Kidney Foundation-Dialysis Outcomes Quality Initiative Research Articles

Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience.

Primary use of the autogenous arteriovenous access is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. In spite of troublesome comorbidities associated with basilic vein transposition (BVT), it is still the most preferred technique when autologous veins are not suitable to construct radio-cephalic fistula (RCF) and brachiocephalic fistula (BCF), arteriovenous fistula (AVF). The present study highlights our experience with BVT, with small incision technique, over a period of two years with excellent outcome. This retrospective study included all the patients who underwent BVT at our tertiary care center between March 2013 and March 2015. It was performed in patients with failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. The patients with minimum 3 mm basilic vein diameter on Doppler were only included in the study. A 3-cm horizontal incision was made in antecubital fossa to expose brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2-3 cm) were made to explore proximal part of basilic vein. Side branches of the vein were isolated and ligated. The divided basilic vein in antecubital fossa was brought over fascia through newly created subcutaneous tunnel followed by end-to-side anastomosis. A total of 18 (12 males and 6 females) underwent BVT in the two years period. The mean fistula maturation time was 42 ± 10 days. Maturation rate was 100%, and the postoperative flow rate was 290 ± 22 (mL/min). No bleeding, thrombosis, failure, pseudo aneurysm, or rupture occurred in our patients. Arm edema occurred in ix (33%) patients, infection in three (17%), and lymphorrhea in five (28%). The mean follow-up was six months. BVT is an alternative method with excellent initial maturation and functional patency rates requiring less extensive skin incision and surgical dissection. It is the most durable hemodialysis access procedure for those patients having multiple forearm AVF surgeries.

COMPARATIVE STUDY BETWEEN ONE-STAGE AND TWO- STAGE BRACHIO BASILIC ARTERIOVENOUS FISTULA AS A HEMODIALYSIS ACCESS PROCEDURE

Background: The primary use of autogenous arteriovenous access for chronic hemodialysis is recommended by the National Kidney Foundation–Dialysis Outcomes Quality Initiative practice guidelines. Brachiaobasilic (BB) fistulae are a form of vascular access for patients requiring dialysis. Brachiaobasilic (BB) fistulae can be created with either a single stage or a two stage procedure. Objective: The goal of this study was to compare the failure rates and functional patencies of one-stage vs two-stages brachiobasilic fistulas. Patients and Methods: Fifty patients with chronic renal failure (CRF) with the cephalic vein was unsuitable for use or failed brachio cephalic were admitted to The Vascular Surgery Unit in Al-Hussein University Hospital in the period from Jun. 2011 to Jun 2013.One stage procedure was done to twenty five patients of them and two stages procedure was done to the rest of the patients. Results: Two stages procedure failure rates were lower than one stage procedure. Two stage procedure survived longer than one stage procedure. There was no difference in primary failure between the two groups which were due to hypotension, thrombosis of vein , and small sized basilic vein. Two cases of wound infection had occurred in obese and diabetic patients which was controlled by drainage and umbrella of antibiotics. Conclusion: Two stage procedure BB fistulae was better than one stage procedure in primary patency and access survival.

COMPARISON OF Kt/V AND UREA REDUCTION RATIO IN MEASURING DIALYSIS ADEQUACY IN PAEDIATRIC HAEMODIALYSIS IN ENGLAND

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (KDOQI) guidelines and the Renal Association recommend the use of either Kt/V or urea reduction ratio (URR) to measure haemodialysis adequacy. To determine the methods used to measure paediatric haemodialysis adequacy and to assess consistency between calculations of single pool Kt/V (spKt/V) and URR. A service evaluation was conducted to establish current practices in measuring dialysis adequacy. A prospective longitudinal study was conducted to compare spKt/V and URR. Thirty-two children were recruited consisting of 13 males and 19 females in five paediatric dialysis centres. Inconsistencies were reported of the method of post-urea sampling with 4 of the 10 centres using the KDOQI recommended sampling method. Five dialysis centres reported using URR and five reported using spKt/V. There were substantial differences between the two measures. Using URR suggested that up to 44% of children did not receive adequate dialysis, whereas measurement by spKt/V suggested no more than 6% of the same dialysis sessions were not adequate. One standard measure should be used to assess dialysis adequacy in paediatric centres in England. KDOQI guidelines were not consistently followed in obtaining a post-urea blood sample and this procedure should be standardised.

