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Giannikouris IE, Spiliopoulos S, Giannakopoulos T, Katsanos K, Passadakis P, Georgiadis G. Evaluation of arteriovenous fistula maturation and early prediction of clinical eligibility, using ultrasound: The Fistula Maturation Evaluation (FAME) Study. J Vasc Access 2024:11297298241255519. [PMID: 38801003 DOI: 10.1177/11297298241255519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION The study of time-related alterations of ultrasound-determined parameters during maturation, and the assessment of time to hemodynamic maturation, enabling early prediction of clinical eligibility, of hemodialysis autologous arteriovenous fistulae (AVF). METHODS This is an observational, prospective, study of only AVF-eligible patients referred for access creation, from 02/2019 to 02/2022 (ClinicalTrials.gov identifier: NCT0473687). Brachial artery diameter (dBA), access flow volume (FV), non-augmented efferent vein diameter (dEV), resistivity index (RI), and efferent vein total wall thickness (tEV), were assessed by ultrasound. Measurements were conducted daily in the first week and repeated on days 14, 21, 30, 60, and 90, postoperatively. The primary endpoint included the documentation of serial changes of flow and structural parameters related to AVF maturation in the first 90 days of the post-operative period and maturation early prediction. Secondary endpoints included the determination of factors affecting maturation. RESULTS One hundred one participants (mean age, 67 ± 6 years; 76 males) were enrolled. Average dBA and FV reached maximum on day 60 (5.64 ± 0.85 mm) and 90 (1.172 ± 617 mL/min), respectively. Day 7 values of dBA (5.48 ± 0.73 mm) and FV (1.039 ± 531 mL/min) did not alter significantly during the follow-up period. Parameters indicative of clinical functionality, dEV (5.82 ± 0.90 mm) and tEV (0.493 ± 0.10 mm), reached approximately 90% of maximum (6.66 ± 1.42 mm and 0.526 ± 0.11 mm), by day 14. RI reached minimum on day 30 (0.46 ± 0.09), without significant changes after day 2 (0.48 ± 0.09, p = 0.284). A significant correlation was identified, between day 7 FV and day 60 dEV (r = 0.40, p = 0.0002). A FV cut-off value ⩾657.51 mL/min, on day 7, predicted successful fistula maturation with 85% sensitivity and 100% specificity. Multivariate analysis identified female gender, age >75, diabetes, and wrist access as independent predictors of decreased values of maturation parameters. CONCLUSION Hemodynamic maturation is completed by the first postoperative week, while AVF is clinically functional, by the second. FV can be used for early prediction of maturation.
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Affiliation(s)
- Ioannis E Giannikouris
- Department of Nephrology and Hemodialysis Unit, Mediterraneo Hospital, Glyfada, Athens, Attika, Greece
| | - Stavros Spiliopoulos
- 2nd Radiology Department, Division of Interventional Radiology, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Chaidari, Athens, Attika, Greece
| | - Triantafyllos Giannakopoulos
- Department of Vascular and Endovascular Surgery, Mediterranean Hospital of Cyprus, Limassol, Limassol (Lemesos), Cyprus
| | - Konstantinos Katsanos
- Department of Radiology, Health Sciences Division, School of Medicine, University of Patras, Patra, Achaia, Greece
| | - Ploumis Passadakis
- Department of Nephrology, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
| | - George Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace School of Health Sciences, Alexandroupolis, Thrace, Greece
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Richards J, Summers D, Sidders A, Allen E, Ayaz Hossain M, Paul S, Slater M, Bartlett M, Lagaac R, Laing E, Hopkins V, Fitzpatrick-Creamer C, Hudson C, Parsons J, Turner S, Tambyraja A, Somalanka S, Hunter J, Dutta S, Hoye N, Lawman S, Salter T, Aslam MF, Bagul A, Sivaprakasam R, Smith GE, Thomas HL, Moinuddin Z, Knight SR, Barnett N, Motallebzadeh R, Pettigrew GJ. Doppler ultrasound surveillance of recently formed haemodialysis arteriovenous fistula: the SONAR observational cohort study. Health Technol Assess 2024; 28:1-54. [PMID: 38768043 DOI: 10.3310/ytbt4172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background Arteriovenous fistulas are considered the best option for haemodialysis provision, but as many as 30% fail to mature or suffer early failure. Objective To assess the feasibility of performing a randomised controlled trial that examines whether, by informing early and effective salvage intervention of fistulas that would otherwise fail, Doppler ultrasound surveillance of developing arteriovenous fistulas improves longer-term arteriovenous fistula patency. Design A prospective multicentre observational cohort study (the 'SONAR' study). Setting Seventeen haemodialysis centres in the UK. Participants Consenting adults with end-stage renal disease who were scheduled to have an arteriovenous fistula created. Intervention Participants underwent Doppler ultrasound surveillance of their arteriovenous fistulas at 2, 4, 6 and 10 weeks after creation, with clinical teams blinded to the ultrasound surveillance findings. Main outcome measures Fistula maturation at week 10 defined according to ultrasound surveillance parameters of representative venous diameter and blood flow (wrist arteriovenous fistulas: ≥ 4 mm and > 400 ml/minute; elbow arteriovenous fistulas: ≥ 5 mm and > 500 ml/minute). Mixed multivariable logistic regression modelling of the early ultrasound scan data was used to predict arteriovenous fistula non-maturation by 10 weeks and fistula failure at 6 months. Results A total of 333 arteriovenous fistulas were created during the study window (47.7% wrist, 52.3% elbow). By 2 weeks, 37 (11.1%) arteriovenous fistulas had failed (thrombosed), but by 10 weeks, 219 of 333 (65.8%) of created arteriovenous fistulas had reached maturity (60.4% wrist, 67.2% elbow). Persistently lower flow rates and venous diameters were observed in those fistulas that did not mature. Models for arteriovenous fistulas' non-maturation could be optimally constructed using the week 4 scan data, with fistula venous diameter and flow rate the most significant variables in explaining wrist fistula maturity failure (positive predictive value 60.6%, 95% confidence interval 43.9% to 77.3%), whereas resistance index and flow rate were most significant for elbow arteriovenous fistulas (positive predictive value 66.7%, 95% confidence interval 48.9% to 84.4%). In contrast to non-maturation, both models predicted fistula maturation much more reliably [negative predictive values of 95.4% (95% confidence interval 91.0% to 99.8%) and 95.6% (95% confidence interval 91.8% to 99.4%) for wrist and elbow, respectively]. Additional follow-up and modelling on a subset (n = 192) of the original SONAR cohort (the SONAR-12M study) revealed the rates of primary, assisted primary and secondary patency arteriovenous fistulas at 6 months were 76.5, 80.7 and 83.3, respectively. Fistula vein size, flow rate and resistance index could identify primary patency failure at 6 months, with similar predictive power as for 10-week arteriovenous fistula maturity failure, but with wide confidence intervals for wrist (positive predictive value 72.7%, 95% confidence interval 46.4% to 99.0%) and elbow (positive predictive value 57.1%, 95% confidence interval 20.5% to 93.8%). These models, moreover, performed poorly at identifying assisted primary and secondary patency failure, likely because a subset of those arteriovenous fistulas identified on ultrasound surveillance as at risk underwent subsequent successful salvage intervention without recourse to early ultrasound data. Conclusions Although early ultrasound can predict fistula maturation and longer-term patency very effectively, it was only moderately good at identifying those fistulas likely to remain immature or to fail within 6 months. Allied to the better- than-expected fistula patency rates achieved (that are further improved by successful salvage), we estimate that a randomised controlled trial comparing early ultrasound-guided intervention against standard care would require at least 1300 fistulas and would achieve only minimal patient benefit. Trial Registration This trial is registered as ISRCTN36033877 and ISRCTN17399438. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR135572) and is published in full in Health Technology Assessment; Vol. 28, No. 24. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- James Richards
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Dominic Summers
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Anna Sidders
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | - Elisa Allen
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | | | - Subhankar Paul
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Matthew Slater
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Regin Lagaac
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emma Laing
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | | | | | - Cara Hudson
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | - Joseph Parsons
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | | | | | | | - James Hunter
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sam Dutta
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Neil Hoye
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Sarah Lawman
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Tracey Salter
- Epsom and St Helier University Hospitals NHS Trust, Epsom, UK
- Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Atul Bagul
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | - Helen L Thomas
- NHS Blood and Transplant Clinical Trials Unit, London, UK
| | - Zia Moinuddin
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon R Knight
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Gavin J Pettigrew
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
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Fisher AT, Mulaney-Topkar B, Sheehan BM, Garcia-Toca M, Sorial E, Sgroi MD. Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis. J Vasc Surg 2024; 79:1187-1194. [PMID: 38157996 DOI: 10.1016/j.jvs.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. METHODS We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. RESULTS We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both). CONCLUSIONS In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Bianca Mulaney-Topkar
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Brian M Sheehan
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular Surgery, Intermountain Health, Salt Lake City, UT
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ehab Sorial
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Vascular and Interventional Specialists of Orange County, Orange, CA
| | - Michael D Sgroi
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
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Kim MJ, Ko H, Kim SM. Predicting factors for early failure of vascular access in hemodialysis patients. Ann Surg Treat Res 2024; 106:255-262. [PMID: 38725806 PMCID: PMC11076948 DOI: 10.4174/astr.2024.106.5.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose This study aimed to investigate the incidence of early failure of vascular access for hemodialysis, and determine which factors measured in duplex ultrasound study could predict early failure. Methods We performed a retrospective review of patients who underwent arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation for hemodialysis between September 2019 and January 2023. Early failure was defined as any event that required surgical or endovascular intervention within 6 months following AVF or AVG creation. Results A total of 189 patients were included. Early failure occurred in 36 patients (19.0%), which included 22 AVFs and 14 AVGs. In the patients who underwent AVF, the preoperative venous diameter, postoperative venous and arterial diameters, and flow volume of AVF all were significantly smaller in the early failure group compared to the patent group. In AVG, the preoperative venous diameter was the only parameter that differed between the 2 groups. A sonographic score was defined based on these factors. In a multivariable analysis, male sex, a previous history of AVF or AVG creation, and sonographic score were found to be significantly associated with early failure. The postoperative venous diameter in AVF and the preoperative venous diameter in AVG were highly predictive of early failure (areas under the curves 0.92 and 0.82, respectively). Conclusion Venous diameter measured 6 weeks following AVF operation and preoperative venous diameter in AVG were highly predictive of early failure among the duplex ultrasound parameters. Surveillance strategies in the early phase following vascular access creation can be based on these factors.
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Affiliation(s)
- Min Jun Kim
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Suh Min Kim
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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Hafeez MS, Eslami MH, Chaer RA, Yuo TH. Comparing post-maturation outcomes of arteriovenous grafts and fistulae. J Vasc Access 2024; 25:779-789. [PMID: 36847168 DOI: 10.1177/11297298231151365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Though arteriovenous grafts (AVG) mature more reliably than arteriovenous fistulae (AVF) and require fewer maturation procedures (MP) to obtain functional patency, AVG are thought to have worse function after maturation. We explored differences in post-maturation outcomes between the following groups: AVF patients who did (AS-AVF) and did not (unAS-AVF) require assisted maturation and AVG patients who did (AS-AVG) and did not (unAS-AVG) require assisted maturation. METHODS Using the US Renal Data System (2012-2017), we retrospectively identified patients who initiated dialysis with a central venous catheter, underwent AVF or AVG placement and achieved successful two-needle cannulation. Primary patency and access abandonment after maturation were compared across groups using competing risks regression methods, generating sub-hazards ratios (sHR). RESULTS We identified 42,664 AVF and 12,335 AVG that met inclusion criteria. A larger proportion of AVFs required interventions: 18,408 AVF (43.2%) versus 2594 AVG (21.0%; p < 0.01). Both AS-AVG and AS-AVF patients experienced patency loss at 1 year more frequently compared with unAS-AVG (67.5% & 57.5% vs 55.2% respectively). Patency loss was lowest in unAS-AVF (38.9%). These trends were robust on adjusted analysis (unAS-AVG reference, AS-AVG sHR = 1.44, p < 0.01; AS-AVF sHR = 1.08, p < 0.01, unAS-AVF sHR = 0.67, p < 0.01). AS-AVGs were more likely to be abandoned than unAS-AVGs (11.7% unAS-AVG vs 17.2% AS-AVG). Fistulae, assisted or not, had lower unadjusted rates of 1-year abandonment than grafts (8.9% AS-AVF vs 7.3% unAS-AVF). On adjusted analysis, AVF usage was protective against abandonment (unAS-AVG, reference; AS-AVF sHR = 0.67, p < 0.01; unAS-AVF sHR = 0.59, p < 0.01) while AS-AVG was not (AS-AVG sHR = 1.32, p < 0.01). CONCLUSIONS unAS-AVF have the best long-term outcomes. AS-AVF lose primary patency at a higher rate than unAS-AVG. AVGs may be a better choice than AVFs if veins are marginal and likely to require assisted maturation. Further research is needed to identify anatomic and physiologic factors that affect long-term performance and influence conduit choice.
