Pietro Ravani1, Robert R Quinn2, Matthew J Oliver3, Divya J Karsanji4, Matthew T James2, Jennifer M MacRae5, Suetonia C Palmer6, Giovanni F M Strippoli7. 1. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. Electronic address: pravani@ucalgary.ca. 2. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. 3. Department of Medicine, University of Toronto, Toronto, Canada. 4. Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. 5. Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada. 6. Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand. 7. Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy; Diaverum Academy, Bari, Italy; Diaverum Medical Scientific Office, Lund, Sweden; Sydney School of Public Health, University of Sydney, Sydney, Australia.
Abstract
BACKGROUND: Preemptive correction of a stenosis in an arteriovenous (AV) access (fistula or graft) that is adequately providing hemodialysis (functional AV access) may prolong access survival as compared to waiting for signs of access dysfunction to intervene (deferred salvage). However, the evidence in support of preemptive intervention is controversial. We evaluated benefits and harms of preemptive versus deferred correction of AV access stenosis. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials. SETTING & POPULATION: Adults receiving hemodialysis by a functional AV access. SELECTION CRITERIA FOR STUDIES: We searched the Cochrane Kidney and Transplant Specialised Register and EMBASE to October 15, 2015. INTERVENTION: Active access surveillance (flow measurement and Doppler or venous pressure) and preemptive correction of a newly identified stenosis versus routine clinical monitoring and deferred salvage, or preemptive correction of a known stenosis versus deferred salvage. OUTCOMES: Access loss (primary outcome) and thrombosis (overall and by access type), infection, mortality, hospitalization, and access-related procedures. RESULTS: We included 14 trials (1,390 participants; follow-up, 6-38 months). Relative to deferred salvage, preemptive correction of AV access stenosis had a nonsignificant effect on risk for access loss (risk ratio [RR], 0.81; 95% CI, 0.65-1.02; I(2)=0%) and a significant effect on risk for thrombosis (RR, 0.79; 95% CI, 0.65-0.97; I(2)=30%). Treatment effects were larger in fistulas than in grafts for both risk for access loss (subgroup difference, P=0.05) and risk for thrombosis (subgroup difference, P=0.002). Results were heterogeneous or imprecise for mortality, rates of access-related infections or procedures, and hospitalization. LIMITATIONS: Small number and size of primary studies limited analysis power. CONCLUSIONS: Preemptive stenosis correction in a functional AV access does not improve access longevity. Although preemptive stenosis correction may be promising in fistulas, existing evidence is insufficient to guide clinical practice and health policy.
BACKGROUND: Preemptive correction of a stenosis in an arteriovenous (AV) access (fistula or graft) that is adequately providing hemodialysis (functional AV access) may prolong access survival as compared to waiting for signs of access dysfunction to intervene (deferred salvage). However, the evidence in support of preemptive intervention is controversial. We evaluated benefits and harms of preemptive versus deferred correction of AV access stenosis. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials. SETTING & POPULATION: Adults receiving hemodialysis by a functional AV access. SELECTION CRITERIA FOR STUDIES: We searched the Cochrane Kidney and Transplant Specialised Register and EMBASE to October 15, 2015. INTERVENTION: Active access surveillance (flow measurement and Doppler or venous pressure) and preemptive correction of a newly identified stenosis versus routine clinical monitoring and deferred salvage, or preemptive correction of a known stenosis versus deferred salvage. OUTCOMES: Access loss (primary outcome) and thrombosis (overall and by access type), infection, mortality, hospitalization, and access-related procedures. RESULTS: We included 14 trials (1,390 participants; follow-up, 6-38 months). Relative to deferred salvage, preemptive correction of AV access stenosis had a nonsignificant effect on risk for access loss (risk ratio [RR], 0.81; 95% CI, 0.65-1.02; I(2)=0%) and a significant effect on risk for thrombosis (RR, 0.79; 95% CI, 0.65-0.97; I(2)=30%). Treatment effects were larger in fistulas than in grafts for both risk for access loss (subgroup difference, P=0.05) and risk for thrombosis (subgroup difference, P=0.002). Results were heterogeneous or imprecise for mortality, rates of access-related infections or procedures, and hospitalization. LIMITATIONS: Small number and size of primary studies limited analysis power. CONCLUSIONS: Preemptive stenosis correction in a functional AV access does not improve access longevity. Although preemptive stenosis correction may be promising in fistulas, existing evidence is insufficient to guide clinical practice and health policy.
Authors: Pietro Ravani; Robert Quinn; Matthew Oliver; Bruce Robinson; Ronald Pisoni; Neesh Pannu; Jennifer MacRae; Braden Manns; Brenda Hemmelgarn; Matthew James; Marcello Tonelli; Brenda Gillespie Journal: Clin J Am Soc Nephrol Date: 2017-05-18 Impact factor: 8.237
Authors: Pietro Ravani; Robert R Quinn; Matthew J Oliver; Divya J Karsanji; Matthew T James; Jennifer M MacRae; Suetonia C Palmer; Giovanni F M Strippoli Journal: Cochrane Database Syst Rev Date: 2016-01-07
Authors: Jennifer M MacRae; Christine Dipchand; Matthew Oliver; Louise Moist; Charmaine Lok; Edward Clark; Swapnil Hiremath; Joanne Kappel; Mercedeh Kiaii; Rick Luscombe; Lisa M Miller Journal: Can J Kidney Health Dis Date: 2016-09-27
Authors: Chance Dumaine; Mercedeh Kiaii; Lisa Miller; Louise Moist; Matthew J Oliver; Charmaine E Lok; Swapnil Hiremath; Jennifer M MacRae Journal: Can J Kidney Health Dis Date: 2018-02-28