95% confidence interval 1.95-3.02), 2.06 (1.67-2.53), 1.57 (1.40-1.76), and 1.06 (0.97-1.15) for 0-6 months, >6-12 months, >1-3 years, and >3 years after dialysis initiation, respectively]. Comparison between patients initiated on HD-CVD and PD-PDC showed similar estimates. No difference in withdrawal risk was observed between patients initiated on HD-AVF and PD-PDC.

Conclusions

Patients initiated on HD-CVC were twice as likely to experience early death from dialysis withdrawal compared with patients who had initiated dialysis with HD-AVF or PD-PDC. The increased risks diminished over time and were not observed after 3 years on dialysis.

The effects of hemodialysis on the cardiovascular system

Chronic kidney disease and dialysis-dependent end-stage renal disease are increasing in prevalence in the United States. The costs associated with end-stage renal disease management comprise approximately 1% of the federal government's annual budget. Chronic kidney disease and end-stage renal disease cause significant derangements of the cardiac and vascular system. Pathophysiologic hallmarks include alterations of the renin-angiotensin system, chronically increased sympathetic tone, calcium and phosphate imbalance, pro-inflammatory cytokine release, and uremic toxin accumulation. This results in several pathologies specific to the cardiac and vascular systems, which will each be reviewed separately herein.

Arteriovenous fistula for haemodialysis as a predictor of de novo heart failure in kidney transplant recipients

Background

The haemodynamic effects of a functioning haemodialysis arteriovenous fistula (AVF) can cause or exacerbate heart failure (HF). We investigated whether the presence of an AVF at the time of kidney transplant (KT) is associated with de novo HF.

Methods

This was an observational cohort study including adult patients who received a KT in the West of Scotland between 2010 and 2020. We evaluated the risk and associations of pretransplant factors with de novo HF, alone and as a composite cardiovascular (CV) outcome (including non-fatal myocardial infarction, non-fatal stroke, de novo HF and CV death). Multivariable proportional hazards regression and sensitivity analyses were used to identify independent correlates of the outcomes.

Results

Among 1330 included patients, the incident rate of de novo HF after transplantation was 58/1000 person-years [95% confidence interval (CI) 50-67] in AVF patients (n = 716) compared with 33/1000 person-years (95% CI 27-41) in non-AVF patients (n = 614). De novo HF was associated with the presence of an AVF [adjusted hazard ratio (aHR) 2.14 (95% CI 1.40-3.26)], duration of dialysis [aHR 1.03/year increase (95% CI 1.01-1.04)], age at transplant [aHR 1.03/year increase (95% CI 1.02-1.05)], female sex [aHR 1.93 (95% CI 1.40-2.65)] and pretransplant diabetes [aHR 2.43 (95% CI 1.48-4.01)]. The presence of an AVF was also associated with the composite CV outcome [aHR 1.91 (95% CI 1.31-2.78)].

Conclusions

The presence of an AVF may be an underrecognized modifiable predictor of de novo HF posttransplantation.

Arteriovenous Fistula-induced Cardiac Remodeling Shows Cardioprotective Features in Mice

Objective

Arteriovenous fistulae (AVF) placed for hemodialysis have high flow rates that can stimulate left ventricular (LV) hypertrophy. LV hypertrophy generally portends poor cardiac outcomes, yet clinical studies point to superior cardiac-specific outcomes for patients with AVF when compared with other dialysis modalities. We hypothesize that AVF induce physiologic cardiac hypertrophy with cardioprotective features.

Methods

We treated 9- to 11-week-old C57Bl/6 male and female mice with sham laparotomy or an aortocaval fistula via a 25G needle. Cardiac chamber size and function were assessed with serial echocardiography, and cardiac computed tomography angiography. Hearts were harvested at 5 weeks postoperatively, and the collagen content was assessed with Masson's trichrome. Bulk messenger RNA sequencing was performed from LV of sham and AVF mice at 10 days. Differentially expressed genes were analyzed using Ingenuity Pathway Analysis (Qiagen) to identify affected pathways and predict downstream biological effects.

Results

Mice with AVF had similar body weight and wet lung mass, but increased cardiac mass compared with sham-operated mice. AVF increased cardiac output while preserving LV systolic and diastolic function, as well as indices of right heart function; all four cardiac chambers were enlarged, with a slight decrement in the relative LV wall thickness. Histology showed preserved collagen density within each of the four chambers without areas of fibrosis. RNA sequencing captured 19 384 genes, of which 857 were significantly differentially expressed, including transcripts from extracellular matrix-related genes, ion channels, metabolism, and cardiac fetal genes. The top upstream regulatory molecules predicted include activation of angiogenic (Vegf, Akt1), procardiomyocyte survival (Hgf, Foxm1, Erbb2, Lin9, Areg), and inflammation-related (CSF2, Tgfb1, TNF, Ifng, Ccr2, IL6) genes, as well as the inactivation of cardiomyocyte antiproliferative factors (Cdkn1a, FoxO3, α-catenin). The predicted downstream effects include a decrease in heart damage, and increased arrhythmia, angiogenesis, and cardiogenesis. There were no significant sex-dependent differences in the AVF-stimulated cardiac adaptation.

Conclusions

AVF stimulate adaptive cardiac hypertrophy in wild-type mice without heart failure or pathologic fibrosis. Transcriptional correlates suggest AVF-induced cardiac remodeling has some cardioprotective, although also arrhythmogenic features. (JVS–Vascular Science 2021;2:110-28.)

