Severe hemodialysis access-induced distal ischemia may be associated with poor survival

Abstract

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.

Use of chronically occluded fistula to establish access outflow

“…Maintaining a long-term functioning vascular access is particularly challenging in a group of patients with severe arterial disease and multiple previous interventions. 1,2 We have previously described our modus operandi that is…”

A preoperative modified Allen test result may be associated with long term mortality after hemodialysis access construction

“…1,21,22 Several studies found that hand ischemia as reflected by a low systolic finger pressure (P dig ) was associated with increased mortality rates in HD populations. [6][7][8][9][10] Based on these findings, we hypothesized an association between drop in P dig (∂P dig ) during a MAT and mortality in CKD patients who were scheduled for access surgery. Interestingly, 52% of the individuals demonstrating a ∂P dig > 50 mmHg at the preoperative MAT had died after 4 years compared to just 15% with a ∂P dig < 15 mmHg.…”

“…This finding may reflect lack of compensatory capacity of the vascular system in some of these fragile patients. [6][7][8][9][10] Prior to choosing the optimal type of HD access in an CKD patient, stratification of risk factors is required. For instance, a patient having multiple risk factors and possibly a limited life expectancy may benefit from a permanent indwelling line rather than from an arteriovenous fistula or loop.…”

The prognostic role of finger pressures and access flows in hemodialysis patients

“…In contrast, a recent publication on the natural history of a general HD-ward reported 21 deaths during 148 observed patient years (1:7). 95 However, mean age was substantially higher and diabetes more common. 95 In one other study, patients with Q a <1.0 L/min had poorer survival compared with patients with Q a >1.0 L/min.…”

“…95 However, mean age was substantially higher and diabetes more common. 95 In one other study, patients with Q a <1.0 L/min had poorer survival compared with patients with Q a >1.0 L/min. Interestingly, Q a >2.0 L/min was not related to excess mortality.…”