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Nagaraj A, Skummer PT, Gunasekaran V, Johnson C, Roza A, Klinger D, White S, Smolock AR. Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy. Cardiovasc Intervent Radiol 2023; 46:204-208. [PMID: 36536145 PMCID: PMC10123846 DOI: 10.1007/s00270-022-03329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous pharmacomechanical thrombectomy ("declot"). MATERIALS AND METHODS This was an institutional review board-approved retrospective review of AVG declot procedures between July 2019 and August 2020. AVG characteristics, bleeding complications, anticoagulation and antiplatelet medication regimens, and thrombosis free survival were evaluated. Recurrent time-to-event analysis was performed using a Prentice-Williams-Peterson Gap time model was performed to evaluate AVG thrombosis free survival. RESULTS A total of 109 declots were technically successful and performed in 63 individual patients. The majority of procedures were performed in upper arm grafts (71%, n = 45). Dual antiplatelet (DAPT) was prescribed after 52 declots (48%), single antiplatelet was prescribed after 36 declots (33%), and anticoagulation was prescribed after 31 declots (28%). Median thrombosis free survival was 37 days (range 1-412 days) in the no antiplatelet group, 84 days (range 1-427 days) in the single antiplatelet group, and 93 days (range 3-407 days) in the DAPT group. Anti-platelet medications trended towards protective of AVG thrombosis in multivariate analysis (hazard ratio 0.84, 95% confidence interval 0.60-1.19); however, this did not reach statistical significance (P = 0.33). A total of 4 major and 5 minor bleeding events occurred. CONCLUSION The results of this study support further evaluation of AP therapy in preventing secondary rethrombosis of dialysis AVG.
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Affiliation(s)
- Aaditya Nagaraj
- Radiology Partners Houston, Medical Plaza 1, 902 Frostwood Dr., Ste 184, Houston, TX, 77024, USA
| | - Philip T Skummer
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave. Room 2803, Milwaukee, WI, 53226, USA
| | | | | | - Allan Roza
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dean Klinger
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah White
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave. Room 2803, Milwaukee, WI, 53226, USA
| | - Amanda R Smolock
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave. Room 2803, Milwaukee, WI, 53226, USA.
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Anapalli SR, N. HD, Sarma P, Srikanth L, V. SK. Thrombophilic risk factors and ABO blood group profile for arteriovenous access failure in end stage kidney disease patients: a single-center experience. Ren Fail 2022; 44:34-42. [PMID: 35094650 PMCID: PMC8812770 DOI: 10.1080/0886022x.2021.2011746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Thrombosis of fistula occurs most frequently in end-stage kidney disease (ESKD) patients receiving hemodialysis. However, the role of thrombophilia in arteriovenous fistula (AVF) failure has not been well established. Hence, this study was aimed at assessing the roles of hereditary and acquired thrombophilic factors in association with AVF failure among patients with ESKD undergoing hemodialysis. METHODS A cross-sectional study was conducted on 100 ESKD patients, of whom 50 patients with well-functioning AVFs with no fistula failures earlier were enrolled as Group 1, and 50 patients who have had AVF failure were enrolled as Group 2. The hereditary factors as factor V Leiden, factor XIII, prothrombin, and methylene tetrahydrofolate reductase and the acquired factors as lipoprotein (a), fibrinogen, homocysteine, and anticardiolipin antibodies IgG and IgM were studied. RESULTS Among the hereditary factors, no statistically significant difference was observed in relation to factor V Leiden and Prothrombin (p > 0.05). However, for factor XIII and methylene tetrahydrofolate reductase, a statistically significant difference was observed between patients with well-functioning AVFs and patients who have had AVF failure (p < 0.05). We found a statistically significant increase in all the acquired factors in patients who have had AVF failure in comparison with patients with well-functioning AVFs (p < 0.001). Association between ABO blood groups and thrombophilic factors showed significant association between factor V Leiden, anticardiolipin antibody IgG and IgM and ABO blood groups (p < 0.05), whereas none of the other thrombophilic factors showed significant association (p > 0.05). CONCLUSION Thus, our study suggests significant role of acquired factors in causing AVF failure.
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Affiliation(s)
- Sunnesh Reddy Anapalli
- Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Harini Devi N.
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Pvgk Sarma
- Department of Biotechnology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Lokanathan Srikanth
- Department of Biotechnology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Siva Kumar V.
- Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Mohamed I, Kamarizan MFA, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2021; 7:CD002786. [PMID: 34298589 PMCID: PMC8406473 DOI: 10.1002/14651858.cd002786.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with end-stage renal disease (ESRD) often require either the formation of an arteriovenous fistula (AVF) or an interposition prosthetic arteriovenous graft (AVG) for haemodialysis. These access sites should ideally have a long life and a low rate of complications (e.g. thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the fourth update of the review first published in 2003. OBJECTIVES To assess the effects of adjuvant drug treatment in people with ESRD on haemodialysis via autologous AVFs or prosthetic interposition AVGs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and ClinicalTrials.gov trials register to 6 August 2020. SELECTION CRITERIA Randomised controlled trials of active drug versus placebo in people with ESRD undergoing haemodialysis via an AVF or prosthetic interposition AVG. DATA COLLECTION AND ANALYSIS For this update, two review authors (IM, MFAK) independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence according to GRADE. We resolved disagreements by discussion or consultation with another review author (ADS). The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay; complications such as infection, aneurysm formation, stenosis and distal limb ischaemia; and number of related surgical or radiological interventions. MAIN RESULTS For this update, one additional study was suitable for inclusion, making a total of 13 trials with 2080 participants. Overall the certainty of the evidence was low or moderate due to short follow-up periods, heterogeneity between trials, small sample sizes, and risk of bias due to incomplete reporting. Medical adjuvant treatments used in the included trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone and glyceryl trinitrate (GTN) patch. All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; 3 studies, 175 participants; low-certainty evidence). The meta-analysis for graft patency comparing ticlopidine versus placebo favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; 3 studies, 339 participants; moderate-certainty evidence). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (OR 0.24, 95% CI 0.03 to 1.95; 2 studies, 220 participants; low-certainty evidence); and studies comparing clopidogrel and placebo (OR 0.40, 95% CI 0.13 to 1.19; 2 studies, 959 participants; moderate-certainty evidence). Similarly, there was insufficient evidence to determine if there was a difference in graft patency comparing the effect of dipyridamole versus placebo (OR 0.46, 95% CI 0.11 to 1.94; 1 study, 42 participants, moderate-certainty evidence) and dipyridamole plus aspirin versus placebo (OR 0.64, CI 0.16 to 2.56; 1 study, 41 participants; moderate-certainty evidence); comparing low-intensity warfarin with placebo (OR 1.76, 95% CI 0.78 to 3.99; 1 study, 107 participants; low-certainty evidence); comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98; 1 study, 16 participants; low-certainty evidence) and comparing GTN patch and placebo (OR 1.26, 95% CI 0.63 to 2.54; 1 study, 167 participants; moderate-certainty evidence). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. None of the included studies reported on the duration of hospital stay. Most studies reported complications ranging from mortality to nausea. However, data on complications were limited and reporting varied between studies. AUTHORS' CONCLUSIONS The meta-analyses of three studies for ticlopidine (an antiplatelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AVFs and AVGs in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, dipyridamole, dipyridamole plus aspirin, warfarin, sulphinpyrazone and GTN patch. The certainty of the evidence was low to moderate due to short follow-up periods, the small number of studies for each comparison, small sample sizes, heterogeneity between trials and risk of bias due to incomplete reporting. Therefore, it appears reasonable to suggest further prospective studies be undertaken to assess the use of these antiplatelet drugs in renal patients with an AVF or AVG.
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Affiliation(s)
- Imran Mohamed
- Wales Deanery, Health Education and Improvement Wales, Nantgarw, UK
| | | | - Antonio Da Silva
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham, UK
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5
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Jothi S, KG H, Lesley N, Vijayan M, Haridas Anupama S, Mathew M, Parthasarathy R, Sundarajan S, P N, Kumaraswamy L, Abraham G. A multicentre analysis of the outcome of arteriovenous fistula in maintenance haemodialysis. Semin Dial 2020; 33:388-393. [DOI: 10.1111/sdi.12907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Swathi Jothi
- Madras Medical Mission Hospital Chetpet, Chennai India
| | - Hareesh KG
- St.Gregorios Hospital Parumala Thiruvalla India
| | - Nancy Lesley
- Madras Medical Mission Hospital Chetpet, Chennai India
| | | | | | - Milly Mathew
- Madras Medical Mission Hospital Chetpet, Chennai India
- Pondicherry Institute of Medical Sciences Kalapet Puduchery India
| | | | | | - Nagarajan P
- Madras Medical Mission Hospital Chetpet, Chennai India
| | | | - Georgi Abraham
- Madras Medical Mission Hospital Chetpet, Chennai India
- Pondicherry Institute of Medical Sciences Kalapet Puduchery India
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Chang TI, Chen CH, Hsieh HL, Chen CY, Hsu SC, Cheng HS, Huang WC, Sue YM, Hsu YH, Lin FY, Shih CM, Lin SJ, Huang PH, Liu CT. Effects of cardiovascular medications on primary patency of hemodialysis arteriovenous fistula. Sci Rep 2020; 10:12135. [PMID: 32699337 PMCID: PMC7376157 DOI: 10.1038/s41598-020-69019-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
While the patency of vascular access is essential for hemodialysis patients, optimal pharmaceutical treatment to maintain arteriovenous fistula (AVF) patency remains lacking. As cardiovascular diseases are highly prevalent in patients with end-stage renal disease, various cardiovascular medications have also been used to maintain AVF patency. However, previous studies revealed inconsistent therapeutic effects and a comprehensive evaluation of this issue is needed. The present retrospective, longitudinal cohort study included patients receiving successful AVF creation. The evaluated cardiovascular medications included antiplatelet agents, antihypertensive agents, nitrates and nitrites, statins, dipyridamole, and pentoxifylline. The outcome was AVF primary patency. All laboratory data and medication profiles were recorded at baseline and followed at 3-month interval, until the end of the 2-year study period. Cox proportional regression model with time-dependent covariates was used to evaluate the risk for AVF patency loss. A total of 349 patients were included in the present study, in which 57% were men and the mean age was 65 ± 14 years. Among the included patients, 40% used antiplatelet agents, 27% used dipyridamole and 36% used statins at baseline. Of all the evaluated cardiovascular medications, only dipyridamole showed significant association with a higher risk for loss of AVF patency. To evaluate the effect of combination of antiplatelet agents and dipyridamole, the patients were classified into four groups, I: combine use of antiplatelet agents and dipyridamole, II: antiplatelet only, III: dipyridamole only; IV: none of both were used. Of the four groups, group IV exhibited highest AVF patency (52.4%), which was followed by group III (42.7%), group II (40%), and group I (28.6%), respectively. Compared with group IV, only group I showed a significantly higher risk for AVF patency loss. None of the cardiovascular medications evaluated in the present study showed a beneficial effect on AVF patency. Furthermore, dipyridamole showed an association with a higher risk of AVF patency loss. We do not suggest a beneficial effect of dipyridamole on maintaining AVF patency, particularly in combination with antiplatelet agents.