Clinical Relevance

Arteriovenous fistulae (AVF) are commonly used as access for hemodialysis in patients with end-stage renal disease. AVF induce a high-output state that is associated with long-term structural cardiac remodeling, including left ventricle hypertrophy, but this element has uncertain clinical significance. Although left ventricle hypertrophy has traditionally been associated with an increased risk of cardiovascular disease, clinical studies have suggested that cardiac-specific outcomes of patients with end-stage renal disease were better with AVF compared with other dialysis modalities. This study uses a mouse model of AVF to study the structural, functional, and molecular correlates of AVF-induced cardiac remodeling. It finds that AVF causes an adaptive cardiac hypertrophy without functional decline or fibrosis. Transcriptional correlates suggest an electrical remodeling and the upregulation of proangiogenic, procardiogenic, and prosurvival factors, implying that AVF-induced cardiac hypertrophy is potentially cardioprotective, but also arrhythmogenic.

Detecting the prevalence of bacterial colonization on tunneled cuffed hemodialysis catheters using quantitative PCR targeting 16S rRNA and scanning electron microscopy

BACKGROUND AND OBJECTIVES

Tunneled cuffed hemodialysis catheters (TCC) get colonized by microorganisms, increasing risk for catheter related bacteremia (CRB). Our objective was to detect the prevalence of bacterial colonization of TCC by using quantitative PCR (qPCR) targeting 16S rRNA and by determining the intraluminal adherent biological material (ABM) coverage.

METHODS

A total of 45 TCC were investigated. The 16S rRNA qPCR technique was used to detect bacterial colonization after scraping the intraluminal ABM. Proximal, middle, and distal TCC were evaluated by scanning electron microscopy (SEM) to determine the percentage (%) of intraluminal ABM coverage. All catheters were cultured following sonication.

RESULTS

A total of 45 TCC were removed: 7 due to CRB, 3 for suspected CRB and 35 were removed for non-infectious etiologies. Bacterial colonization was detected in 27 TCC by documenting 16S rRNA qPCR (+) results (60%). Seven of these 16S rRNA qPCR (+) catheters were removed due to CRB. There was no difference in demographic, clinical, or laboratory values between the 16S rRNA (+) versus (-) TCC. The 16S rRNA qPCR (-) outcome was highly associated with CRB-free status with negative predictive value of 100%. Bacterial colonization was documented in 10 TCC using catheter cultures (22%), which was significantly less compared to qPCR method (p = 0.0002). ABM were detected in all catheter pieces, with mean intraluminal surface coverage (ABMC) of 68.4 ± 26.1%. ABM was unlikely to be microbial biofilm in at least 36% of removed TCC as their 16S rRNA qPCR and catheter culture results were both negative.

CONCLUSIONS

Detecting bacterial colonization of TCC was significantly higher with 16S rRNA qPCR compared to catheter cultures. The 16S rRNA qPCR (-) cannot be predicted and was strongly associated with absence of CRB. Intraluminal ABM was not associated with microbial presence in about 1/3 of the TCC. These pieces of evidence may help to improve prophylactic strategies against CRB.

The survival analysis of tunnel-cuffed central venous catheter versus arteriovenous hemodialysis access among elderly patients: A retrospective single center study

BACKGROUND

There is currently a controversy for the optimal vascular access option in the elderly, regarding their multiple comorbidities and life expectancies. Our study aimed to compare the survival of tunneled cuff venous catheter (CVC) and arteriovenous access (AV access) in elderly patients.

METHODS

A retrospective cohort study was performed by electronic medical record review. All hemodialysis patients aged 65 years and over who firstly initiated dialysis from January 1, 2012 to December 31, 2016 at Siriraj hospital, Thailand, were included. The primary outcomes are to compare a 2-year period of survival between CVC and AV access in terms of abandonment, death, and combined outcome. Propensity score covariate and Charlson Comorbidity Score (CCI) were used for multivariable analysis adjustment.

RESULTS

A total of 359 patients were included; 216 (60.2%) patients had initiated hemodialysis via CVC while the rest used AV access. The patients' average ages were 76.7 ± 7.0 and 74.0 ± 5.8 years (p-value<0.001) in the CVC and AV access group, respectively. The 2-year mortality rates of CVC and AV access groups were 24.1% and 15.4%, respectively (p-value = 0.038). Multivariable analyses showed that the adjusted hazard ratio (aHR) of combined endpoints, i.e., vascular access abandonment and death, was statistically different only in the CCI-adjusted model (aHR = 0.68, 95% CI: 0.46-0.99). Mortality from infection cause was more common in the CVC group than the AV access group.

CONCLUSION

CVC access maybe considers an alternative option for frail elderly patients. However, the patient selection is a crucial issue, given higher infection-related mortality in patients using CVC.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Self-management, self-efficacy and knowledge among patients under haemodialysis: a case in Iran

BACKGROUND

Promotion of self-management is one of the effective ways to improve the quality of life of patients under haemodialysis. Therefore, a better understanding of the factors that are effective on self-management might help nurses find an appropriate method for the promotion of self-management.

AIMS

This study aimed to examine self-management and its correlation with self-efficacy and knowledge of haemodialysis among patients under haemodialysis in Yazd, Iran in 2016.

METHODS

This is a cross-sectional study conducted in four haemodialysis centres. All patients who were referred to these centres were selected. Demographic characteristic forms, self-management questionnaires, haemodialysis knowledge questionnaires and chronic diseases self-efficacy scales were used to collect data.