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Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Theodore H Yuo
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Lovelady A, Glowczwski A, Glowczwski J, Azimuddin A, Ross J, Hohmann S, Fridley J, Simon BT. Ruminant model for hemodialysis cannulation. J Vasc Access 2024:11297298241247085. [PMID: 38659087 DOI: 10.1177/11297298241247085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Preventative strategies that minimize hemodialysis access complications remain limited. OBJECTIVE This study aimed to address this gap by developing a Caprine cannulation model to investigate the impact of repeated cannulations on vascular access patency rates. RESEARCH DESIGN AND MEASURES In this pilot study, a meta-analysis was conducted using experimental control data from four trials to explore the impact of Caprine breed (independent variable) on the dependent variables that affect hemodialysis cannulation, including AVF growth, AVF depth, and flow rate. SUBJECTS Arteriovenous Fistulas (AVFs) were created using the carotid artery and jugular vein in the necks of seven goats from the French alpine, dwarf, and pygmy breeds. All seven AVFs exhibited vessel remodeling patterns similar to that observed in humans and remained patent, enabling hemodialysis access over the 6 month study. RESULTS Over the course of 18 weeks, a total of 291 cannulations were completed using standard 15 g dialysis needles without complications demonstrating the feasibility of using the Caprine species as a cannulation model. The ease of access coupled with the animals' cooperative behavior further contributes to the suitability of the Caprine species for hemodialysis investigations. Notably, no infections or clinically significant incidents were observed throughout the study. CONCLUSIONS The stability of AVF patency and flow underscores the viability and potential of the Caprine species animal model as a valuable research platform for exploring interventions aimed at improving vascular access survival in hemodialysis patients.
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Affiliation(s)
- April Lovelady
- School of Engineering Medicine, Texas A&M University, Houston, TX, USA
| | - Alan Glowczwski
- Voyager Biomedical, Inc., Houston, TX, USA
- Veterinary Medical Park, Texas A&M University, College Station, TX, USA
| | | | - Ahad Azimuddin
- School of Medicine, Texas A&M University, Houston, TX, USA
| | - John Ross
- Voyager Biomedical, Inc., Houston, TX, USA
- Vascular Surgery, Regional Medical Center, Orangeburg, SC, USA
| | | | - Jennifer Fridley
- Veterinary Medical Park, Texas A&M University, College Station, TX, USA
| | - Bradley T Simon
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Texas A&M University, College Station, TX, USA
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Lok CE, Huber TS, Orchanian-Cheff A, Rajan DK. Arteriovenous Access for Hemodialysis: A Review. JAMA 2024; 331:1307-1317. [PMID: 38497953 DOI: 10.1001/jama.2024.0535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Importance Hemodialysis requires reliable vascular access to the patient's blood circulation, such as an arteriovenous access in the form of an autogenous arteriovenous fistula or nonautogenous arteriovenous graft. This Review addresses key issues associated with the construction and maintenance of hemodialysis arteriovenous access. Observations All patients with kidney failure should have an individualized strategy (known as Patient Life-Plan, Access Needs, or PLAN) for kidney replacement therapy and dialysis access, including contingency plans for access failure. Patients should be referred for hemodialysis access when their estimated glomerular filtration rate progressively decreases to 15 to 20 mL/min, or when their peritoneal dialysis, kidney transplant, or current vascular access is failing. Patients with chronic kidney disease should limit or avoid vascular procedures that may complicate future arteriovenous access, such as antecubital venipuncture or peripheral insertion of central catheters. Autogenous arteriovenous fistulas require 3 to 6 months to mature, whereas standard arteriovenous grafts can be used 2 to 4 weeks after being established, and "early-cannulation" grafts can be used within 24 to 72 hours of creation. The prime pathologic lesion of flow-related complications of arteriovenous access is intimal hyperplasia within the arteriovenous access that can lead to stenosis, maturation failure (33%-62% at 6 months), or poor patency (60%-63% at 2 years) and suboptimal dialysis. Nonflow complications such as access-related hand ischemia ("steal syndrome"; 1%-8% of patients) and arteriovenous access infection require timely identification and treatment. An arteriovenous access at high risk of hemorrhaging is a surgical emergency. Conclusions and Relevance The selection, creation, and maintenance of arteriovenous access for hemodialysis vascular access is critical for patients with kidney failure. Generalist clinicians play an important role in protecting current and future arteriovenous access; identifying arteriovenous access complications such as infection, steal syndrome, and high-output cardiac failure; and making timely referrals to facilitate arteriovenous access creation and treatment of arteriovenous access complications.
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Affiliation(s)
- Charmaine E Lok
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas S Huber
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Dheeraj K Rajan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Medical Imaging Toronto, University Health Network, Toronto, Ontario, Canada
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Kanchanasuttirak P, Pitaksantayothin W, Kanchanasuttirak W. Accuracy of physical examination versus Doppler ultrasonography for determining maturity in postoperative arteriovenous fistula formation. Asian J Surg 2024:S1015-9584(24)00603-1. [PMID: 38609821 DOI: 10.1016/j.asjsur.2024.03.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Differentiating between arteriovenous fistula (AVF) maturation and failure can help determine which AVF will undergo successful canulation and which ones will require immediate rescue. METHODS A prospective observational study was conducted at Vajira Hospital in Bangkok, Thailand, between October 2020-November 2022. A single vascular surgeon performed a physical examination on patients with chronic kidney disease undergoing AVF placement, and a radiologist conducted Doppler ultrasonography during the second and sixth postoperative weeks. Dialysis nurses determined AVF maturity by performing cannulation. The study compared the accuracy of physical examination and Doppler ultrasonography. A model was developed to predict the success of AVF use. RESULTS Out Of the 125 recruited patients, 81% demonstrate unassisted maturation of their AVF. The male sex and brachiocephalic type are associated with AVF maturation. The physical examination findings of palpable thrill and the absence of a strong pulse at the 6th week show an area under the receiver operating curve (AUC) value of 0.79. Similarly, arterial end-diastolic velocity on ultrasonography at the 6th week also demonstrates a comparable predictive value with an AUC of 0.82 (p = 0.697). Meanwhile, the model that combined end-diastolic velocity and venous volume flow yields the best results for predicting AVF maturation, with an AUC of 0.92. These models provide more accurate predictions compared to physical examination alone (AUC: 0.92 vs. 0.79; p < 0.01). CONCLUSION Although a prudent physician predicts AVF maturation through a thorough physical examination, Doppler ultrasonography is preferred in anticipating the success of postoperative AVF placement.
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Affiliation(s)
- Pong Kanchanasuttirak
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand.
| | - Wacharaphong Pitaksantayothin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
| | - Wiraporn Kanchanasuttirak
- Department of Radiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
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Julkaew S, Wongsirichot T, Damkliang K, Sangthawan P. Improving accuracy of vascular access quality classification in hemodialysis patients using deep learning with K highest score feature selection. J Int Med Res 2024; 52:3000605241232519. [PMID: 38573764 PMCID: PMC10996358 DOI: 10.1177/03000605241232519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/26/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To develop and evaluate a novel feature selection technique, using photoplethysmography (PPG) sensors, for enhancing the performance of deep learning models in classifying vascular access quality in hemodialysis patients. METHODS This cross-sectional study involved creating a novel feature selection method based on SelectKBest principles, specifically designed to optimize deep learning models for PPG sensor data, in hemodialysis patients. The method effectiveness was assessed by comparing the performance of multiple deep learning models using the feature selection approach versus complete feature set. The model with the highest accuracy was then trained and tested using a 70:30 approach, respectively, with the full dataset and the SelectKBest dataset. Performance results were compared using Student's paired t-test. RESULTS Data from 398 hemodialysis patients were included. The 1-dimensional convolutional neural network (CNN1D) displayed the highest accuracy among different models. Implementation of the SelectKBest-based feature selection technique resulted in a statistically significant improvement in the CNN1D model's performance, achieving an accuracy of 92.05% (with feature selection) versus 90.79% (with full feature set). CONCLUSION These findings suggest that the newly developed feature selection approach might aid in accurately predicting vascular access quality in hemodialysis patients. This advancement may contribute to the development of reliable diagnostic tools for identifying vascular complications, such as stenosis, potentially improving patient outcomes and their quality of life.
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Affiliation(s)
- Sarayut Julkaew
- College of Digital Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thakerng Wongsirichot
- Division of Computational Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kasikrit Damkliang
- Division of Computational Science, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pornpen Sangthawan
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Prince of Songkhla University, Hat Yai, Songkhla, Thailand
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10
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Richards J, Summers D, Sidders A, Allen E, Thomas H, Hossain MA, Paul S, Slater M, Bartlett M, Lagaac R, Laing E, Hopkins V, Fitzpatrick-Creamer C, Hudson C, Parsons J, Turner S, Tambyraja A, Somalanka S, Hunter J, Dutta S, Hoye N, Lawman S, Salter T, Aslam M, Bagul A, Sivaprakasam R, Smith G, Moinuddin Z, Knight S, Barnett N, Motallebzadeh R, Pettigrew GJ. Early Ultrasound Surveillance of Newly-Created Hemodialysis Arteriovenous Fistula. Kidney Int Rep 2024; 9:1005-1019. [PMID: 38765580 PMCID: PMC11101727 DOI: 10.1016/j.ekir.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction We assess if ultrasound surveillance of newly-created arteriovenous fistulas (AVFs) can predict nonmaturation sufficiently reliably to justify randomized controlled trial (RCT) evaluation of ultrasound-directed salvage intervention. Methods Consenting adults underwent blinded fortnightly ultrasound scanning of their AVF after creation, with scan characteristics that predicted AVF nonmaturation identified by logistic regression modeling. Results Of 333 AVFs created, 65.8% matured by 10 weeks. Serial scanning revealed that maturation occurred rapidly, whereas consistently lower fistula flow rates and venous diameters were observed in those that did not mature. Wrist and elbow AVF nonmaturation could be optimally modeled from week 4 ultrasound parameters alone, but with only moderate positive predictive values (PPVs) (wrist, 60.6% [95% confidence interval, CI: 43.9-77.3]; elbow, 66.7% [48.9-84.4]). Moreover, 40 (70.2%) of the 57 AVFs that thrombosed by week 10 had already failed by the week 4 scan, thus limiting the potential of salvage procedures initiated by that scan's findings to alter overall maturation rates. Modeling of the early ultrasound characteristics could also predict primary patency failure at 6 months; however, that model performed poorly at predicting assisted primary failure (those AVFs that failed despite a salvage attempt), partly because patency of at-risk AVFs was maintained by successful salvage performed without recourse to the early scan data. Conclusion Early ultrasound surveillance may predict fistula maturation, but is likely, at best, to result in only very modest improvements in fistula patency. Power calculations suggest that an impractically large number of participants (>1700) would be required for formal RCT evaluation.
