MOHAMMED ALSUNAID, MD Section Head, Nephrology Department of Medicine King Faisal Specialist...
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Transcript of MOHAMMED ALSUNAID, MD Section Head, Nephrology Department of Medicine King Faisal Specialist...
MOHAMMED ALSUNAID, MDMOHAMMED ALSUNAID, MD
Section Head, NephrologyDepartment of Medicine
King Faisal Specialist Hospital & Research Centre
Riyadh, Saudi Arabia
Clinical Scenario
• Mr Ahmed is 43 years old• CKD stage 4 due to FSGS• eGFR 18 mL/min• He was educated for preservation of
vascular access sites• Renal replacement therapy options
were discussed• He chose Hemodialysis (HD)
• Several years later, he came to the clinic with eGFR 9 mL/min
• Types of Chronic HD vascular access:A. Native arteriovenous fistulas (AVF), RC AVFB. Grafts (AVG)C. Double-lumen tunneled cuffed catheters
Clinical Scenario
AVF vs AVG46.4
20.6
0
10
20
30
40
50
AVFN=139
AVGN=78
P=0.001
Prospective study pre-operative vascular mapping
Allon, M, et al KI 2001; 60:2013-2020
Pri
mary
Failu
re R
ate
%
AVF vs AVG
0102030405060708090
AVFN=108
AVGN=52
58
7469
83
Prospective observational study RC AVF
Pri
mary
Pate
ncy
Rate
%
Silva, Jr, et al J Vasc Surg 1998;27:302-308
12 months
24 months
AVF vs AVGPri
mary
Su
rviv
al R
ate
%
at
2 y
ears
66
52
0
10
20
30
40
50
60
70
AVFN=139
AVGN=78
P=0.005
Prospective study pre-operative vascular mapping
Allon, M, et al KI 2001; 60:2013-2020
AVF vs AVG
P<0.001
0.57
1.67
0
0.5
1
1.5
2
AVFN=139
AVGN=78
Prospective study
Tota
l A
ccess
In
terv
en
tion
s/year
Pre-operative vascular mapping
Allon, M, et al KI 2001; 60:2013-2020
Access intervention: thrombectomy, angioplasty or surgical revision
AVF vs AVG
0
11.5
0
2
4
6
8
10
12
AVFN=108
AVGN=52
Infe
ctio
n R
ate
%
Prospective observational study Mean FU 15.2 months
Silva, Jr, et al J Vasc Surg 1998;27:302-308
Type of Vascular Access and Mortality
28
38 40
0
5
10
15
20
25
30
35
40
AVFN=1340
AVGN=3129
CVCN=875
2 Y
ears
Mort
alit
y %
Observational study USRDS DMMS Wave 1 Prevalent diabetic pts
Dhingra, RK, et al KI 2001; 60:1443-1451
Adjusted RR AVF vs AVG 1.41 (95%CI, 1.13 to 1.77) P<0.003Adjusted RR AVF vs CVC 1.54 (95%CI, 1.17 to 2.02) P<0.002
Type of Vascular Access and Mortality
An
nu
al M
ort
alit
y R
ate
%
11.7
14.216.1
02468
101214161820
AVFN=185
AVGN=296
CVCN=603
Adjusted RH AVF vs CVC 1.5 (95%CI, 1 to 2.2)Adjusted RH AVF vs AVG 1.2 (95%CI, 0.8 to 1.8)
Analysis from CHOICE Study Incident HD pts
Astro, BC, et al JASN 2005;16:1449-1455
AVF vs AVG
HigherLowerComplication Rate
LowerHigherPatency Rate
ShorterLongerTime to Use
LowerHigherPrimary Failure Rate
AVGAVF
Clinical Scenario
• He was referred to vascular surgeon
• Vascular surgeon referred him to radiologist for left upper extremity vascular mapping by duplex ultrasound
Is pre-operative vascular mapping by duplex US should be performed in all patients before
vascular access creation?
