The impact of location and patency of the arteriovenous fistula on quality of life of kidney transplant recipients (original) (raw)
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Permanent Arteriovenous Fistula or Catheter Dialysis for Heart Failure Patients
Journal of Vascular Access, 2016
Therefore, the AVF should not be always the VA of first choice for all incident HD patients and we must to select the most appropriate VA for the individual patient. In agreement with Roy-Chaudhury et al, it is necessary to "get the right access into the right patient at the right time" (2). The subgroup of ESRD patients with heart failure (HF) illustrates this point of view because the decision to create an AVF or insert a CVC should be individualized according to the degree of cardiac involvement. Magnitude of the problem The burden of HF among chronic kidney disease (CKD) patients is high (6-10). The recent report from the United States Renal Data System indicate that HF is the most frequent cardiovascular disease that has been associated with CKD, with its prevalence in CKD patients aged ≥66 years exceeding 40% in 2012 (6). Trespalacios et al studied 1995 ESRD patients starting dialysis therapy and reported an HF incidence of 71/1000 person-years that was substantially greater than the incidence of acute coronary syndromes (29/1000 person-years) (7). Harnett et al performed a prospective study in 432 ESRD patients and showed that 31% had HF or a history of this condition at the start of dialysis, 56% of whom had a recurrence of HF during the follow-up (8). Martínez-Gallardo et al performed a prospective study involving 562 CKD patients stages 4 or 5 pre-dialysis which
Circulation: Cardiovascular Quality and Outcomes, 2013
H eart failure (HF) currently affects ≈5.7 million adults in the United States and is associated with an estimated $29 billion in hospital charges annually. 1 Driven by a variety of factors, the prevalence of HF is a current and increasing public health problem nationally and internationally. Many patients with HF also have chronic kidney disease (CKD), most frequently manifest as a reduced glomerular filtration rate (GFR), and the risk of developing HF is substantially increased with worsening stage of CKD. 2 Many of the same factors contribute to the development of both chronic diseases, including age, diabetes mellitus, and hypertension. 2,3 Although patients with HF suffer poor outcomes, including a death rate of ≈50% within 5 years of diagnosis, 1 the co-occurrence of CKD and HF seems to confer an even higher rate of poor outcomes, especially in those with HF and reduced left ventricular ejection fraction (HF-REF). 4 The physiological relations between CKD and HF are multifactorial and causally intertwined. For example, kidney dysfunction contributes to HF by increased salt retention and volume expansion, upregulation of neurohormonal pathways, proinflammatory mechanisms, and likely other mechanisms. HF worsens CKD by decreasing renal perfusion and activation of the catecholaminergic and renin-angiotensin-aldosterone system. 5-7 In addition, both CKD and HF can cause or worsen other comorbid conditions, including anemia, 8 coronary and peripheral atheroschlerosis, 9 and malnutrition. 10 Because the population prevalence of HF has increased, so has the proportion of patients with HF preserved left ventricular EF (HF-PEF). 11 Few studies have, however, examined how CKD affects clinically meaningful outcomes among patients with HF-PEF. Existing data have largely come from studies Background-There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction (HF-PEF). Methods and Results-We identified a community-based cohort of patients with HF. Electronic medical record data were used to divide into HF-PEF and reduced left ventricular EF on the basis of quantitative and qualitative estimates. Level of CKD was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all-cause). Multivariable Cox regression estimated the adjusted relative-risk of outcomes by level of CKD, separately for HF-PEF and HF with reduced left ventricular EF. We identified 14 579 patients with HF-PEF and 9762 with HF with reduced left ventricular EF. When compared with patients with eGFR between 60 and 89 mL/min per 1.73 m 2 , lower eGFR was associated with an independent graded increased risk of death and hospitalization. For example, among patients with HF-PEF, the risk of death was nearly double for eGFR 15 to 29 mL/min per 1.73 m 2 and 7× higher for eGFR<15 mL/min per 1.73 m 2 , with similar findings in those with HF with reduced left ventricular EF. Conclusions-CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective inter ventions for the growing number of patients with HF complicated by CKD.
