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1.
J Surg Res ; 251: 16-25, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32097780

RESUMO

BACKGROUND: The study aimed to perform continuous and dynamic observation on the blood flow changes in a rat abdominal model of supercharged flaps to examine the roles of arterial and venous supercharging in preventing distal flap necrosis. MATERIALS AND METHODS: Eighteen rats were divided into three experimental groups. The left-sided flaps in all groups were used as controls such that the subxiphoid perforator vessels served as the only pedicle. Experimental groups I, II, and III consisted of supercharged right-sided flaps. Group I, the arteriovenous supercharging group, had flaps supercharged by the suprapubic perforator arteries and veins. Group II, the arterial supercharging group, had flaps supercharged by the suprapubic perforator arteries. Group III, the venous supercharging group, had flaps supercharged by the suprapubic perforator veins. Laser-induced near-infrared fluorescence angiography was performed before and after surgery. RESULTS: As revealed by near-infrared fluorescence angiography, the control group and venous supercharging group exhibited rapid reductions in blood supply and loss of arterial perfusion in distal areas. The distal flap necrosis was much smaller in the venous supercharging group than in the control group. Both the arteriovenous supercharging group and the arterial supercharging group exhibited adequate perfusion and resulted in full postoperative survival of the flaps. CONCLUSIONS: These findings indicated that the distal arterial hypoperfusion is the major cause of the distal venous stasis and necrosis in the flaps. Sufficient arterial supercharging ensures the distal arterial perfusion and therefore diminishes the occurrence of distal flap necrosis.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Retalhos Cirúrgicos/irrigação sanguínea , Animais , Angiofluoresceinografia , Verde de Indocianina , Masculino , Ratos Sprague-Dawley
2.
J Am Soc Nephrol ; 31(3): 625-636, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31941721

RESUMO

BACKGROUND: Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC). METHODS: To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013. RESULTS: At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft. CONCLUSIONS: Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.


Assuntos
Disparidades em Assistência à Saúde/etnologia , Falência Renal Crônica/terapia , Medicare/estatística & dados numéricos , Diálise Renal/métodos , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres Venosos Centrais/efeitos adversos , Cateteres Venosos Centrais/estatística & dados numéricos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Falência Renal Crônica/diagnóstico , Masculino , Racismo , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos
3.
Am J Kidney Dis ; 75(6): 879-886, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31767192

RESUMO

RATIONALE & OBJECTIVE: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. PREDICTORS: Facility-level burden of patient comorbid conditions; patient characteristics. OUTCOMES: Odds of AVFs versus other access types; facility-level use of AVFs. ANALYTICAL APPROACH: Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. RESULTS: Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. LIMITATIONS: Limited to Medicare dialysis-dependent patients treated for 1 year or more. CONCLUSIONS: After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.


Assuntos
Derivação Arteriovenosa Cirúrgica , Unidades Hospitalares de Hemodiálise , Falência Renal Crônica , Múltiplas Afecções Crônicas/epidemiologia , Diálise Renal , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Efeitos Psicossociais da Doença , Feminino , Unidades Hospitalares de Hemodiálise/normas , Unidades Hospitalares de Hemodiálise/estatística & dados numéricos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Padrões de Prática Médica/normas , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/normas , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
4.
Ren Fail ; 41(1): 1036-1044, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31814501

RESUMO

Background: Most prior studies have explored surgery for the treatment of failed autologous arteriovenous fistulas (AVFs) with limited follow-up times and a lack of end point mortality. Accordingly, we conducted a retrospective cohort study to evaluate the clinical outcomes of the surgery of new AVF proximal to the failed forearm AVF.Methods: In this study, 538 end-stage renal disease patients (group A, 418 with primary AVF; and group B, 120 with failed AVF) were consecutively enrolled between January 2013 and June 2016, with a median follow-up time of 41 months. Primary and secondary patency, all-cause mortality, and risk factors associated with AVF failure were explored by the Kaplan-Meier method or Cox proportional hazards model.Results: In group A (n = 418), the primary and secondary patencies of AVF were 85.6% vs. 96.8%, 79.7% vs. 95.0%, 75.1% vs.93.9%, 73.2% vs. 93.6% and 73.2% vs. 93.6% at 12, 24, 36, 48 and 60 months, respectively. The primary patencies of AVF in group B were 95.0%, 91.7%, 89.2%, 88.3% and 88.3% at 12, 24, 36, 48 and 60 months, respectively. After adjusting for potential confounders, age, angiotensin-converting inhibitors or angiotensin-receptor blockers (anti-RAAS) drugs and D-dimer were independent predictors of AVF failure. However, there were no differences between functional and failed AVF regarding all-cause mortality.Conclusions: The study revealed that the primary and secondary patiencies of the surgery of new AVF proximal to the failed ones were ideal operations to restore failed forearm AVF.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Feminino , Humanos , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Falha de Tratamento , Adulto Jovem
5.
BMC Nephrol ; 20(1): 420, 2019 11 25.
Artigo em Inglês | MEDLINE | ID: mdl-31760936