RESULTS

The score of self-management was between 32 and 80. The mean scores of self-management, knowledge and self-efficacy were 58.88 ± 10.41 (possible score 20-80), 16.15 ± 2.91 (possible score 0-25), 5.24 ± 1.99 (possible score 0-10), respectively. There was a significant positive correlation among self-management, knowledge and self-efficacy.

CONCLUSIONS

The level of self-management was moderate among patients under haemodialysis. Effective interventions including training related to dialysis system, laboratory tests and diet are needed to improve self-management among patients under haemodialysis.

Effects of hemodialysis access type on right heart geometry in adolescents

INTRODUCTION

This study aimed to investigate the complication frequency and the changes in right heart geometry with different access types in the pediatric population.

METHODS

We included 32 consecutive patients aged between 10 and 19 and who underwent hemodialysis sessions via permanent hemodialysis catheter (n_HC = 18) or arterio-venous fistula (n_AVF = 14) between January 2013 and March 2018. We recorded and compared the complication frequency and the changes in echocardiography findings with different access types.

FINDINGS

Demographic data were similar in both groups. Number of new access creation (n_HC = 15 vs n_AVF = 1) and all complications (n_HC = 19 vs n_AVF = 6) were significantly higher in hemodialysis catheter group and the statistical analysis showed the superiority of arterio-venous fistula group in comparison of event-free survival (event-free patients; n_AVF = 8 (57%), n_HC = 3 (16%); p = 0.02). Control echocardiography showed impressive delta-change in right atrium diameter (p = 0.04), right ventricular end-diastolic volume (p = 0.004), right ventricular end-systolic volume (p < 0.001), and right ventricular free wall thickness (p = 0.009) in arterio-venous fistula group, but no significant difference between two groups in terms of delta-change of right ventricular ejection fraction (p = 0.35), fractional area change (p = 0.21), and tricuspid annular plane systolic excursion (p = 0.13) parameters.

CONCLUSION

Arterio-venous fistula has lower risk of complications, but overloading stress on right heart chambers triggers remodeling process and geometrical changes, which can be early pieces of evidence of delayed right heart dysfunction in pediatric hemodialysis patients.

Survival comparison between superficialization of the brachial artery and tunneled central venous catheter placement in hemodialysis patients with heart failure: A retrospective study

It remains unclear which vascular access provides better survival in hemodialysis patients with heart failure, superficialization of the brachial artery (SBA), or tunneled central venous catheter (TCVC). We retrospectively followed up 60 hemodialysis patients with heart failure who underwent SBA (n = 36) or TCVC placement (n = 24). During the median 2.2-year follow-up period, 36 patients died. The median survival time was significantly longer for the SBA group than for the TCVC group (5.7 vs 1.7 years; P < .05, log-rank test). A multivariate-adjusted Cox regression analysis showed that SBA was associated with a reduced risk of all-cause death (hazard ratio [HR] 0.30; 95% confidence interval [CI] 0.14-0.65). In the cohort of propensity score-matched 15 pairs, patients with SBA experienced fewer all-cause deaths (HR 0.29; 95% CI 0.10-0.77). Our study suggests that SBA is an alternative option in hemodialysis patients with heart failure.

Association Between Type of Vascular Access Used in Hemodialysis Patients and Subsequent Kidney Transplant Outcomes

RATIONALE & OBJECTIVE

Vascular access type (arteriovenous fistula [AVF] vs arteriovenous graft [AVG] vs central venous catheter [CVC]) associates with clinical outcomes in patients with end-stage kidney disease undergoing hemodialysis. Whether a similar association exists with outcomes after kidney transplantation is unknown. We hypothesized that AVGs would associate with worse outcomes, perhaps owing to persistent subclinical inflammation.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using US registry data merged with electronic health records of a large dialysis organization (2006-2011), we selected patients receiving a first-ever kidney transplant after undergoing more than 30 days of hemodialysis.

EXPOSURE

Hemodialysis access used during the patient's last pretransplantation hemodialysis session.

OUTCOMES

Patients were followed up from kidney transplantation for all-cause mortality, kidney allograft loss from any cause, and allograft loss not from death.

ANALYTICAL APPROACH

Time-to-event analysis including Kaplan-Meier plots and Cox proportional hazards regression estimated cause-specific HRs and 95% CIs.

RESULTS

Among 9,291 patients who underwent kidney transplantation between 2006 and 2011, a total of 65.3% used an AVF, 20.4% used an AVG, and 14.3% used a CVC for hemodialysis before transplantation. Multivariable regression models adjusted for demographic variables, comorbid conditions, transplant characteristics, and laboratory parameters identified no independent associations between vascular access type and all-cause mortality (HRAVG, 1.13 [95% CI, 0.97-1.33]; HRCVC, 1.00 [95% CI, 0.83-1.21]). Similarly, AVG and CVC use were not independently associated with all-cause allograft loss compared with AVF use (HRAVG, 1.13 [95% CI, 1.00-1.28]; HRCVC, 1.12 [95% CI, 0.96-1.29]). CVC use was associated with 30% higher risk for allograft loss from causes other than death compared with AVF use (HRCVC, 1.30 [95% CI, 1.06-1.57]), but AVGs were not (HRAVG, 1.17 [95% CI, 0.98-1.39]).

LIMITATIONS

Nonrandomized exposure leading to potential residual confounding.

