Vascular Access Failure Research Articles

Hemodialysis vascular access in the elderly: Promising results from a tertiary center

BackgroundHemodialysis patients, particularly the elderly, present challenges for vascular access (VA) creation due to age-related vascular changes and comorbidities. This study aimed to characterize outcomes related to VA in elderly patients (≥75 years) and compare them with younger patients, focusing on primary failure, maturation failure, and patency rates. MethodsThis retrospective study included patients evaluated in VA consultations between January 2019 and December 2021; patients were evaluated through physical examination and Color Doppler Ultrasound to determine the suitability of vessels for VA construction. Demographic data, proposed and created VA types were assessed. The primary outcomes were the evaluation and comparison of primary failure and maturation failure of VA in the elderly (O) and younger (Y) groups. Secondary outcomes included the assessment of primary patency and primary assisted patency at 6, 12, and 24 months in both groups. ResultsAmong 167 patients, 36 were elderly. There were no significant differences in proposed and created VA types between the Y and O groups and radial-cephalic AVFs were the most commonly constructed VA in both groups.Primary and maturation failure rates were similar (Y group: 17.3% and 5.6%; O group: 9.7% and 10.7%, respectively). Primary patency and primary assisted patency rates did not significantly differ between groups at 6, 12, and 24 months. ConclusionThe impact of age on the feasibility of VA should not be exaggerated. Preoperative assessment and a tailored approach enable successful autologous access creation in elderly patients, resulting in outcomes comparable to those of younger patients.

Association of neutrophil-to-lymphocyte ratio and hemodialysis access failure in patients with end stage renal disease: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to assess the association of neutrophil-to-lymphocyte ratio (NLR) with an elevated risk of vascular access failure in end-stage renal disease (ESRD) patients undergoing hemodialysis. A comprehensive database search of MEDLINE (via PubMed), Scopus, and Cochrane Central was performed. Studies reporting the values of NLR in both functional and non-functional AVF groups in ESRD patients were selected. Quality assessment was performed using the Modified Newcastle-Ottawa scale for observational studies. Meta-analysis was performed using an inverse variance random effects model. Seven observational studies met the inclusion criteria, including 1313 participants with 554 cases and 759 controls. Pooled results showed significantly high NLR levels in patients with non-functional arteriovenous fistula (AVF) compared to functional AVF (SMD = 1.19, 95% CI = 0.74-1.65, p < 0.001). Subgroup analysis confirmed the consistency of the association between NLR and AVF failure across study design (SMD = 1.76, 95% CI = 0.78-2.73, p = 0.0004 in prospective vs SMD = 0.87, 95% CI = 0.42-1.32, p = 0.0001 in retrospective studies), etiology (SMD = 1.63, 95% CI = 0.75-2.52, p = 0.0003 in stenosis or thrombosis; and SMD = 0.80, 95% CI = 0.27-1.34, p = 0.003 in failure to mature of AVF), and NLR measurement timing (SMD = 0.98, 95% CI = 0.42-1.54, p = 0.0006 in preoperative vs SMD = 1.58, 95% CI = 0.47-2.69, p = 0.005 in postoperative NLR). The pooled odds ratio revealed high NLR values as a significant predictor of AVF failure in ESRD patients (OR = 3.91, 95% CI = 1.91-7.98, p = 0.0002). The pooled sensitivity and specificity were 89.72% (95% CI = 77.51%-95.67%) and 72.95% (95% CI = 63.82%-80.47%), respectively. The high NLR is a useful and predictive marker for AVF failure in hemodialysis patients. Future studies should prioritize larger cohort studies to validate and reinforce these observations.

A perspective on integrated dialysis access management: in advance of integrated care plan

(To read the full article, in English or French, click on the pdf logo on the right). We would like to draw attention to the critical issue of dialysis access management and vascular access (VA) options in patients transitioning to chronic renal replacement therapy and from peritoneal dialysis (PD) to hemodialysis (HD). We advocate for the establishment of dedicated consultation services for integrated dialysis access management to optimize patient outcomes. We highlight specific cases where a tailored approach to VA selection is essential, emphasizing the importance of risk stratification and timely access preparation. The preferred use of arteriovenous fistula in HD patients and the challenges surrounding its maturation are discussed. We also explore circumstances necessitating urgent versus planned transitions to HD, incorporating considerations for patient-centered care and education. Sonography’s role in managing PD-related infections and the potential benefits of home HD in the transition process are also examined. We suggest the development of scoring systems to predict patient transitions and emphasize the need for an integrated approach to dialysis access management. Overall, we advocate for proactive measures to prevent vascular access failure and ensure a safe and effective transition process for patients with chronic kidney disease.