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Affiliation(s)
- James Richards
- Addenbrooke’s Hospital, Hill Road, Cambridge, UK
- University of Cambridge, Hill Road, Cambridge, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Dominic Summers
- Addenbrooke’s Hospital, Hill Road, Cambridge, UK
- University of Cambridge, Hill Road, Cambridge, UK
| | - Anna Sidders
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Elisa Allen
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | | | - Subhankar Paul
- Addenbrooke’s Hospital, Hill Road, Cambridge, UK
- University of Cambridge, Hill Road, Cambridge, UK
| | | | | | - Regin Lagaac
- Addenbrooke’s Hospital, Hill Road, Cambridge, UK
| | - Emma Laing
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Valerie Hopkins
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | | | - Cara Hudson
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Joseph Parsons
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | | | | | - Subash Somalanka
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
| | - James Hunter
- University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sam Dutta
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Neil Hoye
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Sarah Lawman
- Brighton and Sussex University Hospitals NHS Trust, Worthing, West Sussex, UK
| | - Tracey Salter
- Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
- Frimley Health NHS Foundation Trust, Camberley, Surrey, UK
| | | | - Atul Bagul
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - George Smith
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Zia Moinuddin
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon Knight
- Oxford University Hospitals NHS Foundation Trust, Headington Oxford, UK
| | | | | | - Gavin J. Pettigrew
- Addenbrooke’s Hospital, Hill Road, Cambridge, UK
- University of Cambridge, Hill Road, Cambridge, UK
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11
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Wang T, Lu P, Wan Z, He Z, Cheng S, Zhou Y, Liao S, Wang M, Wang T, Shu C. Adaptation process of decellularized vascular grafts as hemodialysis access in vivo. Regen Biomater 2024; 11:rbae029. [PMID: 38638701 PMCID: PMC11026144 DOI: 10.1093/rb/rbae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024] Open
Abstract
Arteriovenous grafts (AVGs) have emerged as the preferred option for constructing hemodialysis access in numerous patients. Clinical trials have demonstrated that decellularized vascular graft exhibits superior patency and excellent biocompatibility compared to polymer materials; however, it still faces challenges such as intimal hyperplasia and luminal dilation. The absence of suitable animal models hinders our ability to describe and explain the pathological phenomena above and in vivo adaptation process of decellularized vascular graft at the molecular level. In this study, we first collected clinical samples from patients who underwent the construction of dialysis access using allogeneic decellularized vascular graft, and evaluated their histological features and immune cell infiltration status 5 years post-transplantation. Prior to the surgery, we assessed the patency and intimal hyperplasia of the decellularized vascular graft using non-invasive ultrasound. Subsequently, in order to investigate the in vivo adaptation of decellularized vascular grafts in an animal model, we attempted to construct an AVG model using decellularized vascular grafts in a small animal model. We employed a physical-chemical-biological approach to decellularize the rat carotid artery, and histological evaluation demonstrated the successful removal of cellular and antigenic components while preserving extracellular matrix constituents such as elastic fibers and collagen fibers. Based on these results, we designed and constructed the first allogeneic decellularized rat carotid artery AVG model, which exhibited excellent patency and closely resembled clinical characteristics. Using this animal model, we provided a preliminary description of the histological features and partial immune cell infiltration in decellularized vascular grafts at various time points, including Day 7, Day 21, Day 42, and up to one-year post-implantation. These findings establish a foundation for further investigation into the in vivo adaptation process of decellularized vascular grafts in small animal model.
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Affiliation(s)
- Tun Wang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Peng Lu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Zicheng Wan
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Zhenyu He
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Siyuan Cheng
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Yang Zhou
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Sheng Liao
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Mo Wang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Tianjian Wang
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha 410011, China
- Institute of Vascular Diseases, Central South University, Changsha 410011, China
- Center of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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12
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Chen JW, Ting M, Chang PY, Jung CJ, Chang CH, Fang SY, Liu LW, Yang KJ, Yu SH, Chen YS, Chi NH, Hsu RB, Wang CH, Wu IH, Yu HY, Chan CY. Computer-assisted image analysis of preexisting histological patterns of the cephalic vein to predict wrist arteriovenous fistula non-maturation. J Formos Med Assoc 2024:S0929-6646(24)00149-9. [PMID: 38492985 DOI: 10.1016/j.jfma.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/07/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND We used computer-assisted image analysis to determine whether preexisting histological features of the cephalic vein influence the risk of non-maturation of wrist fistulas. METHODS This study focused on patients aged 20-80 years who underwent their first wrist fistula creation. A total of 206 patients participated, and vein samples for Masson's trichrome staining were collected from 134 patients. From these, 94 patients provided a complete girth of the venous specimen for automatic image analysis. Maturation was assessed using ultrasound within 90 days after surgery. RESULTS The collagen to muscle ratio in the target vein, measured by computer-assisted imaging, was a strong predictor of non-maturation in wrist fistulas. Receiver operating characteristic analysis revealed an area under the curve of 0.864 (95% confidence interval of 0.782-0.946, p < 0.001). The optimal cut-off value for the ratio was 1.138, as determined by the Youden index maximum method, with a sensitivity of 89.0% and specificity of 71.4%. For easy application, we used a cutoff value of 1.0; the non-maturation rates for patients with ratios >1 and ≤ 1 were 51.7% (15 out of 29 patients) and 9.2% (6 out of 65 patients), respectively. Chi-square testing revealed significantly different non-maturation rates between the two groups (X2 (1, N = 94) = 20.9, p < 0.01). CONCLUSION Computer-assisted image interpretation can help to quantify the preexisting histological patterns of the cephalic vein, while the collagen-to-muscle ratio can predict non-maturation of wrist fistula development at an early stage.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mao Ting
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Po-Ya Chang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiau-Jing Jung
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Shi-Yu Fang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Wei Liu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Kelvin Jeason Yang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sz-Han Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hsin Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ron-Bin Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yang Chan
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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13
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Suraj HS, Anil Kumar S, Rachegowda N, Rajeswari GT, Yashas Ullas L, Revanth RB. Role of Doppler Evaluation in Assessing the Maturation of the Arteriovenous Fistula for Hemodialysis: An Observational Study. Cureus 2024; 16:e55527. [PMID: 38576632 PMCID: PMC10992732 DOI: 10.7759/cureus.55527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Arteriovenous fistulas (AVFs) are the preferred type of vascular access for hemodialysis due to their lower risk of complications. This study aimed to determine the role of Doppler evaluation in assessing AVF. Materials and methods We conducted an 18-month prospective observational study of 33 hemodialysis patients who underwent a procedure for the creation of AVF at the Department of Radio-Diagnosis at Sri Devaraj Urs Academy of Higher Education and Research. Patients were evaluated using color Doppler ultrasound. Participants underwent a careful history and clinical examination to diagnose the disease. All relevant parameters were documented in a structured study proforma. AVF maturation was assessed postoperatively at four weeks using Doppler ultrasound color flow evaluation by looking for vascular components (flow volume, vein, and arterial diameter). Data were analyzed using CoGuide V 1.0.3 Statistical Software (CoGuide, Bangalore, India). Results A total of 33 patients, with a mean age of 54.6 ± 7.8 years, were evaluated. Of the 33 participants, 24 (72.7%) were male, and nine (27.3%) were female. The majority (47%, n=16) of participants had diabetes mellitus, eight (24%) had hypertension, and 10 (29%) had both diabetes mellitus and hypertension. A brachiocephalic fistula was created in 45.5% of participants, and 33.33% had radiocephalic anastomoses. Five participants were diagnosed with AVF complications: two had a pseudoaneurysm, and three had a cephalic vein thrombus. Clinical and demographic characteristics (age, vascular components, and complications) were not significantly related to AVF maturation. Conclusions Doppler ultrasound plays an important role in selecting vessels for AVF preoperatively and assessing AVF maturation postoperatively, thus reducing the primary fistula failure rate. The findings suggest that Doppler evaluation can be a reliable tool for assessing AVF maturation and predicting surgical success, which could help healthcare providers make informed decisions about the best course of treatment for their patients. Continued research is warranted in this area to further understand the role of Doppler ultrasound in evaluating AVF surgery.
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Affiliation(s)
- H S Suraj
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Sakalecha Anil Kumar
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - N Rachegowda
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | | | - L Yashas Ullas
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - R B Revanth
- Radiodiagnosis, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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14
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Lu P, Wang T, Wan Z, Wang M, Zhou Y, He Z, Liao S, Liu H, Shu C. Immune-Related Genes and Immune Cell Infiltration Characterize the Maturation Status of Arteriovenous Fistulas: An Integrative Bioinformatics Study and Experimental Validation Based on Transcriptome Sequencing. J Inflamm Res 2024; 17:137-152. [PMID: 38223424 PMCID: PMC10785828 DOI: 10.2147/jir.s433525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024] Open
Abstract
Purpose Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis, but the low maturation rate is concerning. Immune cells' impact on AVF maturation lacks bioinformatics research. The study aims to investigate the potential predictive role of immune-related genes and immune cell infiltration characteristics in AVF maturation. Patients and Methods We analyzed the high-throughput sequencing dataset to identify differentially expressed genes (DEGs). Then, we performed enrichment analyses (GO, KEGG, GSEA) on immune-related genes and pathways in mature AVF. We focused on differentially expressed immune-related genes (DEIRGs) and constructed a PPI network to identify hub genes. These hub genes were validated in other databases and experiments, including qPCR and immunohistochemistry (IHC). The immune cell infiltration characteristics in native veins, failed AVFs, and matured AVFs were analyzed by cibersortX. Partial experimental validation was conducted using clinical samples. Results Our results showed that immune-related genes and signaling pathways are significantly enriched in mature AVF. We validated this in other databases and ultimately identified three hub genes (IL1B, IL6, CXCR4) in combination with experiments. Significant differences in immune cell infiltration characteristics were observed among native veins, failed AVFs, and matured AVFs. Immune cell infiltration analysis revealed that accumulation of CD4+ T cells, dendritic cells, mast cells and M2 macrophages contribute to AVF maturation. These immune-related genes and immune cells have the potential to serve as predictive factors for AVF maturation. We partially validated this experimentally. Conclusion From a bioinformatics perspective, our results have identified, for the first time, a set of immune-related genes and immune cell infiltration features that can characterize the maturation of AVF and significantly impact AVF maturation. These features hold potential as predictive indicators for AVF maturation outcomes.
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Affiliation(s)
- Peng Lu
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Tun Wang
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Zicheng Wan
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Mo Wang
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Yang Zhou
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Zhenyu He
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Sheng Liao
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
| | - Haiyang Liu
- Department of Geriatrics, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Chang Shu
- Department of Vascular Surgery, the Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute of Vascular Diseases, Central South University, Changsha, People’s Republic of China
- Center of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China
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15
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Heindel P, Dey T, Fitzgibbon JJ, Mamdani M, Hentschel DM, Belkin M, Ozaki CK, Hussain MA. Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app. J Vasc Access 2023:11297298231203356. [PMID: 38143431 DOI: 10.1177/11297298231203356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023] Open
Abstract
OBJECTIVE Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness. METHODS Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines. RESULTS Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com. CONCLUSIONS The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.
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Affiliation(s)
- Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanujit Dey
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muhammad Mamdani
- Data Science and Advanced Analytics, Unity Health Toronto, Toronto, ON, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON, Canada
| | - Dirk M Hentschel
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charles Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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16
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Gamé V, Callejón R, Fontseré N, Mestres G. Prediction of intraoperative arteriovenous fistula flow using infrared thermal imaging. Nefrologia 2023; 43 Suppl 2:128-130. [PMID: 38228462 DOI: 10.1016/j.nefroe.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/03/2022] [Indexed: 01/18/2024] Open
Affiliation(s)
- Victoria Gamé
- Vascular Access Functional Unit, Vascular Surgery Department, Instituto de Enfermedades Cardiovasculares [Institute of Cardiovascular Diseases], Hospital Clínic, Barcelona, Spain.
| | - Regina Callejón
- Vascular Access Functional Unit, Vascular Surgery Department, Instituto de Enfermedades Cardiovasculares [Institute of Cardiovascular Diseases], Hospital Clínic, Barcelona, Spain.
| | - Nestor Fontseré
- Vascular Access Functional Unit, Nephrology Department, Instituto de Nefrología y Urología [Institute of Nephrology and Urology], Hospital Clínic, Barcelona, Spain.
| | - Gaspar Mestres
- Vascular Access Functional Unit, Vascular Surgery Department, Instituto de Enfermedades Cardiovasculares [Institute of Cardiovascular Diseases], Hospital Clínic, Barcelona, Spain.