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Affiliation(s)
- Te-I Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Cheng-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Hui-Ling Hsieh
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Chun-You Chen
- Department of Radiation Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Chang Hsu
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ho-Shun Cheng
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Emergency Department, Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yuh-Mou Sue
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Yung-Ho Hsu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Urology and Kidney, Taipei, Taiwan
| | - Feng-Yen Lin
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Ming Shih
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Shing-Jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Taipei Medical University, Taipei, Taiwan.,Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Te Liu
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. .,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,TMU Research Center of Urology and Kidney, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 890] [Impact Index Per Article: 222.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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8
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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Effect of antiplatelet therapy on cardiovascular and kidney outcomes in patients with chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2019; 20:309. [PMID: 31390997 PMCID: PMC6686545 DOI: 10.1186/s12882-019-1499-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The benefits and risks of antiplatelet therapy for patients with chronic kidney disease (CKD) remain controversial. We undertook a systematic review and meta-analysis to investigate the effects of antiplatelet therapy on major clinical outcomes. METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library for trials published before April 2019 without language restriction. We included rrandomized controlled trials that involved adults with CKD and compared antiplatelet agents with controls. RESULTS Fifty eligible trials that included at least one event were identified, providing data for 27773patients with CKD, including 4518 major cardiovascular events and 1962 all-cause deaths. Antiplatelet therapy produced a 15% (OR, 0.85; 95% CI 0.74-0.94) reduction in the odds of major cardiovascular events (P = 0.002), a 48% reduction for access failure events (OR, 0.52; 95% CI, 0.31-0.73), but had no significantly effect on all-cause death (OR, 0.87; 95% CI, 0.71-1.01) or kidney failure events (OR, 0.87; 95% CI, 0.32-1.55). Adverse events were significantly increased by antiplatelet therapy, including major (OR, 1.33; 95% CI, 1.11-1.59) or minor bleeding (OR, 1.66; 95% CI, 1.27-2.05). Among every 1000 persons with CKD treated with antiplatelet therapy for 12 months, 23 major cardiovascular events will be prevented while nine major bleeding events will occur. CONCLUSIONS Major prevention with antiplatelet agents (cardiovascular events and access failure), might outweigh the risk of bleeding, and there seemed to be an overall net benefit. Individual evaluation and careful monitoring are required.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.,Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.
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Tsukada H, Nakamura M, Mizuno T, Satoh N, Nangaku M. Pharmaceutical prevention strategy for arteriovenous fistula and arteriovenous graft failure. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0210-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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10
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Fan PY, Lee CC, Liu SH, Li IJ, Weng CH, Tu KH, Hsieh MY, Kuo CF, Chang TY, Tian YC, Yang CW, Wu HH. Preventing arteriovenous shunt failure in hemodialysis patients: a population-based cohort study. J Thromb Haemost 2019; 17:77-87. [PMID: 30472783 DOI: 10.1111/jth.14347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Indexed: 11/29/2022]
Abstract
Essentials Uncertainty remains about antiplatelets for vascular access patency in hemodialysis patients. 95 971 people under hemodialysis were followed in a claims database in Taiwan. Aspirin reduced vascular access failure rate and did not increase major bleeding rate. Clopidogrel, Aggrenox, and warfarin might increase major bleeding rate. SUMMARY: Background Dialysis adequacy is a major determinant of survival for patients with end-stage renal disease. Good vascular access is essential to achieve adequate dialysis. Objectives This study evaluated the impacts of different drugs on the vascular access failure rate of an arteriovenous fistula or an arteriovenous graft and the rate of major bleeding in hemodialysis patients. Patients and methods We studied patients with end-stage renal disease registered in the Taiwan National Health Insurance program from 1 January 1997 to 31 December 2012. A total of 95 971 patients were enrolled in our study. Vascular access dysfunction was defined as the need for thrombectomy or percutaneous angioplasty. Major bleeding was defined as emergency department visits or hospitalization with a primary diagnosis of gastrointestinal bleeding or intracerebral hemorrhage. The adjusted odds ratios between person-quarters with or without antiplatelet or oral anticoagulant use were calculated using a generalized estimating equation. Results The odds ratio of vascular access failure was 0.21 (0.11-0.39) for aspirin, 0.76 (0.74-0.79) for clopidogrel, 0.67 (0.59-0.77) for dipyridamole, 0.67 (0.53-0.86) for Aggrenox and 0.96 (0.90-1.03) for warfarin. The highest odds ratio for intracerebral hemorrhage was 5.33 (1.25-22.72) in younger patients using Aggrenox. The highest odds ratio for gastrointestinal bleeding was 1.34 (1.10-1.64) for clopidogrel. Conclusion Antiplatelet agents, but not warfarin, might reduce the vascular access thrombosis rate. The gastrointestinal bleeding rate was increased in the group using clopidogrel. Aggrenox should be used with caution in young individuals because it might increase the rate of intracerebral hemorrhage.
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Affiliation(s)
- P Y Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
| | - C C Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, , Taiwan
| | - S H Liu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, , Taiwan
| | - I-J Li
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
| | - C H Weng
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, , Taiwan
| | - K H Tu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, , Taiwan
| | - M Y Hsieh
- Big Data Research Office, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
| | - C F Kuo
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - T-Y Chang
- Department of Neurology, Stroke Center, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y C Tian
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
| | - C W Yang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
| | - H H Wu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan
- Department of Medicine, Chang Gung University, Taoyuan, , Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, , Taiwan
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Wan Z, Zhu Y, Yang R, Zhang Y, Yang C, Cao L, Yan W, Wang Q, Li N, Zhao M, Gui K, Xiong M. Beraprost sodium versus clopidogrel for preventing vascular thromboembolic events of arteriovenous fistula in uraemic patients: a retrospective study with a mean 3-year follow-up. J Int Med Res 2018; 47:252-264. [PMID: 30270798 PMCID: PMC6384486 DOI: 10.1177/0300060518800517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the efficacy of beraprost sodium (BPS) or clopidogrel (CL) using vascular thromboembolic events (VTEs) of arteriovenous fistula as a primary endpoint in patients with end-stage renal disease (ESRD) undergoing arteriovenous fistula surgery. METHODS We performed a multicentre, retrospective cohort study from August 2012 to August 2016. We studied patients with ESRD who underwent arteriovenous fistula surgery and received peroral administration of 40 µg BPS, three times per day, for 1 month, or 75 mg CL (initial dose of 300 mg), one time per day, for 1 month. The time to first on-study VTE was the primary endpoint. RESULTS The BPS-treated cohort had a significantly delayed time to first VTE compared with the CL-treated cohort (hazard ratio 0.33, 95% confidence interval 0.18-0.56). An increased incidence of VTEs was detected in the 1-month follow-up, with rates of 2.4% and 8.7% for BPS and CL, respectively. This difference persisted over time, with rates of 8.0% and 18.1% at the final follow-up, respectively. CONCLUSION CL-treated patients with ESRD have a greater risk of VTEs compared with BPS-treated patients. CL-treated patients also tend to experience a VTE within the first month after cessation of oral administration.
