Thrombophilia and the Risk for Hemodialysis Vascular Access Thrombosis

Knoll, Greg; Wells, Philip S.; Young, Darlene; Perkins, Sherry L.; Pilkey, Rachel M.; Clinch, Jennifer; Rodger, Marc

doi:10.1681/asn.2004110999

Cited by 93 publications

(91 citation statements)

References 46 publications

(54 reference statements)

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“…Antiphospholipid antibodies were more common in men but did not seem to affect the AVF outcome. High incidence of thrombophilia is reportedly associated with risk of thrombosis after access surgery or revascularization among patients with ESRD and those with other vascular conditions (2,11,14). The difference in thrombophilia prevalence among the studies reflects various definitions of thrombophilia.…”

Section: Discussionmentioning

confidence: 99%

“…In fact, in the United States the annual costs of access failure are approximately $1 billion (1). The main causes of access dysfunction-thrombosis and stenosisare associated with vascular injury and intimal hyperplasia caused by high-shear-rate conditions in the access (2,3).…”

Section: Introductionmentioning

confidence: 99%

“…This is due to limited patient numbers, retrospective thrombophilia screening, and differences in definition and inclusion of individual types of thrombophilia (4)(5)(6)(7)(8)(9)(10)(11). One large retrospective study of 419 patients undergoing HD found at least one thrombophilic disorder in 43% of patients with ESRD, and any thrombophilic disorder increased the risk for access thrombosis (2).…”

Section: Introductionmentioning

confidence: 99%

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Thrombophilia and Arteriovenous Fistula Survival in ESRD

Salmela

Hartman²,

Peltonen³

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives The role of thrombophilia in failing arteriovenous fistula (AVF) among patients with ESRD undergoing hemodialysis is not established. This study aimed to assess whether AVF primary patency is associated with thrombophilia and coagulation abnormalities.Design, setting, participants, & measurements This observational study screened 219 patients between 2002 and 2004 for thrombophilia before AVF surgery. Thrombophilia included factor V Leiden and prothrombin G20210A mutations, protein C and antithrombin activities, and protein S. Coagulation abnormalities included high factor VIII:C, homocysteine, fibrinogen, and D-dimer levels; presence of antiphospholipid antibodies; and short thrombin time. We reviewed patient charts for comorbid conditions, AVF maturation and interventions, kidney transplantation, and patient survival (mean follow-up duration, 3.6 [range, 2.3-5.8] years). Primary patency from the AVF placement and functional primary patency from the first AVF cannulation were analyzed with Kaplan-Meier and Cox proportional hazards models.Results Thrombophilia was present in 9% of the patients, and coagulation abnormalities occurred in 77%. One-year primary patency was 68%; 46% of the AVF failures occurred before the initiation of hemodialysis. Female sex (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.7-4.1) and thrombophilia (HR, 2.2; 95% CI, 1.2-4.2) were independent risk factors for loss of primary patency. Thrombophilia mutations or low antithrombin level (HR, 3.8), female sex (HR, 2.5), and diabetes (HR, 1.9) were associated with shortened functional primary patency of AVF.Conclusions Against the background of frequent coagulation abnormalities, thrombophilia and female sex predispose patients with ESRD to access failure, mostly due to thrombosis or stenosis.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Thrombophilia and Arteriovenous Fistula Survival in ESRD

Salmela

Hartman²,

Peltonen³

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…40 Thrombophilic risk factors were moderately associated with access thrombosis (OR < 3) in a case control study by Knoll. 39 FVL, elevated factor VIII levels, elevated homocysteine and elevated lipoprotein (a) were associated with excess thrombosis. Overall 55% of patients with access thrombosis had one thrombophilic defect and for each additional thrombophilic defect the odds of thrombosis increased significantly, OR 1.87.…”

Section: Hemodialysis Vascular Access Thrombosismentioning

confidence: 97%

“…Several studies have reported associations between hereditary hypercoagulable disorders, elevated homocysteine levels and antiphospholipid antibodies and increased frequency of ac-cess thrombosis. 39 In a small retrospective series by LeSar et al 40 42% of 67 thrombotic events reviewed were associated with thrombophilic disorders without an identified anatomic vascular stenosis and an additional 19% of events were associated with thrombophilia in the presence of vascular stenosis. Presence of a lupus anticoagulant was found in 16.5% of 97 patients with end-stage renal disease and was associated with a higher frequency of access thrombosis (62% vs 26%).…”

Section: Hemodialysis Vascular Access Thrombosismentioning

confidence: 98%

Management of Hereditary Hypercoagulable Disorders

Bockenstedt¹

2006

Hematology

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The clinical management of individuals with hereditary hypercoaguable disorders has evolved from initial broad recommendations of lifelong anticoagulation after first event of venous thromboembolism to a more intricate individualized risk-benefit analysis as studies have begun to delineate the complexity of interactions of acquired and hereditary factors which determine the predilection to thrombosis. The contribution of thrombophilic disorders to risk of thrombotic complications of pregnancy, organ transplantation, central venous catheter and dialysis access placement have been increasingly recognized. The risk of thrombosis must be weighed against risk of long-term anticoagulation in patients with venous thromboembolism. Thrombophilia screening in select populations may enhance outcome. Initial DecisionsThe clinical management of individuals with hereditary hypercoagulable disorders has evolved from initial broad recommendations of lifelong anticoagulation after first event of venous thromboembolism (VTE) to a more intricate, individualized risk-benefit analysis as the complexity of interactions of acquired and hereditary factors that determine the predilection to thrombosis are now recognized. Important behind stratifying risk of recurrent events is the necessity of correctly identifying hereditary thrombophilic disorders, especially in circumstances in which laboratory results, e.g., mildly low antithrombin III (ATIII) or protein S levels, may be more indicative of a temporary acquired deficiency. The relevance of thrombophilic testing is debated, but most clinicians agree that prothrombotic assessment should be considered in individuals with unprovoked thrombosis at age less than 40 years, individuals who have had thrombosis at an unusual anatomic site or who have had repeated thromboses, or when the family history suggests multiple affected individuals. For review of the laboratory assessment of thrombophilia see references [1][2][3] . The following discussion is not meant to be comprehensive, but serves to highlight a few of the clinical management decisions important in the care of the thrombophilic patient. Therapeutic considerations involving individuals with antiphospholipid syndrome (APS) will be included where pertinent. Duration of anticoagulant therapyThe decision to extend therapy beyond 6-12 months after an incident thrombotic event must be made on an individual basis. Patients with a transient risk factor such as oral contraceptive use, postsurgical state or limb immobilization have a low risk of recurrence of thrombosis once anticoagulation has been completed. (For review see 4,5 .) Identifying the individual with moderate to high risk of recurrent thrombosis is important to prevent the unnecessary risk of hemorrhage from long-term anticoagulation. From studies of patients with a first VTE (both with and without diagnosed hereditary thrombophilia), one third of patients with unprovoked VTE will have a reoccurrence over the next 10 years and 6% of patients with VTE develop postphlebitic syndrom...

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