CONCLUSIONS

No association was found for AVG use before kidney transplantation with mortality, all-cause allograft loss, and allograft loss from all causes other than death, compared with AVF use. The association of CVC use with allograft loss from causes other than death requires further investigation.

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.

Should a fistula first policy be revisited in elderly haemodialysis patients?

Life-sustaining haemodialysis requires a durable vascular access (VA) to the circulatory system. The ideal permanent VA must provide longevity for use with minimal complication rate and supply sufficient blood flow to deliver the prescribed dialysis dosage. Arteriovenous fistulas (AVFs) have been endorsed by many professional societies as the VA of choice. However, the high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and arterial hypertension in elderly people, usually make VA creation more difficult in the elderly. Many of these patients may have an insufficient vasculature for AVF maturation. Furthermore, many AVFs created prior to the initiation of haemodialysis may never be used due to the competing risk of death before dialysis is required. As such, an arteriovenous graft and, in some cases, a central venous catheter, become a valid alternative form of VA. Consequently, there are multiple decision points that require careful reflection before an AVF is placed in the elderly. The traditional metrics of access patency, failure and infection are now being seen in a broader context that includes procedure burden, quality of life, patient preferences, morbidity, mortality and cost. This article of the European Dialysis (EUDIAL) Working Group of ERA-EDTA critically reviews the current evidence on VA in elderly haemodialysis patients and concludes that a pragmatic patient-centred approach is mandatory, thus considering the possibility that the AVF first approach should not be an absolute.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Hemodialysis-induced cardiovascular disease

More than half of all deaths among end stage renal disease (ESRD) patients are due to cardiovascular disease (CVD). Cardiovascular changes secondary to renal dysfunction, including fluid overload, uremic cardiomyopathy, secondary hyperparathyroidism, anemia, altered lipid metabolism, and accumulation of gut microbiota-derived uremic toxins like trimethylamine N-oxidase, contribute to the high risk for CVD in the ESRD population. In addition, conventional hemodialysis (HD) itself poses myocardial stress and injury on the already compromised cardiovascular system in uremic patients. This review will provide an overview of cardiovascular changes in chronic kidney disease and ESRD, a description of reported mechanisms for HD-induced myocardial injury, comparison of HD with other treatment modalities in the context of CVD, and possible management strategies.

Prevalence and correlates of central venous catheter use among haemodialysis patients in the Irish health system - a national study

Background

Central venous catheters (CVC) are associated with substantial morbidity and mortality among patients undergoing haemodialysis (HD), yet they are frequently used as the primary vascular access for many patients on HD. The goal of this study was to determine the prevalence and variation in CVC use across centres in the Irish health system.

Methods

Data from the National Kidney Disease Clinical Patient Management System (KDCPMS) was used to determine CVC use and patterns across centres. Data on demographic characteristics, primary cause of end-stage kidney disease (ESKD), comorbid conditions, laboratory values and centre affiliation were extracted for adult HD patients (n = 1, 196) who were on dialysis for at least three months up to end of December 2016. Correlates of CVC use were explored using multivariable logistic regression.

Results

Overall prevalence of CVC use was 54% and varied significantly across clinical sites from 43% to 73%, P < 0.001. In multivariate analysis, the likelihood of CVC use was lower with increasing dialysis vintage, OR 0.40 (0.26–0.60) for 4 years vs 1 year vintage, rising serum albumin, OR 0.73 (0.59–0.90) per 5 g/L), and with cystic disease as a cause of ESKD, OR 0.38 (95% CI 0.21–0.6). In contrast, catheter use was greater for women than men, OR 1.77 (1.34–2.34) and for 2 out of 10 regional dialysis centres, OR 1.98 (1.02–3.84) and OR 2.86 (1.67–4.90) respectively compared to referent group).

Conclusions

Catheters are the predominant type of vascular access in patients undergoing HD in the Irish health system. Substantial centre variation exists which is not explained by patient-level characteristics.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0873-x) contains supplementary material, which is available to authorized users.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery

Background

The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow.

Methods

A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause.

Results

The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months. Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group.

Conclusions

In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Race and contrast-induced nephropathy in patients undergoing coronary angiography and cardiac catheterization

Contrast-induced nephropathy (CIN) is an acute worsening of renal function after receiving intravascular contrast during a procedure. Some of the predisposing factors include underlying diabetes, chronic kidney disease, congestive heart failure, periprocedural hypotension, anemia, contrast volume, and osmolality of contrast; however, it remains unclear if risk varies for CIN with race and ethnicity. There is evidence in the literature showing the link between race/ethnicity and the discrepancies in the utilization of preventive care services and the resources related to cardiovascular and renal health. While these disparities continue to exist and affect some of the predictors of CIN, this review will explore the extent to which race and ethnicity directly affect CIN.

Cardiovascular impact in patients undergoing maintenance hemodialysis: Clinical management considerations

Patients undergoing maintenance hemodialysis develop both structural and functional cardiovascular abnormalities. Despite improvement of dialysis technology, cardiovascular mortality of this population remains high. The pathophysiological mechanisms of these changes are complex and not well understood. It has been postulated that several non-traditional, uremic-related risk factors, especially the long-term uremic state, which may affect the cardiovascular system. There are many cardiovascular changes that occur in chronic kidney disease including left ventricular hypertrophy, myocardial fibrosis, microvascular disease, accelerated atherosclerosis and arteriosclerosis. These structural and functional changes in patients receiving chronic dialysis make them more susceptible to myocardial ischemia. Hemodialysis itself may adversely affect the cardiovascular system due to non-physiologic fluid removal, leading to hemodynamic instability and initiation of systemic inflammation. In the past decade there has been growing awareness that pathophysiological mechanisms cause cardiovascular dysfunction in patients on chronic dialysis, and there are now pharmacological and non-pharmacological therapies that may improve the poor quality of life and high mortality rate that these patients experience.

