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Best Threshold for Diagnosis of Stenosis Or Thrombosis Within Six Months of Access Flow Measurement in Arteriovenous Fistulae

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Best Threshold for Diagnosis of Stenosis Or Thrombosis Within Six Months of Access Flow Measurement in Arteriovenous Fistulae J Am Soc Nephrol 14: 3264–3269, 2003 Best Threshold for Diagnosis of Stenosis or Thrombosis within Six Months of Access Flow Measurement in Arteriovenous Fistulae MARCELLO TONELLI,*†‡ GIAN S. JHANGRI,§ DAVID J. HIRSCH,ʈ¶ JOANNE MARRYATT,¶ PAULA MOSSOP,¶ COLLEEN WILE,¶ and KAILASH K. JINDAL* *Department of Medicine, University of Alberta, Edmonton, Canada; †Department of Critical Care, University of Alberta, Edmonton, Canada; ‡Institute of Health Economics, Edmonton, Canada; §Department of Public Health Sciences, University of Alberta, Edmonton, Canada; ʈDepartment of Medicine, Dalhousie University, Halifax, Canada; and ¶Queen Elizabeth II Health Sciences Centre, Halifax, Canada Abstract. Canadian clinical practice guidelines recommend within 6 mo, and both seemed superior to Ͻ400 ml/min. performing angiography when access blood flow (Qa) is Ͻ500 However, the frequency of the composite definition of stenosis ml/min in native vessel arteriovenous fistulae (AVF), but data among AVF with Qa between 500 and 600 ml/min was only 6 on the value of Qa that best predicts stenosis are sparse. (25%) of 24, as compared with 58 (76%) of 76 when Qa was Because correction of stenosis in AVF improves patency rates, Ͻ500 ml/min. This suggests that most lesions that would be this issue seems worthy of investigation. Receiver-operating found using a threshold of Ͻ600 ml/min occurred in AVF with characteristic curves were constructed to examine the relation- Qa Ͻ500 ml/min and that the small gain in sensitivity associ- ship between different threshold values of Qa and stenosis in ated with the Ͻ600-ml/min threshold would be outweighed by 340 patients with AVF. Stenosis was defined by the composite the reduced specificity compared with Ͻ500 ml/min. Correct- outcome of access failure or angiographic stenosis occurring ing Qa for BP did not improve diagnostic performance or within 6 mo of the first Qa measurement. The Qa value was change these results, which were consistent in several sensi- then classified as true negative, true positive, false negative, or tivity analyses. Qa measurements seemed to predict stenosis or false positive for stenosis. An additional analysis was per- incipient access failure equally well in groups defined by formed in which Qa was corrected for systolic BP before diabetic status, gender, and AVF location. In conclusion, it was assigning it to one of the four diagnostic categories. The area found that Qa Ͻ500 ml/min seems to be the most appropriate under the curve for the composite definition of stenosis was threshold for performing angiography in patients with native 0.86. Graphically, Qa thresholds of Ͻ500 and Ͻ600 ml/min vessel AVF. It is recommended that clinicians arrange angiog- had similar efficacy for detecting stenosis or access failure raphy when Qa is Ͻ500 ml/min in AVF. Measurements of access blood flow (Qa) have been shown to already occurs in patients who have positive screening studies and are identify first and recurrent episodes of stenosis in patients with awaiting fistulography (1). However, because no large-scale compar- native vessel arteriovenous fistulae (AVF) (1,2). Canadian clinical ison of different threshold values for angiography has been per- practice guidelines recommend performing angiography in AVF formed, the potential value of using thresholds other than 500 ml/min when Qa is Ͻ500 ml/min (3), which is associated with a positive is uncertain. Because correction of stenosis in AVF improves access predictive value for stenosis of approximately 70%. patency and reduces access-related morbidity (6), determining the Because AVF seem to remain patent at Qa that would be associ- optimal Qa threshold for performing angiography may be particularly ated with thrombosis in polytetrafluoroethylene (PTFE) grafts (4,5), important. reserving angiography for lower levels of Qa might reduce the false- We used receiver-operating characteristic (ROC) curves to positive rate associated with screening. Conversely, such a strategy examine the relationship between different levels of Qa and ste- might result in increased rates of AVF loss, because thrombosis nosis in a large group of patients with AVF. We hypothesized that performing angiography only when Qa was Ͻ400 ml/min would improve the predictive accuracy of Qa measurements. In addition, Received June 19, 2003. Accepted September 13, 2003. because BP is known to influence Qa (7), we assessed the diag- Correspondence to Dr. Marcello Tonelli, 11-108 Clinical Sciences Building, nostic performance of Qa that had been adjusted for BP. 8440-112 Street, Edmonton, Alberta T6G 2G3, Canada. Phone: 780-407-8716; Fax: 780-407-7878; E-mail: [email protected] 1046-6673/1412-3264 Materials and Methods Journal of the American Society of Nephrology Study Design Copyright © 2003 by the American Society of Nephrology We began routinely screening patients with functioning AVF using