Renal Function as a Predictor of Outcome in a Broad Spectrum of Patients With Heart Failure
Circulation, 2006
on behalf of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Investigators Background-Decreased renal function has been found to be an independent risk factor for cardiovascular outcomes in patients with chronic heart failure (CHF) with markedly reduced left ventricular ejection fraction (LVEF). The aim of this analysis was to evaluate the prognostic importance of renal function in a broader spectrum of patients with CHF. Methods and Results-The Candesartan in Heart Failure:Assessment of Reduction in Mortality and Morbidity (CHARM) program consisted of three component trials that enrolled patients with symptomatic CHF, based on use of ACE inhibitors and reduced (Յ40%) or preserved LVEF (Ͼ40%). Entry baseline creatinine was required to be below 3.0 mg/dL (265 mol/L). Routine baseline serum creatinine assessments were done in 2680 North American patients. An analysis of the estimated glomerular filtration rate (eGFR), using the Modification of Diet in Renal Disease equation and LVEF on risk of cardiovascular death or hospitalization for heart failure, as well as on all-cause mortality, was conducted on these 2680 patients. The proportion of patients with eGFR Ͻ60 mL/min per 1.73 m 2 was 36.0%; 42.6% for CHARM-Alternative, 33.0% for CHARM-Added, and 34.7% for CHARM-Preserved. During the median follow-up of 34.4 months (total 6493 person-years), the primary outcome of cardiovascular death or hospital admission for worsening CHF occurred in 950 of 2680 subjects. Both reduced eGFR and lower LVEF were found to be significant independent predictors of worse outcome after adjustment for major confounding baseline clinical characteristics. The risk for cardiovascular death or hospitalization for worsening CHF as well as the risk for all-cause mortality increased significantly below an eGFR of 60 mL/min per 1.73 m 2 (adjusted hazard ratio, 1.54 for 45 to 60 mL/min per 1.73 m 2 and 1.86 for Ͻ45 mL/min per 1.73 m 2 for the primary outcome, both PϽ0.001, and hazard ratio of 1.50, Pϭ0.006, and 1.91, Pϭ0.001, respectively, for all-cause mortality). The prognostic value of eGFR was not significantly different among the three component trials. There was no significant interaction between renal function, the effect of candesartan, and clinical outcome. Conclusions-Impaired renal function is independently associated with heightened risk for death, cardiovascular death, and hospitalization for heart failure in patients with CHF with both preserved as well as reduced LVEF. There was no evidence that the beneficial effect of candesartan was modified by baseline eGFR. (Circulation. 2006;113:671-678.)
BMC Nephrology, 2009
Background: Chronic heart failure (CHF) has a high morbidity and mortality. Chronic kidney disease (CKD) has consistently been found to be an independent risk factor for unfavorable cardiovascular (CV) outcomes. Early intervention on CKD reduces the progression of CHF, hospitalizations and mortality, yet there are very few studies about CKD as a risk factor in the early stages of CHF. The aims of our study were to assess the prevalence and the prognostic importance of CKD in patients with systolic CHF stages B and C.
American Journal of Transplantation, 2004
The long-term effects of hemodialysis arteriovenous fistula (AVF) closure on left ventricular (LV) morphology are unknown. Using echocardiography, we prospectively studied 17 kidney transplant recipients before, 1, and, 21 months after AVF closure (mean fistula flow 1371 ± 727 mL/min). Eight kidney transplant recipients with a patent AVF, matched for age, time after AVF creation, and time after transplantation, served as controls. LV mass index (LVMI) decreased from 139 ± 44 g/m 2 before AVF closure to 127 ± 45 g/m 2 and 117 ± 40 g/m 2 at 1 and 21 months post-closure, respectively (p < 0.001), but remained unchanged in controls. LV hypertrophy prevalence (LVMI > 125 g/m 2 ) decreased from 65% before, to 41% early, and 18%, late, after surgery (p = 0.008), mostly from a decrease in LV end-diastolic diameter. Consequently, the prevalence of LV concentric remodeling (relative wall thickness > 0.45 without hypertrophy) increased from 12% before, to 35% early, and 65% late, after surgery (p = 0.003). Diastolic arterial blood pressure increased from 78 ± 15 mmHg before, to 85 ± 13 mmHg early, and 85 ± 10 mmHg late, after surgery (p < 0.015).In conclusion, closure of large and/or symptomatic AVF induces longterm regression of LV hypertrophy. However, residual concentric remodeling geometry as well as diastolic blood pressure increase may blunt the expected beneficial cardiac effects of the procedure.
Kidney360, 2021
BackgroundThe long-term effects of arteriovenous fistula (AVF) ligation on cardiovascular structure following kidney transplantation remain uncertain. A prospective randomized, controlled trial (RCT) examined the effect of AVF ligation at 6 months on cardiovascular magnetic resonance imaging (CMR)–derived parameters in 27 kidney transplant recipients compared with 27 controls. A mean decrease in left ventricular mass (LVM) of 22.1 g (95% CI, 15.0 to 29.1) was observed compared with an increase of 1.2 g (95% CI, −4.8 to 7.2) in the control group (P<0.001). We conducted a long-term follow-up observational cohort study in the treated cohort to determine the evolution of CMR-derived parameters compared with those documented at 6 months post-AVF ligation.MethodsWe performed CMR at long-term follow-up in the AVF ligation observational cohort from our original RCT published in 2019. Results were compared with CMR at 6 months postintervention. The coprimary end point was the change in CM...