Prevalence of Chronic Kidney Disease in Patients Undergoing Cardiac Rhythm Device Removal

Cardiac implantable electronic device (CIED) leads can cause central venous stenosis (CVS). In addition, these devices can get infected. Both are critically important considerations in patients with chronic kidney disease (CKD) for at least two reasons: (i) central veins serve as the final pathway should these patients need an arteriovenous access to provide dialysis therapy; and (ii) the presence of renal failure increases the risk of CIED infection. In this analysis, we investigated the prevalence as well as the degree of chronic kidney disease in patients harboring a CIED. Patients undergoing CIED removal were evaluated from 2001 to 2011. The patients were categorized into CKD stage I-V based on National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. A total of 503 patients underwent CIED removal. Demographic characteristics revealed that 30% had hypertension, 44% were diabetics, 77% had coronary artery disease, and 84% suffered from congestive heart failure. Ninety percent (452/503) of the patients had CKD (stage I = I9 [4.2%], stage II = 189 [41.8%], stage III A = 96 [21.2%], stage III B = 59 [13.0%], stage IV = 45 [9.9%], and stage V = 44 [9.7%]). Overall, 148 (32.7%) patients (stage III B, stage IV, and stage V) of 452 had advanced renal failure. The results of this study reveal that one-third of CIED patients undergoing device removal have advanced chronic kidney disease.

Superficialization of the Basilic Vein Technique in Brachiobasilic Arteriovenous Fistula: Surgical Experience of 350 Cases During 4 Years Period

The primary use of autogenous arteriovenous fistula for chronic hemodialysis patients is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative practice guidelines (Am J Kidney Dis 2001;37(1 Suppl. 1):S7-S64; Am J Kidney Dis 1997;30(4 Suppl. 3):S150-S191). Brachiobasilic arteriovenous fistula offers excellent access in difficult cases. Many surgical techniques have been described to create brachiobasilic fistula. The purpose of this study was to present and discuss the technique of superficialization of the basilic vein in brachiobasilic arteriovenous fistula with long-term results of 350 cases. A total of 375 brachiobasilic arteriovenous fistulas were constructed with superficialization of the basilic vein technique. Of these, 350 fistulas were used in hemodialysis (93.3%). One hundred fifty-five (44%) patients were male, 195 (56%) were female. Mean age was 57.8 (range, 18-88) years. A 2-cm longitudinal incision was made in antecubital fossa to expose brachial artery and basilic vein under local anesthesia. A separate second skin incision (4-6 cm) was done to explore proximal part of the basilic vein. Side branches of the basilic vein were isolated and ligated carefully using this second skin incision. The basilic vein was divided in antecubital fossa and brought over the fascia through the subcutaneous tunnel at the same anatomical position. Anastomosis was performed with end-to-side technique. Mean follow-up was 48 months (range, 2-84). The mean time to first puncture and use of the fistula time was 52 days (range, 25-75). Bleeding required surgical exploration which occurred in 3 (0.9%) patients. Primary patency of basilic vein superficialization fistulas was 92%, 78%, 64%, and 54% at 1, 2, 3, and 4 years, respectively. Secondary patency was 93%, 81%, 66%, and 56% at 1, 2, 3, and 4 years, respectively. Superficialization of the basilic vein technique is a logical alternative method of the basilic vein transposition. Superficialization requires less extensive skin incision and surgical dissection. Long-term patency was good.

