Background Advantages of the arteriovenous fistula (AVF), including long patency and few complications, were ascertained more than 2 decades ago and may not apply to the contemporary dialysis ...population. Study Design Systematic review and meta-analysis. Estimates were pooled using a random-effects model and sources of heterogeneity were explored using metaregression. Setting & Population Patients treated with long-term hemodialysis using an AVF. Selection Criteria for Studies English-language studies indexed in MEDLINE between 2000 and 2012 using prospectively collected data on 100 or more AVFs. Predictor Age, AVF location, and study location. Outcomes Outcomes of interest were primary AVF failure and primary and secondary patency at 1 and 2 years. Results 7,011 citations were screened and 46 articles met eligibility criteria (62 unique cohorts; n = 12,383). The rate of primary failure was 23% (95% CI, 18%-28%; 37 cohorts; 7,393 AVFs). When primary failures were included, the primary patency rate was 60% (95% CI, 56%-64%; 13 studies; 21 cohorts; 4,111 AVFs) at 1 year and 51% (95% CI, 44%-58%; 7 studies; 12 cohorts; 2,694 AVFs) at 2 years. The secondary patency rate was 71% (95% CI, 64%-78%; 10 studies; 11 cohorts; 3,558 AVFs) at 1 year and 64% (95% CI, 56%-73%; 6 studies; 11 cohorts; 1,939 AVFs) at 2 years. In metaregression, there was a significant decrease in primary patency rate in studies that started recruitment in more recent years. Limitations Low quality of studies, variable clinical settings, and variable definitions of primary AVF failure. Conclusions In recent years, AVFs had a high rate of primary failure and low to moderate primary and secondary patency rates. Consideration of these outcomes is required when choosing a patient's preferred access type.
A 28-year-old woman was presented to the emergency department with a 4-day history of shortness of breath and fatigue. The patient had received a diagnosis of immunoglobulin A (IgA) nephropathy 1 ...month previously, after presenting with a creatinine level of 558, nephrotic range proteinuria and consistent histology on kidney biopsy. She received 3 days of treatment with methylprednisolone (1 g once daily) and then a weaning course of oral prednisone (starting at 60 mg/d). She was also prescribed trimethoprim-sulfamethoxazole (800 mg/160 mg orally 3 times weekly) as prophylaxis for pneumonia caused by the fungus Pneumocystis jirovecii. A rash developed 12 days before this presentation, which was attributed to trimethoprim-sulfamethoxazole, and she was prescribed dapsone (100 mg/d taken orally), a second-line antibiotic for pneumocystis pneumonia prophylaxis, instead. On examination, the patient had central cyanosis, was not in respiratory distress and was hemodynamically stable. Cardiac and pulmonary examinations were unremarkable and her oxygen saturation level was 89%-91% on room air and 91% on supplemental oxygen (10 L/min).
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, ...there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease “Life-Plan” and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic ...review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts;
>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts;
=1827 fistulas), 0.11 infections (16 cohorts;
>6439 fistulas), 0.05 steal events (15 cohorts;
>2543 fistulas), 0.24 thrombotic events (26 cohorts;
=4232 fistulas), and 0.03 venous hypertensive events (1 cohort;
=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.
Prior guidelines were based on observational studies that were prone to confounding by indica- tion (i.e., patients who had earlier initiation of dial- ysis may have been in poorer health with a ...worse prognosis than those who started dialysis later) and cannot provide accurate estimates of the benefits and harms associated with starting dialysis early versus late. The IDEAL study compared early ver- sus late initiation of dialysis, based on estimated creatinine clearance (eCrCl) thresholds (10-14 v. 5-7 mL/min per 1.73 m2) as estimated by the Cockroft-Gault formula.6 Patients randomly assigned to the group receiving late initiation of dialysis could cross over to an earlier initiation based on clinical symptoms and other complica- tions of advanced chronic kidney disease. For the purposes of this guideline, we defined this as an "intent-to-defer" approach to dialysis initiation. Similarly, patients randomly assigned to an early start could cross over to a later start; this was termed an "intent-to-start-early" strategy. In the IDEAL study, the researchers found a difference in eCrCl of 2.2 mL/min between the intent-to-defer and intent-to-start-early groups. The intent-to-defer strategy resulted in a cross- over rate of 75%, and a mean eCrCl of 9.8 mL/ min (MDRD eGFR 7.2 mL/min) at dialysis in- itiation. There was also a 19% crossover rate among patients in the intent-to-start-early group, resultin g in a mean eCrCl of 12.0 mL/mi n (MDRD eGFR 9.0 mL/min) at dialysis initia- tion.17 Despite adequate power, there was no sta- tistically significant difference in survival (haz- ard ratio HR 1.04, 95% confidence interval CI 0.83-1.30) with the intent-to-start-early ver- sus intent-to-defer groups, using intent-to-treat analysis.6 The recently published systematic review of survival outcomes found a similar result in the pooled analysis of 15 observational studies (HR 1.04, 95% CI 1.03-1.05).19 Importantly, however, no published clinical trials have studied the effects of deferring dialysis beyond the threshold of 5-7 mL/min per 1.73 m2 (eGFR ≤ 6 mL/min per 1.73 m2). In the IDEAL study, all patients who remained in the intent-to- defer group initiated dialysis when the eCrCl reached 5-7 mL/min, regardless of whether they had symptoms. We therefore consider an MDRD eGFR range of 6 mL/min per 1.73 m2 or less a reasonable lower threshold for the intent-to-defer strategy in a Canadian population. Hence, it seems prudent to initiate dialysis once this thresh- old is reached, based on this uncertainty and to reduce the risk of emergent dialysis.
Can Additional Water a Day Keep the Cysts Away, in Patients with Polycystic Kidney Disease? If a patient with autosomal dominant polycystic kidney disease could drink enough water to suppress ...arginine vasopressin release, would cyst growth be attenuated, thereby reducing the decline in kidney function over time? Louise M. Moist, M.D. discusses this randomized controlled trial.
IntroductionPatients with kidney failure with replacement therapy (KFRT) suffer premature cardiovascular (CV) mortality and events with few proven pharmacological interventions. Omega-3 ...polyunsaturated essential fatty acids (n-3 PUFAs) are associated with a reduced risk of CV events and death in non-dialysis patients and in patients with established CV disease but n-3 PUFAs have not been evaluated in the high risk KFRT patient population.Methods and analysisThis multicentre randomised, placebo controlled, parallel pragmatic clinical trial tests the hypothesis that oral supplementation with n-3 PUFA, when added to usual care, leads to a reduction in the rate of serious CV events in haemodialysis patients when compared with usual care plus matching placebo. A target sample size of 1100 KFRT patients will be recruited from 26 dialysis units in Canada and Australia and randomised to n-3 PUFA or matched placebo in a 1:1 ratio with an expected intervention period of at least 3.5 years. The primary outcome to be analysed and compared between intervention groups is the rate of all, not just the first, serious CV events which include sudden and non-sudden cardiac death, fatal and non-fatal myocardial infarction, stroke, and peripheral vascular disease events.Ethics and disseminationThis study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences.Trial registration numberISRCTN00691795
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