RESUMO

BACKGROUND: Arteriovenous fistula (AVF) is the vascular access of choice for patients on hemodialysis. Recent evidence suggests that AVF creation may slow estimated glomerular filtration rate (eGFR) decline. The study objective was to assess the impact of the AVF creation on eGFR decline, after controlling for key confounding factors. METHODS: This retrospective cohort study included adult patients followed in a single-center predialysis clinic between 1999 and 2016. Patients with a patent AVF were followed up to 2 years pre- and post-AVF creation. Estimated GFR trajectory was reported using linear mixed models adjusted for demographic characteristics, comorbidities and use of renin-angiotensin-aldosterone blockade. RESULTS: A total of 146 patients were studied with a median age 68.7 (60.5-75.4) years and a median eGFR at time of AVF creation of 12.8 (11.3-13.9) mL/min/1.73m2. The crude annual eGFR decline rates were - 3.60 ± 4.00 mL/min/1.73 m2 pre- and - 2.28 ± 3.56 mL/min/1.73 m2 post-AVF, resulting in a mean difference of 1.28 mL/min/1.73 m2 (95% CI 0.49, 2.07). In a mixed effect linear regression model, monthly eGFR decline was - 0.63 (95% CI -0.81, - 0.46; p <  0.001) mL/min/1.73m2/month. The period after AVF creation was associated with a relatively higher eGFR (ß 0.94, 95% CI 0.61-1.26, p <  0.001). There was a significant association between follow-up time and the period pre/post AVF (ß 0.19, 95% CI 0.16, 0.22; p <  0.001) such that eGFR decline was more attenuated each month after AVF creation. CONCLUSIONS: In this cohort, AVF creation was associated with a significant reduction of eGFR decline. Further prospective studies are needed to confirm this association.


Assuntos
Derivação Arteriovenosa Cirúrgica , Taxa de Filtração Glomerular , Administração dos Cuidados ao Paciente , Diálise Renal , Insuficiência Renal Crônica , Idoso , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Canadá/epidemiologia , Estudos de Coortes , Progressão da Doença , Feminino , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Estudos Retrospectivos
6.
Am Surg ; 85(10): 1079-1082, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657298

RESUMO

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Feminino , Cirurgia Geral/estatística & dados numéricos , Humanos , Masculino , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Razão de Chances , Sistema de Registros , Estudos Retrospectivos , Cirurgiões/classificação , Cirurgia Torácica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
7.
Clin Nephrol ; 92(5): 233-236, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31496512

RESUMO

OBJECTIVE: To compare the functions and complications of forearm basilic vein transposition-arteriovenous fistula (BVT-AVF) created using the no-touch technique with that of conventional radiocephalic arteriovenous fistula (RC-AVF). MATERIALS AND METHODS: The no-touch technique was used to created basilic vein transposition-radial artery fistula in 22 patients. Another 30 patients received surgeries for RC-AVF. The fistula functions and complications were compared between these two groups. RESULTS: The two groups did not differ significantly in the incidence of postoperative bleeding, limb swelling, infection, steal syndrome, fistula thrombosis, fistula aneurysm, fistula flow, fistula maturation time, Kt/v, and fistula median survival. CONCLUSION: Forearm BVT-AVF created by the no-touch technique is a good alternative access for patients in whom the standard arteriovenous fistula cannot be established.