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Affiliation(s)
- Ziming Wan
- 1 Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Ying Zhu
- 2 Radiology Department, The First Affiliated Hospital, Sun Yat-sen University, Yuexiu District, Guangzhou, China
| | - Ruikun Yang
- 3 Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Yuexiu District, Guangzhou, China
| | - Yongjian Zhang
- 4 Department of Thoracic surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Jianghan District, Wuhan, Hubei, China
| | - Chen Yang
- 5 Department of Physical Examination, The First Affiliated Hospital, Sun Yat-sen University, Yuexiu District, Guangzhou, China
| | - Lei Cao
- 6 Department of Anesthesiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Jianghan District, Wuhan, Hubei, China
| | - Wenjing Yan
- 7 The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Jianghan District, Wuhan, Hubei, China
| | - Qi Wang
- 6 Department of Anesthesiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Jianghan District, Wuhan, Hubei, China
| | - Ning Li
- 8 Department of Neurology, The Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Mingdong Zhao
- 9 Department of Orthopaedics, Jinshan Hospital, Fudan University, Jinshan District, Shanghai City, China
| | - Keke Gui
- 9 Department of Orthopaedics, Jinshan Hospital, Fudan University, Jinshan District, Shanghai City, China
| | - Min Xiong
- 9 Department of Orthopaedics, Jinshan Hospital, Fudan University, Jinshan District, Shanghai City, China
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Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, Haage P, Hamilton G, Hedin U, Kamper L, Lazarides MK, Lindsey B, Mestres G, Pegoraro M, Roy J, Setacci C, Shemesh D, Tordoir JH, van Loon M, ESVS Guidelines Committee, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Naylor R, Vega de Ceniga M, Vermassen F, Verzini F, ESVS Guidelines Reviewers, Mohaupt M, Ricco JB, Roca-Tey R. Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:757-818. [DOI: 10.1016/j.ejvs.2018.02.001] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Locham S, Beaulieu RJ, Dakour-Aridi H, Nejim B, Malas MB. Role of antiplatelet therapy in the durability of hemodialysis access. J Nephrol 2018; 31:603-611. [PMID: 29730781 DOI: 10.1007/s40620-018-0490-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/09/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Antiplatelet therapy (APT) is often used on anecdotal grounds to improve vascular access patency. The aim of this study was to assess the role of APT in hemodialysis (HD) patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement. METHODS All patients in a large HD vascular qualitative initiative database (2011-2017) were included and divided into no antiplatelet therapy (no-APT) vs. any APT [aspirin (ASA) or P2Y12 inhibitors (PI)]. Multivariate [logistic (MLR) and Cox (MCR) regression] analyses were used as appropriate. RESULTS A total of 24,847 patients undergoing HD access creation were identified (78% AVF). APT was noted among 49 and 46% of AVG and AVF patients, respectively. In MLR analysis, patients on no-APT vs. APT had a 12-fold increased risk of in-hospital mortality (odds ratio (OR) 11.79, [95% confidence interval 5.30-26.26]) and the risk of developing steal syndrome was higher among patients discharged on APT (OR 1.81, [1.19-2.76]). In patients undergoing AVF, primary patency (PP) was similar between APT and no-APT. However, in patients undergoing AVG, PP rates at 12 months were significantly higher for APT: ASA (47 vs. 41%) and PI (51 vs. 41%) than for no-APT (p = 0.008). At MCR analysis, the loss of PP at 12 months was 13% lower in ASA users (hazard ratio (HR) 0.87, [0.77-0.97], p = 0.02) and 24% lower in PI users (HR 0.76, [0.57-0.99], p = 0.046) compared to no-APT. CONCLUSION In a large national database, we showed that antiplatelet therapy was associated with lower in-hospital mortality. Aspirin and P2Y12-inhibitor use among AVG patients demonstrated improved PP rates compared to no antiplatelet therapy. We recommend the use of antiplatelet therapy especially in patients on AVG.
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Affiliation(s)
- Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | | | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA. .,Center for Research Excellence and Clinical Trials, Johns Hopkins Hospital, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Noh Y, Lee J, Shin S, Park I, Bae SK, Oh E, Lee S. Effects of cilostazol and renin-angiotensin system (RAS) blockers on the renal disease progression of Korean patients: a retrospective cohort study. Int J Clin Pharm 2017; 40:160-168. [PMID: 29282632 DOI: 10.1007/s11096-017-0578-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 12/13/2017] [Indexed: 12/27/2022]
Abstract
Background Decline in estimated glomerular filtration rate (eGFR) is an important surrogate marker for the assessment of renal function. Addition of a second agent to angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) treatment may improve current therapeutic strategies aimed at suppressing renal disease progression. Objective To determine the effect of cilostazol in combination with ACEI or ARB treatment on the decline in eGFR. Setting A tertiary hospital in Korea. Method In an observational cohort study, we analyzed 5505 patients who were prescribed ACEI or ARB and cilostazol or other antiplatelet agents. Main outcome measure The primary outcome assessed was worsening of renal function defined as a 30% decline in eGFR per year. The secondary outcomes included commencement of dialysis, renal transplantation, death, myocardial infarction, and ischemic stroke. Results Following propensity score matching, eGFR decreased over time in the majority of patients, but the decline was less in patients in the cilostazol treated (CT) group of stage 1-2 category compared to the cilostazol untreated (CU) group (OR 0.80; 95% CI 0.66-0.98). In the subgroup analysis, the strongest effect in slowing eGFR decline was observed in CT patients at a high risk of diabetes (OR 0.782; 95% CI 0.615-0.993) and the elderly (OR 0.693; 95% CI 0.504-0.953) in the stage 1-2 category. No significant increase in cardiovascular risk was observed between the CT and CU groups. Conclusion Treatment with cilostazol plus ACEI or ARB was observed to prevent worsening of renal progression in patients in the stages 1-2.
