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      Primary Failure of Arteriovenous Fistulae in Auto-Immune Disease

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          Background/Aim: Chronic haemodialysis depends on an arteriovenous fistula. Primary failure of vascular access is a common problem which is mainly related to thrombosis. As ambulatory surgery is common, it is mandatory to identify patients with a high thrombophilic risk to allow better prevention (anticoagulation) and direct re-intervention after thrombosis. The purpose of this study was to determine thrombophilic risk factors for primary access failure in order to identify patients at risk before the operation. Methods: We performed a retrospective study on 62 chronic haemodialysis patients who received permanent vascular access. We evaluated established risk factors for chronic access failure as well as the number of earlier shunt operations in these patients. Results: The patients predominantly suffered from auto-immune diseases. The frequency of a successful first vascular access was above average (92.5%). We identified four major risk factors for primary access failure: number of previous vascular access thromboses (p < 0.01; R = 0.96), pre-existing thrombophilic risk factors (p < 0.01), pre-operative fibrinogen (p < 0.02), and vasculitis (p < 0.01). Conclusions: We identified four risk factors which allowed an individual risk evaluation. Among the factors investigated, the activity of the auto-immune disease was the most striking. Our data suggest not to perform a vascular access during an active period of vasculitis.

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          Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access.

          Care of patients with end-stage renal disease (ESRD) is important and resource intense. To enable ESRD programs to develop strategies for more cost-efficient care, an accurate estimate of the cost of caring for patients with ESRD is needed. The objective of our study is to develop an updated and accurate itemized description of costs and resources required to treat patients with ESRD on dialysis therapy and contrast differences in resources required for various dialysis modalities. One hundred sixty-six patients who had been on dialysis therapy for longer than 6 months and agreed to enrollment were followed up prospectively for 1 year. Detailed information on baseline patient characteristics, including comorbidity, was collected. Costs considered included those related to outpatient dialysis care, inpatient care, outpatient nondialysis care, and physician claims. We also estimated separately the cost of maintaining the dialysis access. Overall annual cost of care for in-center, satellite, and home/self-care hemodialysis and peritoneal dialysis were US $51,252 (95% confidence interval [CI], 47,680 to 54,824), $42,057 (95% CI, 39,523 to 44,592), $29,961 (95% CI, 21,252 to 38,670), and $26,959 (95% CI, 23,500 to 30,416), respectively (P < 0.001). After adjustment for the effect of other important predictors of cost, such as comorbidity, these differences persisted. Among patients treated with hemodialysis, the cost of vascular access-related care was lower by more than fivefold for patients who began the study period with a functioning native arteriovenous fistula compared with those treated with a permanent catheter or synthetic graft (P < 0.001). To maximize the efficiency with which care is provided to patients with ESRD, dialysis programs should encourage the use of home/self-care hemodialysis and peritoneal dialysis. Copyright 2002 by the National Kidney Foundation, Inc.
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            Prevalence and risk factors of carotid plaque in women with systemic lupus erythematosus.

            To determine the prevalence of carotid atherosclerosis and associated risk factors in women with systemic lupus erythematosus (SLE). Carotid plaque and intima-media wall thickness (IMT) were measured by B-mode ultrasound in women with SLE. Risk factors associated with carotid plaque and IMT were determined at the time of the ultrasound scan and included traditional cardiovascular risk factors, SLE-specific variables, and inflammation markers. The 175 women with SLE were predominantly white (87%), with a mean age of 44.9 years (SD 11.5). Twenty-six women (15%) had a previous arterial event (10 coronary [myocardial infarction or angina], 11 cerebrovascular [stroke or transient ischemic attack], and 5 both). The mean +/- SD IMT was 0.71 +/- 0.14 mm, and 70 women (40%) had focal plaque. Variables significantly associated with focal plaque (P < 0.05) included age, duration of lupus, systolic, diastolic, and pulse pressure, body mass index, menopausal status, levels of total and low-density lipoprotein (LDL) cholesterol, fibrinogen and C-reactive protein levels, SLE-related disease damage according to the Systemic Lupus International Collaborating Clinics (SLICC) damage index (modified to exclude cardiovascular parameters), and disease activity as determined by the Systemic Lupus Activity Measure. Women with longer duration of prednisone use and a higher cumulative dose of prednisone as well as those with prior coronary events were more likely to have plaque. In logistic regression models, independent determinants of plaque (P < 0.05) were older age, higher systolic blood pressure, higher levels of LDL cholesterol, prolonged treatment with prednisone, and a previous coronary event. Older age, a previous coronary event, and elevated systolic blood pressure were independently associated with increased severity of plaque (P < 0.01). Older age, elevated pulse pressure, a previous coronary event, and a higher SLICC disease damage score were independently related to increased IMT (P < 0.05). B-mode ultrasound provides a useful noninvasive technique to assess atherosclerosis in women with SLE who are at high risk for cardiovascular disease. Potentially modifiable risk factors were found to be associated with the vascular disease detected using this method.
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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.

                Author and article information

                Kidney Blood Press Res
                Kidney and Blood Pressure Research
                S. Karger AG
                19 November 2003
                : 26
                : 5-6
                : 362-367
                Departments of aNephrology and bSurgery, University Hospital Essen, Essen, and cKlinikum rechts der Isar der Technischen Universität München, München, Germany
                73943 Kidney Blood Press Res 2003;26:362–367
                © 2003 S. Karger AG, Basel

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                Figures: 4, Tables: 1, References: 24, Pages: 6
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