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17
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Higgins MCSS, Diamond M, Mauro DM, Kapoor BS, Steigner ML, Fidelman N, Aghayev A, Chamarthy MRK, Dedier J, Dillavou ED, Felder M, Lew SQ, Lockhart ME, Siracuse JJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol 2023; 20:S382-S412. [PMID: 38040461 DOI: 10.1016/j.jacr.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Matthew Diamond
- Research Author, Boston Medical Center, Boston, Massachusetts
| | - David M Mauro
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Ayaz Aghayev
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Julien Dedier
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | - Ellen D Dillavou
- WakeMed Hospital System, Raleigh, North Carolina; Society for Vascular Surgery
| | - Mila Felder
- Advocate Christ Medical Center, Oak Lawn, Illinois; American College of Emergency Physicians
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Jeffrey J Siracuse
- Boston University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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18
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Michas V, Taghipour M, Papachristodoulou A, Sidiropoulou M, Partovi S, Cokkinos D, Rafailidis V, Gadani S, Gill A, Michell H, Prassopoulos P. Multiparametric ultrasound for upper extremity dialysis access evaluation. Ultrasonography 2023; 42:490-507. [PMID: 37723649 PMCID: PMC10555685 DOI: 10.14366/usg.23064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 09/20/2023] Open
Abstract
The evolution of ultrasound (US) techniques has greatly improved the evaluation of many parameters in dialysis vascular access, which is typically achieved through an arteriovenous fistula (AVF) or graft (AVG). These techniques include grayscale B-mode, color Doppler, power Doppler, spectral Doppler, non-Doppler US flow imaging techniques, contrast-enhanced US, and elastography. In conjunction with a patient's medical history and physical examination, US provides crucial information about the native vascular bed prior to the surgical creation of an arteriovenous anastomosis. It also tracks the maturation progress of the newly created AVF or AVG and aids in diagnosing potential complications of the vascular access. These complications include thrombosis, steal syndrome, aneurysms, pseudoaneurysms, hematomas, infection, ischemic neuropathy, exacerbation of preexisting congestive heart failure, and stenosis.
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Affiliation(s)
- Vasileios Michas
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Mehdi Taghipour
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | | | - Maria Sidiropoulou
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Sasan Partovi
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | | | - Vasileios Rafailidis
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Sameer Gadani
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Amanjit Gill
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Hans Michell
- Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Panos Prassopoulos
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
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Plauche L, Farber A, King EG, Levin SR, Cheng TW, Rybin D, Siracuse JJ. Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes. Ann Vasc Surg 2023; 96:98-103. [PMID: 37178905 DOI: 10.1016/j.avsg.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/19/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Patients with tunneled dialysis catheters (TDCs) have a time-sensitive need for a functional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and, ultimately, TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence. METHODS The Vascular Quality Initiative hemodialysis registry was analyzed from 2011 to 2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis, were assessed. RESULTS There were 2,359 patients with TDC, of whom 1,389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59 years, and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, nonindependently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥3 mm (all P < 0.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P = 0.88), primary assisted patency was 86.7% vs. 86.9% (P = 0.64), freedom from reintervention was 51.1% vs. 46.3% (P = 0.44), and survival was 81.3% vs. 84.9% (P = 0.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.91-1.36, P = 0.316), primary assisted patency loss (HR 1.11, 95% CI 0.72-1.29, P = 0.66), and reintervention (HR 1.01, 95% CI 0.81-1.27, P = 0.92). Access being used at 3 months was similar but trending towards RCF being used more often (odds ratio 0.7, 95% CI 0.49-1, P = 0.05). CONCLUSIONS BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.
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Affiliation(s)
- Lenee Plauche
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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20
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Sun J, Hu PP, Zhan S, Cui R, Hou F, Wang YZ. Model and online calculator for prediction of fistula maturation based on vein dilation and age: A retrospective cohort study in a single-center. Asian J Surg 2023; 46:4267-4276. [PMID: 36805275 DOI: 10.1016/j.asjsur.2023.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE A model that considers the characteristics of dialysis patients may help predict successful fistula maturation. We evaluated factors associated with radiocephalic arteriovenous fistula (RCAVF) maturation at 3 months in dialysis patients with end-stage renal disease (ESRD). METHODS A total of 184 patients who received an initial RCAVF at Beijing Haidian Hospital (Haidian Section of Peking University Third Hospital) were recruited. Fistula maturation was assessed within 3 months. Patient characteristics and preoperative vascular assessment indices were examined. Factors associated with fistula maturation were analyzed using logistic regression and least absolute shrinkage and selection operator (LASSO) binary logistic regression. Boostrapping was used for internal validation. RESULTS The development data consisted of 184 ESRD patients receiving an initial RCAVF, 140 (76%) of whom achieved fistula maturation. The main predictors of RCAVF maturation in the final model were sex, age-adjusted vein dilation (eVD), radial artery volume (Vartery), and diastolic blood pressure. The difference of vein diameter with and without a tourniquet was significantly larger in the mature RCAVF group (3.0 ± 0.5 vs. 2.2 ± 0.5 mm). The area under receiver operating characteristic (AUROC) curve for prediction of fistula maturation was 0.77, and the Hosmer-Lemeshow statistic indicated agreement between observed and predicted values (P = 0.792). Analysis of internal validation using bootstrapping indicated the C-index was 0.75. CONCLUSION The ratio of vein dilation and age were the major predictors of fistula maturation at 3 months in our patients. The resulting online prediction model may help in clinical decision-making for patients receiving a RCAVF.
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Affiliation(s)
- Jing Sun
- Department of Nephrology, Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital), No.1751, Xinhu Road, Dezhou, 253014, Shandong, People's Republic of China
| | - Pu-Ping Hu
- Department of Nephrology, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, No.29, Zhongguancun Road, 100080, Beijing, People's Republic of China
| | - Shen Zhan
- Department of Nephrology, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, No.29, Zhongguancun Road, 100080, Beijing, People's Republic of China
| | - Rui Cui
- Department of Nephrology, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, No.29, Zhongguancun Road, 100080, Beijing, People's Republic of China
| | - Fang Hou
- Department of Nephrology, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, No.29, Zhongguancun Road, 100080, Beijing, People's Republic of China
| | - Yu-Zhu Wang
- Department of Nephrology, Beijing Haidian Hospital, Haidian Section of Peking University Third Hospital, No.29, Zhongguancun Road, 100080, Beijing, People's Republic of China.
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21
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Barcena AJR, Perez JVD, Bernardino MR, Damasco JA, Cortes A, Del Mundo HC, San Valentin EMD, Klusman C, Canlas GM, Heralde FM, Avritscher R, Fowlkes N, Bouchard RR, Cheng J, Huang SY, Melancon MP. Bioresorbable Mesenchymal Stem Cell-Loaded Electrospun Polymeric Scaffold Inhibits Neointimal Hyperplasia Following Arteriovenous Fistula Formation in a Rat Model of Chronic Kidney Disease. Adv Healthc Mater 2023; 12:e2300960. [PMID: 37395729 PMCID: PMC10592251 DOI: 10.1002/adhm.202300960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/18/2023] [Accepted: 06/30/2023] [Indexed: 07/04/2023]
Abstract
Bioresorbable perivascular scaffolds loaded with antiproliferative agents have been shown to enhance arteriovenous fistula (AVF) maturation by inhibiting neointimal hyperplasia (NIH). These scaffolds, which can mimic the three-dimensional architecture of the vascular extracellular matrix, also have an untapped potential for the local delivery of cell therapies against NIH. Hence, an electrospun perivascular scaffold from polycaprolactone (PCL) to support mesenchymal stem cell (MSC) attachment and gradual elution at the AVF's outflow vein is fabricated. Chronic kidney disease (CKD) in Sprague-Dawley rats is induced by performing 5/6th nephrectomy, then AVFs for scaffold application are created. The following groups of CKD rats are compared: no perivascular scaffold (i.e., control), PCL alone, and PCL+MSC scaffold. PCL and PCL+MSC significantly improve ultrasonographic (i.e., luminal diameter, wall-to-lumen ratio, and flow rate) and histologic (i.e., neointima-to-lumen ratio, neointima-to-media ratio) parameters compared to control, with PCL+MSC demonstrating further improvement in these parameters compared to PCL alone. Moreover, only PCL+MSC significantly reduces 18 F-fluorodeoxyglucose uptake on positron emission tomography. These findings suggest that adding MSCs promotes greater luminal expansion and potentially reduces the inflammatory process underlying NIH. The results demonstrate the utility of mechanical support loaded with MSCs at the outflow vein immediately after AVF formation to support maturation by minimizing NIH.
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Affiliation(s)
- Allan John R Barcena
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
- College of Medicine, University of the Philippines Manila, Manila NCR, 1000, Philippines
| | - Joy Vanessa D Perez
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
- College of Medicine, University of the Philippines Manila, Manila NCR, 1000, Philippines
| | - Marvin R Bernardino
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jossana A Damasco
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Andrea Cortes
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Huckie C Del Mundo
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Erin Marie D San Valentin
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Carleigh Klusman
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
- School of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Gino Martin Canlas
- Department of Chemistry, Lamar University, P.O. Box 10009, Beaumont, TX, 77710, USA
| | - Francisco M Heralde
- College of Medicine, University of the Philippines Manila, Manila NCR, 1000, Philippines
| | - Rony Avritscher
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Natalie Fowlkes
- Department of Veterinary Medicine and Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Richard R Bouchard
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jizhong Cheng
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Steven Y Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Marites P Melancon
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, 77030, USA
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22
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Feng R, Wang S, Yu J, Zheng X, Chen W, Wang X, Chang G. The feasibility and efficiency for constructing arteriovenous fistula with <2 mm vein-a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1226136. [PMID: 37808887 PMCID: PMC10552868 DOI: 10.3389/fcvm.2023.1226136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Autogenous arteriovenous fistula (AVF) is an efficient hemodialysis access for patients with end-stage kidney disease (ESKD). The specific threshold of vein diameter still not reached a consensus. Method We conducted a comprehensive search in PubMed, Embase, and Web of Science databases for articles which comparing the treatment outcomes of AVF with 2 mm as vein diameter threshold. Fixed and random effect model were used for synthesis of results. Subgroup analysis was designed to assess the risk of bias. Result Eight high-quality articles were included finally. Among a total of 1,075 patients (675 males and 400 females), 227 and 809 patients possessed <2 mm and ≥2 mm vein respectively. Apart from gender and coronary artery disease (P < 0.05), there was no significant difference in age, diabetes, hypertension or radial artery between maturation and non-maturation groups. The functional maturation rate was lower in patients with <2 mm vein according to fixed effect model [OR = 0.19, 95% CI (0.12, 0.30), P < 0.01]. There was no significant difference in primary [OR = 0.63, 95% CI (0.12, 3.25), P = 0.58] or cumulative patency rates [OR = 0.40, 95% CI (0.13, 1.19), P = 0.10]. Conclusion Vein diameter less than 2 mm has a negative impact on the functional maturation rate of AVF, while it does not affect the primary and cumulative patency rates (12 months).
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Affiliation(s)
- Ruijia Feng
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Siwen Wang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianwen Yu
- Department of Nephrology, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xunhua Zheng
- Department of Nephrology, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xin Wang
- Department of Nephrology, NHC Key Laboratory of Nephrology, Guangdong Provincial Key Laboratory of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangqi Chang
- Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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23
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Kim J, Kwon Y, Choi TW, Won JH. Management of Immature Arteriovenous Fistulas. Cardiovasc Intervent Radiol 2023; 46:1125-1135. [PMID: 37142801 DOI: 10.1007/s00270-023-03440-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/30/2023] [Indexed: 05/06/2023]
Abstract
In patients requiring long-term hemodialysis for chronic kidney disease, an arteriovenous fistula is the preferred mode of hemodialysis access over synthetic arteriovenous graft or hemodialysis catheters. The National Kidney Foundation recommended in their Kidney Dialysis Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines that the creation of an autogenous arteriovenous fistula should initially be sought whenever possible. In 2003, a program named the Fistula First Breakthrough Initiative was initiated in the U.S. to increase the use of arteriovenous fistula for hemodialysis and to ultimately surpass the goal of 50% fistula use in incident and 40% fistula use in prevalent hemodialysis patients per recommendation by KDOQI Guidelines. While this goal was achieved, the encouraged creation of arteriovenous fistulas saw a rise in fistulas that failed to mature. Researchers have focused on developing strategies to optimize fistula maturation. Studies have revealed that the presence of stenoses and accessory draining veins may contribute to unsuccessful fistula maturation. Endovascular treatment, including balloon angioplasty and accessory vein embolization, aim to correct anatomical factors that negatively affect the maturation process. This article reviews the techniques and outcomes of endovascular treatment in the management of immature fistulas.