Validation of arteriovenous access stage (AVAS) classification: a prospective, international multicentre study.

The arteriovenous access stage (AVAS) classification provides evaluation of upper extremity vessels for vascular access (VA) suitability. It divides patients into classes within three main groups: suitable for native fistula (AVAS1) or prosthetic graft (AVAS2), and patients not suitable for conventional native or prosthetic VA (AVAS3). We validated this system on a prospective dataset. A prospective, international observational study (NCT04796558) involved 11 centres from 8 countries. Patient recruitment was from March 2021 to January 2024. Demographic data, risk factors, vessels parameters, VA types, AVAS class and early VA failure were collected. Percentage agreement was used to assess predictive ability of AVAS (comparison of AVAS and created VA) and consistency of AVAS assessment between evaluators. Pearson's Chi-squared test was used for comparison of early failure rate of conventional (predicted by AVAS) and unconventional (not predicted by AVAS) VA. From 1034 enrolled patients, 935 had arteriovenous fistula or graft, 99 patients did not undergo VA creation due opting for alternative renal replacement therapies, experiencing health complications, death or non-compliance. AVAS1 had 91.2%, AVAS2 7.2% and AVAS3 1.6% of patients. Agreement between evaluators was 89%. The most frequently created VAs were radial-cephalic (46%) and brachial-cephalic (27%) fistulae. The accuracy of AVAS versus created access was 79%. In comparison, VA predicted by clinicians versus created access was 62.1%. Inaccuracy of AVAS prediction was more common with higher AVAS classes, and the most common reason for inaccuracy was creation of distal VA despite less favourable anatomy (17%). Patients with unconventional VA had higher early failure rate than patients with conventional VA (20% vs 9.3%, respectively, P=.002). AVAS is effective in predicting VA creation, but overall accuracy is reduced at higher AVAS classes when the complexity of decision-making increases and proximal vessels require preservation. When AVAS was followed by clinicians, early failure was significantly decreased.

Effects of tanshinone IIA on endothelial cell dysfunction in uremic condition.

An arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis in uremic patients, yet its dysfunction poses a significant clinical challenge. Venous stenosis, primarily caused by venous neointimal hyperplasia, is a key factor in the failure of vascular access. During vascular access dysfunction, endothelial cells (ECs) transform mechanical stimuli into intracellular signals and interact with vascular smooth muscle cells. Tanshinone IIA, an important compound derived from Salvia miltiorrhiza, has been widely used to treat cardiovascular diseases. However, its role in modulating ECs under uremic conditions remains incompletely understood. In this research, ECs were exposed to sodium tanshinone IIA sulfonate (STS) and subjected to shear stress and uremic conditions. The results indicate that STS can reduce the suppressive effects on the expression of NF-κB p65, JNK and Collagen I in uremia-induced ECs. Moreover, the downregulation of NF-κB p65, JNK and Collagen I can be enhanced through the inhibition of ERK1/2 and the upregulation of Caveolin-1. These findings suggest that tanshinone IIA may improve EC function under uremic conditions by targeting the Caveolin-1/ERK1/2 pathway, presenting tanshinone IIA as a potential therapeutic agent against AVF immaturity caused by EC dysfunction.

The Clinical Significance and Application of Heart Rate Variability in Dialysis Patients: A Narrative Review.

Autonomic nervous system (ANS) dysfunction is prevalent in end-stage kidney disease (ESKD) patients, carrying significant risks for morbidity and mortality. Heart rate variability (HRV) is a simple and non-invasive method to evaluate ANS functions and predict prognoses in specific patient populations. Since there is a lack of a clear understanding of the clinical significance of HRV in predicting prognoses in ESKD patients, an updated review on this topic is urgently warranted. The clinical significance of HRV in dialysis patients includes its associations with metabolic syndrome, nutritional status, intradialytic hypotension, vascular access failure, major adverse cardiovascular events, and mortality. These findings underscore the essential role of the autonomic reserve, which might denote the elevation of ANS activity as a response to external stimulus. Patients with a higher level of sympathetic activity at the resting stage, but who are unable to adequately elevate their sympathetic activity under stress might be susceptible to a worse outcome in critical circumstances. Further applications of HRV include HRV biofeedback, risk classification, and real-time HRV monitoring. Overall, HRV is an optimal tool for predicting prognoses in dialysis patients. Further study is encouraged in order to gain a clearer understanding of the clinical significance and application of HRV, and thereby enhance the care of ESKD patients.

