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Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis
Jehad Almasri1, Mouaz Alsawas1, Maria Mainou2
1Evidence-Based Practice Research Program and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
Insights
Autogenous vascular access, like fistulas, offers better patency and lower mortality for hemodialysis patients compared to grafts or catheters. Patient factors such as diabetes and age influence these outcomes.
Area of Science:
- Nephrology
- Vascular Surgery
- Public Health
Background:
- Vascular access selection for hemodialysis is complex, influenced by patient-specific factors.
- Optimal access type and location are crucial for successful long-term dialysis.
- Patient characteristics significantly impact hemodialysis access outcomes.
Purpose of the Study:
- To evaluate the effect of patient characteristics on hemodialysis vascular access outcomes.
- To synthesize evidence on patency, mortality, infection, and maturation rates.
- To inform clinical decision-making regarding vascular access planning.
Main Methods:
- Systematic literature search of major databases (MEDLINE, Embase, etc.) up to November 2014.
- Inclusion of studies reporting on patency, mortality, infection, and maturation in adult dialysis patients.
- Data extraction and meta-analysis using a random-effects model.
Main Results:
- 200 studies analyzed 875,269 vascular accesses with low to moderate risk of bias.
- Primary patency at 2 years: fistulas (55%) > catheters (50%) > grafts (40%).
- Lower patency observed in patients with diabetes, coronary artery disease, older individuals, and women.
- 2-year mortality: catheters (26%) > grafts (17%) > fistulas (15%).
Conclusions:
- Autogenous vascular access is recommended when feasible due to superior outcomes.
- Incidence rates in subgroups can guide shared decision-making for access planning.
- Evidence supports informed patient-provider conversations about vascular access choices.
Background:
The decision about the type and location of a hemodialysis vascular access is challenging and can be affected by multiple factors. We explored the effect of several a priori chosen patient characteristics on access outcomes.
Methods:
We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through November 13, 2014. We included studies that evaluated patency, mortality, access infection, and maturation of vascular access in adults requiring long-term dialysis. Pairs of reviewers working independently selected the studies and extracted the data. Outcomes were pooled across studies using the random-effects model.
Results:
Two hundred studies met the eligibility criteria reporting on 875,269 vascular accesses. Overall, studies appeared to have provided incidence rates at low to moderate risk of bias. The overall primary patency at 2 years was higher for fistulas than for grafts and catheters (55%, 40%, and 50%, respectively). Patency was lower in individuals with diabetes, coronary artery disease, older individuals, and in women. Mortality at 2 years was highest with catheters, followed by grafts then fistulas (26%, 17%, and 15%, respectively).
Conclusions:
The current evidence remains in support of autogenous access as the best approach when feasible. We provide incidence rates in various subgroups to inform shared decision making and facilitate the conversation with patients about access planning.
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