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1.
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
2.
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
3.
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
4.
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
5.
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
6.
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
7.
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
8.
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
9.
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
10.
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
11.
Saudi J Kidney Dis Transpl ; 29(3): 615-622, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29970738

RESUMO

The arteriovenous fistula (AVF) is the vascular access of the first choice for hemodialysis (HD). Studies on patency of AVF and its affecting factors reveal a high risk for access failure. The aim of this study was to assess the primary and secondary AVF patency and their determinant factors. It was a retrospective, descriptive study conducted in the HD facility of the Nephrology Department in Rabta University Hospital. We included AVF created before December 2009 in end-stage renal disease (ESRD) patients. The end of the follow-up was fixed in December 2013. We included 126 AVFs created in 111 patients; 22.5% were aged >65 years, 39.6% were diabetic, 68.5% were hypertensive, and 26.1% had peripheral vascular disease. The primary patency rates were 78% at one year and 42% at five years. The secondary patency rates were 80% at one year and 69% at five years. Multivariate analysis revealed that the factors affecting the primary patency of AVF were: the use of jugular catheter for longer than three months (odds ratio (OR):1.91, P = 0.044) and a C-reactive protein >5 mg/L (OR: 1.7, P = 0.049). Aging (>65 years) (OR: 2.46, P = 0.042), referral time to a nephrologist <6 months before onset of ESRD (OR: 2.87, P = 0.015), absence of an antiplatelet therapy (OR: 4.47, P = 0.005), and serum phosphorus <45 mg/L (OR: 2.07, P = 0.045) were the significant impairing risk factors for secondary AVF patency. Our study suggests that early referral and creation of AVF and maturation before ESRD as well as its adequate monitoring are essential for maintaining patency.


Assuntos
Derivação Arteriovenosa Cirúrgica , Diálise Renal , Grau de Desobstrução Vascular/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/métodos , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Pressão Sanguínea/fisiologia , Feminino , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
12.
J Nephrol ; 31(4): 603-611, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29730781

RESUMO

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.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Diálise Renal/estatística & dados numéricos , Insuficiência Renal Crônica/terapia , Enxerto Vascular/efeitos adversos , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Aspirina/uso terapêutico , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos , Insuficiência Renal Crônica/mortalidade , Estudos Retrospectivos , Síndrome do Roubo Subclávio/epidemiologia , Estados Unidos/epidemiologia , Enxerto Vascular/estatística & dados numéricos
13.
Int Urol Nephrol ; 50(5): 963-971, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29532308

RESUMO

PURPOSE: The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS: A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS: Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION: Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres de Demora/estatística & dados numéricos , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Diálise Peritoneal/estatística & dados numéricos , Lesão Renal Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Disparidades nos Níveis de Saúde , Humanos , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo
14.
J Vasc Interv Radiol ; 29(2): 159-169, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29273282

RESUMO

PURPOSE: To evaluate annual national trends in hemodialysis access maintenance procedures in the Medicare population by specialty and setting. METHODS: Medicare Physician Supplier Procedure Summary Master Files between 2005 and 2015 were analyzed for procedure codes of hemodialysis access angiography and percutaneous thrombectomy. Using physician specialty codes, component procedure volume for endovascular services were queried for radiology, medicine, and surgery. Data entries were analyzed by provider specialty and place of service. Average submitted and allowed charges per intervention were extracted. Linear regression modeling was used to identify trends in number of and allowed charges by specialty and practice setting. RESULTS: Between 2005 and 2015, the frequency of dialysis access angiography for Medicare fee-for-service beneficiaries increased by a total of 74.71% (211,181 to 368,955). Specialty-specific analysis demonstrated volume increases of 220.21% (22,128 to 101,109) for surgery, 249.02% (32,690 to 114,094) for medicine, and 2.81% (135,564 to 139, 367) for radiology. By 2015, an increased trend from hospital-based to non-hospital-based procedures associated with significantly higher reimbursement rates to providers (+18,798 non-hospital-based cases/year, $46.95/year, P ≤ .001) was also observed, with medicine performing the highest volume of non-hospital-based procedures. In this period, there was also a modest total overall increase of percutaneous thrombectomy procedures by 7.75% (61,485 to 66,250). CONCLUSIONS: The frequency of endovascular hemodialysis access maintenance procedures in the Medicare fee-for-service program has increased from 2005 to 2015, with the majority market share transitioning from radiologists to non-radiologists. Similarly, most access maintenance in this time period changed from hospital-based to non-hospital-based interventions.