Assuntos
Derivação Arteriovenosa Cirúrgica , Antebraço/irrigação sanguínea , Artéria Radial/cirurgia , Veias/cirurgia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Humanos , Hemorragia Pós-Operatória/epidemiologia
8.
Nefrologia ; 39(5): 539-544, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31377029

RESUMO

INTRODUCTION: Traditionally, the indication of the type of vascular access (VA) has been based on the surgeon's physical examination, but it is now suggested that imaging methods could provide a clinical benefit. Our aim was to determine whether or not preoperative Doppler ultrasound modifies outcomes of the first VA for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA from June 2014 to July 2017 who had a preoperative Doppler ultrasound (ECO group). They were compared to a historical cohort (January 2012-May 2014) of first VA indicated exclusively by clinical assessment (CLN group). RESULTS: A total of 86 patients from the CLN group were compared to 92 from the ECO group, which was younger (68.4 vs 64.0, P=.038). The primary patency (CLN/ECO) at 1 and 2years was 59.5%/71.9% and 53.1%/57.8% respectively, marginally better in the ECO group (P=.057). The assisted patency at 1 and 2years was 63.2%/80.7% and 58.1%/70.2%, respectively, significantly better for the ECO group (P=.010). Due to lack of patency/utility of the initial VA, 26.7% in the CLN group and 7.6% in the ECO group (P<.001) required a new VA during the first 6months. An average of 1.39 interventions were performed to achieve a useful VA in the CLN group and 1.08 in the ECO group (P<.001), the first VA being useful at the radiocephalic level in 31.0%/45.1% (P=.039). CONCLUSION: The indication of the first VA according to a preoperative Doppler ultrasound examination could decrease the need for new VA, enable them to be made more distal, and significantly improve patency.


Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Diálise Renal , Ultrassonografia Doppler , Grau de Desobstrução Vascular , Fatores Etários , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exame Físico , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Ultrassonografia Doppler/métodos
9.
J Vasc Surg ; 70(5): 1635-1641, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31126771

RESUMO

OBJECTIVE: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. METHODS: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. RESULTS: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 ± 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. CONCLUSIONS: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Oclusão de Enxerto Vascular/epidemiologia , Unidades Hospitalares de Hemodiálise/estatística & dados numéricos , Missões Médicas/estatística & dados numéricos , Diálise Renal/métodos , Adolescente , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Criança , Feminino , Seguimentos , Oclusão de Enxerto Vascular/etiologia , Guatemala , Unidades Hospitalares de Hemodiálise/organização & administração , Humanos , Masculino , Missões Médicas/organização & administração , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular
10.
Enferm. nefrol ; 22(1): 10-17, ene.-mar. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-183589

RESUMO

Objetivo: Valorar la posible asociación entre la forma de punción de la fístula arteriovenosa y el dolor que siente el paciente por la inserción de la aguja. Metodología: Se ha seguido la declaración PRISMA para revisiones sistemáticas. Se han consultado 6 bases de datos; Medline, Scopus, Cuiden, CINAHL, SciELO, y Cochrane PLUS. Además, se realizó una búsqueda secundaría manual para detectar literatura gris no encontrada en las bases de datos o mediantes las estrategias definidas. Criterios de inclusión; estudios de nivel de evidencia 1 en la escala Scottish Intercollegiate Guidelines Network, publicados en los últimos 10 años, idiomas español/inglés, y temática relacionada con las técnicas utilizadas en hemodiálisis para el abordaje de la fistula. Los artículos se evaluaron de forma crítica para detectar cualquier riesgo de sesgo mediante el instrumento CASPe y el manual Cochrane para Revisiones Sistemáticas de Intervenciones. Resultados: Se identificaron un total de 150 resultados, seleccionándose finalmente 9 estudios. Los resultados han sido muy heterogéneas, encontrándose resultados para el dolor, tasas de infección, número de intentos de canalización, flujo sanguíneo, presión venosa, tiempo de hemostasia, seguridad, dilataciones aneurismáticas, estética del brazo portador de la fístula y calidad de vida del paciente. Conclusiones: La evidencia no respalda el uso preferencial de la técnica del ojal sobre la canalización tradicional. Por tanto, se necesita mejorar el rigor metodológico y un mayor tamaño muestral para dilucidar que técnica da mejores prestaciones respecto al dolor, permitiendo por tanto mejorar la calidad de vida de los pacientes de hemodiálisis


