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• W2000360618 abstract "The Dialysis Outcomes Quality Initiative emphasizes increasing arteriovenous fistula prevalence, by promoting referral for fistula creation in patients with stage 4 chronic kidney disease (CKD). The aim is to provide an optimal access for initiation of dialysis, thus avoiding central venous catheter use. The endovascular management of nonmaturing fistulas is more complicated in these patients, where the expected benefit of catheter avoidance must be weighed against the risk of contrast induced nephropathy (CIN). This study reports on the safety of a low-dose radiocontrast regimen, used in performing endovascular fistula salvage procedures in patients with stage 4 CKD. All consecutive endovascular procedures performed over a 2-year period in patients with stage 4 CKD and nonmaturing access were identified. Data collected included the type of procedure, contrast volume per procedure, pre, 2- and 7-day creatinine, need for acute dialysis, and the type of access used to initiate dialysis. Total of 65 procedures were performed in 34 patients. The mean contrast volume was 7.8 ml per procedure. The incidence of CIN (25% increase in serum creatinine) was 4% at 2 days and 4.6% at 1 week. All values returned to baseline within 2 weeks, and no patient required acute dialysis. Among the 33 patients with nonmaturing fistulas, 20 initiated dialysis during the follow-up period, 15 (75%) using their fistula, and five (25%) using a catheter. This study demonstrates that in patients with advanced CKD, fistulas can be successfully salvaged using small contrast volumes with a low incidence of CIN. The Dialysis Outcomes Quality Initiative emphasizes increasing arteriovenous fistula prevalence, by promoting referral for fistula creation in patients with stage 4 chronic kidney disease (CKD). The aim is to provide an optimal access for initiation of dialysis, thus avoiding central venous catheter use. The endovascular management of nonmaturing fistulas is more complicated in these patients, where the expected benefit of catheter avoidance must be weighed against the risk of contrast induced nephropathy (CIN). This study reports on the safety of a low-dose radiocontrast regimen, used in performing endovascular fistula salvage procedures in patients with stage 4 CKD. All consecutive endovascular procedures performed over a 2-year period in patients with stage 4 CKD and nonmaturing access were identified. Data collected included the type of procedure, contrast volume per procedure, pre, 2- and 7-day creatinine, need for acute dialysis, and the type of access used to initiate dialysis. Total of 65 procedures were performed in 34 patients. The mean contrast volume was 7.8 ml per procedure. The incidence of CIN (25% increase in serum creatinine) was 4% at 2 days and 4.6% at 1 week. All values returned to baseline within 2 weeks, and no patient required acute dialysis. Among the 33 patients with nonmaturing fistulas, 20 initiated dialysis during the follow-up period, 15 (75%) using their fistula, and five (25%) using a catheter. This study demonstrates that in patients with advanced CKD, fistulas can be successfully salvaged using small contrast volumes with a low incidence of CIN. Contrast-induced nephropathy (CIN) is a well-recognized cause of acute renal failure. Chronic kidney disease (CKD) with impaired glomerular filtration rate is the most important risk factor for CIN,1.Morcos S.K. Thomsen H.S. Webb J.A. Contrast-media-induced nephrotoxicity: a consensus report. Contrast Media Safety Committee, European Society of Urogenital Radiology (ESUR).Eur Radiol. 1999; 9: 1602-1613Crossref PubMed Scopus (417) Google Scholar, 2.Rudnick M.R. Goldfarb S. Wexler L. et al.Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative Study.Kidney Int. 1995; 47: 254-261Abstract Full Text PDF PubMed Scopus (822) Google Scholar, 3.Guitterez N.V. Diaz A. Timmis G.C. et al.Determinants of serum creatinine trajectory in acute contrast nephropathy.J Interv Cardiol. 2002; 15: 349-354Crossref PubMed Scopus (113) Google Scholar and diabetes with impaired glomerular filtration rate confers a higher CIN risk than renal dysfunction alone. Measures taken to reduce CIN in high-risk patients include minimizing the radiocontrast dose,4.Cigarroa R.G. Lange R.A. Williams R.H. Hillis L.D. