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Significant Correlation Between Ankle-Brachial Index and Vascular Access Failure in Hemodialysis Patients

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Significant Correlation Between Ankle-Brachial Index and Vascular Access Failure in Hemodialysis Patients Significant Correlation between Ankle-Brachial Index and Vascular Access Failure in Hemodialysis Patients Szu-Chia Chen,*† Jer-Ming Chang,*†‡ Shang-Jyh Hwang,*‡ Jer-Chia Tsai,*‡ Chuan-Sheng Wang,† Hsiu-Chin Mai,† Feng-Hsien Lin,† Ho-Ming Su,†‡§ and Hung-Chun Chen*‡ *Division of Nephrology, §Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; †Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University; and ‡Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Background and objectives: Vascular access failure (VAF) is associated with increased morbidity and mortality in hemodialysis patients. The most common cause of VAF is stenosis at the arteriovenous anastomosis because of abnormal neointimal proliferation and extracellular matrix deposition. These two changes are also observed in the classic atheroma, which means atherosclerotic lesions and venous stenosis in VAF may share some similar pathogenic mechanisms. The ankle–brachial index (ABI) is a reliable marker for atherosclerosis. The aim of this study was to evaluate the relationship between ABI <0.9 and VAF. Design, setting, participants, & measurements: All routine hemodialysis patients in one regional hospital were included except for six patients refusing ABI examinations and four patients with atrial fibrillation. Finally, 225 patients formed our study group. The study subjects were observed from arteriovenous access creation until the first episode of VAF. The mean observation period was 42.2 ؎ 42.8 mo. The relative VAF risk was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions. ,(0.039 ؍ Results: VAF episodes were recorded in 111 patients. In multivariate analysis, ABI <0.9 (hazard ratio, 1.893; P were positively associated with (0.043 ؍ and serum triglyceride level (P ,(0.004 ؍ vascular access type of arteriovenous graft (P .was negatively associated with VAF (0.043 ؍ VAF, and serum parathyroid hormone level (P Conclusions: Our findings show that ABI <0.9 is significantly correlated with increased VAF. Screening hemodialysis patients by means of ABI may help to identify a high-risk group for VAF. Clin J Am Soc Nephrol 4: 128–134, 2009. doi: 10.2215/CJN.03080608 ascular access failure (VAF) is a frequent problem in ripheral artery occlusive disease (PAOD), and an ABI Ͻ0.9 has hemodialysis patients for its association with in- been used to identify this condition in clinical practice and V creased morbidity and hospitalization (1,2). The most epidemiologic studies (6–8). Previous studies also demon- common cause of VAF is stenosis at the arteriovenous anasto- strated that a low ABI was a good predictor of all-cause and mosis because of abnormal neointimal proliferation and extra- cardiovascular mortality in hemodialysis patients (9,10). How- cellular matrix deposition (3). These two changes are also ob- ever, there is no study to investigate the relationship between served in the classic atheroma, which means atherosclerotic ABI and vascular access patency in hemodialysis patients. lesions and venous stenosis in VAF may share some similar Thus, this study hypothesizes that an ABI Ͻ0.9, an indicator for pathogenic mechanisms (4,5). Identification of patients at high severe atherosclerosis, may be highly correlated with VAF in risk for VAF and requiring aggressive preventive and interven- patients with hemodialysis. The aim of this study is to evaluate tional strategies is an initial and essential step in managing the potential links between the ABI level and vascular access patients with end-stage renal disease (ESRD) undergoing he- survival. modialysis. The ankle-brachial index (ABI) was reported to be a good Materials and Methods marker for atherosclerosis and useful in the diagnosis of pe- Study Patients and Design The study was conducted at one dialysis clinic in one regional hospital in southern Taiwan. All routine hemodialysis patients in this Received June 24, 2008. Accepted September 8, 2008. hospital were included except for six patients refusing ABI examina- Published online ahead of print. Publication date available at www.cjasn.org. tions and four patients with atrial fibrillation. Finally, 225 patients (98 males and 127 females) formed our study group. The protocol was Correspondence: Dr. Ho-Ming Su, Department of Internal Medicine, Kaohsiung approved by our Institutional Review Board and all enrolled patients Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, 482 Shan-Ming Road, Hsiao-Kang Dist., 812 Kaohsiung, Taiwan, R.O.C. Phone: 886-7-8036783- gave written, informed consent. 