Hemodialysis access problems

F1 王奕淳 / VS 李隆志97.12.10

STRATEGIES TO PREVENT THROMBOSIS  

• Antiplatelet agents  • Systemic anticoagulation  • Proposed preventive medication (ACEI,

CCB…)• Fish oil  • Endovascular radiation• Stents• FIR

• Retrospective medication review

• 1126 vascular acess

• DOPPS is a prospective, longitudinal, observational study of adult hemodialysis patients and facilities in seven countries (France, Germany, Italy, Spain, the United Kingdom, Japan, and the United States)

• All new hemodialysis accesses (either AV graft or AV fistula) created during the course of the study recruitment period (n = 2,844 accesses) were included in this sample.

• Data were obtained between June 1996 and June 2001.

Aspirin

No Aspirin

CCB

No CCB

ACEI

No ACEI

Result

• Treatment with calcium channel blockers was associated with improved primary graft patency (relative risk [RR] for failure, 0.86; P = 0.034).

• Aspirin therapy was associated with better secondary graft patency (RR, 0.70; P < 0.001)

• Treatment with angiotensin-converting enzyme inhibitors was associated with significantly better secondary fistula patency (RR, 0.56; P = 0.010).

• This study was a multicenter, randomized, double-blind, placebo controlled trial in which patients with newly placed (incident) PTFE grafts for hemodialysis access were eligible to participate

• Patients with ESRD and newly placed PTFE grafts were studied at community and academic dialysis centers in Southwestern Ontario.

• Patients were allocated to receive warfarin or matching placebo, with the warfarin administered to achieve a target INR of 1.4 to 1.9

Conclusion

• Low-dose warfarin was associated with an excess of clinically important major bleeding in patients with ESRD enrolled in this study.

• Low-intensity, monitored-dose warfarin does not appear to prolong PTFE graft survival.

• United States Renal Data System (USRDS) database• Retrospective analysis• All patients with a documented AVF, PTFE graft, or

permanent (tunneled) catheter were eligible for inclusion (n =1712)

Conclusion

• Treatment with antiplatelet medications, ticlopidine and dipyridamole (HR, 3.54; 95% CI 1.07–11.76; p =0.04), or aspirin (HR, 2.49; 95% CI 1.31–4.73; p=0.005 ) was associated with significantly worse AVF patency

• Randomized, double-blind, placebo controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007.

• 877 participants with endstage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later.

• Participants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n=441) or placebo (n=436) for 6 weeks starting within 1 day after fistula creation.

Conclusion

• Clopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis.

• A double-blind, randomized trial was conducted. • Twenty-four patients were randomized to receive

4000 mg of fish oil or 4000 mg of control oil. • Both preparations were enriched with

antioxidants and deodorized with peppermint• Patients began therapy within 2 wk after graft

placement and were monitored for 12 mo or until thrombosis developed.

Conclusion

• Fish oils possess unique biologic properties that favorably affect the incidence of polytetrafluorethylene graft thrombosis, and they thus represent a potential treatment strategy for the prevention of access thrombosis

Results• 145 HD patients: 73 in control group and 72 receiving

FIR therapy (by WSTM TY101) • One episode of 40 minutes of FIR therapy increased a

ccess flow (Qa) about 47 ml/min[-33.4±132.3 vs. 13.2±114.7 ml/min; P= 0.021]

• One year of FIR therapy (40 minutes during HD TIW) was associated with (A) a lower incidence of AV fistula malfunction [12.5% vs. 30.1%; P<0.01] (B) a higher incremental change of Qa~147 ml/min [99.2±144.4 vs. -47.5±244.5 ml/min; P < 0.001] (C) a better unassisted patency of AV fistula [85.9% versus 67.6%; P < 0.01]

FIR (+): 85.9%

FIR (-): 67.6%

Thanks for your attention!!!

• PREVENT THROMBOSIS– Antiplatelet agents  – Systemic anticoagulation  – Proposed preventive medication (ACEI,CC

B…)– Fish oil  – Endovascular radiation– Stents

– FIR