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Affiliation(s)
- Jinoo Kim
- Department of Radiology, Ajou University Hospital, 164, World Cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Yohan Kwon
- Department of Radiology, Ajou University Hospital, 164, World Cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Tae Won Choi
- Department of Radiology, Ajou University Hospital, 164, World Cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University Hospital, 164, World Cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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24
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Allon M, Al-Balas A, Young CJ, Cutter GR, Lee T. Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes. J Am Soc Nephrol 2023; 34:1589-1600. [PMID: 37401775 PMCID: PMC10482060 DOI: 10.1681/asn.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/31/2023] [Indexed: 07/05/2023] Open
Abstract
SIGNIFICANCE STATEMENT The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that among patients who initiated hemodialysis with a central vein catheter (CVC), a strategy that maximized AVF placement resulted in a higher frequency of access procedures and greater access management costs for patients who initially received an AVF than an AVG. A more selective policy that avoided AVF placement if an AVF was predicted to be at high risk of failure resulted in a lower frequency of access procedures and access costs in patients receiving an AVF versus an AVG. These findings suggest that clinicians should be more selective in placing AVFs because this approach improves vascular access outcomes. BACKGROUND The optimal choice of initial vascular access-arteriovenous fistula (AVF) or graft (AVG)-remains controversial, particularly in patients initiating hemodialysis with a central venous catheter (CVC). METHODS In a pragmatic observational study of patients who initiated hemodialysis with a CVC and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified end points included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods. RESULTS An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among patients with AVF ($10,642) versus patients with AVG ($6810) in period 1 but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was three-fold higher in patients with AVF versus patients with AVG in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781). CONCLUSIONS A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alian Al-Balas
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlton J. Young
- Division of Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary R. Cutter
- Department of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
- Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama
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25
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Bozzetto M, Poloni S, Caroli A, Curtò D, D'Haeninck A, Vanommeslaeghe F, Gjorgjievski N, Remuzzi A. The use of AVF.SIM system for the surgical planning of arteriovenous fistulae in routine clinical practice. J Vasc Access 2023; 24:1061-1068. [PMID: 34986688 DOI: 10.1177/11297298211062695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The number of patients treated with hemodialysis (HD) in Europe is more than half a million and this number increases annually. The arteriovenous fistula (AVF) is the vascular access (VA) of first choice, but the clinical outcome is still poor. A consistent number of AVFs fails to reach the desired blood flow rate for HD treatment, while some have too high flow and risk for cardiac complications. Despite the skill of the surgeons and the possibility to use Ultrasound investigation for mapping arm vasculature, it is still not possible to predict the blood flow volume that will be obtained after AVF maturation. METHODS We evaluated the potential of using a computational model (AVF.SIM) to predict the blood flow volume that will be achieved after AVF maturation, within a multicenter international clinical investigation aimed at assessing AVF.SIM predictive power. The study population included 231 patients, with data on AVF maturation in 124 patients, and on long-term primary patency in 180 patients. RESULTS At 1 year of follow-up, about 60% of AVFs were still patent, with comparable primary patency in proximal and distal anastomosis. The correlation between predicted and measured blood flow volume in the brachial artery at 40 days after surgery was statistically significant, with an overall correlation coefficient of 0.58 (p < 0.001). The percent difference between measured and predicted brachial blood flow 40 days after surgery was less than 30% in 72% of patients investigated. CONCLUSIONS The results indicate that the use of the AVF.SIM system allowed to predict with a good accuracy the blood flow volume achievable after VA maturation, for a given location and type of anastomosis. This information may help in AVF surgical planning, reducing the AVFs with too low or too high blood flow, thus improving AVF patency rate and clinical outcome of renal replacement therapy.
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Affiliation(s)
- Michela Bozzetto
- Department of Engineering and Applied Sciences, University of Bergamo, Dalmine, Italy
| | - Sofia Poloni
- Department of Biomedical Engineering, Istituto di Ricerche Farmacologiche Mario Negri IRCCS (BG), Bergamo, Italy
| | - Anna Caroli
- Department of Biomedical Engineering, Istituto di Ricerche Farmacologiche Mario Negri IRCCS (BG), Bergamo, Italy
| | - Diego Curtò
- Unit of Nephrology and Dialysis, Asst Santi Paolo e Carlo, Milan, Italy
| | | | | | - Nikola Gjorgjievski
- University Hospital of Nephrology, University SS "Cyril and Methodius," Skopje, Macedonia
| | - Andrea Remuzzi
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
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26
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Satam K, Setia O, Moore MS, Schneider E, Chaar CIO, Dardik A. Arterial Diameter and Percentage of Monocytes are Sex-Dependent Predictors of Early Arteriovenous Fistula Maturation. Ann Vasc Surg 2023; 93:128-136. [PMID: 36812979 PMCID: PMC10277224 DOI: 10.1016/j.avsg.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Arteriovenous fistulae mature less frequently in women than in men, leading to inferior patency and decreased fistula utilization in women. We hypothesized that both anatomic and physiologic sex differences explain reduced maturation. METHODS The electronic medical records of patients who had a primary arteriovenous fistula created from 2016 to 2021 at a single center were reviewed; sample size was determined using a power calculation. Postoperative ultrasound and laboratory tests were obtained at least 4 weeks after fistula creation. Primary unassisted fistula maturation was determined up to 4 years postprocedure. RESULTS A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The inflow brachial artery diameter was smaller in women than in men, both preoperatively (4.2 ± 0.9 vs. 4.9 ± 1.0 mm, P = 0.008) and postoperatively (4.8 ± 0.8 vs. 5.3 ± 0.9 mm, P = 0.039). Despite similar preoperative brachial artery peak systolic velocity, women had significantly lower postoperative arterial velocity (P = 0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0 ± 570.4 vs. 1,117.1 ± 471.3 cc/min, P = 0.003). Percentages of neutrophils and lymphocytes were similar among women and men 6 weeks after fistula creation. However, women had reduced monocytes (8.5 ± 2.0 vs. 10.0 ± 2.6%, P = 0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary analysis using logistic regression suggested that postoperative arterial diameter was associated with maturation in men, while postoperative monocyte percentage was associated with maturation in women. CONCLUSIONS Sex differences during arteriovenous fistula maturation are present in arterial diameter and velocity, suggesting that both anatomic and physiologic differences in arterial inflow contribute to sex differences in fistula maturation. In men, postoperative arterial diameter is correlated with maturation, whereas in women, the significantly lower proportion of circulating monocytes suggests a role for the immune response in fistula maturation.
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Affiliation(s)
- Keyuree Satam
- Yale School of Medicine, New Haven, CT; Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT
| | - Ocean Setia
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Miranda S Moore
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Eric Schneider
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, VA Connecticut Healthcare Systems, West Haven, CT.
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Barbosa WM, Franco RP, Rodrigues AT. Arteriovenous fistulas maturation: predictors of maturation and use of ultrasound. J Bras Nefrol 2023; 45:272-273. [PMID: 37791793 PMCID: PMC10697155 DOI: 10.1590/2175-8239-jbn-2023-e011en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/15/2023] [Indexed: 10/05/2023] Open
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Heindel P, Fitzgibbon JJ, Feliz JD, Hentschel DM, Burke SK, Al-Omran M, Bhatt DL, Belkin M, Ozaki CK, Hussain MA. Evaluating national guideline concordance of recurrent interventions after radiocephalic arteriovenous fistula creation. J Vasc Surg 2023; 77:1206-1215.e2. [PMID: 36567000 PMCID: PMC10038866 DOI: 10.1016/j.jvs.2022.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Radiocephalic arteriovenous fistulas have been historically perceived as requiring multiple follow-up procedural interventions to achieve maturation and maintain patency. Recent clinical practice guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) emphasize a patient-centered hemodialysis access strategy with new maximum targets for intervention rates, potentially conflicting with concomitant recommendations to prioritize autogenous forearm hemodialysis access creation. The present descriptive study seeks to assess whether radiocephalic fistulas can meet the KDOQI guideline benchmarks for interventions following access creation, and to elucidate clinical and anatomic characteristics associated with the timing and frequency of interventions following radiocephalic arteriovenous fistula creation. METHODS Prospective patient-level data from the multicenter PATENCY-1 and PATENCY-2 randomized trials, which enrolled patients undergoing new radiocephalic arteriovenous fistula creation, was analyzed (ClinicalTrials.govNCT02110901 and NCT02414841). The primary outcome was the rate of interventions at 1 year postoperatively. Incidence rates were calculated, and time to surgical or endovascular intervention following fistula creation was modeled using recurrent event extensions of the Cox proportional hazards model. Confidence intervals at the 95% level were calculated using nonparametric bootstrapping. RESULTS The cohort consisted of 914 patients; mean age was 57 years (standard deviation, 13 years), and 22% were female. Median follow-up was 707 days (interquartile range, 447-1066 days). The incidence of interventions per person-year was 1.04 (95% confidence interval [CI], 0.95-1.13) overall; 1.10 (95% CI, 0.98-1.21) before fistula use, and 0.96 (95% CI, 0.82-1.11) after fistula use. The most common interventions overall were balloon angioplasty (54.9% of all interventions), venous side-branch ligation (16.4%), and open revisions (eg, proximalization from snuffbox to wrist, 16.4%). The locations requiring balloon angioplasty included the juxta-anastomotic segment (51.7% of angioplasties), the outflow vein (29.2%), the inflow artery (14.8%), the central veins (3.8%), and the cephalic arch (0.5%). Common indications were to restore or maintain patency (75.6% of all interventions), assist maturation (14.9%), improve depth (4.4%), or improve augmentation (3.0%). In the multivariable regression analysis, female sex (adjusted hazard ratio [HR], 1.21; 95% CI, 1.05-1.45), diabetes (HR, 1.21; 95% CI, 1.01-1.46), and intraoperative vein diameter <3.0 mm (vs ≥4.0 mm: HR, 1.33; 95% CI, 1.02-1.66) were associated with earlier and more frequent interventions. Patients not on hemodialysis at the time of fistula creation underwent less frequent interventions (HR, 0.69; 95% CI, 0.59-0.81). CONCLUSIONS Patients with radiocephalic arteriovenous fistulas can expect to undergo one intervention, on average, in the first year after creation, which aligns with current KDOQI guidelines. Patients already requiring hemodialysis, female patients, patients with diabetes, and patients with intraoperative vein diameters <3.0 mm were at increased risk for repeated intervention. No subgroup exceeded guideline-suggested maximum thresholds for recurrent interventions. Overall, the results demonstrate that creation of radiocephalic arteriovenous fistula remains a guideline-concordant strategy when part of an end-stage kidney disease life-plan in appropriately selected patients.
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Affiliation(s)
- Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jessica D Feliz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Dirk M Hentschel
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Mohammed Al-Omran
- Division of Vascular Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Martinez L, Rojas MG, Tabbara M, Pereira-Simon S, Santos Falcon N, Rauf MA, Challa A, Zigmond ZM, Griswold AJ, Duque JC, Lassance-Soares RM, Velazquez OC, Salman LH, Vazquez-Padron RI. The Transcriptomics of the Human Vein Transformation After Arteriovenous Fistula Anastomosis Uncovers Layer-Specific Remodeling and Hallmarks of Maturation Failure. Kidney Int Rep 2023; 8:837-850. [PMID: 37069981 PMCID: PMC10105062 DOI: 10.1016/j.ekir.2023.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
Introduction The molecular transformation of the human preaccess vein after arteriovenous fistula (AVF) creation is poorly understood. This limits our ability to design efficacious therapies to improve maturation outcomes. Methods Bulk RNA sequencing (RNA-seq) followed by paired bioinformatic analyses and validation assays were performed in 76 longitudinal vascular biopsies (veins and AVFs) from 38 patients with stage 5 chronic kidney disease or end-stage kidney disease undergoing surgeries for 2-stage AVF creation (19 matured, 19 failed). Results A total of 3637 transcripts were differentially expressed between veins and AVFs independent of maturation outcomes, with 80% upregulated in fistulas. The postoperative transcriptome demonstrated transcriptional activation of basement membrane and interstitial extracellular matrix (ECM) components, including preexisting and novel collagens, proteoglycans, hemostasis factors, and angiogenesis regulators. A postoperative intramural cytokine storm involved >80 chemokines, interleukins, and growth factors. Postoperative changes in ECM expression were differentially distributed in the AVF wall, with proteoglycans and fibrillar collagens predominantly found in the intima and media, respectively. Interestingly, upregulated matrisome genes were enough to make a crude separation of AVFs that failed from those with successful maturation. We identified 102 differentially expressed genes (DEGs) in association with AVF maturation failure, including upregulation of network collagen VIII in medial smooth muscle cells (SMCs) and downregulation of endothelial-predominant transcripts and ECM regulators. Conclusion This work delineates the molecular changes that characterize venous remodeling after AVF creation and those relevant to maturation failure. We provide an essential framework to streamline translational models and our search for antistenotic therapies.