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Affiliation(s)
- Yoojin Noh
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, 206 Worldcup-ro, Yeongtong-gu, Suwon, 16499, South Korea
| | - Jimin Lee
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, 206 Worldcup-ro, Yeongtong-gu, Suwon, 16499, South Korea
| | - Sooyoung Shin
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, 206 Worldcup-ro, Yeongtong-gu, Suwon, 16499, South Korea
| | - Inwhee Park
- Department of Nephrology, College of Medicine, Ajou University, Suwon, South Korea
| | - Soo Kyung Bae
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Euichul Oh
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Sukhyang Lee
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, 206 Worldcup-ro, Yeongtong-gu, Suwon, 16499, South Korea.
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A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery. Ann Surg 2017; 267:1-10. [PMID: 28463896 DOI: 10.1097/sla.0000000000002279] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery. SUMMARY OF BACKGROUND DATA The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT. METHODS A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding. RESULTS Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)]. CONCLUSIONS Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.
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Viecelli AK, Mori TA, Roy-Chaudhury P, Polkinghorne KR, Hawley CM, Johnson DW, Pascoe EM, Irish AB. The pathogenesis of hemodialysis vascular access failure and systemic therapies for its prevention: Optimism unfulfilled. Semin Dial 2017; 31:244-257. [DOI: 10.1111/sdi.12658] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Andrea K Viecelli
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Qld Australia
- Australasian Kidney Trials Network; School of Medicine; University of Queensland; Brisbane Qld Australia
| | - Trevor A Mori
- Medical School; University of Western Australia; Perth WA Australia
| | - Prabir Roy-Chaudhury
- Department of Medicine; University of Arizona College of Medicine and Southern Arizona VA Healthcare System; Tucson AZ USA
| | - Kevan R Polkinghorne
- Department of Nephrology; Monash Medical Centre; Melbourne Vic. Australia
- School of Public Health and Preventive Medicine; Monash University; Melbourne Vic. Australia
- Department of Medicine; Monash University; Melbourne Vic. Australia
| | - Carmel M Hawley
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Qld Australia
- Australasian Kidney Trials Network; School of Medicine; University of Queensland; Brisbane Qld Australia
- Translational Research Institute; Brisbane Qld Australia
| | - David W Johnson
- Department of Nephrology; Princess Alexandra Hospital; Brisbane Qld Australia
- Australasian Kidney Trials Network; School of Medicine; University of Queensland; Brisbane Qld Australia
- Translational Research Institute; Brisbane Qld Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network; School of Medicine; University of Queensland; Brisbane Qld Australia
| | - Ashley B Irish
- Australasian Kidney Trials Network; School of Medicine; University of Queensland; Brisbane Qld Australia
- Department of Nephrology; Fiona Stanley Hospital; Perth WA Australia
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Thomas M, Nesbitt C, Ghouri M, Hansrani M. Maintenance of Hemodialysis Vascular Access and Prevention of Access Dysfunction: A Review. Ann Vasc Surg 2017; 43:318-327. [DOI: 10.1016/j.avsg.2017.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/28/2017] [Indexed: 01/24/2023]
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Vlachopanos G, Ghalli FG. Antithrombotic medications in dialysis patients: a double-edged sword. J Evid Based Med 2017; 10:53-60. [PMID: 28276631 DOI: 10.1111/jebm.12235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/20/2016] [Indexed: 01/11/2023]
Abstract
In the clinical context of end-stage renal disease (ESRD), thrombosis and bleeding risks are simultaneously increased and may have devastating consequences. While anticoagulant and antiplatelet drugs are indispensable for the prevention of thromboembolic events, the significantly higher bleeding risk makes their handling extremely complicated. In ESRD, they are frequently administered for a wide array of conditions. For example, atrial fibrillation is quite common in ESRD and warrants the use of anticoagulants like warfarin. Unfractionated heparin and low molecular weight heparins are typically used for clotting prevention in the hemodialysis extracorporeal circuit. The antithrombotics use dilemma has worsened because ESRD patients have been excluded from major clinical trials that defined standard indications, contraindications and optimal management of these medications. That limits our knowledge and results in that the process of decision-making depends on weaker data. Besides the substantial bleeding risk, warfarin may also increase cardiovascular risk because it is implicated in the pathogenesis of vascular calcifications in ESRD. The present article attempts to offer a comprehensive overview of practical considerations for the use of the most common antithrombotic medications in ESRD linking them, at the same time, to the best available evidence from randomized controlled trials and observational studies.