Aims: To assess the possible association between the manner of arteriovenous fistula cannulation and the patient pain related to the insertion of the needle for the hemodialysis session. Methodology: The PRISMA statement for systematic reviews has been followed. Six databases have been consulted: Medline, Scopus, Cuiden, CINAHL, SciELO, and Cochrane PLUS. In addition, a secondary manual search was performed to detect grey literature not found in databases or through defined strategies. Inclusion criteria: studies of level of evidence 1 on the Scottish Intercollegiate Guidelines Network scale, published in the last 10 years, Spanish/English languages, and topics related to the techniques used to canalize the hemodialysis fistula. The articles were critically evaluated to detect any risk of bias using the CASPe instrument and the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 150 results were identified, 9 of which were finally selected. The results have been very heterogeneous, finding results for pain, infection rates number of attempts of channalization, blood flow, venous pressure, time of hemostasis, safety, aneurysmal dilations, esthetics of the fistula-carrying arm and quality of life of the patient. Conclusions: The evidence does not support the preferential use of the buttonhole technique over traditional channeling. Therefore, it is necessary to improve the methodological quality and a larger sample size to elucidate which technique gives better benefits with respect to pain, thus allowing to improve the quality of life of hemodialysis patients


Assuntos
Humanos , Punções/métodos , Derivação Arteriovenosa Cirúrgica/métodos , Dor Aguda/diagnóstico , Medição da Dor/métodos , Diálise Renal/métodos , Percepção da Dor/classificação , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Insuficiência Renal Crônica/terapia
11.
Saudi J Kidney Dis Transpl ; 30(1): 39-44, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30804265

RESUMO

The objective of this study is to determine the impact of a dedicated vascular team in the early detection of complications and improvement of vascular access patency. A dedicated vascular access team comprised four dialysis nurses, a vascular access coordinator and led by a physician. They were assigned for the surveillance and care of all vascular accesses. The team presented problematic cases in the regular quality meeting with documentation of access blood flow, dynamic venous pressure, findings of hematoma, prolonged bleeding, swelling, low arterial pressures, steal syndrome, recirculation studies and dialysis adequacy. In case of failed recirculation or persistently elevated dynamic venous pressure, further evaluation was done either a fistulogram or review by a vascular surgeon. A total of 226 problematic vascular access cases were detected during the study (January 2014 to October 2017). The majority were in 41-70 years age group. A total of 248 referrals were given. Two hundred cases were referred for fistulogram, but it was performed in 188 patients. Vascular access stenosis was detected in 153 patients (81.3%) and angioplasty was performed in 137 (89.5%) of these patients. Fifteen (9.8%) patients were managed conservatively and one patient refused angioplasty. The 15 cases managed conservatively continued to work normally. One patient who refused to angioplasty later clotted his fistula during the follow-up period. Out of 41 cases who were totally noncompliant to referral, nine (22%) clotted their fistula during the follow-up period. In 12 cases in whom fistulogram was requested, but the request was declined by the primary hospital, five patients (41.6%) clotted their fistulas. Subgroup analysis showed that in patients who had both failed recirculation and high venous pressure, the prevalence of stenosis was 90% and angioplasty was performed in 94.4%. In patients who had failed recirculation and low arterial pressure, stenosis was detected in 85.7% and angioplasty was performed in 100% of cases. A dedicated vascular team approach for the care of dialysis vascular access helps in early identification of complications and improve vascular access outcome.


Assuntos
Diálise Renal , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/terapia , Humanos , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Resultado do Tratamento , Dispositivos de Acesso Vascular , Adulto Jovem
12.
Saudi J Kidney Dis Transpl ; 30(1): 166-174, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30804278