Yes N
o
53%
47%
1. Yes2. No
Pre-operative Vascular Mapping
14
62
24
63
30
7
0
10
20
30
40
50
60
70
Clinical ExaminationN=183
Doppler USN=172
AVF
AVG
CVC
AVF
AVG
CVC
Doppler US 9/1994-1/1997Clinical Exam 6/1992-8/1994
P<0.05C
reati
on
Rate
%
Silva, Jr, et al J Vasc Surg 1998;27:302-307
Pre-operative Vascular Mapping
40
8.3
0
5
10
15
20
25
30
35
40
Clinical ExaminationN=25
Doppler USN=108
Clinical Exam 6/1992 – 8/1994 Doppler US 9/1994 – 1/1997
Silva, Jr, et al J Vasc Surg 1998;27:302-308
AV
F Pri
mary
Failu
re R
ate
%
P<0.05
Pre-operative Vascular Mapping
0102030405060708090
Clinical ExaminationN=139
Doppler US (DU)N=160
48
63
8374
Clinical Exam 6/1992 – 8/1994 DU 9/1994-1/1997
Silva, Jr, et al J Vasc 1998; 27:302 - 308
Pri
mary
Pate
ncy
Rate
%
at
1 y
rAVF
AVGP<0.05
Pre-operative Vascular Mapping
25
5.6
0
5
10
15
20
25
Physical ExaminationN=52
Doppler USN=72
P=0.002
Pri
mary
AV
F Fa
ilure
Rate
%
RCT CKD5
Mihmanli, I, et al J Ultras Med 2001; 20:217-222
The minimal advisable diameter of the anastomosed
vessels for the creation of successful AVF is:
5%
10%
28%
14%
43%
a.1 mmb.1.5 mmc. 2 mmd.2.5 mme.3 mm
Pre-Operative Vascular Mapping100
19
0
20
40
60
80
100
< 1.6 mmN=7
> 1.6 mmN=47
Pri
mary
Failu
re R
ate
%
Prospective observational study RC AVF Vessel Diameter
Wong, V, et al Eur J Vasc Endovasc Surg 1996;12:207-213
Pre-operative Vascular MappingR
ate
%83
8.3
0
10
20
30
40
50
60
70
80
90
RC AVF N=108
1 yr Primary Patency
Primary Failure
Prospective observational study Vein diameter > 2.5 mm Artery diameter > 2 mm
Silva, Jr, et al J Vasc Surg 1998;27:302-308
• Left radiocephalic RC AVF was constructed
• Nephrologist decided to initiate HD
Clinical Scenario
The minimum maturation period of AVF
should be ideally:
0%
11%
0%
49%
40%a. < 2 weeksb. 2-4 weeksc. > 4 weeksd. > 6 weekse. > 8 weeks
Timing of First Cannulation%
of
faci
litie
s
2
34 3726
50
29
13 8
74
24
2
0102030405060708090
100
< 1 1-2 2-3 3-4
< 1 1-2 2-3 3-4
< 1 1-2 2-3
US
EURO
JAPAN
Observational study 309 HD facilities AVF 2154
MONTHS
Saran, R, et al (DOPPS) NDT 2004;19:2334-2340
Timing of First CannulationA
dju
sted
Rela
tive R
isk
of
Acc
ess
Failu
re
0.72
10.91 0.87
00.10.20.30.40.50.60.70.80.9
1
< 1 1-2 2-3 >3
P=NS
MONTHS
Observational study 309 HD Facilities AVF 2154
Ref
Saran, R, et al (DOPPS) NDT 2004;19:2334-2340
Time of First CannulationA
dj. H
aza
rd R
ati
o f
or
Pri
mary
AV
F Fa
ilure
1.94
1
0
0.5
1
1.5
2
<30 >30DAYS
Ref
(95% CI, 1.3 to 2.8) P<0.001
Prospective study, MC AVF 513
Ravani, P, et al JASN 2004; 15:204-209
Time of First Cannulation
Rule of 6s:1) Access flow > 600 mL/min2) Vein diameter > 6 mm3) Vein depth < 6 mm
K/DOQI (CPG/CPR 2006) AJKD 2006; 48 (S1): 1
Clinical Scenario
• 6 weeks later, left RC AVF was cannulated smoothly
• Objective monitoring of access function at regular base was performed
The recommended objective monitoring of access function should
be performed at regular base by:
16%
2%
62%
2%
18%
a. Venous pressure measurement
b. Arterial pressure measurement
c. Dynamic venous pressure measurement
d. Static venous pressure measurement
e. Access flow measurement
Vascular Access Blood Flow Measurement
• Duplex US• US flow dilution (Transonic)• Crit-Line III• Crit-Line III TQA• Variable flow Doppler• In graft Velocitymetry• Blood velocity meter• Glucose pump test
Tordoir, J, et al NDT 2007; 22 (S2) : 88-117
Access Blood Flow Measurements Over Dialysis
TimeA
ccess
Blo
od
Flo
w m
L/m
in 1344
1308
1250
1150
1200
1250
1300
1350
1400
30 90 150MINUTES
P=0.03
Prospective study 32 HD Pts US dilution (transonic)
Rehman, SU, et al AJKD 1999; 34: 471-477
( 7%)
Access Blood Flow Measurement and BP
Changes
28
50
Decr
ease
in
Acc
ess
Blo
od
Fl
ow
% A
fter
90
min
s
Decrease MAP % 15 25
Prospective Study 32 HD Patients US Dilution (Transonic)
Rehman, SU, et al AJKD1999; 34: 471-477
Vascular Access Flow Measurement and Number of
Catheter InsertionsR
ela
tive R
isk f
or
the N
o.