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease.Am J Med. 1989; 86: 649-652Abstract Full Text PDF PubMed Scopus (409) Google Scholar, 5.Manske C.L. Sprafka J.M. Strony J.T. Wang Y. Contrast nephropathy in Azotemic diabetic patients undergoing coronary angiography.Am J Med. 1990; 89: 615-620Abstract Full Text PDF PubMed Scopus (451) Google Scholar, 6.Freeman R.V. O’Donnell M. Share D. et al.Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.Am J Cardiol. 2002; 90: 1068-1073Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar selection of a low osmolar contrast media,2.Rudnick M.R. Goldfarb S. Wexler L. et al.Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative Study.Kidney Int. 1995; 47: 254-261Abstract Full Text PDF PubMed Scopus (822) Google Scholar intravenous bicarbonate infusion,7.Merten G.J. Burgess W.P. Gray L.V. et al.Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial.JAMA. 2004; 291: 2328-2334Crossref PubMed Scopus (903) Google Scholar and avoidance of volume depletion using intravenous half-normal or normal saline.8.Solomon R. Werner C. Mann D. et al.Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents.N Engl J Med. 1994; 331: 1416-1420Crossref PubMed Scopus (1101) Google Scholar, 9.Taylor A.J. Hotchkiss D. Morse R.W. McCabe J. PREPARED: Preparation for angiography in renal dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction.Chest. 1998; 114: 1570-1574Crossref PubMed Scopus (194) Google Scholar, 10.Mueller C. Buerkle G. Buettner H.J. et al.Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty.Arch Intern Med. 2002; 162: 329-336Crossref PubMed Scopus (691) Google Scholar, 11.Triverdi H.S. Moore H. Nasr S. et al.A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity.Nephro Clin Pract. 2003; 93: C29-C34Crossref PubMed Scopus (361) Google Scholar Unfortunately, the available literature does not define a safe contrast dose. General consensus is the use of the smallest dose of contrast to achieve an acceptable outcome. For many cardiovascular and radiological procedures, these doses range from 50 to 300 ml, and typically more than 100 ml of contrast is employed. Dialysis access endovascular procedures require considerably lower doses with a range from 10 to 50 ml. Recent studies have shown that autologous arteriovenous fistulas (AVF) have a significant initial failure rate ranging between 20 and 50%.12.Allon M. Robbin M.L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.Kidney Int. 2002; 62: 1109-1124Abstract Full Text Full Text PDF PubMed Google Scholar However, the practice of abandoning nonmaturing fistulas is challenged by studies in which the majority of immature AVF were salvaged to support dialysis, using a variety of interventions.13.Beathard G.A. Settle S.M. Shields M.W. Salvage of the nonfunctioning arteriovenous fistula.Am J Kidney Dis. 1999; 33: 910-916Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 14.Beathard G.A. Arnold P. Jackson J. Litchfield T. Physician operators forum of RMS lifeline: aggressive treatment of early fistula failure.Kidney Int. 2003; 64: 1487-1494Abstract Full Text Full Text PDF PubMed Scopus (332) Google Scholar Until recently, the majority of procedures for nonmaturing access were performed in patients already established on hemodialysis (HD). Here, the risk of radiocontrast use is limited to the uncommon adverse allergic reactions and occasional volume overload when large contrast volumes are used. The Dialysis Outcomes Quality Initiative15.National Kidney Foundation NKF-K/DOQI clinical practice guidelines for vascular access, Guideline 8: Timing of access placement.Am J Kidney Dis. 2001; 37: S137-S181PubMed Google Scholar and the ‘Fistula First’ National Vascular Access Improvement Initiative16.Beasley C. Rowland J. Spergel L. Fistula first: An update for renal providers.Nephrol News Issues. 