Assuntos
Derivação Arteriovenosa Cirúrgica/economia , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Medicare/economia , Padrões de Prática Médica/economia , Padrões de Prática Médica/tendências , Diálise Renal , Angiografia/economia , Angiografia/estatística & dados numéricos , Humanos , Trombectomia/economia , Trombectomia/estatística & dados numéricos , Estados Unidos , Grau de Desobstrução Vascular
15.
Zhong Nan Da Xue Xue Bao Yi Xue Ban ; 42(11): 1270-1274, 2017 Nov 28.
Artigo em Chinês | MEDLINE | ID: mdl-29187653

RESUMO

OBJECTIVE: To investigate the status of vascular access in hemodialysis patients in our center.
 Methods: The general information of hemodialysis patients and types and complications of vascular access at Xiangya Hospital of Central South University from April 2015 to April 2016, were retrospectively analyzed.
 Results: Among 258 prevalent patients, 87.60% of them had arteriovenous fistula (AVF), while 12.40% showed tunneled cuffed catheter. Of the 61 incident patients, 80.33% of them initiated dialysis with a non-tunneled and non-cuffed catheter, 8.19% with an AVF, 9.84% with a tunneled cuffed catheter, and 1.64% with needle puncture. The types of AVF access included 76.55% of wrist radiocephalic fistula, 7.08% of mid-forearm cephalic fistula, 11.06% of elbow brachiocephalic fistula, and 5.31% of antecubital fistula and transposed basilic fistula. Seventy-seven (34.07%) patients with AVF suffered complications and wherein aneurysms accounted for 24.34%.
 Conclusion: In maintenance hemodialysis patients, autologous AVF is the prevalent vascular access. In the beginners for dialysis, non-tunneled and non-cuffed catheter are their choice. Additional efforts and incentives may be necessary to improve vascular access during the initiation of hemodialysis.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres de Demora/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Aneurisma/etiologia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Cateteres de Demora/efeitos adversos , China , Humanos , Punções/métodos , Punções/estatística & dados numéricos , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Estudos Retrospectivos , Universidades
16.
Nephrol Nurs J ; 44(4): 349-352, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29160969

RESUMO

Patients receiving hemodialysis are challenged with maintaining adequate vascular access. Nephrology nurses are on the forefront of daily care, assessment, and monitoring of patients' vascular accesses for hemodialysis. This article discusses the literature and manufacturer information to support best nursing practices.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Falência Renal Crônica/terapia , Diálise Renal , Humanos
17.
Clin J Am Soc Nephrol ; 12(11): 1814-1822, 2017 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-28974524

