Frailty screening for determination of hemodialysis access placement.

OBJECTIVE: Choosing the right hemodialysis vascular access for frail patients remains difficult because the patient's preferences and the likelihood of access function and survival must be considered. We hypothesize that patients identified before arteriovenous (AV) access as frail by the PRISMA-7 score may have worse outcomes, indicating that fistula creation may not be the most clinically beneficial option and it would be in the best interest of the patient to receive either AV graft (AVG) placement or dialysis through a percutaneous catheter. Our pilot study aims to determine whether an association exists between patient frailty as defined by PRISMA-7 and newly created AV fistula (AVF) and AVG access outcomes. METHODS: This was a single institutional prospective cohort study of patients undergoing new AVF or AVG intervention from April 2021 to May 2023. Patients were assessed using the PRISMA-7 frailty questionnaire before their AV access surgery. Patients were grouped by frailty score and score groups were examined for trends. Univariable analysis was performed for baseline differences between frail and nonfrail patients. Failure to achieve maturation, postoperative infection, and 180-day mortality difference was also investigated for frail vs nonfrail patients. Univariable analysis was performed for nonmaturation using standard comorbidities, arterial and venous diameters, and frailty. Multivariable binary logistic regression was performed for the outcome of nonmaturation using frailty as one of the variables in conjunction with the univariable risks associated with nonmaturation. RESULTS: A total of 40 patients undergoing new AV access placement were investigated, among whom 53% were designated as frail (PRISMA-7 score ≥3). When comparing the frail and nonfrail new AV access groups, the access (AVF and AVG combined) failed in 48% (10/21) of the frail patients, but only failed in 5% (1/19) of the nonfrail patients 1 (P = .012). When distinguishing between AV access types, AVF creations followed the overall trend with 60% of AVF access (9/15) sites in frail patients failing to mature when compared with nonfrail patients, who all had fistulas that matured to use (P = .049). Surgical site infection was absent in all frail patients and present in 5% of nonfrail patients (1/19). Both 30-day and 60-day readmission rates were higher in the frail group compared with the nonfrail group. There was 180-day mortality present in 5 of frail patients % (1/21) and absent in nonfrail patients. Multivariable analysis revealed that both frailty (adjusted odd ratio, 10.19; 95% confidence interval, 1.20-82.25); P = .033) and younger age (adjusted odd ratio, 0.953; 95% confidence interval, 0.923-0.983; P = .002) both had a significant association with nonmaturation. Power analysis revealed a power statistic of 0.898 indicating a probability of type 2 error of 10.02% with a P value of .002. Hosmer-Lemeshow goodness of fit for the logistic regression had 75% overall accuracy for the model. CONCLUSIONS: Patient frailty is significantly associated with an increased incidence of AV access failure to mature.

Health care disparities involved in establishing functional arteriovenous fistula hemodialysis access.

OBJECTIVE: Race-related disparities in outcomes associated with cardiovascular disease are well-documented. Arteriovenous fistula (AVF) maturation can be a challenge in establishing functional access in the population of patients with end-stage renal disease requiring hemodialysis. We sought to investigate the incidence of adjunctive procedures required to establish fistula maturation and evaluate the association with demographic factors including patient race. METHODS: This study was a single-institution retrospective review of patients undergoing first-time AVF creation for hemodialysis from January 1, 2007, to December 31, 2021. Subsequent arteriovenous access interventions, such as percutaneous angioplasty, fistula superficialization, branch ligation and embolization, surgical revision, and thrombectomy, were recorded. The total number of interventions performed after index operation was recorded. Demographic data including age, sex, race, and ethnicity was recorded. The need for and number of subsequent interventions was evaluated using multivariable analysis. RESULTS: A total of 669 patients were included in this study. Patients were 60.8% male and 39.2% female. Race was reported as White in 329 (49.2%), Black in 211 (31.5%), Asian in 27 (4.0%), and other/unknown in 102 (15.3%). Of the patients, 355 (53.1%) underwent no additional procedures after initial AVF creation, 188 (28.1%) underwent one additional procedure, 73 (10.9%) had two additional procedures, and 53 (7.9%) had three or more additional procedures. As compared with the White reference group, Black patients were at higher risk of having maintenance interventions (relative risk [RR], 1.900; P ≤ .0001) and additional AVF creation interventions (RR, 1.332; P = .05), and total interventions (RR, 1.551; P ≤ .0001). CONCLUSIONS: Black patients were at significantly higher risk of undergoing additional surgical procedures, including both maintenance and new fistula creations, as compared with their counterparts of other racial groups. Further exploration of the root cause of these disparities is necessary to facilitate the achievement of equivalent high-quality outcomes across racial groups.

Spectroscopic studies of methyl paraoxon decomposition over mesoporous Ce-doped titanias for toxic chemical filtration.

The ever-constant threat of chemical warfare agents (CWA) motivates the design of materials to provide better protection to warfighters and civilians. Cerium and titanium oxide are known to react with organophosphorus compounds such Sarin and Soman. To study the decomposition of methyl paraoxon (CWA simulant) on such materials, we synthesized ordered mesoporous metal oxides (MMO) TiO2, CexTi1-xO2 (x = 0.005, 0.5, 0.10, 0.15) and CeO2. We fully characterized TiO2 and Ce-doped TiO2 and found phase-pure oxides with cylindrical hexagonally packed pores and high surface areas (176-252 m2/g). Methyl paraoxon decomposition was tracked through UV/Vis and found Ce0.15Ti0.85O2 to decompose the most methyl paraoxon, but CeO2 to be the most reactive when normalized to surface area. The surface area normalized rate constant (kSA) for CeO2 was 3-4.6 times larger than that of TiO2 and the CexTi1-xO2 series. While TiO2 and CexTi1-xO2 for 0.05 ≤ x ≤ 0.10 displayed no significant differences in the kinetics, the mostly amorphous Ce0.15Ti0.85O2 displayed a slight increase in reactivity. Our findings indicate that the nature of the cation, Ce4+ vs Ti4+, is less important to methyl paraoxon reactivity on these MMOs compared to other factors such as crystal structure type.