Association Between Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score and Arteriovenous Fistula Failure in Patients on Maintenance Hemodialysis.

Arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis in end-stage renal disease (ESRD) patients but has a significant failure rate. Atherosclerotic cardiovascular disease (ASCVD) is a major cause of mortality in ESRD patients. Atherosclerosis of the peripheral vessels may contribute to poor maturation of AVF leading to the exploration of the ASCVD score as a prognostic tool for AVF failure. Thisstudy included 110 hemodialysis patients with AVFsand aimed to examine the association between ASCVD score and AVF failure. Participants were categorized into the presence of vascular access failure (N=12) and absence of vascular access failure (N=98), and demographic and clinical data were collected. Results: The study comprised predominantly male patients (63.6%), with a notable prevalence of hypertension anddiabetes. Twelve patients experienced AVF failure, with pseudoaneurysms and thrombosis being the predominant causes. The ASCVD risk group at intermediate and high stages exhibited a statistically significant risk (relative risk (RR)=1.403; 95% CI, 1.041-1.904) of AVF failure in comparison to the low and borderline ASCVD risk groups.There was no association of age, gender (male and female), body mass index (BMI),serum calcium, serum phosphorus, intact parathyroid hormone (iPTH), and serum albumin with AVF failure. The ASCVD score emerges as a potential prognostic tool to identify dialysis patients at high risk of AVF failure, suggesting avenues for targeted interventions and improved patient care. However, limitations of the ASCVD risk estimator and study limitations, such as small sample size and absence of mortality data, warrant cautious interpretation and necessitate further exploration in larger patient populations.

Risk factors for thrombosis in dialysis patients: A comprehensive systematic review and meta-analysis

AimTo identify the factors associated with thrombosis in dialysis patients. BackgroundThrombosis is a leading cause of vascular access failure in dialysis patients. Numerous risk factors contribute to thrombosis in this population. MethodsA systematic search was conducted across international databases using standardized keywords. The quality of the selected studies was assessed using the STROBE and CONSORT checklists. The findings were summarized in a Garrard table. Meta-analysis was performed using CMA software. The study adhered to the guidelines outlined in the PRISMA statement. ResultsA total of 180 articles were reviewed. The odds ratio for thrombosis in patients with arteriovenous grafts compared to arteriovenous fistulas was 10.93 (95 % CI: 9.35-12.78), demonstrating statistical significance (P = 0.001). Similarly, hemodialysis patients had an odds ratio of thrombosis 3.60 times higher than non-hemodialysis patients (95 % CI: 3.54-4.19), with statistical significance (P = 0.001). Patients undergoing single-stage basilic vein transposition had a 1.89 times higher risk of thrombosis compared to those undergoing two-stage transposition (95 % CI: 1.04-3.46), also demonstrating statistical significance (P = 0.038). ConclusionsThrombosis in patients with end-stage renal disease undergoing dialysis was significantly associated with various factors, including graft access, single-stage basilic vein transposition, and hemodialysis. Additional contributing factors to thrombosis included diabetes, elevated homocysteine levels, female gender, age over 50, access location, and low access blood flow velocity. The analysis revealed a higher incidence of thrombosis in end-stage renal disease patients undergoing hemodialysis compared to those not undergoing dialysis, as well as in patients with arteriovenous grafts compared to those with arteriovenous fistulas. These findings underscore the importance of recognizing and managing these risk factors to prevent thrombotic events and enhance patient care within the dialysis setting.

#2833 Charlson comorbidity index predicts early failure and overall survival of vascular access among diabetic dialysis patients.