Small incision basilic vein transposition technique: A good alternative to standard method

End-stage renal disease is a significant health problem. The primary use of the autogenous arteriovenous access is recommended by NKF-DOQI (National Kidney Foundation-Dialysis Outcomes Quality Initiative) guidelines. Though basilic vein transposition is well established in multiple failed fistulae's and obese patients, it requires large incision and morbidities like edema and infection. To avoid such compilations we, at our institution, adopted a small incision technique using two small 3-4 cm incisions. This method is inspired by videoendoscopic minimally invasive method used to dissect the basilic vein, thus avoiding extensive dissection and related morbidities.

EPO Adjustments in Patients With Elevated Hemoglobin Levels: Provider Practice Patterns Compared With Recommended Practice Guidelines

This study investigates provider practices regarding recombinant human erythropoietin (rHuEPO) dose when patient hemoglobin levels exceeded National Kidney Foundation-Dialysis Outcomes Quality Initiative target levels and reached 13 g/dL or greater (>or=130 g/L). The study population (N = 167,796) was hemodialysis patients prevalent on January 1, 2003, who were on renal replacement therapy at least 90 days with Medicare as primary payer and rHuEPO claims in 2 or more consecutive months. Patient characteristics were obtained from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report, and comorbid conditions were determined from Medicare claims. Providers and rHuEPO claims were linked by using CMS-assigned provider numbers and the CMS Annual End-Stage Renal Disease Facility Survey. Between-provider differences in patient characteristics were examined by using chi-square test, and provider effect on appropriate response, by using logistic regression. DaVita's percentage of monthly claims for patients with hemoglobin levels of 13 g/dL or greater (>or=130 g/L; 16.7%) and mean monthly rHuEPO dose (54,299 units) were highest. Dialysis Clinic Inc's percentage of such claims (2.0%) and mean monthly dose (38,687 units) were lowest. Dialysis Clinic Inc, Fresenius, and Renal Care Group had the highest percentage of recommended dose adjustments (mean, 70% of units); hospital-based units had the lowest (59%). By adjusted odds ratio, adjustments were 20% more likely for Dialysis Clinic Inc, Fresenius, and Renal Care Group compared with DaVita, National Nephrology Associates, hospital-based units, and independents (17% to 28% less likely). rHuEPO dose reduction practices are dependent on specific dialysis providers and whether units are hospital based or independent.

Excellent performance of one-stage brachial–basilic arteriovenous fistula

According to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) and the European Guidelines, the first and second choice for vascular access for haemodialysis are the radial-cephalic and brachial-cephalic arteriovenous fistula (AVF). Autogenous fistulas have a longer functional lifetime, less thrombotic complications and a lower infection risk compared with prosthetic implants. If it is impossible to create a brachial-cephalic AVF or after failure, either a brachial-basilic (BB) or a prosthetic forearm loop AVF may be considered. To determine the outcome of BB-AVFs, we retrospectively surveyed the results of this type of vascular access. All BB-AVF patient records over a 6 year period were subtracted from an academic hospital registry. Primary failure and primary, assisted primary and secondary patency rates were calculated with the Kaplan-Meier method. Sex, diabetes mellitus (DM), pre-operative duplex diameters, complications and interventions were recorded and correlated with the patency rates. A total of 31 BB-AVFs were created in a one-stage surgical procedure. Of the patients, 36% were male and 19% had DM. Only one patient had a primary failure, leaving 30 (97%) of the BB-AVFs functional for dialysis treatment. Four patients died within 1 year after the operation, one of them from a catheter sepsis. Primary, assisted primary and secondary patency rates after 1 year were, 58, 83 and 90%, respectively. Patient characteristics and pre-operative duplex parameters did not influence patency rates. The BB-AVF is an excellent third choice option for vascular access.

The Dialysis Outcomes and Practice Patterns Study (DOPPS) and the Kidney Disease Outcomes Quality Initiative (K/DOQI): A cooperative initiative to improve outcomes for hemodialysis patients worldwide

The Dialysis Outcomes and Practice Patterns Study (DOPPS) and the Kidney Disease Outcomes Quality Initiative (K/DOQI): A cooperative initiative to improve outcomes for hemodialysis patients worldwide

Transposition of the brachial vein: a new source for autologous arteriovenous fistulas

Increasing the prevalence of arteriovenous fistula over arteriovenous synthetic graft is critical for decreasing the morbidity and costs of dialysis patients. This is highlighted in the guidelines set forth by The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI), which encourage the increased use of autogenous vein in fistula creation. In addition to the basilic and cephalic veins, another source of autogenous vein is the brachial vein, a deep vein of the upper arm. Here we describe 2 patients with absence of adequate superficial veins, in whom a transposed brachial vein was used for the creation of an arteriovenous fistula.