RESUMO

The incidence of end-stage renal disease (ESRD) patients is increasing considerably worldwide, and most of the patients start their therapy by hemodialysis (HD). Arteriovenous fistula (AVF) is the best type of vascular access due to its decreased rate of complications followed by arteriovenous graft (AVG) and finally, central venous catheters which are associated with increased mortality and morbidity. In this study, we aim to find out the proportion of each vascular access type used in HD patients and to evaluate the epidemiology of HD access in Palestine. Six hundred and fifty-eight patients were enrolled in this study from 10 dialysis units distributed in Palestine. The patients were divided into incident patients or prevalent patients. Data were collected by the researchers by regular visits to the units. AVFs were the most common access type (69.3%), catheters came second (27.8%) finally, AVGs (2.9%). Temporary catheters composed 59% of all catheters, followed by the permanent catheters. The subclavian vein was the most common insertion site (68.3%), internal jugular vein (26.8%), and femoral vein (4.9%). Temporary catheters were most commonly used among incident patients (41.5%) and AVFs were the most common in the prevalent patients (75%). There was no statistically significant association between the type of dialysis access use with gender, body mass index, or diabetic status. We recommend close follow-up and early AVF creation when the patients are expected to need HD. We also highly recommend decreasing the duration of temporary catheters. Finally, further prospective studies to follow-up and evaluate the progression in the vascular access status in Palestine are needed.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Diálise Renal/estatística & dados numéricos , Adulto , Idoso , Cateteres de Demora/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Veias Jugulares/cirurgia , Masculino , Pessoa de Meia-Idade , Oriente Médio , Diálise Renal/métodos , Veia Subclávia/cirurgia
13.
Am J Kidney Dis ; 73(1): 62-71, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30122545

RESUMO

RATIONALE & OBJECTIVE: Fistulas are the preferred form of hemodialysis access; however, many fistulas fail to mature into usable accesses after creation. Data for outcomes after placement of a second fistula are limited. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: People who initiated hemodialysis therapy in any of 5 Canadian dialysis programs (2004-2012) and had at least 1 hemodialysis fistula placed. PREDICTOR: Second versus initial fistula; receipt of 2 versus 1 fistula; second versus first fistula in recipients of 2 fistulas. OUTCOMES: Catheter-free fistula use during 1 year following initiation of hemodialysis therapy or following fistula creation, if created after hemodialysis therapy start; proportion of time with catheter-free use; time to catheter free use; time of functional patency. ANALYTICAL APPROACH: Logistic regression; fractional regression. RESULTS: Among the 1,091 study participants (mean age, 64±15 [SD] years; 63% men; 59% with diabetes), 901 received 1 and 190 received 2 fistulas. 38% of second fistulas versus 46% of first fistulas were used catheter free at least once. Average percentages of time that second and initial fistulas were used catheter free were 34% and 42%, respectively (OR, 0.72; 95% CI, 0.54-0.94). Compared with people who received 1 fistula, those who received 2 fistulas were less likely to achieve catheter-free use (26% vs 56%) and remain catheter free (23% vs 49% of time; OR, 0.30, 95% CI, 0.24-0.39). Among people who received 2 fistulas, the proportion of time that the second fistula was used catheter free was 11% higher with each 10% greater proportion of time that the first fistula was used catheter free (95% CI, 1%-22%). Model discrimination was modest (C index, 0.69). LIMITATIONS: Unknown criteria for patient selection for 1 or 2 fistulas; unknown reasons for prolonged catheter use. CONCLUSIONS: Outcomes of a second fistula may be inferior to outcomes of the initial fistula. First and second fistula outcomes are weakly correlated and difficult to predict based on clinical characteristics.


Assuntos
Derivação Arteriovenosa Cirúrgica , Falência Renal Crônica/terapia , Diálise Renal , Idoso , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
14.
Am J Nephrol ; 49(1): 11-19, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30544112