Abstract Background and Aims Vascular access (VA) survival is a determinant factor in the morbidity and mortality of haemodialysis patients, directly influencing their quality of life. Some studies have described the influence of diabetes on the reduced survival of arteriovenous fistulas as an independent factor; however, the correlation between other comorbidities in diabetic patients with vascular access survival has been less well documented. Therefore, our aim is to describe the relationship between comorbidities in diabetic haemodialysis patients and arteriovenous fistula (AVF) patency. Method Descriptive, observational and retrospective study in prevalent patients included in a haemodialysis programme by consulting electronic records over a period of 35 months. Demographic variables; related to vascular access and primary and secondary patency of all accesses were included. The Charlson Comorbidity Index was used to categorise diabetic patients according to comorbidities. Kaplan Meyer survival curves were used to contrast the impact of comorbidities on the different patency. Results 22 patients, mean age 68.36 ± 10.9 years, 68.18% male, 31.82% female, Charlson index with a median of 6.5 (5 - 8), 95.45% had a native fistula, with humero-cephalic location being more frequent (72.72%) and predominance of the left upper arm (68.18%). The time required to reach an event in both primary patency and secondary patency in diabetic patients was longer in patients with a Charlson index less than or equal to 7, this being statistically significant (Log Rank Test (Mantel-Cox): primary patency p=0.022 and secondary patency p=0.032). Conclusion The Charlson Comorbidity Index in our population is a significant factor in arteriovenous fistula survival.

#336 Early detection of vascular access complication in pediatric CKD hemodialysis patients

Abstract Background and Aims Vascular access (VA) dysfunction is a major clinical complication in the hemodialysis (HD) population and has a direct effect on dialysis outcome. Where in patients undergoing HD, neointimal hyperplasia results in vascular stenosis and subsequent thrombosis, which lead to vascular access failure. Interleukin-10 (IL-10), hs CRP, and tumor necrosis factor- (TNF–α) are inflammatory markers which are proved to be involved in the process neointimal hyperplasia &amp; subsequent complications. We aimed to evaluate the value of these inflammatory markers in early detection of arterio-venous fistula (AVF) failure, in pediatric patients on regular HD, together with the clinical &amp; radiological diagnoses, for proper intervention for correcting AVF failure according to guidelines. Method It was an prospective cohort study, where we included 59 pediatric chronic kidney disease patients’ stage 5, on regular HD (CKD5d), who were following up regularly with us for 1 year. Patients with nonfunctioning AVFs due to complications as thrombus occluding fistula, infections, or large aneurysm, were excluded from the beginning of the study. Monitoring of VA by pre-cannulation physical examination was performed to detect the physical signs of dysfunction, at least once per month according to KDOQI guidelines. Venous pressure (VP) and trans-membrane pressure (TMP) were recorded at each HD session, to detect any abnormalities and to record the pressure changes with the appearance of any AVF complications. Doppler ultrasound (DUS) was performed routinely every 3 months for all HD patients, &amp; at the time of development AVF complications. Blood samples for measuring IL10, TNF, hs CRP were collected from the patients every 2 weeks for 12 months, prior to HD sessions, where we included the most recent samples prior to, and at the time of development complications, which were clinically and radiologically confirmed. Results The mean (±SD) age of our patients was 13.97 (±2.65) years, where we had 39 (56.5%) males, and 30 (43.5%) females, with a median (IQR) HD duration of 4.0 (5.0) years. On assessing the AVF complications, 33 patients (55.9%) had experienced complications, where thrombosis was the most common reported one (17 patients, 28.8%), followed by aneurysm formation in 14 patients (23.7%), while 6 patients (10%) had stenosed AVF, early VA failure in 2 patients (3.4%),1 patient (1.7%) had pseudoaneurysm, and another patient (1.7%) had perivascular hematoma. Mean serum levels of Hs-CRP, TNF-α, IL-10 were elevated at timing of early development of complication, in comparison to their baseline levels, meanwhile serum IL10, and TNF alpha were significantly higher among patients who developed AVF stenosis. The baseline hs-CRP had related positively with AVF diameter at the time of the development of the complications. Conclusion The inflammatory markers have no clinically applied role in early detection of AVF abnormalities, therefore, physical examination and DUS are deemed sufficient.

The predictive value of systemic immune-inflammation index for vascular access survival in chronic hemodialysis patients.

