Access Monitoring Does Not Really Improve Outcomes

Paulson, William D.

doi:10.1159/000082011

Cited by 27 publications

(12 citation statements)

References 48 publications

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“…In our patients, 44% of thromboses occur without a preceding reduction in Q (10,11). Consequently, the efficacy of flow surveillance has been debated at several recent nephrology symposia and in the literature (12)(13)(14).…”

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confidence: 79%

Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

White

Ram

Jones

et al. 2006

Clinical Journal of the American Society of Nephrology

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Randomized controlled trials have not shown that surveillance of graft blood flow (Q) prolongs graft life. Because luminal diameters affect flow resistance, this study examined whether the influence of diameters on Q can explain the limitations of surveillance. Inflow artery and outflow vein diameters were determined from duplex ultrasound studies of 94 patients. These diameters were applied to a mathematical model for determination of how they affect the relation between Q and stenosis. Also determined was the correlation between Q (by ultrasound dilution) and diameters, stenosis, and mean arterial pressure in 88 patients. Artery and vein diameters varied widely between patients, but arteries generally were narrower than veins. The model predicts that the relation between Q and stenosis is sigmoid: as stenosis progresses, Q initially remains unchanged but then rapidly decreases. A narrower artery increases flow resistance, causing a longer delay followed by a more rapid reduction in Q. In a multiple regression analysis of data from patients, Q correlated with artery and vein diameters, sum of largest stenoses from each circuit segment, and mean arterial pressure (R ‫؍‬ 0.689, P < 0.001). This study helps to explain why Q surveillance predicts thrombosis in some patients but not others. Luminal diameters control the relation between Q and stenosis, and these diameters vary widely. During progressive stenosis, the delay and then rapid reduction in Q may impair recognition of low Q before thrombosis occurs. Surveillance outcomes might be improved by taking frequent measurements so that there is no delay in discovering that Q has decreased.

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confidence: 79%

Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

White

Ram

Jones

et al. 2006

Clinical Journal of the American Society of Nephrology

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“…Preemptive intervention (either radiological or surgical) extends the duration of access sites and may even reduce health care costs, [1][2][3][4][5] although, because of recent negative trials, this issue has become more controversial. 6 The Kidney Disease Outcome Quality Initiative (K/DOQI) Clinical Practice Guidelines for Vascular Access strongly recommend surveillance of vascular access monitoring by periodical flow measurements. 7 The most commonly used technique to measure access flow is the saline dilution technique, as introduced by Krivitski.…”

mentioning

confidence: 99%

Comparison Between Two On-Line Reversed Line Position Hemodialysis Vascular Access Flow Measurement Techniques: Saline Dilution and Thermodilution

Wijnen¹,

Essers²,

Meijel³

et al. 2006

ASAIO Journal

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Periodical access flow measurements can predict the development and presence of vascular access flow-limiting stenosis and subsequent thrombosis. Access flow measurement has become a standard in vascular access care. Different techniques to measure access flow are available. The aim of this study was to compare an integrated access flow measurement device, based on thermodilution (Blood Temperature Monitor, BTM, Fresenius Medical Care, Bad Homburg, Germany), with the gold standard, the HD01 (Transonic Systems Inc., Ithaca, NY), whose technique is based on saline dilution. In 40 patients with end-stage renal disease, 40 vascular accesses were studied to determine the correlation between access flow measurements by both techniques. Reproducibility of access flow measurements by both techniques was assessed in 20 patients on a weekly interval.A total of 40 measurement series were performed. Average access flow measured with the saline technique and the thermodilution technique was 1053 (+/-495) ml/min and 1034 (+/-527) ml/min, respectively (p = ns) (n = 40). Correlation between access flow measurements by both techniques expressed in R was 0.79 (r = 0.89). Reproducibility of saline and thermodilution subsequent measurements with a weekly interval, expressed in relative difference (Delta xrel) was 13 (+/-11)% and 24 (+/-14)%, respectively (p < 0.01) (n = 20).BTM access flow measurements correlated well with the HD01 access flow measurements. However, the better reproducibility of HD01 and shorter measurement time compared with BTM access flow measurements should be considered when implementing access flow measurement to prevent vascular access failure.

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“…Some papers [12,13] have criticized the monitoring of vascular access flow as unnecessary because it has not been shown to prolong access patency. It has even been suggested that, on the contrary, it might even lead to an increase in the re-stenosis incidence due to vascular access endothelium injury during forced dilation using balloon angioplasty.…”

Section: Discussionmentioning

confidence: 99%

Physiologic Variability of Vascular Access Blood Flow for Hemodialysis

et al. 2008

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Aim: To assess the variability of blood flow (QVA) through a native arteriovenous fistula (AVF) in the long-term and to determine the QVA reduction at which an intervention is appropriate. Patients and Methods: The study was performed in a group of 34 chronic hemodialysis patients with no history of a AVF intervention. QVA was measured using the thermodilution method (Blood Thermodilution Monitor, Fresenius). Median follow-up was 41 months and the median number of QVA measurements in each patient was 15. The coefficient of variation (CV) of QVA was calculated for each patient. Results: Mean QVA was 904 ± 334 ml/min. The mean CV was 23.3 ± 11.2%. Conclusion: QVA may fluctuate during a long-term follow-up period. The detection of QVA decrease by 20–25% could be still within physiological limits. Based on the results we recommend to first repeat the measurement at a shorter interval and to refer the patient to a radiologist only when the decreasing trend is confirmed.

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Access Monitoring Does Not Really Improve Outcomes

Cited by 27 publications

References 48 publications

Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

Comparison Between Two On-Line Reversed Line Position Hemodialysis Vascular Access Flow Measurement Techniques: Saline Dilution and Thermodilution

Physiologic Variability of Vascular Access Blood Flow for Hemodialysis

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