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      Weight-Based Assessment of Access Flow Threshold to Predict Arteriovenous Fistula Functional Patency


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          The 2019 Kidney Disease Outcome Quality Initiative (K/DOQI) guideline recommended evaluating arteriovenous fistula (AVF) malfunction risks primarily based on clinical monitoring, which can be assisted with the value of vascular access flow (Qa). Nevertheless, Qa thresholds recommended by different guidelines vary, ranging from 300 to 500 ml/min. This study investigated the optimal Qa threshold to predict future functional patency in AVFs with Qa <500 ml/min.


          Both the clinical indicators of access dysfunction and the Qa value were monitored in patients receiving hemodialysis by the radiocephalic AVF. Routine access flow surveillance was performed by the ultrasound dilution method (HD03, Transonic Inc.). The development of clinically significant indicators of access dysfunction, which necessitated percutaneous transluminal angiography (PTA) to maintain functional patency, was analyzed in this cohort.


          Among the enrolled 302 patients, Qa of 52 patients was under 500 ml/min. These 52 patients received 2 Qa measurements during the follow-up period. Of these 52 patients, serial Qa of 17 patients varied trivially and their AVF remained functional. Multivariable logistic regression analysis revealed that a low Qa per ideal body weight (IBW) is an independent predictor of AVF functional loss. Receiver operating characteristic curve analysis of Qa/IBW in predicting future AVF functional loss revealed that the best cutoff value of Qa is 7.1 times the IBW.


          For radiocephalic AVFs with Qa <500 ml/min, the minimally required Qa to maintain access function is associated with individual IBW. The IBW-based Qa threshold assessment would allow more flexibility in the treatment of patients and reduce unnecessary invasive measures.

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          KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

          The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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            Simplified calculation of body-surface area.

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              The inconsistency of "optimal" cutpoints obtained using two criteria based on the receiver operating characteristic curve.

              The use of biomarkers is of ever-increasing importance in clinical diagnosis of disease. In practice, a cutpoint is required for dichotomizing naturally continuous biomarker levels to distinguish persons at risk of disease from those who are not. Two methods commonly used for establishing the "optimal" cutpoint are the point on the receiver operating characteristic curve closest to (0,1) and the Youden index, J. Both have sound intuitive interpretations--the point closest to perfect differentiation and the point farthest from none, respectively--and are generalizable to weighted sensitivity and specificity. Under the same weighting of sensitivity and specificity, these two methods identify the same cutpoint as "optimal" in certain situations but different cutpoints in others. In this paper, the authors examine situations in which the two criteria agree or disagree and show that J is the only "optimal" cutpoint for given weighting with respect to overall misclassification rates. A data-driven example is used to clarify and demonstrate the magnitude of the differences. The authors also demonstrate a slight alteration in the (0,1) criterion that retains its intuitive meaning while resulting in consistent agreement with J. In conclusion, the authors urge that great care be taken when establishing a biomarker cutpoint for clinical use.

                Author and article information

                Kidney Int Rep
                Kidney Int Rep
                Kidney International Reports
                24 November 2021
                March 2022
                24 November 2021
                : 7
                : 3
                : 507-515
                [1 ]Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
                [2 ]Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
                [3 ]Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
                [4 ]Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
                [5 ]Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
                [6 ]Center for Intelligent Drug Systems and Smart Bio-devices (IDS 2B), National Yang Ming Chiao Tung University, Hsinchu, Taiwan
                [7 ]Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
                Author notes
                [] Correspondence: Chih-Yu Yang, Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University and Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, R208, 2F, Shou-Ren Building, 155, Section 2, Li-Nong Street, Beitou District, Taipei 11221, Taiwan. cyyang3@ 123456vghtpe.gov.tw
                © 2021 International Society of Nephrology. Published by Elsevier Inc.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                : 25 June 2021
                : 21 October 2021
                : 15 November 2021
                Clinical Research

                access blood flow,arteriovenous fistula,functional patency,ideal body weight,personalization


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