2004; 18: 88-90PubMed Google Scholar emphasize increasing AVF prevalence, in part by promoting early referral for AVF creation. These initiatives will undoubtedly result in an increase in the number of patients with stage 4 CKD and fistulas. The aim of early fistula creation is to provide an optimal access for the initiation of HD, thus entirely avoiding central venous catheter use. The management of nonmaturing or thrombosed fistulas is more complicated in patients with CKD, where the expected benefit of catheter avoidance must be weighed against the CIN risk in a setting of reduced glomerular filtration rate. This paper describes the experience of an interventional nephrology center in performing fistula salvage procedures in patients with stage 4 CKD, using a low-dose radiocontrast regimen, with particular focus on the incidence of CIN. Baseline demographic and clinical characteristics are summarized in Table 1. The mean age was 68 years, and 38% of the patients were over the age of 75. In total, 20 patients (59%) were diabetic. A total of 65 procedures were performed. The volume of contrast ranged from 1.5 to 25 ml per procedure (mean 7.8±5.2 ml; median 6 ml). Therefore, the total volume of diluted contrast (combined in a 1:3 ratio with saline) was four times these values (mean 31.2 ml). The preprocedure mean creatinine was 4.37 mg/dl. For all patients, an estimation of the baseline glomerular filtration rate was performed using the Modification of Diet in Renal Disease formula. This showed a mean glomerular filtration rate of 16 (median 14; range 6–33).Table 1Demographic characteristicsAge (mean±s.d)68±13 yearsMale20 (59%)Diabetes20 (59%)Race Caucasian23 (68%) Hispanic7 (20%) African American3 (9%) Asian1 (3%) Open table in a new tab Preprocedure and 7-day creatinine levels were available for all 65 procedures (Table 2). The 2-day creatinine was available for 50 procedures. There was a small and nonsignificant increase in mean serum creatinine at day 2 (+0.04 mg/dl; 95% CI: -0.14, +0.23) and day 7 (+0.11 mg/dl; 95% CI: -0.02, +0.23; P=0.09 for the comparison between preprocedure and 7-day creatinine). CIN, defined as a 25% increase in serum creatinine, occurred following two procedures (4%) at day 2, and three procedures (4.6%) at day 7. In all cases, creatinine values returned to baseline within 2 weeks, and there were no episodes of CIN requiring dialysis. There was no relationship between the volume of contrast and the occurrence of CIN in this cohort, with four of five CIN episodes occurring after the infusion of contrast volumes below the median dose of 6 ml. The percentage change in serum creatinine was similar whether the procedure was performed using contrast volumes ≤ or > than the median dose of 6 ml (P=0.7).Table 2Renal outcomes (all procedures)Preprocedure (n=65)Day 2 (n=50)Day 7 (n=65)Creatinine (mg/dl)4.37 (4.0–4.8)4.64 (4.1–5.2)4.47 (4.1–4.9)Change in creatinine (mg/dl)+0.04 (-0.1 to +0.2)+0.1 (-0.02 to +0.2)% Change in creatinine (%)+1.3 (-2.6 to +5.1)+3.0 (+2.5 to +5.7)>25% rise in creatinine2/50 (4%)3/65 (4.6%)Data are reported as means (95% confidence intervals) for continuous variables and as proportions for categorical variables. The P-value for the difference between the mean preprocedure and 7-day creatinine values is 0.09 (paired t-test). Open table in a new tab Data are reported as means (95% confidence intervals) for continuous variables and as proportions for categorical variables. The P-value for the difference between the mean preprocedure and 7-day creatinine values is 0.09 (paired t-test). Table 3 summarizes characteristics and outcomes of procedures by diabetic status. The mean preprocedure creatinine was 4.4 mg/dl, with a nonsignificant trend towards higher preprocedure creatinine in non-diabetics (4.7 versus 4.0 mg/dl; P=0.1). The mean volume of contrast did not differ significantly between diabetics and non-diabetics (8.1 versus 7.2 ml; P=0.5). The mean percentage change in serum creatinine at day 7 was +3%, and did not vary significantly by diabetic status (P=0.6).Table 3Renal outcomes by diabetic statusDiabetes (n=39)No diabetes (n=26)P-valuePreprocedure creatinine (mg/dl)4.0 (3.6–4.5)4.7 (4.0–5.3)0.1Contrast volume (ml)8.1 (6.2–10.1)7.2 (5.7–8.7)0.5Change in creatinine at day 7 (mg/dl)+0.12 (-0.16, +0.28)+0.09 (-0.12, +0.28)0.9% Change in creatinine at day 7+ 3.7 (0.0, +7.3)+2.1 (-2.3, +6.5)0.6Data are reported as means (95% confidence intervals) for continuous variables. Reported P-values are for the comparison between diabetic and non-diabetic patients. Open table in a new tab Data are reported as means (95% confidence intervals) for continuous variables. Reported P-values are for the comparison between diabetic and non-diabetic patients. A total of 65 procedures were performed in 34 patients (average 1.9 procedures/patient). A total of 62 procedures were performed in 