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Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Miguel G. Rojas
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Simone Pereira-Simon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Mohd Ahmar Rauf
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Akshara Challa
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Anthony J. Griswold
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Juan C. Duque
- Katz Family Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Roberta M. Lassance-Soares
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Omaida C. Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Loay H. Salman
- Division of Nephrology, Albany Medical College, Albany, New York, USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
- Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida, USA
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Kim H, Park HS, Ban TH, Yang SB, Kwon YJ. Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database. Hemodial Int 2023. [PMID: 36943638 DOI: 10.1111/hdi.13077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/12/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years. METHODS In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared. RESULTS Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001). CONCLUSION Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Medical Center, Seoul, Korea
| | - Hoon Suk Park
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Tae Hyun Ban
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, The Catholic University of Korea School of Medicine/Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Seung Boo Yang
- Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Young Joo Kwon
- Division of Nephrology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Montelongo S, Brooks DE, Klopfenstein J, Peden EK. Surgical creation of upper extremity arteriovenous fistula and grafts: a narrative review. Cardiovasc Diagn Ther 2023; 13:147-155. [PMID: 36864949 PMCID: PMC9971303 DOI: 10.21037/cdt-21-565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 07/04/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective Surgical creation of arteriovenous fistulas (AVF) and grafts (AVG) continues to be the mainstay access for hemodialysis (HD). Avoidance of dependence on dialysis catheters continues to be a worldwide mission in dialysis access. Importantly, there is no one-size-fits-all approach to hemodialysis access and each patient should undergo access creation that is patient-centered. The aim of this paper is to review the literature, current guidelines, and discuss the common types of upper extremity hemodialysis access and their reported outcomes. We will also share our institutional experience regarding the surgical creation of upper extremity hemodialysis access. Methods The literature review incorporates twenty-seven relevant articles from 1997 to present and one case report series from 1966. Sources were gathered from electronic databases including PubMed, EMBASE, Medline, and Google Scholar. Only articles written in the English language were considered and study designs varied from current clinical guidelines, systematic and meta-analyses, randomized controlled trials, observational studies, and two main vascular surgery textbooks. Key Content and Findings This review exclusively focuses on the surgical creation of upper extremity hemodialysis accesses. Creating a graft versus fistula ultimately is decided by the existing anatomy, and is centered around the need of the patient. Preoperatively, the patient should undergo a thorough history and physical exam, with special attention to any previous central venous access, as well as, delineating the vascular anatomy with ultrasound imaging. The major tenets of access creation are choosing the most distal site of the non-dominant upper extremity whenever possible; and ideally creation of an autogenous access is preferred over a prosthetic graft. Described in this review are multiple surgical approaches for upper extremity hemodialysis access creation and associated institutional practices performed by the surgeon author. In the postoperative period, follow up care and surveillance are imperative to preserve a functioning access. Conclusions The most recent guidelines regarding hemodialysis access still favor arteriovenous fistula as the primary goal for patients with suitable anatomy. Preoperative evaluation including patient education, intraoperative ultrasound assessment, meticulous technique, and careful postoperative management are all paramount for successful access surgery. Dialysis access remains quite challenging, but with diligence the great majority of patients can be dialyzed without catheter dependence.
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Affiliation(s)
- Simon Montelongo
- Department Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Dylan E Brooks
- Department Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | | | - Eric K Peden
- Department Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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Sabiu G, Gallieni M. Pathophysiology of Arteriovenous Fistula Maturation and Nonmaturation. Clin J Am Soc Nephrol 2023; 18:8-10. [PMID: 36446601 PMCID: PMC10101610 DOI: 10.2215/cjn.13101122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Gianmarco Sabiu
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milan, Italy
- School of Nephrology, University of Milan, Milan, Italy
| | - Maurizio Gallieni
- Nephrology Unit, ASST Fatebenefratelli Sacco, Milan, Italy
- School of Nephrology, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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He Y, Shiu YT, Imrey PB, Radeva MK, Beck GJ, Gassman JJ, Northrup HM, Roy-Chaudhury P, Berceli SA, Cheung AK. Association of Shear Stress with Subsequent Lumen Remodeling in Hemodialysis Arteriovenous Fistulas. Clin J Am Soc Nephrol 2023; 18:72-83. [PMID: 36446600 PMCID: PMC10101625 DOI: 10.2215/cjn.04630422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Blood flow-induced wall shear stress is a strong local regulator of vascular remodeling, but its effects on arteriovenous fistula (AVF) remodeling are unclear. METHODS In this prospective cohort study, we used computational fluid dynamics simulations and statistical mixed-effects modeling to investigate the associations between wall shear stress and AVF remodeling in 120 participants undergoing AVF creation surgery. Postoperative magnetic resonance imaging data at 1 day, 6 weeks, and 6 months were used to derive current wall shear stress by computational fluid dynamic simulations and to quantify subsequent changes in AVF lumen cross-sectional area at 1-mm intervals along the proximal artery and AVF vein. RESULTS Combining artery and vein data, prior mean wall shear stress was significantly associated with lumen area expansion. Mean wall shear stress at day 1 was significantly associated with change in lumen area from day 1 to week 6 (11% larger area per interquartile range [IQR] higher mean wall shear stress, 95% confidence interval [95% CI], 5% to 18%; n =101), and mean wall shear stress at 6 weeks was significantly associated with change in lumen area from 6 weeks to month 6 (14% larger area per IQR higher, 95% CI, 3% to 28%; n =52). The association of mean wall shear stress at day 1 with lumen area expansion from day 1 to week 6 differed significantly by diabetes ( P =0.009): 27% (95% CI, 17% to 37%) larger area per IQR higher mean wall shear stress without diabetes and 9% (95% CI, -1% to 19%) with diabetes. Oscillatory shear index at day 1 was significantly associated with change in lumen area from day 1 to week 6 (5% smaller area per IQR higher oscillatory shear index, 95% CI, 3% to 7%), and oscillatory shear index at 6 weeks was significantly associated with change in lumen from 6 weeks to month 6 (7% smaller area per IQR higher oscillatory shear index, 95% CI, 2% to 11%). Wall shear stress spatial gradient was not significantly associated with subsequent remodeling. In a joint model, wall shear stress and oscillatory shear index statistically significantly interacted in their associations with lumen area expansion in a complex nonlinear fashion. CONCLUSIONS Higher wall shear stress and lower oscillatory shear index were associated with greater lumen expansion after AVF creation surgery.
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Affiliation(s)
- Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Milena K. Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gerald J. Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Jennifer J. Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Hannah M. Northrup
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
- Department of Medicine, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida
- Vascular Surgery Section, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
- Renal Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
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Minxia L, Yuehong L, Jiaxuan L, Xianglan W, Chong W, Zhiyong B, Yue L. Association between brachial artery peak systolic velocity and ipsilateral radio-cephalic arteriovenous fistula maturation. Int J Artif Organs 2022; 46:3-8. [DOI: 10.1177/03913988221140424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To evaluate the association between brachial artery blood velocity by color Doppler flow imaging (CDFI) and primary maturation of radio-cephalic autologous arteriovenous fistula (RC-AVF). Methods: Clinical data from patients who underwent end-to-side cephalic-radial anastomosis were collected from December 2015 to December 2020. The anastomosis diameter (mm), blood velocity (cm/s), and brachial artery diameters (mm) 7 cm proximal to the elbow pre- and postoperation were measured by GE LOGIC-E9 ultrasound. The AVF was mature if it could be cannulated successfully and the blood flow was >200 ml/min during dialysis. Results: A total of 197 patients were included in our statistical analysis. A total of 163 patients had mature AVFs, and 34 patients had poor maturity (assisted and failed maturation). There were no significant differences in the clinical characteristics, peak systolic velocity (PSV) of the brachial artery, diameter of the radial artery or cephalic vein measured by CDFI preoperatively. The diameter of the brachial artery (5.41 ± 0.77 vs 4.89 ± 0.90, p = 0.00) and the fistula anastomosis (2.79 ± 0.78 vs 2.45 ± 0.85, p = 0.02) and PSV of the brachial artery (123.58 ± 37.11 vs 89.63 ± 28.31, p = 0.00) in the mature group were higher than those in the immature group. Conclusion: Brachial artery PSV and increased brachial artery PSV could be used to detect RC-AVF maturation in the early stage.
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Affiliation(s)
- Li Minxia
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Li Yuehong
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Lv Jiaxuan
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Wu Xianglan
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Wang Chong
- Department of Nephrology, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, Beijing, China
| | - Bai Zhiyong
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, China
| | - Liu Yue
- Department of Ultrasound, Beijing Tsinghua Changgung Hospital, Medical Center, Tsinghua University, China
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Ross DW, Moses AA, Niyyar VD. Point-of-care ultrasonography in nephrology comes of age. Clin Kidney J 2022; 15:2220-2227. [PMID: 36381376 PMCID: PMC9664573 DOI: 10.1093/ckj/sfac160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 03/22/2024] Open
Abstract
The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology.
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Affiliation(s)
- Daniel W Ross
- Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Division of Kidney Diseases and Hypertension, Great Neck, NY, USA
| | - Andrew A Moses
- Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lenox Hill Division of Nephrology, New York, NY, USA
| | - Vandana Dua Niyyar
- Emory University, Division of Nephrology, Woodruff Memorial Research Building, Atlanta GA, USA
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Northrup H, He Y, Le H, Berceli SA, Cheung AK, Shiu YT. Differential hemodynamics between arteriovenous fistulas with or without intervention before successful use. Front Cardiovasc Med 2022; 9:1001267. [PMID: 36407418 PMCID: PMC9669082 DOI: 10.3389/fcvm.2022.1001267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/17/2022] [Indexed: 08/22/2023] Open
Abstract
A significant number of arteriovenous fistulas (AVFs) fail to maturate for dialysis. Although interventions promote maturation, functional primary patency loss is higher for AVFs with interventions (assisted maturation) than AVFs without interventions (un-assisted maturation). Although blood flow-associated hemodynamics have long been proposed to affect AVF remodeling, the optimal hemodynamic parameters for un-assisted maturation are unclear. Additionally, AVF maturation progress is generally not investigated until 6 weeks after AVF creation, and the examination is focused on the AVF's venous limb. In this exploratory study, patients (n = 6) underwent magnetic resonance imaging (MRI) at 1 day, 6 weeks, and 6 months after AVF creation surgery. Before successful use for hemodialysis, three AVFs required intervention and three did not. MRI of the AVFs were used to calculate lumen cross-sectional area (CSA) and perform computational fluid dynamics (CFD) to analyze hemodynamics, including velocity, wall shear stress (WSS), and vorticity. For the venous limb, the no-intervention group and intervention group had similar pre-surgery vein diameter and 1-day post-surgery venous CSA. However, the no-intervention group had statistically larger 1-day venous velocity (0.97 ± 0.67 m/s; mean ± SD), WSS (333 ± 336 dyne/cm2) and vorticity (1709 ± 1290 1/s) than the intervention group (velocity = 0.23 ± 0.10 m/s; WSS = 49 ± 40 dyne/cm2; vorticity = 493.1 ± 227 1/s) (P < 0.05). At 6 months, the no-intervention group had statistically larger venous CSA (43.5 ± 27.4 mm2) than the intervention group (15.1 ± 6.2 mm2) (P < 0.05). Regarding the arterial limb, no-intervention AVF arteries also had statistically larger 1-day velocity (1.17 ± 1.0 m/s), WSS (340 ± 423 dyne/cm2), vorticity (1787 ± 1694 1/s), and 6-month CSA (22.6 ± 22.7 mm2) than the intervention group (velocity = 0.64 ± 0.36 m/s; WSS = 104 ± 116 dyne/cm2, P < 0.05; vorticity = 867 ± 4551/s; CSA = 10.7 ± 6.0 mm2, P < 0.05). Larger venous velocity, WSS, and vorticity immediately after AVF creation surgery may be important for later lumen enlargement and AVF maturation, with the potential to be used as a tool to help diagnose poor AVF maturation earlier. However, future studies using a larger cohort are needed to validate this finding and determine cut off values, if any.