Basilic vein transposition fistula: a good option for maintaining hemodialysis access site options?

Purpose The primary use of autogenous arteriovenous access for chronic hemodialysis is recommended by the National Kidney Foundation–Dialysis Outcomes Quality Initiative practice guidelines. We review the outcomes of basilic vein transposition (BVT) to assess its value as a primary upper arm arteriovenous access option. Methods A retrospective review of 56 patients undergoing BVT was performed. Thirty patients were men; average age was 56 years. Etiology of end-stage renal disease, complications, and time to maturation were tabulated. Primary and secondary patency rates were determined by using life table methods. Multivariate regression analysis was performed to assess risk factors for fistula failure. Results Renal failure was associated with diabetes in 32 (57%) patients, and BVT was the primary access procedure in 22 (39%) patients. Perioperative complications occurred in 5 (9%) patients and included hematoma (n = 3), myocardial infarction (n = 1), and death (n = 1). The average time to maturation was 74 days (range, 12-265 days), and maturation failure occurred in 21 (38%) patients. Logistic regression analysis showed that age older than 60 years was associated with poorer maturation and patency rates. On an intent-to-treat basis, 1-year primary and secondary patencies were 35% and 47%, respectively, but only 18% and 28%, respectively, for age >60 years. Forty-two percent of failed BVT were subsequently replaced with a prosthetic graft by using the same upper arm vessels. Conclusion BVT frequently do not mature in patients older than 60 years, which compromises its utility as a primary access. However, fistulas that mature provide acceptable patency rates, and subsequent conversion to a prosthetic access is frequently possible. Selective use of BVT might improve the utilization of available access sites.

Developing clinical performance measures based on the Dialysis Outcomes Quality Initiative Clinical Practice Guidelines: process, outcomes, and implications1,2

Background:The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines established a widely accepted set of recommendations for high-quality dialysis care. To enhance the End-Stage Renal Disease Core Indicators Project, an ongoing effort to assess and improve dialysis care in the United States, the Centers for Medicare and Medicaid Services (CMS) commissioned a project to develop clinical performance measures (CPMs) based on the NKF-DOQI guidelines. Methods:The CMS contracted with Qualis Health, a private nonprofit organization serving as a Medicare Quality Improvement Organization, to facilitate a 9-month project to develop dialysis CPMs with the participation of a broad range of stakeholders from the renal community. Work groups were established to develop CPMs addressing 4 areas: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access management, and anemia management. The NKF-DOQI guidelines were prioritized based on the strength of the evidence supporting the guidelines, the feasibility of developing performance measures, and the significance of the areas addressed to the quality of care delivered to dialysis patients. Expert panels developed data specifications, sampling approaches, data-collection tools, and analytic strategies. Results:Sixteen CPMs were developed based on 22 of 114 NKF-DOQI guidelines. After establishing reliability through field-testing of data-collection instruments, the CPMs were applied to a sample of 8,838 randomly selected hemodialysis patients and 1,650 randomly selected adult peritoneal dialysis patients in summer 1999. Conclusion:The development of CPMs based on the NKF-DOQI Clinical Practice Guidelines for dialysis care was accomplished in a timely and effective manner by engaging a broad range of stakeholders and technical experts. The CPMs are important tools to assess and improve the quality of dialysis care in the United States. Few comparable efforts exist in other fields of medicine.