To examine the prognostic values of systemic immune-inflammation indices of hemodialysis (HD) vascular access failure and develop a prediction model for vascular access failure based on the most pertinent systemic immune-inflammation index. A prospective cohort study. Patients undergoing autogenous HD vascular access surgeries or arteriovenous graft as a permanent hemodialysis access in a tertiary center in southwest China from January 2020 to June 2022. Systemic immune-inflammation indices, including NLR, dNLR, AAPR, SIRI, SII, PNI, PLR, and LIPI, and clinical variables. The outcome was defined as survival of the hemodialysis access, with both occluded and stenotic access being considered as instances of access failure. Cox proportional hazard regression model. 2690 patients were included in the study population, of whom 658 experienced access failure during the follow-up period. The median duration of survival for HD vascular access was 18 months. The increased systemic immune-inflammation indices, including dNLR, NLR, SII, PNI, SIRI, PLR, and LIPI, are predictive of HD access failure, with SII demonstrating the strongest prognostic value. A simple SII-based prediction model for HD access failure was developed, achieving C-indexes of 0.6314 (95% CI: 0.6249 - 0.6589) and 0.6441 (95% CI: 0.6212 - 0.6670) for predicting 6- and 12-month access survival, respectively. Systemic immune-inflammation indices are significantly and negatively associated with HD vascular access survival. A simple SII-based prediction model was developed and anticipates further improvement through larger study cohort and validation from diverse centers.

Rate and reasons for peritoneal dialysis dropout following haemodialysis to peritoneal dialysis switch: a systematic review and meta-analysis

BackgroundPatient experiences and survival outcomes can be influenced by the circumstances related to dialysis initiation and subsequent modality choices. This systematic review and meta-analysis aimed to explore the rate and reasons for peritoneal dialysis (PD) dropout following haemodialysis (HD) to PD switch.MethodThis systematic review conducted searches in four databases, including Medline, PubMed, Embase, and Cochrane. The protocol was registered on PROSPERO (study ID: CRD42023405718). Outcomes included factors leading to the switch from HD to PD, the rate and reasons for PD dropout and mortality difference in two groups (PD first group versus HD to PD group). The Critical Appraisal Skills Programme (CASP) checklist and the GRADE tool were used to assess quality.Results4971 papers were detected, and 13 studies were included. On meta-analysis, there was no statistically significant difference in PD dropout in the PD first group (OR: 0.81; 95%CI: 0.61, 1.09; I2 = 83%; P = 0.16), however, there was a statistically significant reduction in the rate of mortality (OR: 0.48; 95%CI: 0.25, 0.92; I2 = 73%; P = 0.03) compared to the HD to PD group. The primary reasons for HD to PD switch, included vascular access failure, patient preference, social issues, and cardiovascular disease. Causes for PD dropout differed between the two groups, but inadequate dialysis and peritonitis were the main reasons for PD dropout in both groups.ConclusionCompared to the PD first group, a previous HD history may not impact PD dropout rates for patients, but it could impact mortality in the HD to PD group. The reasons for PD dropout differed between the two groups, with no statistical differences. Psychosocial reasons for PD dropout are valuable to further research. Additionally, establishing a consensus on the definition of PD dropout is crucial for future studies.

Differential expression of serum TM, PAF, and CD62P in patients with autologous arteriovenous fistula and the correlation with vascular access function.

End-stage renal disease (ESRD) is the final stage of chronic kidney disease (CKD). We aimed to analyze the expression differences of serum thrombomodulin (TM), platelet-activating factor (PAF), and P-selectin (CD62P) in patients with autologous arteriovenous fistula (AVF) and the correlation with vascular access function. The case data were retrospectively analyzed. Moreover, 160 patients with AVF maintenance hemodialysis were selected as the AVF group, and 150 healthy participants were selected as the healthy control group. According to the function of vascular access, patients in the AVF group were divided into Group A (n = 50, after the first establishment of AVF), Group B (n = 64, normal vascular access function after hemodialysis treatment), and Group C (n = 46, vascular access failure). Pearson analysis was conducted to explore the correlation between serum TM, PAF, CD62P content, and vascular pathological examination indicators, to evaluate the value of TM, PAF, and CD62P levels in predicting vascular access failure in patients with AVF. The serum levels of TM, PAF, and CD62P were positively correlated with the expressions of CD68 and MCP-1, respectively (p < .001). Serum TM was positively correlated with the levels of PAF and CD62P (p < .001), and PAF was positively correlated with the levels of CD62P (p < .001), respectively. Serum levels of TM, PAF and CD62P were risk factors for vascular access failure in AVF patients (p < .05). The area under the curve of serum TM, PAF and CD62P levels in predicting vascular access failure in AVF patients was 0.879. The serum levels of TM, PAF, and CD62P in AVF patients were correlated with the vascular access function of AVF patients, which was very important for maintaining the stability of vascular access function, and had certain value in predicting vascular access failure/disorder in AVF patients, and could be popularized and applied.