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Affiliation(s)
- Hannah Northrup
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Yong He
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, United States
| | - Ha Le
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, United States
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, United States
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Rajaram N, Thelen BJ, Hamilton JD, Zheng Y, Morgan T, Funes-Lora MA, Yessayan L, Shih AJ, Henke P, Osborne N, Bishop B, Krishnamurthy VN, Weitzel WF. Semiautomated Software to Improve Stability and Reduce Operator-Induced Variation in Vascular Ultrasound Speckle Tracking. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2755-2766. [PMID: 35170801 DOI: 10.1002/jum.15960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Ultrasound is useful in predicting arteriovenous fistula (AVF) maturation, which is essential for hemodialysis in end-stage renal disease patients. We developed ultrasound software that measures circumferential vessel wall strain (distensibility) using conventional ultrasound Digital Imaging and Communications in Medicine (DICOM) data. We evaluated user-induced variability in measurement of arterial wall distensibility and upon finding considerable variation we developed and tested 2 methods for semiautomated measurement. METHODS Ultrasound scanning of arteries of 10 subjects scheduled for AVF surgery were performed. The top and bottom of the vessel wall were tracked using the Kanade-Lucas-Tomasi (KLT) feature-tracking algorithm over the stack of images in the DICOM cine loops. The wall distensibility was calculated from the change of vessel diameter over time. Two semiautomated methods were used for comparison. RESULTS The location of points selected by users for the cine loops varied significantly, with a maximum spread of up to 120 pixels (7.8 mm) for the top and up to 140 pixels (9.1 mm) for the bottom of the vessel wall. This variation in users' point selection contributed to the variation in distensibility measurements (ranging from 5.63 to 41.04%). Both semiautomated methods substantially reduced variation and were highly correlated with the median distensibility values obtained by the 10 users. CONCLUSIONS Minimizing user-induced variation by standardizing point selection will increase reproducibility and reliability of distensibility measurements. Our recent semiautomated software may help expand use in clinical studies to better understand the role of vascular wall compliance in predicting the maturation of fistulas.
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Affiliation(s)
- Nirmala Rajaram
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian J Thelen
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Statistics, University of Michigan, Ann Arbor, Michigan, USA
- Michigan Tech Research Institute, Michigan Technological University, Ann Arbor, Michigan, USA
| | - James D Hamilton
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Yihao Zheng
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Timothy Morgan
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan, USA
| | | | - Lenar Yessayan
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Albert J Shih
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Henke
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas Osborne
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brandie Bishop
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Venkataramu N Krishnamurthy
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Radiology, Case Western Reserve, Cleveland, Ohio, USA
| | - William F Weitzel
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Heindel P, Dey T, Feliz JD, Hentschel DM, Bhatt DL, Al-Omran M, Belkin M, Ozaki CK, Hussain MA. Predicting radiocephalic arteriovenous fistula success with machine learning. NPJ Digit Med 2022; 5:160. [PMID: 36280681 PMCID: PMC9592575 DOI: 10.1038/s41746-022-00710-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
After creation of a new arteriovenous fistula (AVF), assessment of readiness for use is an important clinical task. Accurate prediction of successful use is challenging, and augmentation of the physical exam with ultrasound has become routine. Herein, we propose a point-of-care tool based on machine learning to enhance prediction of successful unassisted radiocephalic arteriovenous fistula (AVF) use. Our analysis includes pooled patient-level data from 704 patients undergoing new radiocephalic AVF creation, eligible for hemodialysis, and enrolled in the 2014-2019 international multicenter PATENCY-1 or PATENCY-2 randomized controlled trials. The primary outcome being predicted is successful unassisted AVF use within 1-year, defined as 2-needle cannulation for hemodialysis for ≥90 days without preceding intervention. Logistic, penalized logistic (lasso and elastic net), decision tree, random forest, and boosted tree classification models were built with a training, tuning, and testing paradigm using a combination of baseline clinical characteristics and 4-6 week ultrasound parameters. Performance assessment includes receiver operating characteristic curves, precision-recall curves, calibration plots, and decision curves. All modeling approaches except the decision tree have similar discrimination performance and comparable net-benefit (area under the ROC curve 0.78-0.81, accuracy 69.1-73.6%). Model performance is superior to Kidney Disease Outcome Quality Initiative and University of Alabama at Birmingham ultrasound threshold criteria. The lasso model is presented as the final model due to its parsimony, retaining only 3 covariates: larger outflow vein diameter, higher flow volume, and absence of >50% luminal stenosis. A point-of-care online calculator is deployed to facilitate AVF assessment in the clinic.
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Affiliation(s)
- Patrick Heindel
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Tanujit Dey
- grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Jessica D. Feliz
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Dirk M. Hentschel
- grid.38142.3c000000041936754XDivision of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Deepak L. Bhatt
- grid.38142.3c000000041936754XDivision of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mohammed Al-Omran
- grid.17063.330000 0001 2157 2938Division of Vascular Surgery and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON Canada ,grid.415310.20000 0001 2191 4301Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Michael Belkin
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - C. Keith Ozaki
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mohamad A. Hussain
- grid.38142.3c000000041936754XDivision of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
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Barcena AJR, Perez JVD, Liu O, Mu A, Heralde FM, Huang SY, Melancon MP. Localized Perivascular Therapeutic Approaches to Inhibit Venous Neointimal Hyperplasia in Arteriovenous Fistula Access for Hemodialysis Use. Biomolecules 2022; 12:biom12101367. [PMID: 36291576 PMCID: PMC9599524 DOI: 10.3390/biom12101367] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/23/2022] [Indexed: 01/14/2023] Open
Abstract
An arteriovenous fistula (AVF) is the preferred vascular access for chronic hemodialysis, but high failure rates restrict its use. Optimizing patients' perioperative status and the surgical technique, among other methods for preventing primary AVF failure, continue to fall short in lowering failure rates in clinical practice. One of the predominant causes of AVF failure is neointimal hyperplasia (NIH), a process that results from the synergistic effects of inflammation, hypoxia, and hemodynamic shear stress on vascular tissue. Although several systemic therapies have aimed at suppressing NIH, none has shown a clear benefit towards this goal. Localized therapeutic approaches may improve rates of AVF maturation by providing direct structural and functional support to the maturating fistula, as well as by delivering higher doses of pharmacologic agents while avoiding the adverse effects associated with systemic administration of therapeutic agents. Novel materials-such as polymeric scaffolds and nanoparticles-have enabled the development of different perivascular therapies, such as supportive mechanical devices, targeted drug delivery, and cell-based therapeutics. In this review, we summarize various perivascular therapeutic approaches, available data on their effectiveness, and the outlook for localized therapies targeting NIH in the setting of AVF for hemodialysis use. Highlights: Most systemic therapies do not improve AVF patency outcomes; therefore, localized therapeutic approaches may be beneficial. Locally delivered drugs and medical devices may improve AVF patency outcomes by providing biological and mechanical support. Cell-based therapies have shown promise in suppressing NIH by delivering a more extensive array of bioactive substances in response to the biochemical changes in the AVF microenvironment.
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Affiliation(s)
- Allan John R. Barcena
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | - Joy Vanessa D. Perez
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | - Olivia Liu
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Grossman School of Medicine, New York University, New York, NY 10016, USA
| | - Amy Mu
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas Southwestern Medical School, Dallas, TX 75390, USA
| | - Francisco M. Heralde
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | - Steven Y. Huang
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Marites P. Melancon
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
- Correspondence:
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The Predictive Value of Systemic Inflammatory Markers, the Prognostic Nutritional Index, and Measured Vessels' Diameters in Arteriovenous Fistula Maturation Failure. Life (Basel) 2022; 12:life12091447. [PMID: 36143483 PMCID: PMC9506395 DOI: 10.3390/life12091447] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 12/31/2022] Open
Abstract
Background: An arteriovenous fistula (AVF) is the first-line vascular access pathway for patients diagnosed with end-stage renal disease (ESRD). In planning vascular access, it is necessary to check the diameters of the venous and arterial components for satisfactory long-term results. Furthermore, the mechanism underlying the maturation failure and short-term patency in cases of AVFs is not fully known. This study aims to verify the predictive role of inflammatory biomarkers (the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory index (SII), and C-reactive protein (CRP)), Ca-P product, the prognostic nutritional index (PNI), and the diameters of the venous and arterial components in the failure of AVF maturation. Methods: The present study was designed as an observational, analytical, and retrospective cohort study with a longitudinal follow-up, and included all patients with a diagnosis of ESRD that were admitted to the Vascular Surgery Clinic of the Targu Mures Emergency County Hospital, Romania, between January 2019 and December 2021. Results: The maturation of AVF at 6 weeks was clearly lower in cases of patients in the high-NLR (31.88% vs. 91.36%; p < 0.0001), high-PLR (46.94% vs. 85.55%; p < 0.0001), high-SII (44.28% vs. 88.89%; p < 0.0001), high-CRP (46.30% vs. 88.73%; p < 0.0001), high-Ca-P product (40.43% vs. 88.46%; p < 0.0001), and low-PNI (34.78% vs. 91.14%; p < 0.0001) groups, as well as in patients with a lower radial artery (RA) diameter (40% vs. 94.87%; p = 0.0009), cephalic vein (CV) diameter (44.82% vs. 97.14%; p = 0.0001) for a radio-cephalic AVF (RC-AVF), and brachial artery (BA) diameter (30.43% vs. 89.47%; p < 0.0001) in addition to CV diameter (40% vs. 94.59%; p < 0.0001) for a brachio-cephalic AVF (BC-AVF), respectively. There was also a significant increase in early thrombosis and short-time mortality in the same patients. A multivariate analysis showed that a baseline value for the NLR, PLR, SII, CRP, Ca-P product, and PNI was an independent predictor of adverse outcomes for all of the recruited patients. Furthermore, for all patients, a high baseline value for vessel diameter was a protective factor against any negative events during the study period, except for RA diameter in mortality (p = 0.16). Conclusion: Our findings concluded that higher NLR, PLR, SII, CRP, Ca-P product, and PNI values determined preoperatively were strongly predictive of AVF maturation failure, early thrombosis, and short-time mortality. Moreover, a lower baseline value for vessel diameter was strongly predictive of AVF maturation failure and early thrombosis.
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Predicción del flujo intraoperatorio de fístulas arteriovenosas mediante el uso de imágenes térmicas infrarrojas. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Radiocephalic Arteriovenous Fistula Patency and Use. ANNALS OF SURGERY OPEN 2022; 3:e199. [PMID: 36199486 PMCID: PMC9508986 DOI: 10.1097/as9.0000000000000199] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 01/05/2023] Open
Abstract
We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Mini-abstract: In this post hoc analysis of randomized clinical trial data including 914 adults with chronic kidney disease, the most robust predictors of radiocephalic arteriovenous fistula patency were larger cephalic vein diameter and access creation prior to a chronic hemodialysis requirement. Successful use occurred at increased rates in men, patients with larger diameter cephalic veins, smaller diameter arteries (albeit ≥2 mm), and when accesses were created using regional anesthesia and at higher volume centers.
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Snuff-Box Versus Wrist Radiocephalic Arteriovenous Fistulas for Hemodialysis: Maturation Tend and its Affecting Factors. Ann Vasc Surg 2022; 87:495-501. [PMID: 35780948 DOI: 10.1016/j.avsg.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.