United States Renal Data System assessment of the impact of the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines

Since 1989, significant efforts have focused on improving the care of dialysis patients in the United States. Numerous organizations have developed clinical practice guidelines; however, few guidelines have received the broad support given to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI). These guidelines, independently developed from an extensive review of the literature, include sections on dialysis adequacy, anemia treatment, and vascular access. To assess the impact of these guidelines on clinical practice, we evaluated data on hematocrits, recombinant human erythropoietin dosing, hemodialysis adequacy, and simple fistula and dialysis catheter utilization using Medicare dialysis provider claims and Medicare Part B physician services. Hematocrits have increased steadily, with the exception of the period when the Hematocrit Measurement Audit was in effect. After cancellation of the policy, hematocrits increased to the midpoint of the DOQI target range (34.4%). Although the level of dialysis therapy has stabilized, with the average urea reduction rate of 68% to 69.9% in 1997 to 1999 being slightly greater than the DOQI target of 65% or greater, geographic variability is apparent. Simple fistula placement rates increased by 45% during the pre-DOQI and post-DOQI period from 1994 to 1999. The use of temporary catheters decreased, whereas placement of permanent catheters has increased, which may reflect recommended practice guidelines. Although it appears that clinical practice guidelines have improved the clinical care of dialysis patients, considerable regional variations in care across the country should be given significant attention. © 2002 by the National Kidney Foundation, Inc.

Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data: predicting the impact of NKF-DOQI clinical practice guidelines for vascular access.

National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Vascular Access Guidelines 29 (40% of prevalent patients should have a native fistula) and 30 (<10% use of catheters for chronic hemodialysis) are currently based on opinion, rather than published evidence. The impact of these guidelines on reducing vascular access infection rates is unknown and was tested using data from an outpatient prospective cohort analysis. Patients undergoing hemodialysis from January 1998 through December 2000 at six outpatient facilities in Idaho and Oregon were evaluated prospectively for vascular access infections. There were 111,383 dialysis sessions (DSs) with 471 infections identified (4.2 infections/1,000 DSs). The risk for infection relative to arteriovenous (AV) fistulae was highly dependent on type of access used: 2.2 (P = 0.002) for AV grafts, 13.6 (P < 0.0001) for tunneled catheters, and 32.6 (P < 0.0001) for temporary catheters. Based on incidence infection rates, the number of infections predicted to occur with implementation of guidelines 29 and 30 in this population was calculated, and the percentage of reduction in infection was determined. Following either guideline 29 or 30 alone would have predictably prevented 103 or 97 total infections (22% and 21% reduction) and 40 or 51 bloodstream infections (24% and 30% reduction), respectively. Following both guidelines simultaneously would have prevented 151 total infections (32% reduction) and 64 bloodstream infections (38% reduction). These epidemiological data firmly establish that a major risk for vascular access infections is the type of access used (temporary catheters > tunneled catheters > AV grafts > AV fistulae). Furthermore, they strongly support the role of these NKF-DOQI guidelines in preventing infectious complications attributed to vascular access.

Evaluation of DOQI guidelines: early start of dialysis treatment is not associated with better health-related quality of life.

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI) guideline, which is largely opinion based, promotes an earlier initiation of dialysis treatment than usual. Implementation of this guideline would require an expansion of dialysis capacity, leading to a considerable increase in costs. Such an expansion can only be justified by an improvement in patient outcome. We studied the effect of late versus timely initiation of dialysis treatment on the course of health-related quality of life (HRQOL) in new dialysis patients. As part of a large Dutch prospective multicenter study (Netherlands Cooperative Study on the Adequacy of Dialysis-2), we consecutively included all new patients with end-stage renal disease for whom residual renal function could be obtained 0 to 4 weeks before the start of dialysis therapy. HRQOL was assessed by means of the Kidney Disease and Quality of Life Short Form at regular intervals during the first year of chronic dialysis treatment. According to the DOQI guideline, 90 of the 237 included patients (38%) started dialysis treatment too late. All patients showed marked improvement in HRQOL during the first 6 months after the start of dialysis treatment. Compared with patients who started dialysis treatment too late, patients who started in time had significantly higher HRQOL for a number of dimensions immediately after the start of treatment. After 12 months of dialysis treatment, these differences had disappeared. An evidence-based recommendation on an early start of dialysis treatment is still difficult to give. In the short term, an earlier start resulted in better HRQOL. However, within 1 year, this advantage had disappeared. It is unclear whether this short-term benefit outweighs the extra restrictions associated with earlier initiation of dialysis therapy. Consequently, only the patient, in consultation with the nephrologist, is able to weigh both sides.

Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas

Renewed interest in transposed brachiobasilic fistulas has occurred since the release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines because it is an alternative method to achieve an upper arm fistula in patients who cannot achieve a functional brachiocephalic fistula. The objective of this study was to compare outcomes among transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas. A cohort of patients with upper arm accesses was retrospectively identified. Access outcomes were determined from medical records and contact with physicians, dialysis providers, and patients. Primary outcome was thrombosis-free survival. Secondary outcomes were primary failure, time to use, risk of catheter-related bacteremia, need for intervention, incidence of access-related complications, cumulative, and functional patency. Group differences in age, sex, race, diabetes, peripheral vascular disease, and number of previous accesses were adjusted for in the analysis where appropriate. Transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas were compared in 59, 82, and 56 patients, respectively. Compared with transposed brachiobasilic fistulas, upper arm grafts were more likely to thrombose with an adjusted relative risk (RR) of 2.6 (95% CI, 1.3 to 5.3) excluding primary failures and 1.6 (95% CI, 1.0 to 2.7) when accounting for the lower risk of primary failure for grafts. Transposed brachiobasilic fistulas also required less intervention (0.7 vs. 2.4 per access-year, P < 0.01) and were less likely to become infected (0 vs. 13%, P < 0.05) than grafts. Mature brachiocephalic fistulas were less likely to fail (RR 0.3, 95% CI, 0.1 to 1.0) and showed a trend for less thrombosis (RR 0.3, 0.1 to 1.1) than mature brachiobasilic fistulas. There was no significant difference in cumulative patency (failure-free survival) among the three types of access if primary failure was included at the median follow-up of 594 days. Transposed brachiobasilic fistulas provided catheter-free access one month sooner than brachiocephalic fistulas and one month later than upper arm grafts. Transposed brachiobasilic fistulas provide cumulative patency equivalent to upper arm grafts and brachiocephalic fistulas. They are less likely to thrombose and become infected than upper arm grafts. Compared with brachiocephalic fistula, they are more likely to mature but are at increased risk of thrombosis after maturation. Transposed brachiobasilic fistulas should be considered before placing an upper arm graft for patients that cannot achieve a functional brachiocephalic fistula.

What are the clinical correlates of adequate peritoneal dialysis?

The efficacy of peritoneal dialysis in terms of the clearance of small molecules such as urea and creatinine is referred to as "adequacy." Treatment guidelines and adequacy targets have been developed and distributed by the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) in an effort to reduce variations in end-stage renal disease (ESRD) treatment. Much effort has been made to determine the correlation between dialysis dose and various clinical outcome measures (eg, hospitalization, mortality) in adults in an attempt to define the optimal dialysis dose. The delineation of this issue in the pediatric ESRD population is more complex because of the small number of patients and the need to define sensitive outcome measures that are unique to children. The review addresses the possible clinical correlates of dialysis adequacy in children that exist today and the additional data on the topic that needs to be collected in the future.

Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: Our initial experience

Purpose: The National Kidney Foundation–Dialysis Outcomes Quality Initiative guidelines favor autogenous vein for arteriovenous fistulas (AVFs). This report describes our experience constructing AVFs in the lower extremities of selected patients with the superficial femoral vein (SFV). Patients and Methods: This is a retrospective analysis of 25 patients who had AVF construction with SFV from March 1998 to July 2000. In all patients upper extremity access had been exhausted. Eighteen (72%) patients were female, 15 (60%) had diabetes, and 14 (56%) were obese (body mass index > 30 kg/m2). The SFV was freed from the supragenicular popliteal level to the profunda femoris vein and divided distally. Eighteen (72%) patients had SFV transposition and distal superficial femoral artery reimplantation; 10 veins were banded to reduce the incidence of postoperative steal syndrome. In seven patients (28%) a composite loop fistula was constructed with a deeply buried 4- to 7-mm polytetrafluoroethylene (PTFE) graft proximally and with superficially transposed SFV distally. One of these seven patients had a PTFE above-knee femoral-popliteal bypass graft with banding of the vein at its takeoff from the distal PTFE graft. Results: Mean follow-up was 9.1 months. One patient died before the fistula could be used. Seven patients (28%) experienced major wound complications. Mean ankle/brachial index before operation was 1.03, and after operation it was 0.81 (paired difference [n = 16] = –0.26.) Mean ankle circumference before operation was 19.5 cm, and after operation it was 20.7 cm (paired difference [n = 17] = +0.87.) Cumulative primary fistula patency at 6 and 12 months was 78% and 73%, respectively. Cumulative secondary fistula patency at 6 and 12 months was 91% and 86%, respectively. There were no fistula infections. One patient eventually had an above-knee amputation after experiencing an acute compartment syndrome. Eight patients required a second operation to alleviate a symptomatic steal syndrome. Conclusions: The SFV is an excellent conduit for vascular access, whether it is transposed or is part of a composite PTFE-SFV fistula. In this series, fistula infection was nonexistent, thrombosis rates were low, and clinical evidence of venous hypertension was minimal. The major impediment to unrestricted use of SFV in constructing AVFs is a high incidence of clinically significant postoperative ischemia requiring reoperation. (J Vasc Surg 2001;33:968-75.)

Hematocrit levels and associated Medicare expenditures

Clinical studies and the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines suggest that a target hematocrit of 33% to less than 36% is appropriate for patient benefit. Previous studies have shown an association of lower risks for death and hospitalization when hematocrits were 33% to less than 36%. In this study, we assessed the relationship between hematocrit value and associated Medicare expenditures, analyzing incident Medicare hemodialysis patients from January 1, 1991, through June 30, 1995. All patients survived at least 90 days to normalize eligibility and an additional 6-month entry period to assess comorbidity and hematocrit values. All patients were followed up from July 1, 1991, through December 31, 1996. We assessed the association between hematocrit values in the 6-month entry period and the Medicare-allowable Part A and Part B per-member-per-month (PMPM) expenditures in the follow-up period, controlling for other variables, including patient demographic characteristics, comorbid conditions, and severity of disease. We found that hematocrits of 33% to less than 36% and 36% and higher were associated with lower Medicare-allowable payments in the follow-up period. Compared with reference patients with hematocrits of 30% to less than 33%, the Medicare-allowable PMPM expenditures were significantly greater for patients with hematocrits less than 27% and 27% to less than 30% (12.7% and 5.3%, respectively), and the Medicare-allowable PMPMs were significantly less for patients with hematocrits of 33% to less than 36% and 36% and higher (6.0% and 8.2%, respectively). Although these findings suggest that the treatment of anemia may be associated with significant savings in total patient Medicare expenditures, caution should be considered because these findings are associations and should not be deemed as showing causality.

Methods used to evaluate the quality of evidence underlying the National Kidney Foundation-dialysis outcomes quality initiative clinical practice guidelines: Description, findings, and implications

This report describes the approach the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) used to assess the strength of published evidence pertinent to individual NKF-DOQI Clinical Practice Guidelines, as well as the relationship between that approach and methods used by the US Preventive Services Task Force, the Cochrane Collaboration, and the Agency for Health Care Policy and Research to rate the quality and/or strength of evidence. We also present the results of an analysis of the strength of evidence underlying the NKF-DOQI Guidelines showing that one cannot infer the quality of evidence reported in a study (rated either on a 0-to-1 scale or categorically as excellent, very good, good, fair, or poor) simply by knowing the type of study design used (randomized trial, nonrandomized trial, natural experiment, cohort study, cross-sectional study, case-control study, case report). Issues related to assessment of the strength of evidence underlying a practice guideline opposed to that reported in an individual study are highlighted.