ANTIPLATELET MEDICATIONS IN HEMODIALYSIS: A SYSTEMATIC REVIEW

Background: Vascular access failure is a common complication seen among hemodialysis (HD) patients. Antiplatelet (AP) medications are often prescribed to help reduce thrombosis and increase vascular access patency. Studies on AP agents evaluating the bleeding risk for HD patients have produced inconsistent results. We aimed to investigate the utilization of AP medications among patients who undergo hemodialysis (HD). We performed a systematic review and meta-analysis of observational studies on AP medicaations used in HD therapy. Methods: This systematic review used Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 as standards. Inclusion criteria for literature eligibility are full-text literature, written in english, and published between 2014 and 2024. Exclusion criteria used for this study were editorials, review articles and identical journal that has been published, and submissions without DOI. Literatures were collected from online reference sources like Pubmed and SagePub. Result: In the PubMed database, the results of our search brought up 23 articles, whereas the results of our search on SagePub brought up 19 articles. The results of the search conducted for the last year of 2014 yielded a total 9 articles for PubMed and 5 articles for SagePub. In the end, we compiled a total of 5 papers, 4 of which came from PubMed and 1 of which came from SagePub. We included five research that met the criteria. Conclusion: AP medications are given in HD patients with high cardiovascular commorbidities to increase vascular patency and prevent thrombosis. Aspirin and P2Y12 inhibitors (PI) such as clopidogrel are commonly used. AP medications might cause shortened longevity of AV access for HD patients. The benefits of AP therapy for cardiovascular protection needs to be evaluated along with its possible effect on AVG outcomes.

Predicting factors for early failure of vascular access in hemodialysis patients.

This study aimed to investigate the incidence of early failure of vascular access for hemodialysis, and determine which factors measured in duplex ultrasound study could predict early failure. We performed a retrospective review of patients who underwent arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation for hemodialysis between September 2019 and January 2023. Early failure was defined as any event that required surgical or endovascular intervention within 6 months following AVF or AVG creation. A total of 189 patients were included. Early failure occurred in 36 patients (19.0%), which included 22 AVFs and 14 AVGs. In the patients who underwent AVF, the preoperative venous diameter, postoperative venous and arterial diameters, and flow volume of AVF all were significantly smaller in the early failure group compared to the patent group. In AVG, the preoperative venous diameter was the only parameter that differed between the 2 groups. A sonographic score was defined based on these factors. In a multivariable analysis, male sex, a previous history of AVF or AVG creation, and sonographic score were found to be significantly associated with early failure. The postoperative venous diameter in AVF and the preoperative venous diameter in AVG were highly predictive of early failure (areas under the curves 0.92 and 0.82, respectively). Venous diameter measured 6 weeks following AVF operation and preoperative venous diameter in AVG were highly predictive of early failure among the duplex ultrasound parameters. Surveillance strategies in the early phase following vascular access creation can be based on these factors.

Evaluation of risk factors affecting the lifespan and efficiency of dialysis accesses installed in dialysis patients referees to Ahvaz therapeutic centers in a two-year cohort study

Introduction: It is crucial in order to provide optimal hemodialysis to patients with end-stage renal disease (ESRD) to establish venous access with the least amount of complications. Objectives: In this study, we examined the risk factors that affect the efficiency and longevity of dialysis access for patients receiving dialysis in Ahvaz medical centers. Patients and Methods: In our retrospective study, 180 hemodialysis patients were referred to the Golestan educational and medical center in Ahvaz, Iran. An arteriovenous fistula (AVF) or catheter was conducted to provide them with vascular access. Detailed demographic information about the patient was collected, including age, gender, height, weight, body mass index (BMI), cause of ESRD, duration of renal failure, duration of dialysis, and comorbidities. There were instances of access inefficiency as a result of infection, stenosis, closure, thrombosis, bleeding, and pseudoaneurysms. The data was analyzed using Mann-Whitney U, t test, and chi-square tests with SPSS version 22. Statistics were considered significant at a P value of 0.05. Results: The mean age of the patients was 50.08 ± 12.213 years, and the mean BMI was 27.90 ± 9.112 kg/m2 . Among dialysis patients, there was a significant relationship between male gender, clopidogrel administration, diabetes history, hypertension and access failure. It is estimated that 36.7% of vascular access failures are caused by thrombosis, while 32.8% are due to access stenosis or closure. Conclusion: Our study showed that male gender, clopidogrel administration, and a history of diabetes and hypertension were risk factors affecting dialysis access quality and efficiency. According to our study, it may be possible to develop a more appropriate approach for determining the type and location of dialysis access.