RESUMO

BACKGROUND: Despite national vascular access guidelines promoting the use of arteriovenous fistulas (AVF) over arteriovenous grafts (AVGs) for dialysis, AVF use is substantially lower in females. We assessed clinically relevant AVF and AVG surgical outcomes in elderly male and female patients initiating hemodialysis with a central venous catheter (CVC). METHODS: Using the United States Renal Data System standard analytic files linked with Medicare claims, we assessed incident hemodialysis patients in the United States, 9,458 elderly patients (≥67 years; 4,927 males and 4,531 females) initiating hemodialysis from July 2010 to June 2011 with a catheter and had an AVF or AVG placed within 6 months. We evaluated vascular access placement, successful use for dialysis, assisted use (requiring an intervention before successful use), abandonment after successful use, and rate of interventions after successful use. RESULTS: Females were less likely than males to receive an AVF (adjusted likelihood 0.57, 95% CI 0.52-0.63). Among patients receiving an AVF, females had higher adjusted likelihoods of unsuccessful AVF use (hazard ratio [HR] 1.46, 95% CI 1.36-1.56), assisted AVF use (OR 1.34, 95% CI 1.17-1.54), and AVF abandonment (HR 1.28, 95% CI 1.10-1.50), but similar relative rate of AVF interventions after successful use (relative risk [RR] 1.01, 95% CI 0.94-1.08). Among patients receiving an AVG, females had a lower likelihood of unsuccessful AVG use (HR 0.83, 95% CI 0.73-0.94), similar rates of assisted AVG use (OR 1.05, 95% CI 0.78-1.40) and AVG abandonment, and greater relative rate of interventions after successful AVG use (RR 1.16, 95% CI 1.01-1.33). CONCLUSIONS: While AVFs should be considered the preferred vascular access in most circumstances, clinical AVF surgical outcomes are uniformly worse in females. Clinicians should also consider AVGs as a viable alternative in elderly female patients initiating hemodialysis with a CVC to avoid extended CVC dependence.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Falência Renal Crônica/terapia , Diálise Renal/métodos , Enxerto Vascular/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Medicare/estatística & dados numéricos , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular
15.
J Vasc Surg ; 68(4): 1166-1174, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30244924

RESUMO

BACKGROUND: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use. METHODS: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality. RESULTS: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001). CONCLUSIONS: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.


Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/tendências , Cateterismo Venoso Central/tendências , Padrões de Prática Médica/tendências , Diálise Renal/tendências , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/mortalidade , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Prótese Vascular/efeitos adversos , Prótese Vascular/estatística & dados numéricos , Prótese Vascular/tendências , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/estatística & dados numéricos , Infecções Relacionadas a Cateter/etiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/mortalidade , Cateterismo Venoso Central/estatística & dados numéricos , Cateteres Venosos Centrais/efeitos adversos , Cateteres Venosos Centrais/estatística & dados numéricos , Cateteres Venosos Centrais/tendências , Bases de Dados Factuais , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Auditoria Médica , Medicare , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
16.
J Surg Orthop Adv ; 27(2): 109-112, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30084817

RESUMO

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).


Assuntos
Protocolos Clínicos/normas , Fraturas Ósseas/cirurgia , Centros de Traumatologia , Lesões do Sistema Vascular/cirurgia , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Bases de Dados Factuais , Fixadores Externos/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Humanos , Estudos Retrospectivos
17.
Saudi J Kidney Dis Transpl ; 29(4): 924-929, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30152431

RESUMO

End-stage renal disease (ESRD) is prevalent in our region. A major mode of treatment is by maintenance hemodialysis, and reliable vascular access is paramount for this to be successful. Arteriovenous fistula (AVF) creation offers permanent vascular access in patients with ESRD. We present our experience on AVF creation over a 10-year period. Our objective was to retrospectively review the outcome of all cases of AVF that have been created for ESRD patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife Nigeria between January 2006 and December 2015. The demographic characteristics, indications, clinical and intraoperative findings, operative complications and outcomes were filled into a pre-designed proforma. A total of 80 cases were reviewed. The age range was 17-80 years, with a mean of 49.03 ± 16.34 years. Males (85%) were more common than females (15%). Chronic glomerulonephritis and hypertension accounted for about 77.5% of etiology of ESRD in these patients. The left (non-dominant) upper limb was used in 88.1% of cases whereas 11.9% were created on the right upper limb. The distal radio-cephalic AVF (76.3%) was most commonly performed; with either the end (vein) to side (artery) (68.8%) or side-to-side (31.2%) anastomotic techniques employed. There was a primary failure in six patients (7.5%). Primary failure was more common in diabetics and thrombosis (7.5%) was the most common cause for primary failure. AVF creation has very good outcome in well-selected patients.


