RUDI with GSV interposition for HFA offers acceptable patency rates after 3 years although re-interventions are often required. High immediate post-operative flows and young age are associated with recurrent high flow.
Basilic vein transposition for an unsuitable upper arm needle access segment may attenuate hand ischemia in patients with a brachial AVF previously reporting hemodialysis access-induced distal ischemia.
Background: Some hemodialysis patients develop hemodialysis access-induced distal ischemia due to insufficient loco-regional perfusion pressure and consequent poor arterial flow. We hypothesized that patients with severe hemodialysis access-induced distal ischemia had worse survival compared with patients with mild or no hemodialysis access-induced distal ischemia. Methods: This single-center retrospective observational cohort study included three groups of prevalent hemodialysis patients with an upper extremity vascular access between 2006 and 2018. Symptomatic patients had signs and symptoms of hemodialysis access-induced distal ischemia and low digital brachial indices (<60%) and were divided into a mild (Grade I–IIa) and a severe hemodialysis access-induced distal ischemia (IIb–IV) group. The control group consisted of hemodialysis patients without signs of hemodialysis access-induced distal ischemia with digital brachial indices ≥60%. Factors potentially related to 4-year survival were analyzed. Results: Mild hemodialysis access-induced distal ischemia-patients displayed higher digital brachial indices ( n = 23, 41%, ±3) compared with severe hemodialysis access-induced distal ischemia-patients ( n = 28, 24%, ±4), whereas controls had the highest values ( n = 48, 80%, ±2; p < .001). A total of 44 patients (44%) died during follow-up. Digital brachial index (hazards ratio 0.989 [0.979–1.000] p = .046) was related to overall mortality following correction for presence of arterial occlusive disease (hazards ratio 2.28 [1.22–4.29], diabetes (hazards ratio 2.00 [1.07–3.72], and increasing age (hazards ratio 1.03 [1.01–1.06] as was digital pressure (hazards ratio 0.990 [0.983–0.998], p = .011). Overall survival was similar in mild hemodialysis access-induced distal ischemia and controls (2-year, 79% ±5; 4-year, 57% ±6, p = .818). In contrast, 4-year survival was >20% lower in patients with severe hemodialysis access-induced distal ischemia (2-year 62%± 10; 4-year 34% ± 10; p = .026). Conclusion: Presence of severe hemodialysis access-induced distal ischemia may be associated with poorer survival in hemodialysis patients. Lower digital brachial index values are associated with higher overall mortality, even following correction for other known risk factors.
Background
Aim of the study was to determine associations between characteristics of arteriovenous access (AVA) access flow volume (Qa, mL/min) and four year freedom from cardiovascular mortality (4yr-CVM) in hemodialysis (HD) patients.
Methods
HD patients who received a primary AVA between January 2010 and December 2017 in one center were analyzed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point of time. Changes in actual Qa were expressed per 3-month periods. CVM was assessed according to the ERA-EDTA classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristic curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4yr-CVM.
Results
A total of 5208 Qa measurements (165 patients, male n = 103; age 70±12 years, autologous AVA n = 146, graft n = 19) were analyzed. During follow-up (Dec 2010-Jan 2018, median 36 months), 79 patients (48%) died. An initial Qa < 900 mL/min was associated with an increased 4y-CVM risk (HR: 4.05; 95% CI [1.94-8.43], P<0.001). After 4 years, freedom from CVM was 34% lower in patients with a Qa < 900 mL/min (53 ±7% vs. Qa ≥ 900 mL/min: 87 ±4%, P <0.001). An association between increases in actual Qa over 3-month periods and mortality was found (HR: 4.48 per 100mL/min, 95% CI [1.44-13.97], P =0.010) indicating that patients demonstrating increasing Qa were more likely to die. By contrast, actual Qa per se was not related to survival.
Conclusions
Studying novel arteriovenous access Qa characteristics may contribute to understanding excess CVM in HD patients.
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