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Affiliation(s)
| | - Farid Girgis Ghalli
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
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Tanner NC, da Silva AF. Medical Adjuvant Treatment to Improve the Patency of Arteriovenous Fistulae and Grafts: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2016; 52:243-52. [PMID: 27289558 DOI: 10.1016/j.ejvs.2016.04.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many patients using haemodialysis for end-stage renal disease (ESRD) require arteriovenous fistulae (AVF) or grafts. Patency can be variable, and this systematic review aimed to determine the effects of adjuvant drug treatment on the patency of AVFs and grafts. METHODS The Cochrane Peripheral Vascular Diseases Group searched the Specialised Register and CENTRAL for all randomised controlled trials (RCTs) investigating the effect of active drug versus placebo on patency. The primary outcome was fistula or graft patency rate. The odds ratio (OR) was used as the measure of effect for each outcome. If several trials assessed the same adjuvant therapy then a meta-analysis was conducted using a Mantel-Haenszel model. RESULTS Fifteen trials were deemed suitable for inclusion, investigating nine drug treatments in 2,230 participants. Overall, the quality of evidence was low. Three trials compared ticlopidine (a platelet aggregation inhibitor) versus placebo and favoured active treatment (OR 0.45, 95% CI 0.25 to 0.82; p = .009). Three RCTs assessed aspirin versus placebo and did not show a statistical benefit (OR 0.40, 95% CI 0.07-2.25; p = .30). Two trials compared clopidogrel with placebo. The overall result did not favour treatment (OR 0.40, 95% CI 0.13 to 1.19; p = .10). Three trials evaluated human type-I pancreatic elastase but did not provide evidence of improved patency (OR 0.75, 95% CI 0.42-1.32; p = .31). Finally, two RCTs assessed fish oil and did not favour treatment (OR 0.24, 95% CI 0.03-1.95; p = .18). Single trials comparing dipyridamole alone, dipyridamole plus aspirin, and sulfinpyrazone against placebo favoured active treatment but a meta-analysis could not be undertaken. Finally, a single trial of warfarin versus placebo found warfarin resulted in increased complications and worse patency rates. CONCLUSION This systematic review has not demonstrated a beneficial effect for any adjuvant treatment to increase the patency of AVF or grafts in the short term, except ticlopidine which has been taken off the market.
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Affiliation(s)
- N C Tanner
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK.
| | - A F da Silva
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
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Should patients be on antithrombotic medication for their first arteriovenous fistulae? J Vasc Access 2015; 17:118-23. [PMID: 26660039 DOI: 10.5301/jva.5000491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Evidence on the effect of antithrombotic medication on reducing early and late fistula failure is inconclusive. Antithrombotic use carries risks in patients with end-stage renal failure and could increase the risk of needling complications as a result of bleeding. The objectives of this study are to determine the effect of antithrombotic agents on early and late fistula failure and on the risk of interrupted start of cannulation of the fistula. METHODS Retrospective analysis of two prospectively maintained databases of access operations and dialysis sessions of 671 patients who had their first fistula between 2004 and 2011. Early failure was defined as failure to reach six consecutive dialysis sessions at any time with two needles on the index form of access. Fistula survival was defined as the time from when the fistula was first used to fistula abandonment. RESULTS Primary failure was similar between patients on antiplatelet (18.8%), anticoagulants (18.4%) or no antithrombotic medication (18.8%; p = 0.998). Antithrombotic medication did not have an effect on AVF survival (p = 0.86). Antithrombotic medication did not increase complicated cannulation rates, defined as the percentage of patients failing to achieve six uninterrupted dialysis sessions from the start (p = 0.929). CONCLUSIONS Antithrombotic medication had no significant effect on primary failure rate, long-term fistula survival or initial complicated cannulation rates in our study. This suggests that patients already on antithrombotic medication can continue taking them without increasing the risk of interrupted dialysis.
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Tanner NC, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2015; 2015:CD002786. [PMID: 26184395 PMCID: PMC7104664 DOI: 10.1002/14651858.cd002786.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) patients often require either the formation of an arteriovenous (AV) fistula or an AV interposition prosthetic shunt for haemodialysis. These access sites should ideally have a long life and a low rate of complications (for example thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the second update of the review first published in 2004. OBJECTIVES To assess the effects of adjuvant drug treatment in ESRD patients on haemodialysis via autologous AV fistulae or prosthetic interposition AV shunts. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2015) and CENTRAL (2015, Issue 2). SELECTION CRITERIA Randomised controlled trials (RCTs) of active drug versus placebo in people with ESRD undergoing haemodialysis via an AV fistula or prosthetic interposition AV graft. DATA COLLECTION AND ANALYSIS For this update, the two review authors (NCT, ADS) independently assessed trial quality and one review author (NCT) extracted data. Information on adverse events was collected from the trials. The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay, complications and number of related surgical interventions. MAIN RESULTS For this update, an additional six studies were deemed suitable for inclusion, making a total of 15 trials with 2230 participants. Overall the quality of the evidence was low due to short follow-up periods, heterogeneity between trials and moderate methodological quality of the studies due to incomplete reporting. Medical adjuvant treatments used in the trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone, and human type I pancreatic elastase (PRT-201). Where possible, the included studies were pooled into similar medical adjuvant groups for meta-analyses.All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (three RCTs, 175 participants) (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; P = 0.30). The meta-analysis for graft patency comparing ticlopidine versus placebo (three RCTs, 339 participants) favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; P = 0.009). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (two RCTs, 220 participants; OR 0.24, 95% CI 0.03 to 1.95; P = 0.18); and studies comparing clopidogrel and placebo (two RCTs, 959 participants; OR 0.40, 95% CI 0.13 to 1.19; P = 0.10). Similarly, there was insufficient evidence to determine if there was a difference in graft patency in three studies (306 participants) comparing PRT-201 versus placebo (OR 0.75, 95% CI 0.42 to 1.32; P = 0.31); in one trial comparing the effect of dipyridamole versus placebo (42 participants; OR 0.46, 95% CI 0.11 to 1.94, P = 0.29) and dipyridamole plus aspirin versus placebo (41 participants; OR 0.64, CI 0.16 to 2.56, P = 0.52); in one trial comparing low-dose warfarin with placebo (107 participants; OR 1.76, 95% CI 0.78 to 3.99, P = 0.17); and one trial (16 participants) comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98, P = 0.53). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. No studies reported on the length of hospital stay and data reporting on complications was limited and varied between studies. AUTHORS' CONCLUSIONS The meta-analyses of three studies for ticlopidine (an anti-platelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AV fistulae and grafts in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, PRT-201, dipyridamole, dipyridamole plus aspirin, warfarin, and sulphinpyrazone. However, the quality of the evidence was low due to short follow-up periods, the small number of studies for each comparison, heterogeneity between trials and moderate methodological quality of the studies due to incomplete reporting. It, therefore, appears reasonable to suggest further prospective studies be undertaken to assess the use of these anti-platelet drugs in renal patients with an arteriovenous fistula or graft.