Assuntos
Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nigéria , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Centros de Atenção Terciária , Adulto Jovem
18.
Am J Nephrol ; 48(1): 56-64, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30071516

RESUMO

BACKGROUND: The arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis. However, approximately half of AVFs fail to mature. The use of angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) exerts favorable endothelial effects and may promote AVF maturation. We tested associations of ACE-I and ARBs, CCBs, beta-blockers, and diuretics with the maturation of newly created AVFs. METHODS: We evaluated 602 participants from the Hemodialysis Fistula Maturation Study, a multi-center, prospective cohort study of AVF maturation. We ascertained the use of each medication class within 45 days of AVF creation surgery. We defined maturation outcomes by clinical use within 9 months of surgery or 4 weeks of initiating hemodialysis. RESULTS: Unassisted AVF maturation failure without intervention occurred in 54.0% of participants, and overall AVF maturation failure (with or without intervention) occurred in 30.1%. After covariate adjustment, CCB use was associated with a 25% lower risk of overall AVF maturation failure (95% CI 3%-41% lower) but a non-significant 10% lower risk of unassisted maturation failure (95% CI 23% lower to 5% higher). ACE-I/ARB, beta-blocker, and diuretic use was not significantly associated with AVF maturation outcomes. None of the antihypertensive medication classes were associated with changes in AVF diameter or blood flow over 6 weeks following surgery. CONCLUSIONS: CCB use may be associated with a lower risk of overall AVF maturation failure. Further studies are needed to determine whether CCBs might play a causal role in improving AVF maturation outcomes.


Assuntos
Anti-Hipertensivos/administração & dosagem , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Falência Renal Crônica/terapia , Grau de Desobstrução Vascular/efeitos dos fármacos , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Diálise Renal/métodos , Falha de Tratamento
19.
Am J Nephrol ; 48(1): 4-14, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29990994

RESUMO

BACKGROUND: Arteriovenous (AV) access confers survival benefits over central venous catheters (CVC) in hemodialysis patients. Although chronic kidney disease disproportionately affects women and racial minorities, disparities in the -utilization of hemodialysis access across Asians, Native Americans, Hispanics, blacks, and whites among males and females after accounting for pre-dialysis health are not well studied. METHODS: We evaluated 885,699 patients with end-stage renal disease who initiated hemodialysis between January 1, 2004 and December 31, 2014 using the US Renal Data System. Multivariable logistic regression models -adjusted for pre-dialysis health were used to test the associations between gender and race on type of vascular access (AV access vs. CVC, and AV fistula vs. AV graft) at hemodialysis initiation as primary outcome, and on 1-year mortality as a secondary outcome. RESULTS: Mean age was 65 ± 14 years. Females were less likely to use AV access for hemodialysis initiation than were males (OR 0.85; 95% CI 0.84-0.86). Compared to whites, adjusted odds of AV access for hemodialysis initiation were higher in blacks (OR 1.08; 95% CI 1.07-1.70), Asians (OR 1.11; 95% CI 1.07-1.14); and lower in Hispanics (OR 0.89; 95% CI 0.87-0.90). There was no -significant difference in mortality between males and females. Compared to whites, 1-year adjusted mortality was lower in Asians (OR 0.55; 95% CI 0.53-0.56), blacks (OR 0.67; 95% CI 0.66-0.68), Hispanics (OR 0.62; 95% CI 0.61-0.63), and Native Americans (OR 0.62; 95% CI 0.58-0.66). CONCLUSION: Females had lower odds of using AV access than do males for hemodialysis initiation. As compared to whites, blacks and Asians were more likely, and Hispanics were less likely to use AV access for first outpatient hemodialysis. Further investigation of biological and process of care factors may help in developing ways to reduce these disparities.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres Venosos Centrais/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Falência Renal Crônica/terapia , Diálise Renal/estatística & dados numéricos , Adolescente , Adulto , Idoso , Grupos de Populações Continentais/estatística & dados numéricos , Feminino , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto Jovem
20.
J Neurosurg Pediatr ; 22(5): 550-558, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30052118

RESUMO

The authors performed a nationwide study in Japan to evaluate the annual detected rate of pediatric intracranial arteriovenous (AV) shunts such as brain AV malformations (BAVMs), pial AV fistulas (PAVFs), vein of Galen aneurysmal malformations (VGAMs), and dural AV fistulas (DAVFs). These rates were revealed for the first time and showed that VGAM, DAVF, and PAVF were relatively common but that BAVMs were extremely rare in neonates and infants.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Malformações Arteriovenosas Intracranianas/cirurgia , Pré-Escolar , Procedimentos Endovasculares , Feminino , Humanos , Lactente , Recém-Nascido , Japão , Masculino , Inquéritos e Questionários , Resultado do Tratamento
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