33 patients with fistulas, and three procedures were performed in a single patient with a graft. There were 57 episodes of venography and angioplasty in 29 patients with nonmaturing access, and eight thrombectomies in five patients with clotted access (mean volume of contrast used for thrombectomies was 7.9 ml). Two patients experienced mild extravasations and grade I hematomas. There were no major complications. For nonmaturing fistulas, location and the lesions treated are summarized in Table 4. A total of 85 lesions were treated (1.5 lesions per procedure). Arterial anastamosis and Juxta-anastamotic segment lesions were more common in the forearm access, and fistula body and cephalic arch lesions were more prevalent in the upper arm fistula. Four patients with fistulas underwent six thrombectomies. Immediate anatomic success was achieved in five of these procedures. One patient started dialysis using the fistula, and one patient remained dialysis-independent with a patent fistula at the end of the study period. In two patients, the access was eventually abandoned. The single patient with the graft required two thrombectomies. During the follow-up period, the patient had not yet initiated dialysis and the graft remained patent.Table 4Site of lesions in relation to access locationSite of lesionForearm fistula (22 procedures)Upper arm fistula (35 procedures)Arterial, arterial anastamosis72JAS99AVF body815Cephalic arch017Central01Accessory vein ligation78AVF, arteriovenous fistulas; JAS, Juxta-anastamotic segment. Open table in a new tab AVF, arteriovenous fistulas; JAS, Juxta-anastamotic segment. By the end of the study period, 15 of the 33 patients with fistulas had started dialysis using the fistula (46%), 13 (39%) remained in stage 4 CKD, and 5 (15%) patients required a catheter at the initiation of dialysis. While programs aimed at improving vascular access management in prevalent HD patients are important, the success of any vascular access quality improvement initiative requires reduction of the number of incident HD patients treated with a catheter.17.Walters B. Pennell P. Bosch J. Quality assurance and continuous quality improvement programs for vascular access care.Contrib Nephrol. 2004; 142: 323-349Crossref PubMed Google Scholar, 18.Arora P. Obrador G.T. Ruthazer R. et al.Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center.J Am Soc Nephrol. 1999; 10: 1281-1286PubMed Google Scholar Guideline 8 of Dialysis Outcomes Quality Initiative proposes proactive access planning during stage 4 CKD.15.National Kidney Foundation NKF-K/DOQI clinical practice guidelines for vascular access, Guideline 8: Timing of access placement.Am J Kidney Dis. 2001; 37: S137-S181PubMed Google Scholar The ‘Fistula First’ initiative includes 11 concepts to foster AVF prevalence, one of which is the ‘fistula only’ vascular surgery consult for stage 4 CKD patients.16.Beasley C. Rowland J. Spergel L. Fistula first: An update for renal providers.Nephrol News Issues. 2004; 18: 88-90PubMed Google Scholar Multiple steps are involved in increasing the number of patients that start HD with a functional AVF.12.Allon M. Robbin M.L. Increasing arteriovenous fistulas in hemodialysis patients: problems and solutions.Kidney Int. 2002; 62: 1109-1124Abstract Full Text Full Text PDF PubMed Google Scholar, 13.Beathard G.A. Settle S.M. Shields M.W. Salvage of the nonfunctioning arteriovenous fistula.Am J Kidney Dis. 1999; 33: 910-916Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 19.Faiyaz R. Abreo K. Zaman F. et al.Salvage of poorly developed arteriovenous fistulae with percutaneous ligation of accessory veins.Am J Kidney Dis. 2002; 39: 824-827Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar An important part of the vascular access cycle from creation to cannulation is the postoperative monitoring and correction of lesions in immature and failing fistulas. Barriers to provision of these services result in an increase in emergency access procedures and emergent use of catheters for dialysis.20.Sands J.J. Montis A.L. Etheredge G.D. Systemic barriers to vascular access care: implications for clinical outcomes.Contrib Nephrol. 