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Martinez L, Perla M, Tabbara M, Duque JC, Rojas MG, Falcon NS, Pereira-Simon S, Salman LH, Vazquez-Padron RI. Systemic Profile of Cytokines in Arteriovenous Fistula Patients and Their Associations with Maturation Failure. KIDNEY360 2022; 3:677-686. [PMID: 35721613 PMCID: PMC9136910 DOI: 10.34067/kid.0006022021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022]
Abstract
Background Systemic cytokines are elevated in patients with chronic kidney disease (CKD) and on hemodialysis compared with the general population. However, whether cytokine levels interfere with vascular remodeling, increasing the risk of arteriovenous fistula (AVF) failure, remains unknown. Methods This is a case-control study of 64 patients who underwent surgery for AVF creation (32 with AVF maturation failure and 32 matching controls with successful maturation). A total of 74 cytokines, including chemokines, interferons, interleukins, and growth factors, were measured in preoperative plasma samples using multiplex assays. Sixty-two patients were included in the statistical analyses. Associations with AVF failure were assessed using paired comparisons and conditional logistic regressions accounting for paired strata. Results Seven cytokines were significantly higher in patients with AVF maturation failure than in matching controls (G-CSF, IL-6, MDC, RANTES, SDF-1α/β, TGFα, and TPO). Of these, G-CSF (odds ratio [OR]=1.71; 95% confidence interval [95% CI], 1.05 to 2.79 per 10 pg/ml), MDC (OR=1.60, 95% CI, 1.08 to 2.38 per 100 pg/ml), RANTES (OR=1.55, 95% CI, 1.10 to 2.17 per 100 pg/ml), SDF-1α/β (OR=1.18, 95% CI, 1.04 to 1.33 per 1000 pg/ml), and TGFα (OR=1.39, 95% CI 1.003, 1.92 per 1 pg/ml) showed an incremental association by logistic regression. Conclusions This study identified a profile of plasma cytokines associated with adverse maturation outcomes in AVFs. These findings may open the doors for future therapeutics and markers for risk stratification.
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Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Mikael Perla
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan C Duque
- Katz Family Division of Nephrology, Department of Medicine, University of Miami, Miami, Florida
| | - Miguel G Rojas
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Simone Pereira-Simon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, New York
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.,Bruce W. Carter VA Medical Center, Department of Veterans Affairs, Miami, Florida
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Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study. J Nephrol 2022; 35:1689-1698. [PMID: 35347647 PMCID: PMC9300570 DOI: 10.1007/s40620-022-01288-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/16/2022] [Indexed: 12/20/2022]
Abstract
Background Evidence surrounding vascular access options for commencing dialysis in pregnancy complicated by chronic kidney disease (CKD) is limited. Creation of new arteriovenous fistulas (AVFs) in pregnant women is rare. Methods Retrospective cohort study of approaches to vascular access in pregnancy in centres in Australia, the United Kingdom (UK) and Canada (2002–2018). Results Twenty-three women with advanced CKD commenced dialysis in pregnancy (n = 20) or planned to commence (n = 3). Access at dialysis start was a tunnelled catheter (n = 13), temporary catheter (n = 1), AVF created pre-conception but used in pregnancy (n = 3) and AVF created during pregnancy (n = 3). No women commencing dialysis with an AVF required a catheter. No differences in perinatal outcomes were observed comparing AVFs and catheters at dialysis commencement. No AVFs were created in pregnancy in Canadian women. From Australia and the UK, 10 women had a new AVF created in pregnancy, at median gestation 14.5 weeks (IQR 12.5, 20.75). Four women still needed a catheter for dialysis initiation and 3 eventually used the new AVF. Six AVFs were successfully used in pregnancy at median gestation 24 weeks (IQR 22.5, 28.5), 2 were successfully created but not used and 2 had primary failure. No catheter-associated complications were identified except one episode of catheter-related sepsis. Conclusions Catheter-related complications were minimal. In selected women, with sufficient pre-planning, an AVF can be created and successfully used during pregnancy to minimise catheter use if preferred. Pre-conception counselling in advanced CKD should include discussing vascular access options reflecting local expertise and patient preferences. Graphic abstract ![]()
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Abreu R. New hemodynamic variables as predictors of arteriovenous fistula maturation. Semin Dial 2022; 35:358-362. [PMID: 35193155 DOI: 10.1111/sdi.13062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/12/2021] [Accepted: 02/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Failure to mature of native arteriovenous fistula (AVF) assessed by image is not well documented. METHODS The aim of this study is to evaluate AVF maturation by Doppler ultrasound within 6 weeks after surgery and check for new hemodynamic variables as prognostic factors. RESULTS A total of 155 native AVFs were created in 3 years. Median age of patients was 71 years (60;79), with male gender predominance of 59.4% (n = 92). Diabetes was present in 60.6% (n = 94). AVF was created in distal forearm in 49.7% (n = 77). Un-assisted and overall maturation was of 67.1% (n = 104) and 83.9% (n = 130), respectively. Failure to mature occurred in 21.3% (n = 33) and primary failure in 9.7% (n = 15). In univariate analysis, preoperative variables such as diameter of artery (3.5 vs. 2.2 mm; p < 0.001) and pulsatility index (7.9 vs. 6.6; p = 0.055) were associated with failure to mature of AVF. Postoperative variables as Qa (994 vs. 401 mL/min; p < 0.001), resistance index (0.52 vs. 0.63; p < 0.001), pulsatility index (0.74 vs. 1.21; p < 0.001), and acceleration time (0.17 vs. 0.12; p < 0.001) also predicted an unfunctional AVF. Spearman correlation coefficient (r) was good for resistance index (-0.628) and pulsatility index (-0.707) in comparison with blood flow (Qa). In multivariate analysis, postoperative pulsatility index was an independent predictor of AVF dysfunction (OR: 16.5; p < 0.001). CONCLUSIONS Failure to mature was of 21.3%. Pulsatility index could be an important tool as new hemodynamic variable to predict failure to mature of native AVF.
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Affiliation(s)
- Rui Abreu
- Nephrology Department, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Niyyar VD, Agarwal AK, Salman LH. Clinical Aspects of Dialysis Interventions: Physical and Sonographic Findings. Semin Intervent Radiol 2022; 39:9-13. [PMID: 35210727 PMCID: PMC8856772 DOI: 10.1055/s-0041-1740946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Physical examination (PE) of arteriovenous access remains of high clinical value and continues to be recommended by leading societies and guidelines. PE is easy to learn and perform. Once learned, examiners can provide a comprehensive arteriovenous (AV) access examination in 20 to 30 seconds. Therefore, we continue to advocate that AV access PE should be part of the training for all dialysis care providers. Similarly, ultrasound can provide important AV access evaluation and provide key information. It is relatively cheap and can be readily available at the bed side. Additionally, it is well accepted by patients, as it is not expected to be associated with pain or discomfort during the examination. We present in this review the key components of PE, signs and symptoms of AV access dysfunction, and the role of ultrasound in AV access evaluation as a complementary tool to PE.
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Affiliation(s)
- Vandana Dua Niyyar
- Division of Nephrology, Emory University School of Medicine, Atlanta, Georgia
| | - Anil K. Agarwal
- Department of Medicine, VA Central California Health Care System, Fresno, California
| | - Loay H. Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York,Address for correspondence Loay H. Salman, MD, MBA Division of Nephrology and Hypertension, Albany Medical CollegeAlbany, NY 12208
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Hakim AJ, Brooke BS, Beckstrom JL, Sarfati MR, Kraiss LW. Rules of 6 Criteria Predict Dialysis Fistula Maturation but Not All Rules are Equal. J Vasc Surg 2022; 76:232-238.e2. [DOI: 10.1016/j.jvs.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/03/2022] [Indexed: 11/30/2022]
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Funes-Lora MA, Thelen BJ, Shih AJ, Hamilton J, Rajaram N, Lyu J, Zheng Y, Morgan T, Weitzel WF. Ultrasound Measurement of Vascular Distensibility Based on Edge Detection and Speckle Tracking Using Ultrasound DICOM Data. ASAIO J 2022; 68:112-121. [PMID: 34380948 DOI: 10.1097/mat.0000000000001548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
This study presents an edge detection and speckle tracking (EDST) based algorithm to calculate distensibility as percentage of change of vessel diameter during cardiac cycles. Canny edge detector, Vandermonde matrix representation, Kanade Lucas Tomasi algorithm with pyramidal segmentation, and penalized least squares technique identifies the vessel lumen edge, track the vessel diameter, detrend the signal and find peaks and valleys when the vessel is fully distended or contracted. An upper extremity artery from 10 patients underwent an ultrasound examination as part of preoperative evaluation before arteriovenous fistula surgery. Three studies were performed to evaluate EDST with automatic peak and valley selection versus manual speckle selection of expert users using manual peak and valley selection. Results demonstrate the effectiveness of the proposed methodology, to obtain comparable results as those obtained by expert-users, and considerably reducing the variability associated with external factors such as excessive motion, fluctuations in stroke volume, beat-to-beat blood pressure changes, breathing cycles, and arm-transducer pressure.
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Affiliation(s)
- Miguel Angel Funes-Lora
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Brian J Thelen
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
- Michigan Tech Research Institute, Michigan Technological University, Ann Arbor, Michigan
| | - Albert J Shih
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - James Hamilton
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Emerge Now Inc., Los Angeles, California
| | - Nirmala Rajaram
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Jingxuan Lyu
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Yihao Zheng
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
- Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Timothy Morgan
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - William F Weitzel
- From the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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50
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Somarathna M, Hwang PT, Millican RC, Alexander GC, Isayeva-Waldrop T, Sherwood JA, Brott BC, Falzon I, Northrup H, Shiu YT, Stubben CJ, Totenhagen J, Jun HW, Lee T. Nitric oxide releasing nanomatrix gel treatment inhibits venous intimal hyperplasia and improves vascular remodeling in a rodent arteriovenous fistula. Biomaterials 2022; 280:121254. [PMID: 34836683 PMCID: PMC8724452 DOI: 10.1016/j.biomaterials.2021.121254] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 01/03/2023]
Abstract
Vascular access is the lifeline for hemodialysis patients and the single most important component of the hemodialysis procedure. Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis patients, but nearly 60% of AVFs created fail to successfully mature due to early intimal hyperplasia development and poor outward remodeling. There are currently no therapies available to prevent AVF maturation failure. First, we showed the important regulatory role of nitric oxide (NO) on AVF development by demonstrating that intimal hyperplasia development was reduced in an overexpressed endothelial nitric oxide synthase (NOS3) mouse AVF model. This supported the rationale for the potential application of NO to the AVF. Thus, we developed a self-assembled NO releasing nanomatrix gel and applied it perivascularly at the arteriovenous anastomosis immediately following rat AVF creation to investigate its therapeutic effect on AVF development. We demonstrated that the NO releasing nanomatrix gel inhibited intimal hyperplasia formation (more than 70% reduction), as well as improved vascular outward remodeling (increased vein diameter) and hemodynamic adaptation (lower wall shear stress approaching the preoperative level and less vorticity). Therefore, direct application of the NO releasing nanomatrix gel to the AVF anastomosis immediately following AVF creation may enhance AVF development, thereby providing long-term and durable vascular access for hemodialysis.
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Affiliation(s)
- Maheshika Somarathna
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, AL, 35294, USA
| | - Patrick Tj Hwang
- Department of Biomedical Engineering, University of Alabama at Birmingham, AL, 35294, USA; Endomimetics, LLC, Birmingham, AL, 35242, USA
| | | | - Grant C Alexander
- Department of Biomedical Engineering, University of Alabama at Birmingham, AL, 35294, USA; Endomimetics, LLC, Birmingham, AL, 35242, USA
| | - Tatyana Isayeva-Waldrop
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, AL, 35294, USA
| | | | - Brigitta C Brott
- Endomimetics, LLC, Birmingham, AL, 35242, USA; Department of Medicine and Division of Cardiovascular Disease, University of Alabama at Birmingham, AL, 35233, USA
| | - Isabelle Falzon
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - Hannah Northrup
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, 84132, USA; Veterans Affairs Medical Center, Salt Lake City, UT, 84148, USA
| | - Chris J Stubben
- Bioinformatics Shared Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, 84112, USA
| | - John Totenhagen
- Department of Radiology, University of Alabama at Birmingham, AL, 35294, USA
| | - Ho-Wook Jun
- Department of Biomedical Engineering, University of Alabama at Birmingham, AL, 35294, USA; Endomimetics, LLC, Birmingham, AL, 35242, USA
| | - Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, AL, 35294, USA; Veterans Affairs Medical Center, Birmingham, AL, 35233, USA
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