The vascular access is the Achilles' heel of hemodialysis. This thesis focuses on the maturation and long-term outcomes of arteriovenous fistulas and compares them to arteriovenous grafts. Also the... Show moreThe vascular access is the Achilles' heel of hemodialysis. This thesis focuses on the maturation and long-term outcomes of arteriovenous fistulas and compares them to arteriovenous grafts. Also the results from the LIPMAT-study are presented, a randomized controlled trial in which improvement of arteriovenous fistula maturation using liposomal prednisolone was evaluated. Finally, cardiac effects of arteriovenous fistulas are explored. Show less
Voorzaat, B.M.; Bogt, K.E.A. van der; Bezhaeva, T.; Schaik, J. van; Eefting, D.; Putten, K. van der; ... ; Rotmans, J.I. 2020
INTRODUCTION: Maturation failure of radiocephalic arteriovenous fistulas (RCAVF) is a significant clinical issue. Vascular inflammation after AVF surgery is associated with non-maturation.OBJECTIVE... Show moreINTRODUCTION: Maturation failure of radiocephalic arteriovenous fistulas (RCAVF) is a significant clinical issue. Vascular inflammation after AVF surgery is associated with non-maturation.OBJECTIVE: To evaluate whether liposomal prednisolone improves RCAVF maturation in end-stage renal disease (ESRD) patients.DESIGN: The LIPMAT-study was a multi-center, double-blind, 1:1 randomized, placebo-controlled trial.MATERIALS AND METHODS: Subjects were enrolled after RCAVF creation and treated with placebo or 150 mg of liposomal prednisolone at days 1 and 15 after AVF surgery. The primary end point was the juxta-anastomotic diameter of the cephalic vein at 6 weeks after surgery. Secondary end points were the diameter of the cephalic vein, brachial and radial artery at 6 weeks and 3 months after surgery as well as AVF flow and functional use for hemodialysis. Adverse events were compared to assess safety.RESULTS: 29 subjects were included of which 13 received placebo and 16 received liposomal prednisolone. The juxta-anastomitic cephalic vein diameter at 6 weeks was 3.9 mm (95% confidence interval 2.7 – 5.8 mm) in the placebo group and 3.7 mm (95% confidence interval 3.0 – 5.3 mm) in the liposomal prednisolone group (p=0.88). No significant differences in secondary end point parameters were observed. Treatment of end-stage renal disease patients with liposomal prednisolone was not associated with significant side effects.CONCLUSION: Liposomal prednisolone treatment of ESRD patients was safe, but did not result in enhanced RCAVF maturation. Show less
INTRODUCTION: Arteriovenous fistulas (AVFs) for hemodialysis (HD) are often associated with better outcomes than arteriovenous grafts (AVG). We aimed to investigate vascular access (VA) outcomes... Show moreINTRODUCTION: Arteriovenous fistulas (AVFs) for hemodialysis (HD) are often associated with better outcomes than arteriovenous grafts (AVG). We aimed to investigate vascular access (VA) outcomes and assessed if AVF non-maturation outweighs long-term complications of AVGs.METHODS: In this multicenter retrospective cohort-study in the Netherlands, one- and three-year primary, primary assisted, secondary and functional patency were calculated and the incidence of adverse events and procedures was assessed. Functional patency of RCAVFs, upper arm AVFs and AVGs was compared using Cox analyses.RESULTS: 1041 patients who received their first VA were included of which 863 successfully matured. These patients were analyzed with a median follow-up of 25 months. The one-year functional patency was 67 ± 2.0% for RCAVFs, 83 ± 2.0% for upper arm AVFs, and 85 ± 3.5% for AVGs, respectively. Three-year functional patency was 62 ± 2.0% for RCAVFs, 74 ± 2.0% for upper arm AVFs, and 69 ± 5% for AVGs, respectively. AVGs required more procedures per year (3.3/year) of functional patency when compared to upper arm AVFs (1.8/year).CONCLUSION: The functional patency of AVFs and AVGs is comparable, although AVGs required more interventions to maintain usability for hemodialysis. The choice of VA is a trade-off between short-term advantages, favoring AVGs and long-term advantages, favoring AVFs. Which VA is most appropriate depends on the patient’s prognosis and preferences. Show less
Nauta, L.; Voorzaat, B.M.; Rotmans, J.I.; Ghariq, E.; Urlings, T.; Bogt, K.E.A. van der; Linden, E. van der 2019
OBJECTIVE:Arteriovenous fistulas for hemodialysis vascular access are a burden for the cardiovascular system. After successful kidney transplantation, prophylactic arteriovenous fistula ligation... Show moreOBJECTIVE:Arteriovenous fistulas for hemodialysis vascular access are a burden for the cardiovascular system. After successful kidney transplantation, prophylactic arteriovenous fistula ligation may improve cardiac outcomes; however, evidence is scarce. This survey investigates physicians' preference for management of arteriovenous fistulas and identifies the factors associated with preference for either arteriovenous fistula ligation or maintenance.MATERIALS AND METHODS:A survey was sent to members of eight national and international Nephrology and Vascular Surgery societies. The survey comprised eight case vignettes of asymptomatic patients with a functioning arteriovenous fistula after kidney transplantation. Characteristics possibly associated with treatment preferences were arteriovenous fistula flow, left ventricular ejection fraction, and patient age. Respondents were asked to state preference to maintain or ligate the arteriovenous fistula. Linear mixed-effects models were used to investigate the association of treatment preference with case characteristics.RESULTS:A total of 585 surveys were returned. A reduced left ventricular ejection fraction of 30% (beta 0.60, 95% confidence interval 0.55; 0.65) and a high flow of 2500 mL/min (beta 0.46, 95% confidence interval 0.41; 0.51) were associated with a higher preference for arteriovenous fistula ligation. Disagreement among respondents was considerable, as in four out of eight cases less than 70% of respondents agreed on the arteriovenous fistula management strategy.CONCLUSION:Although respondents recognize a reduced left ventricular ejection fraction and a high flow as the risk factors, the high disagreement on management preferences suggests that evidence is inconclusive to recommend arteriovenous fistula ligation or maintenance after kidney transplantation. More research is needed to determine optimal arteriovenous fistula management after successful kidney transplantation. Show less