The impact of haemodialysis arteriovenous fistula on haemodynamic parameters of the cardiovascular system

BACKGROUND

Satisfactory vascular access flow (Qa) of an arteriovenous fistula (AVF) is necessary for haemodialysis (HD) adequacy. The aim of the present study was to further our understanding of haemodynamic modifications of the cardiovascular system of HD patients associated with an AVF. The main objective was to calculate using real data in what way an AVF influences the load of the left ventricle (LLV).

METHODS

All HD patients treated in our dialysis unit and bearing an AVF were enrolled into the present observational cross-sectional study. Fifty-six patients bore a lower arm AVF and 30 an upper arm AVF. Qa and cardiac output (CO) were measured by means of the ultrasound dilution Transonic Hemodialysis Monitor HD02. Mean arterial pressure (MAP) was calculated; total peripheral vascular resistance (TPVR) was calculated as MAP/CO; resistance of AVF (AR) and systemic vascular resistance (SVR) are connected in parallel and were respectively calculated as AR = MAP/Qa and SVR = MAP/(CO - Qa). LLV was calculated on the principle of a simple physical model: LLV (watt) = TPVR·CO(2). The latter was computationally divided into the part spent to run Qa through the AVF (LLVAVF) and that part ensuring the flow (CO - Qa) through the vascular system. The data from the 86 AVFs were analysed by categorizing them into lower and upper arm AVFs.

RESULTS

Mean Qa, CO, MAP, TPVR, LLV and LLVAVF of the 86 AVFs were, respectively, 1.3 (0.6 SD) L/min, 6.3 (1.3) L/min, 92.7 (13.9) mmHg, 14.9 (3.9) mmHg·min/L, 1.3 (0.6) watt and 19.7 (3.1)% of LLV. A statistically significant increase of Qa, CO, LLV and LLVAVF and a statistically significant decrease of TPVR, AR and SVR of upper arm AVFs compared with lower arm AVFs was shown. A third-order polynomial regression model best fitted the relationship between Qa and LLV for the entire cohort (R (2) = 0.546; P < 0.0001) and for both lower (R (2) = 0.181; P < 0.01) and upper arm AVFs (R (2) = 0.663; P < 0.0001). LLVAVF calculated as % of LLV rose with increasing Qa according to a quadratic polynomial regression model, but only in lower arm AVFs. On the contrary, no statistically significant relationship was found between the two parameters in upper arm AVFs, even if mean LLVAVF was statistically significantly higher in upper arm AVFs (P < 0.0001).

CONCLUSIONS

Our observational cross-sectional study describes statistically significant haemodynamic modifications of the CV system associated to an AVF. Moreover, a quadratic polynomial regression model best fits the relationship between LLVAVF and Qa, but only in lower arm AVFs.

We Perform Surveillance for Arteriovenous Graft Stenosis

Successful hemodialysis is dependent on high unimpeded blood flow. Arteriovenous grafts are notorious for access stenosis, a precursor for access thrombosis. Access surveillance techniques are available and in observational studies have been superior to clinical monitoring for the detection of access stenosis and subsequent prevention of thrombosis in arteriovenous grafts. However, in prospective randomized controlled studies, these surveillance techniques have not been superior to clinical monitoring in reducing access thrombosis and or prolonging access survival. Presently, routine surveillance should not be performed until it can be proven to be effective at prolonging thrombosis free graft survival.

Systemic Effects of Hemodialysis Access

Patients with advanced chronic kidney disease are at a high risk of cardiovascular events. Patients with end-stage renal disease have a particularly high morbidity and mortality, in part attributed to the complications and dysfunction related to vascular access in this population. Creation of an arteriovenous access for HD is considered standard of care for most patients and has distinct advantages including less likelihood of infections, less need for intervention, and positive impact on survival as compared with usage of a catheter. However, creation of an arteriovenous shunt incites a series of events that significantly impacts cardiovascular and neurohormonal health in both positive and negative ways. This article will review the short- and long-term effects of dialysis access on cardiovascular, neurohormonal, and pulmonary systems as well as a brief review of their effect on survival on HD. Presence of other comorbidities in a patient with dialysis access can amplify these effects, and these considerations are of paramount importance in individualizing the approach to not only the choice of vascular access but also the modality of kidney replacement therapy.

Effect of the arteriovenous access for hemodialysis on subendocardial viability ratio, pulse pressure and hospitalizations

BACKGROUND

In some patients the potential benefits of the arteriovenous (AV) access over catheter for hemodialysis seem to be outweighed by global cardiovascular status deterioration.

METHODS

We prospectively evaluated 44 pre-dialysis chronic kidney disease patients submitted to vascular access creation during a follow-up of 25 ± 9 months. We performed pulse wave analysis and biochemical assessment before and 2 months after AV access construction, and we registered premature vascular access thrombosis, and all-cause and cardiovascular hospitalizations throughout follow-up.