2004; 142: 350-362Crossref PubMed Google Scholar Concern regarding the consequences of CIN may cause nephrologists to delay fistulography until the CKD patient with an immature fistula is established on dialysis via a central venous catheter. Some fistulas may require more than a single procedure and added time to mature, and some fistulas may never mature despite the interventions. This may unnecessarily prolong catheter use with an associated risk of inadequate dialysis dose delivery, infection, and central venous stenosis. There is a window of opportunity to treat these fistulas before HD initiation. Several inconclusive studies were designed to define a safe contrast dose for interventional procedures. Cigarroa et al.4.Cigarroa R.G. Lange R.A. Williams R.H. Hillis L.D. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease.Am J Med. 1989; 86: 649-652Abstract Full Text PDF PubMed Scopus (409) Google Scholar published the first such study in 1989 on patients with CKD undergoing cardiac catheterization. The authors devised an empiric formula to calculate a safe radiocontrast dose based on the patient's weight and level of renal function, where the maximal radiocontrast dose is equal to 5 × body weight (kg)/serum creatinine (mg/dl). There was a statistically significant lower incidence of CIN in patients with a contrast dose below the maximal radiocontrast dose. Despite the obvious limitations of this study, this was the first attempt to create a guideline for contrast use using an empiric formula. Other interventional cardiologists have attempted to validate the maximal radiocontrast dose formula.6.Freeman R.V. O’Donnell M. Share D. et al.Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.Am J Cardiol. 2002; 90: 1068-1073Abstract Full Text Full Text PDF PubMed Scopus (280) Google Scholar However, the wide variations in the contrast volume administered (100–300 ml) and different contrast agents employed in these studies make comparisons difficult. In 1990, Manske et al.5.Manske C.L. Sprafka J.M. Strony J.T. Wang Y. Contrast nephropathy in Azotemic diabetic patients undergoing coronary angiography.Am J Med. 1990; 89: 615-620Abstract Full Text PDF PubMed Scopus (451) Google Scholar assessed contrast nephropathy in patients with diabetes and advanced renal dysfunction. Patients were undergoing diagnostic cardiac catheterization; therefore, smaller doses of contrast were used (mean 31 ml). This group reported that volumes of nonionic contrast material (iohexol or iopamidol) greater than 30 ml were associated with markedly increased incidence of CIN in this high-risk population. Even patients receiving doses as low as 20 ml were susceptible to developing CIN. In a more recent prospective study, however, low-dose radiocontrast administration was shown to be safe in a group of high-risk patients. Asif et al. assessed the incidence of CIN in advanced CKD patients with a 50% rate of diabetes, undergoing venography for venous mapping. A total of 21 patients with stage 4 or 5 CKD showed no evidence of CIN after receiving 10–20 ml of a low-osmolar contrast agent.21.Asif A. Cherla G. Merrill D. et al.Venous mapping using venography and the risk of radiocontrast-induced nephropathy.Semin Dial. 2005; 18: 239-242Crossref PubMed Scopus (53) Google Scholar Percutaneous AV fistulography requires a significantly lower contrast volume than cardiac and other radiology procedures. Our study suggests that low doses (mean 7.8 ml, range 1.5–25 ml) of a nonionic, low-osmolar contrast agent can be used safely even in patients at a high risk for CIN. In this cohort of patients with stage 4 CKD and a high prevalence of diabetes, the incidence of CIN was 4% at 2 days and 4.6% at 1 week. All values returned to baseline within 2 weeks, and no patient required acute dialysis. Although the study population had a high proportion of diabetics, there was no increased CIN incidence in this group. From the total of 65 procedures, 31 were repeat procedures due to various reasons, including persistent immaturity, thrombosis, re-study of resistant lesions, and planned two-step procedures. Although CIN occurred more frequently after repeat procedures (3/31 or 10%), the long interval between procedures (median 64 days, range 7–334 days) makes it difficult to determine whether the increased risk is attributable to repeated contrast exposure or to progression of underlying CKD. None of the 7 repeat procedures performed within 30 days were complicated by CIN; however, our ability to draw conclusions about the risk of repeat procedures is