Comparative Study between Incremental Hemodialysis and Conventional Thrice Weekly Hemodialysis in Prevalent Hemodialysis Patients

Abstract Background The concept of incremental dialysis is inherent to the increasingly accepted idea of a new patient-centered prescription of dialysis. Objective To compare the intervention arm (incremental HD) with the control arm (standard3 HD/week).Incident patients will be randomized to one of the two treatment groups in equal proportion. Primary outcome is the preservation of RKF assessed as time to anuria (UO &amp;lt; 100 mL/day). Secondary outcomes are all-cause mortality and significant events, including vascular access failure and associated interventions, cardiovascular events and hospital admissions. Patients and Methods Type of Study: Prospective cohort study. Study Setting: Multi centric patients selectionfrom hemodialysis units. Study period: 6 months. Results These findings support the assumption in hand, that a twice weekly regimen is in fact adequate for preserving the RKF. As regarding the occurrence of cerebrovascular events, chest pain, there were no statistically significant differences between the two groups. Arrhythmia was not recorded in the incremental group, while in the conventional group it was recorded in 2 patients with a percentage of 8.0%, and there was no statistically significant difference between the two groups; P-value was 0.490. As regarding the need for hospital admission, there was no significant difference between both groups. As regarding the occurrence of vascular access failure, it was recorded in 2 patients in the incremental group with a percentage of 8.0%, compared to 4 patients in the conventional group with a percentage of 16.0%. There was no significant difference between the two groups; P-value was 0.667. Conclusion HD, RCTs are lacking and are urgently needed. If the potential benefits of incremental HD will be confirmed by RCTs, then starting dialysis at a full dose will be subjecting patients to unnecessarily long or more frequent treatments for an unnecessarily long time, and at higher cost.

Rethinking an effective AV fistula-graft screening program. An "A B C".

The goal of a vascular access screening program is to detect and preemptively correct hemodynamically significant stenosis, however, a practice pattern allowing toimplementsuch a program still remains to be defined. Achieving balance between the increase in access-related procedures by adopting an aggressive screening program, and the risks associated with the absence of any screening program, i.e., failure or abandonment of the arterio-venousaccess with needforcentral venous catheter placement, can be extremely challenging. All major guidelines agree about the role of arterio-venous access monitoring, but the waysurveillance should be managedis still a controversial issue. Preserving long-term vascular access functionshould be a goal for all hemodialysis teams, yet it ideally requires a multidisciplinary effort with a monitoring program, calling fora great deal of involvement by hemodialysis health professionals. In this context, the engagement of skilled nurses and the role of patient empowerment with collaborative decision-making may be the key to a successfulvascular access screening program. Screening programs should be personalized, shared with thepatients, and tailored according to vascular access type and site. In the near future, new devices and the use of artificial intelligence mayallow to support interpretation of complex data and lead to the development of prediction modelsfor vascular access failure.