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Affiliation(s)
- Nicola C Tanner
- Wrexham Maelor HospitalDepartment of Vascular SurgeryCroesnewydd RoadWrexhamUKLL13 7TD
| | - Anthony Da Silva
- Wrexham Maelor HospitalDepartment of Vascular SurgeryCroesnewydd RoadWrexhamUKLL13 7TD
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Abacilar AF, Atalay H, Dogan OF. Oral prostacycline analog and clopidogrel combination provides early maturation and long-term survival after arteriovenous fistula creation: A randomized controlled study. Indian J Nephrol 2015; 25:136-42. [PMID: 26060361 PMCID: PMC4446916 DOI: 10.4103/0971-4065.139490] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Vascular access is used as a lifeline for hemodialysis in patients with end stage renal disease failure (ESRD). Failure of arteriovenous fistula (AVF) maturation is still high. The purpose of this study was to research the effects of clopidogrel in combination with oral iloprost, a synthetic analog of prostacyclin PGI2. Ninety-six diabetic ESRD patients were divided into two groups. In the first group (Group 1, N = 50), clopidogrel (75 mg daily dose) and an oral prostacycline analog (200 mg daily dose) were administered. In the second group (Group 2, N = 46), placebo was given. All patients took study medication 7-10 days prior to surgery. A Doppler ultrasound (USG) was performed for measurement of arterial and venous diameters, and peak systolic velocity of arterial flow based on subsequent fistula adequacy. Autogenous AVFs were constructed in forearm as distally as possible in all patients. Both groups were followed-up for a year. In the placebo group, early AVF thrombosis was detected in two patients (4.3%). AVF maturation failure was noted in 14 patients (30.4%) in placebo group and in four patients (8%) in clopidogrel plus oral prostacycline analog group in the early postoperative period (P = 0.001). The mean maturation time was 38 ± 6.5 and 53 ± 12.8 days in study and placebo groups, respectively (P = 0.023). The mean blood flow was 352 ± 94 mL/min in placebo group and 604 ± 125 mL/min in study group (P = 0.001). The arterial end diastolic velocity was 116 ± 14 cm/s in study group and 72 ± 21 cm/s in placebo group (P = 0.036) 1 year after the surgery. Our data indicated that clopidogrel and oral prostacycline analog combination is effective and safe for the prevention of primary AVF failure in hemodialysis patients and decreased acute and chronic thrombotic events.
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Affiliation(s)
- A F Abacilar
- Department of Cardiovascular Surgery, Izmir Sifa University, Bornova Educational Hospital, İzmir, Turkey
| | - H Atalay
- Department of Cardiovascular Surgery, Mersin Private Meadleeast Hospital, Mersin, Turkey
| | - O F Dogan
- Department of Cardiovascular Surgery, Adana Numune Education and Training Hospital, Adana, Turkey
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Tanios BY, Itani HS, Zimmerman DL. Clopidogrel Use in End-Stage Kidney Disease. Semin Dial 2014; 28:276-81. [DOI: 10.1111/sdi.12338] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Bassem Y. Tanios
- Nephrology Department; Paris Sud University; Le Kremlin Bicêtre France
| | - Houssam S. Itani
- Division of Nephrology; Department of Medicine; University of Ottawa; Ottawa Hospital; Ottawa Ontario Canada
| | - Deborah L. Zimmerman
- Division of Nephrology; Department of Medicine; University of Ottawa; Ottawa Hospital; Ottawa Ontario Canada
- Kidney Research Centre of the Ottawa Hospital Research Institute; Ottawa Ontario Canada
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Palmer SC, Di Micco L, Razavian M, Craig JC, Perkovic V, Pellegrini F, Jardine MJ, Webster AC, Zoungas S, Strippoli GFM. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2013:CD008834. [PMID: 23450589 DOI: 10.1002/14651858.cd008834.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet treatment may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. OBJECTIVES To summarise the effects of antiplatelet treatment (antiplatelet agent versus control or other antiplatelet agent) for the prevention of cardiovascular and adverse kidney outcomes in individuals with CKD. SEARCH METHODS In January 2011 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cochrane Renal Group's Specialised Register without language restriction. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet treatment versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data was pooled using the random-effects model. MAIN RESULTS We included 50 studies, enrolling 27,139 participants; 44 studies (21,460 participants) compared an antiplatelet agent with placebo or no treatment, and six studies (5679 participants) directly compared one antiplatelet agent with another. Compared to placebo or no treatment, antiplatelet agents reduced the risk of myocardial infarction (17 studies; RR 0.87, 95% CI 0.76 to 0.99), but not all-cause mortality (30 studies; RR 0.93, 95% CI 0.81 to 1.06), cardiovascular mortality (19 studies; RR 0.89, 95% CI 0.70 to 1.12) or stroke (11 studies; RR 1.00, 95% CI 0.58 to 1.72). Antiplatelet agents increased the risk of major (27 studies; RR 1.33, 95% CI 1.10 to 1.65) and minor bleeding (18 studies; RR 1.49, 95% CI 1.12 to 1.97). In terms of dialysis access outcomes, antiplatelet agents reduced access thrombosis or patency failure but had no effect on suitability for dialysis. Meta-regression analysis indicated no differences in the relative benefit or harms of treatment (risk of all-cause mortality, myocardial infarction, or major bleeding) by type of antiplatelet agent or stage of CKD. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, treatment in kidney transplant recipients, primary prevention, or risk of ESKD. AUTHORS' CONCLUSIONS Antiplatelet agents reduce myocardial infarction but increase major bleeding. Risks may outweigh harms among people with low annual risks of cardiovascular events, including those with early stages of CKD who do not have clinically-evident occlusive cardiovascular disease.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
