<b><i>Background:</i></b> Heart rate variability (HRV) means the variation in time of beat-to-beat interval. Lower HRV has been shown to be related with death and cardiovascular events in previous studies. In the last few years, the number of patients with ESRD has increased steadily. Maintenance hemodialysis is the most prevalent renal replacement therapy in patients with ESRD. This study aims to investigate if decreased HRV is an independent predictor of mortality in maintenance hemodialysis patients. <b><i>Methods:</i></b> Pubmed/Medline, EMBASE, Ovid, the Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched up to October 1, 2019, for full-text articles in English. Cohort studies reporting the association between HRV and prognosis in hemodialysis patients were selected. Data extraction was performed by 2 reviewers independently, with adjudication by a third reviewer. Extracted data included the study characteristics, HRV measurement and research outcomes. Hazard ratios (HRs) and 95% confidence interval (CI) were pooled in a random-effects model for outcomes of all-cause and cardiovascular mortality. Heterogeneity assessment, subgroup analyses, and sensitivity analysis were conducted. <b><i>Results:</i></b> A total of 7 studies were eligible. HRV metrics consist of SDNN, SDANN, RMSSD, pNN50, HRVTI, ULF, VLF, LF, HF, LF/HF ratio, HRT, DC, and scaling exponents α1 and α2. Decreased HRV was associated with higher all-cause mortality (HR: 1.63, 95% CI: 1.11–2.39, <i>p</i> = 0.014) and cardiovascular mortality (HR: 1.07, 95% CI: 1.00–1.15, <i>p</i> = 0.045). Among the different HRV metrics, decreased SDANN (<i>p</i> &#x3c; 0.001) and decreased LF/HF ratio (<i>p</i> = 0.001) were identified as predictors of all-cause death. Decreased SDNN, SDANN, and LF/HF ratio were identified as predictors of cardiovascular death (<i>p</i> = 0.004, <i>p</i> = 0.001, and <i>p</i> = 0.002). <b><i>Conclusions:</i></b> Decreased HRV is associated with higher risk of all-cause and cardiovascular death in the hemodialysis population. Decreased SDANN and LF/HF were identified as predictors of both all-cause and cardiovascular mortality, while the utility of other HRV metrics requires further investigation. The protocol for this study was registered with PROSPERO (CRD42019141886).

Background: Although the internal jugular vein (IJV) is the most widely used puncture site in hemodialysis catheter insertion and central vein angioplasty, the external jugular vein (EJV) offers an alternative vascular access point in cases when the IJV is inaccessible. The present study aims to observe the efficacy and safety of sharp recanalization of the brachiocephalic vein occlusion through the EJV in hemodialysis patients.Methods: This retrospective study enrolled a cohort of hemodialysis patients who received sharp recanalization of occlusive brachiocephalic vein through the EJV at a university-affiliated hospital between January 2017 and January 2019. The demographic information and clinical outcome data of the patients were collected and analyzed.Results: A total of 16 hemodialysis patients who received right brachiocephalic vein sharp recanalization through the EJV were analyzed. The technical success rate was 100%. Twelve patients (12/16, 75%), whose EJV-subclavian vein angle (E-S angle) was 60-80 degrees, were successfully recanalized on the first attempt.With the other 4 patients (4/16, 25%), whose E-S angle approached 90 degrees, the brachiocephalic vein was recanalized on the second attempt by elevating the ipsilateral shoulder, therefore decreasing the E-S angle to align the course of the EJV with the brachiocephalic vein. Three minor complications were recorded, including 1 patient with blood continuously oozing from the EJV at the puncture site and 2 patients with mild chest pain. After an average of 10 months of follow-up, the clinical patent rate was 81.25% with no procedure-related complications reported.Conclusions: Sharp recanalization through the EJV could be an effective and safe alternative treatment for right brachiocephalic vein occlusion in hemodialysis patients if performed by an experienced practitioner.Measuring the angle formed by the EJV and the subclavian vein might provide helpful information for selecting patients.