of
Cath
ete
r In
sert
ion
s
0.2
0.59
0
0.1
0.2
0.3
0.4
0.5
0.6
AVF N=60 AVG N=101
P < 0.05(95% CI, 0.04 to 0.88)
P < 0.05(95% CI, 0.37 to
0.93)
Meta-analysis AVF=1 RCT AVG=1 RCT Tonelli, M, et al AJKD 2008; 51: 630-640
Vascular Access Flow Measurement and Access
ThrombosisR
ela
tive R
isk f
or
Th
rom
bosi
s
0.47
0.94
0
0.2
0.4
0.6
0.8
1
AVF N=360 AVG N=446
P < 0.05(95% CI, 0.28 to 0.77)
(95% CI, 0.77 to 1.16)
Meta-analysis AVF 4RCT AVG 6RCT
Tonelli, M, et al AJKD 2008; 51: 630-640
Access Flow Measurement and Access Loss
0.65
1.08
0
0.2
0.4
0.6
0.8
1
1.2
AVF N=141 AVG N=381
Meta-analysis AVF 2 RCT AVG 4 RCT
Tonelli, M, et al AJKD 2008; 51: 630-640
Rela
tive R
isk f
or
Acc
ess
Loss (95% CI, 0.83 to 1.40)
(95% CI, 0.28 to 1.51)
Clinical Scenario
US dilution technique was used at monthly bases for access flow measurement
700 (22%)840 (7%)
900Access flow measurement mL/min
7/20086/20082/2007-3/2008
Date
What Should Be Done Next?
16%21%
0%
61%
2%
a. Repeat access flow measurement
b. Perform duplex USc. Perform MRAd. Perform fistulogram
+ percutaneous transluminal angioplasty (PTA)
e. Perform surgical revision
Degree of Stenosis and PTA
72
23
65
17
0
10
20
30
40
50
60
70
80
Baseline Post-PTA Baseline Post-PTAAVF=33 AVG=65
P<0.005
Prospective Observational study, MC US dilution
Van der Linden, J, et al JASN 2002; 13:715 - 720
Deg
ree o
f S
ten
osi
s %
Access Flow Measurement and PTA
304
638
371
674
0
100
200
300
400
500
600
700
Baseline Post-PTA Baseline Post-PTA
AVF=33 AVG=65
P<0.0001
Prospective observational study, MC US dilution
Van der Linden, J, et al JASN 2002; 13:715 - 720
Acc
ess
Flo
w
mL/
min
Primary Patency Post-PTA50
25
0
10
20
30
40
50
AVF AVG
P=0.03
Pri
mary
Pate
ncy
Rate
Post
-PTA
at
6/1
2 %
Prospective observational study, MC US dilution
Van der Linden, J, et al JASN 2002; 13:715 - 720
Repeat PTA Procedures
24 (169 days)
43 (109 days)
0
5
10
15
20
25
30
35
40
45
AVF=25 AVG=35
Prospective observational study, MC US dilution
Rep
eat
PTA
Rate
%
Van der Linden, J, et al JASN 2002; 13:715 - 720
Clinical Scenario
• PTA was done for 70% stenosis at venous outflow site with good result
• Access flow measurement improved from 700 to 860 mL/min (within 1 week)
• Few months later, he underwent kidney transplantation from deceased donor.
The indication for pre-emptive percutaneous transluminal angioplasty
(PTA) is:
7%
40% 42%
5%5%
a. Decrease of access flow > 10%
b. Decrease of access flow > 20%
c. AVG flow < 800 mL/min
d. AVF flow < 800 mL/min
e. AVF flow < 600 mL/min
Pre-emptive Intervention
Variable EBPG 2007
CSN/CPG2006
Reduction of access flow %
> 20 > 20
AVF flow (forearm) mL/min
< 300 < 500
AVG flow mL/min < 600 < 650
1. Tordoir, J, et al NDT 2007; 22 (S2) : 88-1172. Jindal, K, et al JASN 2006; 17 (S1): 1-27
Conclusion1. Upper extremities vein preservation for every
patient with CKD (dorsum of the hand)2. AVF is the preferred type of VA and should be
placed as distal as possible3. Physical examination and vascular mapping
with Doppler US of upper extremity should be performed before VA creation
4. Minimal diameter of vessels is 2 mm for AVF creation
5. Minimal period for AVF maturation is one month
Conclusion
6. Measuring access blood flow at regular base should be performed (US dilution)
7. Early detection of VA dysfunction (thrombosis)
8. Pre-emptive corrective intervention (PTA)9. Decrease patient morbidity, hospital
admissions and healthcare costs10. Access monitoring programs should be
included as part of routine dialysis care