RESUMO

BACKGROUND AND OBJECTIVES: Endocarditis is a serious complication in patients treated with RRT. The study aimed to examine incidence and risk factors of endocarditis in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Danish National Registry on Regular Dialysis and Transplantation contains data on all Danish patients receiving renal replacement (hemodialysis, peritoneal dialysis, or kidney transplantation) for ESRD. Incidence of endocarditis was estimated for each RRT modality. Independent risk factors of endocarditis were identified in multivariable Cox regression models. RESULTS: From January 1st, 1996 to December 31st, 2012, 10,612 patients (mean age 63 years, 36% female) initiated RRT (7233 hemodialysis, 3056 peritoneal dialysis, 323 pre-emptive kidney transplantation). Endocarditis developed in 267 (2.5%); of these 31 (12%) underwent valve surgery. The overall incidence of endocarditis was 627 per 100,000 person-years in patients receiving RRT. Incidence was higher in patients receiving hemodialysis compared with those receiving peritoneal dialysis or kidney transplantation (1092 per 100,000 person-years, 212 per 100,000 person-years, and 85 per 100,000 person-years, respectively). Adjusted hazard ratios for endocarditis in patients receiving hemodialysis were 5.46 (95% confidence interval [95% CI], 3.28 to 9.10) and 0.41 (95% CI, 0.18 to 0.91) for kidney-transplanted recipients, respectively, as compared with patients in peritoneal dialysis. The incidence of endocarditis in hemodialysis recipients with central venous catheters was more than two-fold higher as compared with those with arteriovenous fistulas. Overall mortality, subsequent to endocarditis, was 22% in-hospital and 51% at 1 year. The first 6 months in RRT, aortic valve disease, and previous endocarditis were identified as significant risk factors of endocarditis. CONCLUSIONS: Patients receiving RRT have a high incidence of endocarditis, in particular during hemodialysis treatment using central venous catheters. The first 6 months in RRT, aortic valve disease, and previous endocarditis are significant risk factors for developing endocarditis.


Assuntos
Endocardite/epidemiologia , Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica , Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres Venosos Centrais/estatística & dados numéricos , Dinamarca/epidemiologia , Endocardite/mortalidade , Feminino , Doenças das Valvas Cardíacas/epidemiologia , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/estatística & dados numéricos , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco
18.
Am J Nephrol ; 46(4): 268-275, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28930719

RESUMO

BACKGROUND: Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement. METHODS: All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age. RESULTS: In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments. CONCLUSIONS: HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateterismo Venoso Central/estatística & dados numéricos , Cateteres Venosos Centrais/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Clin J Am Soc Nephrol ; 12(12): 1991-1999, 2017 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-28912248

RESUMO

BACKGROUND AND OBJECTIVES: Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. RESULTS: We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. CONCLUSION: Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateterismo/estatística & dados numéricos , Equipe de Assistência ao Paciente , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/terapia , Reoperação/estatística & dados numéricos , Reoperação/tendências , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
20.
Clin J Am Soc Nephrol ; 12(11): 1823-1830, 2017 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-28798220

RESUMO

BACKGROUND AND OBJECTIVES: The optimal type of initial permanent access for hemodialysis among the elderly is controversial. Duration of central venous catheter dependence, patient comorbidities, and life expectancy are important considerations in whether to place an arteriovenous fistula or graft. We used an observational study design to compare clinical outcomes in elderly patients who initiated hemodialysis with a central venous catheter and subsequently had an arteriovenous fistula or graft placed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified 9458 United States patients ages ≥67 years old who initiated hemodialysis from July 1, 2010 to June 30, 2011 with a central venous catheter and no secondary vascular access and then received an arteriovenous fistula (n=7433) or graft (n=2025) within 6 months. We evaluated key clinical outcomes during the 6 months after vascular access placement coincident with high rates of catheter use and used a matched propensity score analysis to examine patient survival. RESULTS: Central venous catheter dependence was greater in every month during the 6-month period after arteriovenous fistula versus graft placement (P<0.001). However, rates of all-cause infection-related hospitalization (adjusted relative risk, 0.93; 95% confidence interval, 0.87 to 0.99; P=0.01) and bacteremia/septicemia-related hospitalization (adjusted relative risk, 0.90; 95% confidence interval, 0.82 to 0.98; P=0.02) were lower in the arteriovenous fistula versus graft group as was the adjusted risk of death (hazard ratio, 0.76; 95% confidence interval, 0.73 to 0.80; P<0.001). CONCLUSIONS: Despite extended central venous catheter dependence, elderly patients initiating hemodialysis with a central venous catheter who underwent arteriovenous fistula placement within 6 months had fewer hospitalizations due to infections and a lower likelihood of death than those receiving an arteriovenous graft.


Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateteres Venosos Centrais/estatística & dados numéricos , Falência Renal Crônica/terapia , Diálise Renal/métodos , Enxerto Vascular/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/epidemiologia , Cateteres de Demora , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Estados Unidos/epidemiologia
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