RESUMEN

According to the "Fistula First Initiative" surgeon selection should be based on best outcomes, willingness, and ability to provide access services. This analysis presents arteriovenous access placement and outcomes in 75 patients when surgery was performed by one of two dedicated high-volume vascular access surgeons (community [surgeon I] and academic medical center [surgeon II]). Preoperative vascular mapping was performed in all the patients. Demographic characteristics were similar except that patients referred to surgeon I (n = 40) were older (52.7 +/- 16.2 years vs. 45.4 +/- 13.7 years; p = 0.04) and tended to have more previously failed accesses (50% vs. 29%; p = 0.06) and black race (65% vs. 43%; p = 0.055) including a history of previously failed accesses (50% for surgeon I and 29% for surgeon II; p = 0.06). Similarly, there was no significant difference in the size of forearm ([surgeon I: 2.0 +/- 1.0 mm], [surgeon II: 1.9 +/- 0.8 mm]; p = 0.45) or upper arm veins (cephalic vein: surgeon I = 3.2 +/- 1.4 mm, surgeon II = 2.9 +/- 1.2 mm, p = 0.34; basilic vein: surgeon I = 5.0 +/- 1.2 mm, surgeon II = 4.7 +/- 1.3 mm, p = 0.25). Fistulae placement occurred in 98% vs. 71% (p = 0.001) for surgeon I and II, respectively. Characteristics predictive of fistula placement over an arteriovenous graft were surgeon selection (odds ratio [OR] = 19.52; p = 0.01) and no history of diabetes (OR = 7.61; p = 0.016). Kaplan-Meier analysis revealed 6 and 12 months overall access survival rates of 82%, 58% and 82% and 47% for surgeon I and II, respectively (p = 0.007). This analysis demonstrates that surgeon selection can have a significant impact on the rate of fistula placement and its overall survival despite similar findings on preoperative vascular mapping.

Asunto(s)

RESUMEN

Physical examination has recently been demonstrated to detect vascular access stenosis in patients with arteriovenous fistulae. However, its accuracy in the identification of stenoses when compared with the gold standard (angiography) in patients with arteriovenous grafts has not been studied in a systematic fashion. We conducted a prospective study to examine the accuracy of physical examination in the detection of stenotic lesions when compared with angiography. Forty-three consecutive cases referred for an arteriovenous graft dysfunction were included in this analysis. Preprocedure physical examination was performed. The findings of the examination and diagnosis were recorded and secured in a sealed envelope. Angiography from the feeding artery to the right atrium was performed. The images were reviewed by an independent interventionalist with expertise in endovascular dialysis access procedures and the diagnosis was rendered. The reviewer was blinded to the physical examination. Cohen's Kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. There was a strong agreement between the physical examination and the angiography in the diagnosis of vein-graft anastomotic stenosis (kappa = 0.52). The sensitivity and specificity for this lesion was 57% and 89%, respectively. There was a moderate agreement beyond chance regarding the diagnosis of intragraft (kappa = 0.43) and inflow stenoses (kappa = 0.40). The sensitivity and specificity for the intragraft and inflow stenosis was 100%, 73% and 33%, 73%; respectively. The findings of this study demonstrate that physical examination can assist in the detection and localization of stenoses in arteriovenous grafts.

Asunto(s)

RESUMEN

BACKGROUND AND OBJECTIVES: Physical examination has been highlighted to detect vascular access stenosis; however, its accuracy in the identification of stenoses when compared with the gold standard (angiography) has not been validated in a systematic manner. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective study was conducted of 142 consecutive patients who were referred for an arteriovenous fistula dysfunction to examine the accuracy of physical examination in the detection of stenotic lesions when compared with angiography. The findings of a preprocedure physical examination and diagnosis were recorded and secured in a sealed envelope. Angiography from the feeding artery to the right atrium was then performed. The images were reviewed by an independent interventionalist who had expertise in endovascular dialysis access procedures and was blinded to the physical examination, and the diagnosis was rendered. Cohen's kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. RESULTS: There was strong agreement between physical examination and angiography in the diagnosis of outflow (agreement 89.4%, kappa = 0.78) and inflow stenosis (agreement 79.6%, kappa = 0.55). The sensitivity and specificity for the outflow and inflow stenosis were 92 and 86% and 85 and 71%, respectively. There was strong agreement beyond chance regarding the diagnosis of coexisting inflow-outflow lesions between physical examination and angiography (agreement 79%, kappa = 0.54). CONCLUSIONS: The findings of this study demonstrate that physical examination can accurately detect and localize stenoses in a great majority of arteriovenous fistulas.

Asunto(s)

RESUMEN

The focus of blood pressure (BP) lowering is to prevent or reduce the risk for cardiovascular and renal events. This rationale forms the basis for the recent guideline statements issued by the Seventh Joint National Committee, the American Diabetes Association, the European Society of Hypertension, and the Kidney Disease Outcomes Quality Initiative. The goal BP in the majority of hypertensive patients should be less than 140/90 mm Hg, with a lower goal of less than 130/80 mm Hg in patients with diabetes or kidney disease. Meta-analyses of clinical trials with renal end points make it clear that the presence of 1 gram or more of proteinuria mandates a BP approaching 115 mm Hg to slow the progression of advanced nephropathy adequately. Compelling indications also exist for the use of certain antihypertensive agents in the setting of kidney dysfunction, diabetes, heart failure, and coronary artery disease. Initiation with 2 antihypertensive agents should be considered strongly for patients with a BP of more than 20 mm Hg greater than the systolic BP goal. This means that those with a goal BP of less than 130 mm Hg should be started on 2 antihypertensive medications with complementary actions when the systolic BP is 150 mm Hg or greater. In patients with kidney disease, reaching the BP goal requires multiple agents that should include an appropriate diuretic and an agent that blocks the renin-angiotensin-aldosterone system to slow the progression of kidney disease.

Asunto(s)

RESUMEN

Proteinuria is a graded marker for kidney damage, as well as the risk for future cardiovascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) reduce urinary protein excretion and slow progression of renal impairment, independent of blood pressure lowering. Both the Irbesartan Diabetic Nephropathy Trial (IDNT) and the Reduction in Endpoints in NIDDM with the Angiotensin Antagonist Losartan (RENAAL) study were large, randomized, prospective studies in type 2 diabetic patients with proteinuria. There was no reduction in the incidence of myocardial infarction or stroke with the ARBs compared to placebo in either trial. A broader overview of clinical trials comparing ACEIs and ARBs with other antihypertensive drugs fails to show any substantive blood pressure-independent effects on stroke or myocardial infarction with these classes of drugs. Therefore, for cardiovascular end points (as opposed to renal end points), it may be more important that the blood pressure is reduced, rather than how the process is started.

Asunto(s)

Asunto(s)