limited by the small subgroup sample size and the low incidence of CIN with the use of a low-contrast protocol. Physical assessment is essential prior to intervention on an immature fistula.22.Beathard G.A. Physical examination of the dialysis vascular access.Semin Dial. 1998; 11: 231-236Crossref Google Scholar This allows the interventionalist to clinically locate the most significant lesion, thus tailoring the procedure to treat the most important lesions. In this study, an average of 1.9 procedures per patient were required. Some of these were part of a staged procedure, thus avoiding excessive contrast use in a single procedure. For forearm fistula, the majority of the treated lesions were at the inflow, and for the upper arm fistula at the main venous body and the outflow draining veins. By the end of the study period, 20 of the 33 patients with fistulas had started dialysis, 15 (75%) using their fistula and only 5 (25%) patients required a catheter at the initiation of dialysis. Four fistulas required six thrombectomy procedures. Two of these fistulas were patent at the end of the study period, with one being used for HD. While many centers do not perform fistula thrombectomies even in end-stage renal disease patients, this study suggests that the procedure can be safely performed in CKD patients. Although interventional nephrology is a growing field, highly experienced interventionalists who dedicate a substantial proportion of their professional activities to dialysis access procedures are not universally available to CKD programs. The findings of this study may not be applicable to regions with limited availability of experienced and dedicated interventionalists. The isotonic saline infused preprocedure in each patient may have played a role in the apparent safety of contrast use. Distinguishing the relative CIN prophylactic contribution of saline infusion and using low contrast dose by a 1:3 saline dilution is not possible. It is important to note that diluting the contrast in a 1:3 ratio with saline (1 ml of contrast and 3 ml of normal saline, predrawn in a 5 ml syringe) was chosen arbitrarily. During standard venographies, we use a 1:1 ratio (2 ml of contrast and 2 ml of normal saline, predrawn in a 5 ml syringe). In this study by increasing the ratio of saline to contrast, only 1 ml of contrast was used per single injection. Similar outcomes may be obtained by using a 1:2 or other dilution ratios, as long as the actual contrast dose remains low. The contrast agent used in this study is a nonionic, low-osmolar monomeric agent. The overall safety observed in this study might not be reproducible using ionic, high osmolar contrast media. The 7.8 ml mean contrast volume in this study is low compared to other endovascular fistula salvage procedures in the literature. This was achieved by a combination of diluting the contrast and by targeting the procedure to the one or two most significant lesions that are preventing maturation of the fistula. Physical examination played a vital role in the decision making process. If a fistula was noted to have multiple significant lesions or a resistant lesion, the patient would be followed with a repeat examination and possible reintervention. The C-arm fluoroscope used for this study performed digital subtraction angiography at a minimum of 15 frames per second (usually 30 frames per second); therefore, providing adequate imaging when using a 1:3 diluted contrast. A C-arm Fluoroscope performing digital subtraction angiography at a lower frame per second or further diluting the contrast with saline may provide suboptimal imaging. This study demonstrates that in patients with advanced CKD, fistulas can successfully be salvaged using small contrast volumes with a low CIN incidence. A significant proportion of patients in this study were able to initiate dialysis using their fistula, thus entirely avoiding catheter use. Prospective trials using low-osmolar or iso-osmolar contrast media should be performed in patients with stage 4 CKD who require percutaneous procedures for nonmaturing or thrombosed AVF." @default.
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• W2000360618 title "Safety of low-dose radiocontrast for interventional AV fistula salvage in stage 4 chronic kidney disease patients" @default.
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