Effect of high flow arteriovenous fistula on cardiac function in hemodialysis patients
The Egyptian Heart Journal, 2018
Background: Vascular access for hemodialysis (HD) with an inappropriately high flow may underlie the onset of high output heart failure (HOHF). The aim of this study was to determine the prevalence of high flow access (HFA) in chronic HD patients, and to determine its effects on cardiac functions. Methods: This cross sectional study was conducted on 100 chronic hemodialysis patients through arteriovenous fistula (AVF). The study cohort was subdivided into 2 groups based on AVF flow: Group A (Non-HFA group with Qa < 2000 ml/min), and Group B (HFA group with Qa ! 2000 ml/min). AVF flow (Qa) was assessed using Color Doppler ultrasonography. Transthoracic echocardiography was performed for all patients to assess cardiac dimensions and functions. Results: Prevalence of HFA among study population was 24%. Mean AVF Qa was 958.63 ± 487.35 and 3430.13 ± 1256.28 ml/min, for group A and B respectively. The HFA group demonstrated a significant dilatation in LV dimensions and volumes and significantly larger LA volume as compared to non-HFA group. A significantly lower LV ejection fraction [EF] was also observed in group B with a mean value of 57.32 ± 6.19% versus 62.90 ± 5.76%. A significant association between HFA group and high Qa/cardiac output (CO) ratio (!20%) was also observed. Conclusion: HFA is a prevalent hemodialysis vascular access problem. HFA was associated with dilated LV dimensions, impaired LV systolic function. High Qa/CO ratio (!20%) was an independent predictor of high output heart failure (HOHF) in our study population.
The American Journal of Cardiology, 2007
Chronic kidney disease (CKD) is common and associated with increased mortality in heart failure (HF). However, it is unknown whether the effect of CKD on mortality varies by left ventricular ejection fraction (LVEF). We evaluated the effect of CKD on mortality in systolic (LVEF ≤45%) and diastolic (LVEF >45%) HF patients. Of the 7788 patients in the Digitalis Investigation Group trial, 3527 (45%) had CKD (estimated glomerular filtration rate <60 ml/min/1.73m 2). We calculated propensity score for CKD for each patient, using a multivariable logistic regression model (c statistic=0.76; post-match absolute standardized differences <5% for all 32 covariates). We matched 2399 pairs of patients with and without CKD with similar propensity scores. There were 757 (rate, 1,049/10,000 person-year) and 882 (rate, 1,282/10,000 person-year) deaths respectively in patients without and with CKD (hazard ratio=1.22, 95% confidence interval {CI}=1.09-1.36; p<0.0001). CKD-associated mortality was higher in diastolic HF (371 extra deaths/10,000 person-year; hazard ratio=1.71; 95% CI=1.21-2.41; p=0.002) than in systolic HF (214 extra deaths/10,000 person-year; hazard ratios =1.19; 95% CI =1.07-1.32; p=0.001), which was significant (adjusted p for interaction=0.034). There was a graded association between CKD-related deaths and LVEF. Hazard ratios (95% CI) for CKD-associated mortality for LVEF subgroups <35%, 35-55% and >55% were respectively 1.15 (1.02-1.29), 1.35 (1.11-1.64), and 2.33 (1.34-4.06). In conclusion, CKDassociated mortality was higher in diastolic than in systolic HF. Diastolic HF patients should be evaluated for CKD and the role of inhibitors of the renin-angiotensin system in these patients needs to be investigated.
Clinical Nephrology, 2012
Background: In patients without overt cardiac disease, the degree of left ventricular hypertrophy (LVH) gets worse following hemodialysis (HD) initiation; however, in patients with both advanced chronic kidney disease (CKD) and symptomatic heart failure (HF) with reduced ejection fraction (EF), the short-term effect of HD on LVH and LV geometry has not been examined. We hypothesized that left ventricular mass index (LVMI) would decrease following HD initiation in CKD patients with symptomatic HF. Methods: We retrospectively evaluated changes in LVMI, LV geometry, and LV fractional shortening (LVFS), assessed by 2D transthoracic echocardiography (TTE), in 41 patients with HF initiating HD while hospitalized from 1995 to 2006. HF was defined by LVEF ≤ 45% or dyspnea plus two of the following: raised jugular venous pressure, bibasilar crackles, pulmonary venous hypertension, interstitial edema on chest X-ray, or both. TTE was performed within 3 months prior to first HD and repeated 8.6 ± 5.2 months after start of HD. TTE recordings were obtained from storage and analyzed by a cardiologist blinded to patient clinical characteristics. Results: Before initiation of HD, LVMI in 39 patients was 167.9 ± 53.1 g/m 2 and it decreased by-24.3 ± 35.4 g/m 2 by follow-up, p < 0.001. 26% of patients with concentric LVH at baseline had concentric remodeling or eccentric LVH at follow-up. LVFS did not significantly change over time in all 41 patients with HF (25.7 ± 8.7% vs. 26.4 ± 8.7%, p = 0.66). However, in an expanded analysis of all 69 patients with serial TTEs, a 1% increase in LVFS after starting HD was associated with a 16% reduction in risk of cardiovascular hospitalization at follow-up (HR 0.84, 95% CI 0.73-0.96, p = 0.01). Conclusions: LVMI decreases following HD initiation in CKD patients with symptomatic HF and reduced LVEF, possibly due to relief of venous congestion. Increase in LVFS following HD initiation predicts improved cardiac outcome.