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      Access Monitoring Methods

      Blood Purification

      S. Karger AG

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          Most cited references 3

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          Change in access blood flow over time predicts vascular access thrombosis.

          Vascular access thrombosis accounts for at least $1 billion dollars in annual expenses and 25% of hospitalizations for chronic hemodialysis patients. Low vascular access blood flow (less than 800 ml/min) has been shown to modestly increase the relative risk for thrombosis in the subsequent three months. In this study, it is hypothesized that a time-dependent decrease in vascular access blood flow may be more predictive of subsequent thrombosis especially in vascular accesses with flows more than 800 ml/min, since it would indicate the development of a critical outlet stenosis in the graft. Ninety-five accesses in 91 CHD patients were prospectively followed over 18 months. Vascular access blood flow was measured every six months by the ultrasound dilution technique. Thrombotic events were recorded during the three study periods. A total of 34 thrombotic events in 95 accesses were documented through the total study duration. Accesses that thrombosed had a 22% decrease in vascular access blood flow during the first observation period and a further 41% decrease during the second observation period as compared to 4% drop and 15% increase during the first and second observation periods, respectively, for accesses that did not thrombose. There was an estimated 13.6-fold (95%, confidence interval 2.68 to 69.16) increase in the relative risk of thrombosis for accesses with more than 35% decrease in vascular access blood flow compared to those accesses with no change in blood flow. There was no statistical difference in the average vascular access blood flow of all patients over the study period. Accesses that show a large (>15%) decrement in vascular access blood flow are associated with a high risk of thrombosis. Serial measurements of vascular access blood flow predict access thrombosis.
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            Graft flow as a predictor of thrombosis in hemodialysis grafts.

            The effort to reduce the incidence of graft thrombosis is mainly based on predicting venous stenosis by measuring venous drip chamber pressures. In this study we evaluated whether graft flow measurements, using an ultrasound dilution technique, would be of additional value to identify patients at risk for thrombosis. In fifty consecutive patients with a bridge graft we measured graft flow and venous drip chamber pressure at a dialyzer blood flow of 200 ml/min. The results of these flow measurements were not used for selection of patients, nor for a diagnostic or therapeutic procedure. All thrombotic events and (radiological or surgical) interventions were registered. A total of 17 patient-years were analyzed. In 17 patients an intervention was done, and in 18 patients thrombosis occurred. The incidence rate of thrombosis was higher in patients with a flow 600 ml/min (N = 37; rate ratio 7. 2; 95% CI, range 2.84 to 18.24, P 600 ml/min. In the remaining 32 patients only two developed spontaneous thrombosis. Remarkably, venous drip chamber pressure measurements did not discriminate between patients with graft flow > or < 600 ml/min, and showed a wide range in patients who developed spontaneous thrombosis within two months. We suggest that graft flow measurements are helpful in selecting patients at risk for graft thrombosis.
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              Predicting Hemodialysis Access Failure with Color Flow Doppler Ultrasound

              Color flow doppler ultrasound examination of the hemodialysis access was conducted in 2,792 hemodialysis patients to evaluate its value in predicting hemodialysis access failure. After baseline assessment of vascular access function with clinical and laboratory tests including color flow doppler evaluation these patients were followed for a minimal of 6 months or until graft failure occurred (defined as surgery or angioplasty intervention, or graft loss). The patient demographics and vascular accesses were typical of a standard hemodialysis patient population. On the day of the color flow doppler examination systolic and diastolic blood pressure, hematocrit, urea reduction ratio, dialysis blood flow, venous line pressure at a dialysis blood flow of 250 ml/min, and access recirculation rate were measured. At the conclusion of the study 23.5% of the patients had access failure. Case mix predictors for access failure were determined using the Cox Model. Case mix predictors of access failure were race, non-white was higher than white (p < 0.005), younger accesses had a higher risk than older accesses (p < 0.025), accesses with prior thrombosis had a higher risk of failure (p = 0.042), polytetrafluoroethylene (PTFE) grafts had a higher risk than native vein fistulae (p < 0.05), loop PTFE grafts had a higher risk than straight PTFE grafts (p < 0.025), and upper arm accesses had a higher risk than forearm accesses (p = 0.033). Most significant, however, was decreased access blood flow as measured by color flow doppler (p < 0.0001). The relative risk of graft failure increased 40% when the blood flow in the graft decreased to less than 500 ml/min and the relative risk doubled when the blood flow was less than 300 ml/min. This study has shown that color flow doppler evaluation, quantifying blood flow in a prosthetic graft, can identify those grafts at risk for failure. In contrast, color doppler volume flow in native AV fistulae could not predict fistula survival. This technique is noninvasive, painless, portable, and reproducible. We believe that preemptory repair of an anatomical abnormality in vascular access grafts with decreased blood flow may decrease patient inconvenience, associated morbidity, and associated costs.
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                Author and article information

                Journal
                BPU
                Blood Purif
                10.1159/issn.0253-5068
                Blood Purification
                S. Karger AG
                978-3-8055-7080-0
                978-3-318-00581-3
                0253-5068
                1421-9735
                2000
                2000
                18 August 2000
                : 18
                : 4
                : 255-259
                Affiliations
                Division of Nephrology, Department of Medicine, University of West Virginia School of Medicine, Morgantown, W. Va., USA
                Article
                14445 Blood Purif 2000;18:255–259
                10.1159/000014445
                10965064
                © 2000 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                References: 35, Pages: 5
                Product
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/14445
                Categories
                Paper

                Cardiovascular Medicine, Nephrology

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