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      Predialysis vascular access creation: To whom and when

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          Abstract

          Aims: The optimal timing of predialysis vascular access surgery remains uncertain. This study goal was to evaluate the influence of kidney function and clinical characteristics at predialysis vascular access surgery on the likelihood of initiating hemodialysis during follow-up. Methods: Our study retrospectively identified all patients undergoing predialysis arteriovenous fistula creation between 2012-2015. We assessed 3 outcomes: frequency of hemodialysis initiation, death before hemodialysis initiation, and dialysis-free survival after vascular access creation. Multiple variable logistic regression analyzed which factors predicted initiation of dialysis. Results: The study involved 202 patients. Using multiple variable logistic regression, 5 factors were associated with hemodialysis initiation: estimated glomerular filtration rate <10 mL/min/1,73m2 at vascular access placement [OR 4.7, CI: 1.98-8,60, p=0.005], diabetes [OR 2.14, CI: 1.07-4,30, p=0.033], proteinuria>1gr/24 hours [OR 1.88, CI: 0.95-3.71, p=0.049], higher phosphorus levels [OR 6.25, CI: 1.39-13.05, p=0.017] and glomerular filtration rate drop ³3mL/min/1.73m2 in the year preceding vascular surgery [OR 1.67, CI: 0.81-3.45, p=0.016]. Cancer and congestive heart failure were associated with dead before starting dialysis [OR 5.9, CI: 1.15-9.78, p=0.038 and OR 2.4, CI: 1.3-3.9, p=0.021, respectively] and higher hemoglobin (>10g/dL) without erythropoietin stimulating agent levels with survival without needing dialysis [OR 2.34, CI: 1.09-4,58, p=0.028]. Conclusions: Optimizing the timing of vascular access creation in predialysis patients requires consideration not only of the kidney function but also comorbidities such as diabetes, estimated glomerular filtration rate decline in the preceding year and degree of proteinuria

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          Most cited references 15

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          Renal function, neurohormonal activation, and survival in patients with chronic heart failure.

          Because renal function is affected by chronic heart failure (CHF) and it relates to both cardiovascular and hemodynamic properties, it should have additional prognostic value. We studied whether renal function is a predictor for mortality in advanced CHF, and we assessed its relative contribution compared with other established risk factors. In addition, we studied the relation between renal function and neurohormonal activation. The study population consisted of 1906 patients with CHF who were enrolled in a recent survival trial (Second Prospective Randomized study of Ibopamine on Mortality and Efficacy). In a subgroup of 372 patients, plasma neurohormones were determined. The baseline glomerular filtration rate (GFR(c)) was calculated using the Cockroft Gault equation. GFR(c) was the most powerful predictor of mortality; it was followed by New York Heart Association functional class and the use of angiotensin-converting enzyme inhibitors. Patients in the lowest quartile of GFR(c) values ( 76 mL/min). Impaired left ventricular ejection fraction (LVEF) was only modestly predictive (P=0.053). GFR(c) was inversely related with N-terminal atrial natriuretic peptide (ANP; r=-0.53) and, to a lesser extent, with ANP itself (r=-0.35; both P<0.001). Impaired renal function (GFR(c)) is a stronger predictor of mortality than impaired cardiac function (LVEF and New York Heart Association class) in advanced CHF, and it is associated with increased levels of N-terminal ANP. Moreover, impaired renal function was not related to LVEF, which suggests that factors other than reduced cardiac output are causally involved.
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            EBPG on Vascular Access.

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              Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review.

              As late provision of specialist care, before starting dialysis therapy, is believed to be associated with increased morbidity and mortality, a systematic review was undertaken to evaluate clinical outcomes relating to early versus late referral of patients to nephrology services. Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up until September 2008 for studies of early versus late nephrology referral in adult (>18 years) patients with chronic kidney disease. Early referral was defined by the time period at which patients were referred to a nephrologist. No randomized controlled trials were found. Twenty-seven longitudinal cohort studies were included in the final review, providing data on 17,646 participants; 11,734 were referred early and 5912 (33%) referred late. Comparative mortality was higher in patients referred to a specialist late versus those referred early. Odds ratios (OR) for mortality reductions in patients referred early were evident at 3 months (OR 0.51; 95% confidence interval [CI], 0.44-0.59) and remained at 5 years (OR 0.45; 95% CI, 0.38-0.53), both P <.00001. Initial hospitalization was 8.8 days shorter with early referral (95% CI, -10.7 to -7.0 days; P <.00001). Differences in mortality and hospitalization data between the 2 groups were not explained by differences in prevalence of diabetes mellitus, previous coronary artery disease, blood pressure control, serum phosphate, and serum albumin. However, early referral was associated with better preparation and placement of dialysis access. Our analyses show reduced mortality and hospitalization, better uptake of peritoneal dialysis, and earlier placement of arteriovenous fistula for hemodialysis with early nephrology referral. Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                nep
                Portuguese Journal of Nephrology & Hypertension
                Port J Nephrol Hypert
                Sociedade Portuguesa de Nefrologia (Lisboa, , Portugal )
                0872-0169
                September 2017
                : 31
                : 3
                : 162-166
                Affiliations
                Torres Novas orgnameCentro Hospitalar do Médio Tejo orgdiv1Nephrology Department Portugal
                Article
                S0872-01692017000300001

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 19, Pages: 5
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