#5657 FRAILTY AND VASCULAR ACCESS IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Frailty is a geriatric syndrome characterized by increased vulnerability to stressors. The elderly become vulnerable and susceptible to adverse outcomes for their health and to functional restrictions. Previous guidelines suggested fistula creation as first choice for vascular access. Current guidelines suggest a more tailored approach to the patient's needs. Despite the high prevalence of frailty in hemodialysis patients, there is paucity of work investigating the relationship between frailty and vascular access failure. The aim of the study was the estimation of frailty with different scores and relationship with the choice of first vascular access, the current vascular access and vascular failures. Method 67 patients in hemodialysis participated to the study (observational cross-sectional study). Frailty was assessed with 6 different scores,Clinical Frailty Scale (CFS), Frailty Phenotype (FP), Edmonton Frailty Scale (EFS), Groningen Frailty Index GFI), Short Physical Performance Battery (SPPB), Prisma-7 and ankle-brachial index (ABI) and hand grip were also estimated. The current vascular access, the first vascular access, the vascular access failures and the mean duration of the vascular accesses were also recorded. Finally, the levels of the hemoglobin, serum albumin, C reactive protein, cholesterol were measured for all patients and the hemodialysis adequacy (URR, sp Kt/V) was calculated from the levels of urea before and after the hemodialysis session. Finally, the levels of the hemoglobin, albumin, C reactive protein, cholesterol were measured for all patients and the hemodialysis adequacy was calculated from the levels of urea before and after the hemodialysis session. Results The first vascular access of hemodialysis presents statistically significant relation between frail and robust patients that start hemodialysis with central venus catheter and AVF-AVG respectively. (SPPB- tunneled CVC 85, 7%, non tunneled CVC 46,2% ρ=0,032, Prisma-7- frail tunneled CVC 100%, non tunneled CVC 76,9% ρ=0,018, Groningen FI -frail tunneled CVC 100%, non tunneled CVC 65,7% ρ=0,011, Εdmonton FS -AVF-AVG not frail 64,7%, vulnerable 20,6% ρ=0,042) (Table 1-4). ABI presented a statistically significant relationship with the current vascular access. 68,18% of the patients with normal ABI have AVF-AVG and 60,87% of patients with abnormal ABI have tunneled CVC (p=0,022). In addition, the number of vascular accesses per patient, the mean duration of the accesses and the premature failures (3 months after creation) don't present statistically significant relation with frailty. Conclusion The frailty score could be used as a tool for the choice of vascular access in hemodialysis patients. Further studies, in a larger number of patients, are required to define a reliable and easy to use frailty tool, which is best suited to dialysis access selection.

#6848 DIABETES AND HEMODIALYSIS ARTERIOVENOUS ACCESS CONSTRUCTION – A RETROSPECTIVE STUDY IN A SINGLE CENTER

Abstract Background and Aims The preferred vascular access for patients with end-stage renal disease is native arteriovenous fistula (AVF). However, in some patients, given their co-morbidities, vascular access (VA) construction is not feasible. Diabetes Mellitus (DM) is described as one of the main factors associated with vascular access failure. The aim of this study is to characterize in a non-diabetic versus diabetic population the pre-surgical vascular mapping by doppler ultrasound (DUS), as well as analyze which VA could theoretically be constructed, what VA was effectively were constructed and its patency between the two groups. Method We present a retrospective study of a cohort of patients that were evaluated by DUS for pre-surgical planning and VA construction from 2018 to 2021. We collected demographic, clinical and DUS parameters. The feasibility for VA construction was classified in pre-surgical evaluation as possible, non-advisable or as borderline. The patency after surgery was observed until day 45. Results We analyzed a total of 355 patients. Almost half of the population had diabetes (n = 161, 45.4%). The demographics and clinical parameters are summarized in Table 1. Concerning pre-surgical vascular mapping, we observed that patients with diabetes had more severe calcifications than the non-diabetic group. Table 2 summarizes the doppler characteristics of right and left radial and brachial arteries in both groups. Regarding the feasibility of VA construction, the non-diabetic group was more likely to receive a radiocephalic fistula than the diabetic group (33% vs 23.6%, pvalue 0.12). Surprisingly, in our study the non-diabetic group had also more patients that could only sustain a prosthetic fistulas (15.5% vs 12.4%, pvalue 0.41). Diabetic patients showed more likelihood to construct proximal fistulaes (67.4% vs 56.8%, p = 0.06). In terms of what type of VA was effectively created, more radiocephalic fistulas were performed in the non-diabetic group (13.95% vs 7.5%, pvalue 0.17). In the diabetic group more brachiocephalic fistulas (65.6% vs 62.4%, pvalue 0.17) and more prosthestic fistulaes (19.4% vs 14.4%, pvalue 0.17) were constructed. Concerning VA patency at 45 days the diabetic group demonstrated higher rates but with no statistical significance (88.4% vs 83.2%, pvalue &amp;lt; 0.18). Only arterial hypertension, showed to be predictive for VA patency, in the univariate and multivariate analysis that included age, sex, diabetes and ethnicity (OR 0.3, pvalue &amp;lt;0.09 and OR 0.32, pvalue &amp;lt;0.019 respectively). Conclusion We found that diabetic patients had significantly more comorbidities (older age, obesity and peripheral artery disease). Regarding the construction of a VA, in diabetic patients there was a lower probability of creating a radiocephalic fistula but a similar possibility of constructing a proximal fistula. Besides that, after VA construction, no differences were found between the two groups in terms of vascular patency. Although diabetes status reduced the probability for radiocephalic fistulas, once VA construction was successful no differences in VA survival at 45 days was verified.