3441; Fax: 886-7 8063346; E-mail: [email protected] The VAF was defined as thrombosis caused by stenosis having Copyright © 2009 by the American Society of Nephrology ISSN: 1555-9041/401–0128 Clin J Am Soc Nephrol 4: 128–134, 2009 ABI and Vascular Access Failure 129 received thrombectomy or greater than 50% stenosis shown on angiog- ciated with increased age, diabetes mellitus (DM), a history of raphy requiring either surgical revision or percutaneous transluminal coronary artery disease and cerebrovascular disease, increased angioplasty. The occurrence of VAF was confirmed from medical pulse pressure, decreased serum albumin, decreased HDL cho- records. The study subjects were observed from arteriovenous access lesterol, decreased creatinine, and increased hematocrit levels. creation until the first episode of VAF occurred. The mean observation Compared with patients with ABI м0.9, those with ABI Ͻ0.9 period was 42.2 Ϯ 42.8 mo (range 1 to 272). had a higher percentage of usage of arteriovenous graft (AVG) than arteriovenous fistula (AVF). Additionally, the percentage Hemodialysis of patients with an ABI Ͻ0.9 was higher in patients with AVG All patients underwent their routine hemodialysis three times a week using a Toray 321 machine (Toray Medical Company, Tokyo, Japan). (32.6%) than those with AVF (11.2%). Each hemodialysis session was performed for 3 to 4 h using a dialyzer VAF episodes were recorded in 111 patients (49.2%), includ- with a blood flow rate of 250 to 300 ml/min and dialysate flow of 500 ing 67 with vascular stenosis of arteriovenous anastomosis ml/min. (within 3 cm) and 44 with vascular stenosis distant from anas- tomosis (more than 3 cm). Table 2 shows a Cox proportional ABI Measurement hazards regression analysis for VAF. The univariate regression The values of the ABI were measured 10 to 30 min before hemodi- analysis shows the hazard ratio (HR) of ABI Ͻ0.9 was 2.682 alysis. The ABIs were measured by using an ABI-form device (VP1000, (95% confidence interval [CI], 1.746 to 4.118). In addition, other Colin, Komaki, Japan), which automatically and simultaneously mea- variables including older age, vascular access type of AVG, the sures blood pressure (BP) in both arms and ankles using an oscillomet- presence of DM, higher systolic BP, increased pulse pressure, ric method (11–13). The ABI was calculated by the ratio of the ankle higher BMI, increased serum triglyceride, decreased creatinine, systolic BP divided by the arm systolic BP. The systolic BP of the arm and decreased PTH level were also associated with a significant without dialysis access and the lower value of the ankle systolic BP Ͻ were used for the calculation. The ABI measurement was done once in increase in VAF. In the multivariate analysis, ABI 0.9 (HR, each patient. 1.893; 95% CI, 1.034 to 3.466), AVG usage, and serum triglyc- eride level were positively associated with VAF and serum Collection of Demographic, Medical, and Laboratory Data PTH level was negatively associated with VAF. Demographic and medical data including age, gender, smoking his- Figure 1 shows the Cox regression survival curves for vas- Ͻ tory (ever versus never), and comorbid conditions were obtained from cular access patency in hemodialysis patients with ABI 0.9 medical records and interviews with patients. The body mass index versus м 0.9. The curves were adjusted for age, gender, vascular (BMI) was calculated as the ratio of weight in kilograms divided by access type, DM, systolic BP, pulse pressure, BMI, serum trig- square of height in meters. Laboratory data were measured from fast- lycerides, creatinine, and PTH levels. Patients with ABI Ͻ 0.9 ing blood samples using an autoanalyzer (Roche Diagnostics GmbH, had a worse vascular access survival compared with those with D-68298 Mannheim, Germany; COBAS Integra 400). High-sensitivity ABI м 0.9 (P ϭ 0.039). C-reactive protein (CRP) (Dade Behring Marburg GmbH, Marburg, We also analyzed the correlation between an ABI Ͻ0.9 and Germany) was measured by commercially available kits. Serum intact vascular stenosis of different sites. After the multivariate anal- parathyroid hormone (PTH) concentration was evaluated using a com- ϭ mercially available two-sided immunoradiometric assay (CIS bio inter- ysis, we found that AVG usage (HR, 3.214; P 0.001) was ϭ national, Gif-sur-Yvette, France). Blood samples were obtained within 1 positively associated, and serum PTH level (HR, 0.999; P mo of enrollment. Kt/V was evaluated monthly as a marker of dialysis 0.018) was negatively associated, with VAF in the subgroup efficiency, and was determined according to the procedure of Gotch analysis involving the 67 patients with stenosis at the site of (14). arteriovenous anastomosis. However, an ABI Ͻ0.9 (HR, 1.888; P ϭ 0.134) was not significantly associated with VAF in this Statistical Analyses subgroup analysis. In contrast, an ABI Ͻ0.9 (HR, 2.890; P ϭ Statistical analyses were performed using SPSS 12.0 for windows 0.024) was significantly associated with VAF in the subgroup (SPSS Inc., Chicago, Illinois). Data are expressed as numbers and per- analysis involving the 44 patients with stenosis distant from Ϯ centages, or mean SD. The differences between groups were checked arteriovenous anastomosis. by chi-square test for categorical variables, or by independent t test for Because high values (ABI Ͼ1.40) could be related to poor continuous variables.
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