DOI: 10.1097/01.ASN.0000099381.98940.2E Qa measurements in October 1999 as per published guidelines (3,4). J Am Soc Nephrol 14: 3264–3269, 2003 Qa Measurements in AV Fistulae 3265 No other access screening was performed. All incident and prevalent spectively. The length of this period was then varied in sensitivity chronic hemodialysis patients with a functioning AVF at the Queen analyses (3 mo and 9 mo after the Qa measurement, respectively). Elizabeth Health Sciences Centre were eligible for inclusion in the current study. Patients were followed from the time of their first Statistical Analyses screening study until access failure, transplantation, transfer to an- Each Qa measurement was classified as true negative, true positive, other hemodialysis unit, or death. AVF were considered to have failed false negative, or false positive for stenosis. Additional analyses were when they could not deliver sufficient blood flow to permit a hemo- performed in which Qa was corrected for BP before assigning it to one dialysis treatment. of the four diagnostic categories. For all of these analyses, Qa values were categorized into 100-ml/min intervals (Ͻ100, 100 to 199.9, 200 Dialysis Technique to 299.9 etc.). ROC curves were then constructed using standard techniques, and sensitivity, specificity, the likelihood ratio of stenosis Patients were dialyzed according to their usual prescription. No associated with a positive test, and the likelihood ratio of stenosis patients received antiplatelet or anticoagulant agents specifically to associated with a negative test were calculated. To evaluate for the maintain access patency. Blood pump speeds were set as high as presence of spectrum effect (10), we repeated analyses in groups venous pressures would allow, and fistulae were cannulated with defined by diabetic status, gender, and access location. 15-gauge needles whenever possible. Predictive power of the various ROC curves was compared using the method of Delong et al. (11). A two-sided P value of Ͻ0.05 was Procedure for Access Screening considered significant. Statistical analysis was performed using Inter- Screening studies were performed bimonthly with a Transonic cooled Stata (College Station, TX) and SAS 8.2 (Cary, NC). HD01 Monitor (Transonic Systems Inc., Ithaca, NY), using indicator dilution technology, where the ultrasound velocity through blood is Results the indicator and dilution is provided by the bolus of normal saline. Clinical Characteristics and Outcomes The validation of this device has been described elsewhere (8,9). A total of 340 patients were eligible for the study (Table 1). Each patient had Qa measured twice in succession during the same To calculate diagnostic properties of the various Qa thresholds, dialysis treatment, and the mean value was recorded. BP was mea- we used data from all patients, regardless of whether they sured using an automated device within 5 min of the Qa measure- underwent angiography or developed clinical evidence of ste- ments. Studies were not performed during the last hour of hemodial- nosis. Overall, mean Qa was 989 ml/min (range, 30 to 3887 ysis or during periods of clinically significant hypotension (at the discretion of the dialysis unit nurses). To ensure independence of ml/min), and the median within-patient coefficient of variation observations, we considered only the first screening measurement for Qa was 5.0%. In 96 of 340 patients, angiography was made per patient. performed within 6 mo of the Qa measurement. Angiography was indicated only because of abnormal screening values in 62, only because of clinical suspicion of stenosis in 14, and for Gold Standard for Stenosis both reasons in 20. Among the patients with clinical evidence As per published guidelines, patients underwent angiography only of dysfunction, mean Qa was 545 ml/min (range, 110 to 1410 when Qa was Ͻ500 ml/min, when Qa had declined by Ͼ20% from ml/min), and 19 (55.9%) of 34 had Qa Ͻ500 ml/min. Stenosis baseline values (regardless of the Qa value itself), or in cases of clinical access dysfunction (defined by persistent difficulty in nee- was found in 81 (84.4%) of 96 patients undergoing dling, poor Qb, low urea reduction ratio, or physical findings suggest- angiography. ing stenosis) (3). As in our previous work, we referred for angiogra- phy all patients in whom Qa could not be measured (1). Because no Diagnostic Properties of Qa Measurements Qa values were available for these patients, they could not be included The area under the ROC curve (AUC) for the composite in the current analysis; however, many had stenosis as previously definition of stenosis was 0.86. Graphically, Qa thresholds of reported (1). Significant stenosis was defined as Ͼ50% luminal di- ameter on biplanar angiography. Small-caliber vessels were not con- sidered to represent stenosis, but patients in whom this abnormality a was found were referred for creation of a new access when clinically Table 1. Clinical characteristics of patients indicated. Radiologists were asked to ensure that the arteriovenous Ϯ anastomosis was visualized in all AVF undergoing angiography. They Age 64.9 16.4 yr were not aware of Qa results when interpreting angiograms.
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