RESULTS

We found a statistically significant decrease in the subendocardial viability ratio (SEVR) and pulse pressure (PP) parameters after AV access creation while brain natriuretic peptide significantly increased. Receiver operating characteristic curve analysis identified SEVR ≤113 % evaluated 2 months after vascular access construction as the best cutoff value for predicting all-cause and cardiovascular hospitalizations. Kaplan-Meier analysis showed that a SEVR ≤113 % was associated with all-cause (p = 0.010) and cardiovascular (p = 0.029) hospitalizations; Cox regression analysis verified a 4.9-fold higher risk of all-cause hospitalization in patients with SEVR ≤113 % (p = 0.005).

CONCLUSION

To our best knowledge, this report indicates, for the first time, that despite the decrease in PP parameters, the creation of a vascular access for hemodialysis was also associated with a reduction of SEVR which predicted a worse clinical outcome. We argue that the decrease of pulse pressure after arteriovenous construction may reflect a new hemodynamic set-point after vascular access creation and may not indicate a protective cardiovascular effect.

Creation of an iliac arteriovenous shunt lowers blood pressure in chronic obstructive pulmonary disease patients with hypertension

OBJECTIVE

Vasodilators are used with caution in patients with chronic obstructive pulmonary disease (COPD). We have developed a device for percutaneous arteriovenous shunt creation in the iliac region to increase cardiac output and oxygen delivery for patients with COPD. Although this device does not cause significant blood pressure changes in normotensive patients with COPD, we hypothesized that arteriovenous shunt creation might cause vasodilator effects in hypertensive patients because of a reduction in vascular resistance.

METHODS

Twenty-four patients with COPD and hypertension enrolled in an open label study of arteriovenous shunt creation for COPD. We performed cardiac catheterization at baseline and again 3 to 6 months after the procedure. As a safety measure we also recorded office blood pressure at baseline and again after 3, 6, 9, and 12 months.

RESULTS

The procedure increased oxygen delivery (1.1-1.4 L.min(-1)) and cardiac output (6-8.2 L.min(-1)) (P < .001) and lowered both the systemic vascular resistance (P < .001) and the pulmonary vascular resistance (P < .01). After 12 months, however, the average systolic blood pressure was reduced from 145 to 132 mm Hg (P < .0001), and the average diastolic blood pressure was reduced from 86 to 67 mm Hg (P < .0001).

CONCLUSIONS

Percutaneous iliac arteriovenous fistula creation for COPD causes a significant and persistent lowering of blood pressure in patients with co-existing hypertension.

Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities

BACKGROUND

Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously.

STUDY DESIGN

Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics.

SETTING & PARTICIPANTS

4,800 US hemodialysis facilities in the 2009 Centers for Medicare & Medicaid (CMS) End-Stage Renal Disease Annual Facility Survey (CMS-2744 form).

PREDICTORS

Facility characteristics, including profit status, freestanding status, chain affiliation, and geographic region, adjusted for facility size, capacity, functional type, and urbanicity.

OUTCOMES

Patient care staffing levels, including ratios of RNs, licensed practical nurses (LPNs), patient care technicians (PCTs), composite staff (RN + LPN + PCT), social workers, and dietitians to in-center hemodialysis patients.

RESULTS

After adjusting for background facility characteristics, ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively). Regionally, compared to the Northeast, the adjusted RN to patient ratio was 14% (P < 0.001) lower in the Midwest, 25% (P < 0.001) lower in the South, and 18% (P < 0.001) lower in the West. Even after additional adjustments, the large for-profit chains had significantly lower RN and LPN to patient ratios than the largest nonprofit chain, but a significantly higher PCT to patient ratio. Overall composite staffing levels also were lower in for-profit and chain-affiliated facilities. The patterns hold when hospital-based units were excluded.

LIMITATIONS

Nursing hours were not available. Two part-time staff were counted as one full-time equivalent, which may not always be accurate.

CONCLUSIONS

The significant variation in patient care staffing levels and its associations with facility characteristics warrants inclusion in future large-scale hemodialysis outcomes studies. End-stage renal disease networks and hemodialysis facilities should attend to quality assurance and performance improvement initiatives that maximize licensed nurse staffing levels in hemodialysis facilities.

Factors associated with self-management by people undergoing hemodialysis: a descriptive study

BACKGROUND

Improving the level of self-management by people undergoing hemodialysis is an effective way to reduce the incidence of mortality and complications and improve quality of life. A better understanding of what influences an individual's level of self-management can help nurses find appropriate ways to improve self-management.

OBJECTIVES

To examine self-management levels, and discuss the factors influencing self-management, in a sample of patients undergoing hemodialysis in Beijing.

DESIGN

A descriptive study design was chosen.

SETTINGS AND METHODS

A convenience sample of 216 patients undergoing hemodialysis was recruited from dialysis centers in three tertiary hospitals in Beijing from September 2010 to January 2011. Questionnaires were used to examine the variables: level of self-management; knowledge of hemodialysis; self-efficacy; anxiety and depression; and social support. Data analysis involved descriptive statistics, including frequency, percentage, mean and standard deviations, while Spearman correlation, non-parametric Z and χ(2) and multiple linear regression were used for comparative purposes.

RESULTS

The number of returned questionnaires was 198 (91.67% response rate). The overall score of self-management was 56.01 (SD=10.75). The average item scores for each of the four self-management subscales were 3.02 for partnership, 2.98 for problem-solving skills, 2.74 for self-care and 2.47 for emotional management. Multiple linear regression analyses for overall self-management and the four subscales indicated that knowledge, self-efficacy, the availability of social support and depression were the main influencing factors which explained 34.1% of the variance of self-management.