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Palmer SC, Di Micco L, Razavian M, Craig JC, Ravani P, Perkovic V, Tognoni G, Graziano G, Jardine M, Pellegrini F, Nicolucci A, Webster A, Strippoli GF. Antiplatelet Therapy to Prevent Hemodialysis Vascular Access Failure: Systematic Review and Meta-analysis. Am J Kidney Dis 2013; 61:112-22. [DOI: 10.1053/j.ajkd.2012.08.031] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 08/31/2012] [Indexed: 11/11/2022]
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Sultan S, Hynes N, Hamada N, Tawfick W. Patients on Hemodialysis Are Better Served by a Proximal Arteriovenous Fistula for Long-Term Venous Access. Vasc Endovascular Surg 2012; 46:624-34. [DOI: 10.1177/1538574412462635] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with end-stage renal disease should have arteriovenous fistula (AVF) formation 3 to 6 months prior to commencing hemodialysis (HD). However, this is not always possible with strained health care resources. We aim to compare autologous proximal AVF (PAVF) with distal AVF (DAVF) in patients already on HD. Primary end point is 4-year functional primary. Secondary end point is freedom from major adverse clinical events (MACEs). From January 2003 to June 2009, out of 495 AVF formations, 179 (36%) patients were already on HD. These patients had 200 AVF formations (49 DAVF vs 151 PAVF) in arms in which no previous fistula had been formed. No synthetic graft was used. Four-year primary functional patency significantly improved with PAVF (68.9% ± SD 8.8%) compared to DAVF (7.3% ± SD 4.9%; P < .0001). Five-year freedom from MACE was 85% with PAVF compared to 40% with DAVF ( P < .005). Proximal AVF bestows long-term functional access with fewer complications compared to DAVF for patients already on HD.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughishka, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughishka, Galway, Ireland
| | - Nader Hamada
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
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Paraskevas KI, Mikhailidis DP, Roussas N, Giannoukas AD. Effect of Antiplatelet Agents, Statins, and Other Drugs on Vascular Access Patency Rates. Angiology 2011; 63:5-8. [DOI: 10.1177/0003319711414177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College of London (UCL), London, UK
| | - Nikolaos Roussas
- Department of Vascular Surgery, University of Thessalia, University Hospital of Larissa, Larissa, Greece
| | - Athanasios D. Giannoukas
- Department of Vascular Surgery, University of Thessalia, University Hospital of Larissa, Larissa, Greece
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Jackson RS, Sidawy AN, Amdur RL, Khetarpal A, Macsata RA. Angiotensin receptor blockers and antiplatelet agents are associated with improved primary patency after arteriovenous hemodialysis access placement. J Vasc Surg 2011; 54:1706-12. [PMID: 21840155 DOI: 10.1016/j.jvs.2011.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/21/2011] [Accepted: 06/21/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Dialysis access failure is a major cause of morbidity, mortality, and cost in end-stage renal disease. We undertook a study to determine the influence of medication use on dialysis access failure. METHODS After institutional review board approval, we performed a retrospective analysis of all upper extremity hemodialysis accesses placed from 2005 to 2009 at the Washington DC Veterans Affairs Medical Center. For each access, the date of failure was recorded. For patients who died or were lost to follow-up, the date of the last documented functional patency (censoring) was recorded. The primary exposures were 12 medication classes. Patient demographics, behaviors, comorbidities, and access characteristics were used as covariates. Patency rates were calculated using Kaplan-Meier methods. Cox proportional hazard models controlling for patient characteristics and all medication classes, with procedures clustered within patients, were used to determine the influence of medication class on primary patency. RESULTS Two hundred sixty autogenous and 126 prosthetic newly placed accesses were identified. Of these, three lower extremity accesses and six accesses with unknown thrombosis date were excluded. Forty-five (18%) of the remaining 257 autogenous accesses were excluded for primary nonfunctionality (patent, but with inadequate venous dilatation for initial hemodialysis), because the primary outcome was long-term functional patency. The remaining 212 autogenous and 120 prosthetic accesses were analyzed. Primary patency rates at 1 and 2 years were 55.2% and 49.1% for autogenous accesses, and 50.2% and 29.7% for prosthetic accesses, respectively. On multivariable analysis, angiotensin receptor blockers (ARBs) were associated with reduced hazard of both autogenous (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.16-0.76; P = .008) and prosthetic (HR, 0.41; 95% CI, 0.18-0.95;P = .039) access failure. On subgroup analysis, ARBs prolonged autogenous access primary patency among patients receiving antiplatelet medication (aspirin, clopidogrel; HR, 0.16; 95% CI, 0.05-0.52;P = .002) but had no demonstrable benefit among patients not receiving antiplatelets (HR, 1.35; 95% CI, 0.34-5.31;P = .670). There were no significant drug-drug interactions in the analysis of prosthetic accesses. Weighted regression models demonstrated low multicollinearity among the model variables. CONCLUSION Our data suggest that therapy with an ARB plus antiplatelet agent is associated with prolonged autogenous access primary patency, and therapy with an ARB with or without antiplatelet agents is associated with prolonged prosthetic access primary patency. Randomized studies are needed to confirm the causal role of ARBs and to determine the optimal therapeutic regimen (dose, timing, and duration) to promote access patency.
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Affiliation(s)
- Rubie Sue Jackson
- Department of Surgery, Veterans Affairs Medical Center, Washington, DC 20422, USA
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