CONCLUSION

The level of self-management by those undergoing hemodialysis in this study was less than ideal, varying from 'rare' to 'sometimes' for use of self-management behaviors. For the different subscales of self-management, partnership was the most used and emotional management the least used strategy. Patients' knowledge, self-efficacy, the availability of social support and depression were the main factors influencing self-management.

High-output heart failure: how to define it, when to treat it, and how to treat it

Although hemodialysis patients who initiate and maintain a permanent form of dialysis vascular access have improved all-cause and cardiovascular survival compared with those who use catheters, the presence of an arteriovenous fistula has been shown to have a short-term, adverse effect on cardiac function. Through its effect as a left-to-right extracardiac shunt, the arteriovenous fistula can increase cardiac workload substantially, and, in certain patients, result in a high-output state and resultant heart failure over time. Here we review the mechanisms by which dialysis arteriovenous access may promote the development of high-output cardiac failure in end-stage renal disease patients, describe risk factors for and the diagnosis of high-output heart failure, and suggest management strategies for patients who develop high-output heart failure.

Hemodialysis patient preference for type of vascular access: variation and predictors across countries in the DOPPS

PURPOSE

Catheters are associated with worse clinical outcomes than fistulas and grafts in hemodialysis (HD) patients. One potential modifier of patient vascular access (VA) use is patient preference for a particular VA type. The purpose of this study is to identify predictors of patient VA preference that could be used to improve patient care.

METHODS

This study uses a cross-sectional sample of data from the Dialysis Outcomes and Practice Patterns Study (DOPPS 3, 2005-09), that includes 3815 HD patients from 224 facilities in 12 countries. Using multivariable models we measured associations between patient demographic and clinical characteristics, previous catheter use and patient preference for a catheter.

RESULTS

Patient preference for a catheter varied across countries, ranging from 1% of HD patients in Japan and 18% in the United States, to 42% to 44% in Belgium and Canada. Preference for a catheter was positively associated with age (adjusted odds ratio per 10 years=1.14; 95% CI=1.02-1.26), female sex (OR 1.49; 95% CI=1.15-1.93), and former (OR=2.61; 95% CI=1.66-4.12) or current catheter use (OR=60.3; 95% CI=36.5-99.8); catheter preference was inversely associated with time on dialysis (OR per three years=0.90; 95% CI=0.82-0.97).

CONCLUSIONS

Considerable variation in patient VA preference was observed across countries, suggesting that patient VA preference may be influenced by sociocultural factors and thus could be modifiable. Catheter preference was greatest among current and former catheter users, suggesting that one way to influence patient VA preference may be to avoid catheter use whenever possible.

Associations between hemodialysis access type and clinical outcomes: a systematic review

Clinical practice guidelines recommend an arteriovenous fistula as the preferred vascular access for hemodialysis, but quantitative associations between vascular access type and various clinical outcomes remain controversial. We performed a systematic review of cohort studies to evaluate the associations between type of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) and risk for death, infection, and major cardiovascular events. We searched MEDLINE, EMBASE, and article reference lists and extracted data describing study design, participants, vascular access type, clinical outcomes, and risk for bias. We identified 3965 citations, of which 67 (62 cohort studies comprising 586,337 participants) met our inclusion criteria. In a random effects meta-analysis, compared with persons with fistulas, those individuals using catheters had higher risks for all-cause mortality (risk ratio=1.53, 95% CI=1.41-1.67), fatal infections (2.12, 1.79-2.52), and cardiovascular events (1.38, 1.24-1.54). Similarly, compared with persons with grafts, those individuals using catheters had higher risks for mortality (1.38, 1.25-1.52), fatal infections (1.49, 1.15-1.93), and cardiovascular events (1.26, 1.11-1.43). Compared with persons with fistulas, those individuals with grafts had increased all-cause mortality (1.18, 1.09-1.27) and fatal infection (1.36, 1.17-1.58), but we did not detect a difference in the risk for cardiovascular events (1.07, 0.95-1.21). The risk for bias, especially selection bias, was high. In conclusion, persons using catheters for hemodialysis seem to have the highest risks for death, infections, and cardiovascular events compared with other vascular access types, and patients with usable fistulas have the lowest risk.

Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients

BACKGROUND

Central venous catheters (CVC) are a potential source of bacteraemia and have been associated with increased mortality in haemodialysis patients. We aimed to investigate the relationships between haemodialysis vascular access, taking into account changes in vascular access type during patients' lives, and cause specific mortality risk in a national cohort of dialysis patients.

METHODS

Prospective cohort study including all patients receiving haemodialysis in Scotland at annual cross sectional surveys in 2009, 2010 and 2011. Data were collected through the Scottish Renal Registry and by a structured review of case records following death. Cox proportional hazards regression and multivariable logistic regression were used to model survival and risk of death from septicaemia respectively.

RESULTS

Of a cohort of 2666 patients, 873 (32%) died during follow-up. After case-mix adjustment, patients using only tunnelled CVC during follow-up had a higher risk of all cause mortality across all strata of prior renal replacement therapy exposure [adjusted hazard ratio (HR): 1.83-2.08]. Case-mix adjusted risks of cardiovascular death (adjusted HR: 2.20-2.95) and infection-related death (adjusted HR: 3.10-3.63) were also higher in this group. Patients using tunnelled CVCs during follow-up and prior to death had 6.9-fold higher odds of death from septicaemia compared with those using only arteriovenous fistulae or grafts.

CONCLUSION

Compared with an arteriovenous fistula or graft, sustained use of tunnelled CVCs for vascular access is associated with higher risks of all-cause, cardiovascular and infection-related mortality.

Influence of vascular access type on sex and ethnicity-related mortality in hemodialysis-dependent patients

OBJECTIVES

To determine whether sex- and ethnicity-based mortality differences in patients dependent on hemodialysis (hemodialysis patients) are because of prevalence of vascular access type.

METHODS

Southern California Permanente Medical Group Renal Database, which contained 5821 chronic hemodialysis patients between 2000 and 2008, was studied.

RESULTS

Mean age of the patients was 62 years, and 59% were male. Of the population, 33% were white; 32%, Hispanic; 23%, African American; 9%, Asian/Pacific Islander; and 3%, other race or ethnicity. Predominant access type over the course of the study was arteriovenous fistula (AVF) in 73%, arteriovenous graft (AVG) in 12%, and tunneled catheter in 14%. There was a higher percentage of AVF in whites (71%) than in African Americans (63%). Risk of death was independently increased by age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.04-1.05), male sex (HR, 1.33; 95% CI, 1.22-1.45), diabetes (HR, 1.22; 95% CI, 1.12-1.33), use of an AVG (HR, 1.51; 95% CI, 1.34-1.71) or a tunneled catheter (HR, 6.45; 95% CI, 5.78-7.20). Compared with whites, African-American race decreased the risk of death (HR, 0.63; 95% CI, 0.56-0.70), as did Asian/Pacific Islander (HR, 0.58; 95% CI, 0.49-0.69), Hispanic (HR, 0.58; 95% CI, 0.51-0.65), and other race (HR, 0.67; 95% CI, 0.52-0.86).

CONCLUSION

Age, sex, race or ethnicity, access type, and diabetes are independent risk factors for mortality in hemodialysis patients. After controlling for potential confounders, when compared with whites, minorities all demonstrate significantly decreased risk of mortality. African Americans had reduced mortality risk despite a lower prevalence of arteriovenous fistula compared with whites. Male sex increased mortality. Differences in mortality between sexes and ethnicities in this population cannot be accounted for by differences in type of dialysis access.

Synthetic vascular hemodialysis access versus native arteriovenous fistula: a cost-utility analysis

OBJECTIVE

To determine the cost-effectiveness of 2 different vascular access strategies among incident dialysis patients.

BACKGROUND

Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications.

METHODS

A decision analysis using a Markov model was implemented to compare 2 different vascular access strategies among incident dialysis patients: (1) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to (2) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA.

RESULTS

Under base case assumptions, the AVF1st strategy yielded 2.19 quality-adjusted life years (QALYs) compared with 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389 per QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater.

CONCLUSION

The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.

Correlation of Mortality and Location of Arteriovenous Fistula in Hemodialysis Patients

Purpose

Since the type of vascular access is very important and a significant risk factor for mortality in patients on hemodialysis, the aim of our study was to determine the impact of AVF positioning on the mortality of our patients.

Methods

The survey was organized as a prospective, clinical and non-randomized study of 538 surgical interventions on 323 patients, which indicates that a large number of patients had more than one fistula. Among these patients, 120 subjects (81 (67.5%) men and 39 (32.5%) women) died during the study period. We analyzed the demographic structure, the site location and type of anastomosis for the arteriovenous fistula, artery and vein lumen and presence of instillation catheters, as well as measuring flow through the fistula and arterial blood pressure. Biochemical parameters thought to have a significant impact on survival were obtained from routine monthly analyses.

Results

In patients in whom infection was the cause of death, termino-terminal anastomosis was more frequently present (p=0.035). Variables that were statistically significant predictors of death were elderly individuals (Beta 0.033, p<0.001); patients whose diastolic blood pressure was low (Beta –0.028, p<0.001); and the position of the arteriovenous fistula (distal Beta –0.737, p=0.001; proximal Beta –0.581, p=0.008). Patients with a cubital fistula (p=0.001) had a significantly shorter Kaplan-Meier survival curve.

Conclusions

End-to-end artery and vein connection was a significantly more common form of anastomosis in patients who died as a result of infection. Important parameters of mortality in our study were the position of the arteriovenous fistula, age, and the diastolic component of arterial blood pressure.

Catheter-related mortality among ESRD patients

Hemodialysis access-related complications remain one of the most important sources of morbidity and cost among persons with end-stage renal disease, with total annual costs exceeding $1 billion annually. In this context, the creation and maintenance of an effective hemodialysis vascular access is essential for safe and adequate hemodialysis therapy. Multiple reports have documented the type of vascular access used for dialysis and associated risk of infection and mortality. Undoubtedly, the central venous catheter (CVC) is associated with the greatest risk of infection-related and all-cause mortality compared with the autogenous arteriovenous fistula (AVF) or synthetic graft (AVG). The AVF has the lowest risk of infection, longer patency rates, greater quality of life, and lower all-cause mortality compared with the AVG or CVC. It is for these reasons that the National Kidney Foundation's Kidney Disease Outcome Quality Initiative Clinical Practice Guidelines for Vascular Access recommend the early placement and use of the AVF among at least 50% of incident hemodialysis patients. This report presents catheter-related mortality and calls for heightened awareness of catheter-related complications.