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• W2000650473 abstract "Arteriovenous fistulas are the optimal vascular access for hemodialysis patients, whereas catheters are least desirable.1US Renal Data SystemExcerpts from the United States Renal Data System 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.Am J Kidney Dis. 2009; 53 (1): S257-S270Google Scholar, 2Lacson Jr, E. Lazarus J.M. Himmelfarb J. Ikizler T.A. Hakim R.M. Balancing Fistula First with catheters last.Am J Kidney Dis. 2007; 50: 379-395Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 3Lacson Jr, E. Wang W. Lazarus J.M. Hakim R.M. Change in vascular access and mortality in maintenance hemodialysis patients.Am J Kidney Dis. 2009; 54: 912-921Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar Accordingly, strategies for optimizing fistula use and simultaneously avoiding the use of catheters are integral to dialysis patient care. These should include preservation of both central and peripheral vessels for vascular access.4National Kidney FoundationKDOQI Clinical Practice Guidelines for Vascular Access: update 2006.Am J Kidney Dis. 2006; 48: S176-S247PubMed Google Scholar Cardiovascular disease is the leading cause of death in dialysis patients, with substantial rates of sudden cardiac death.5Krane V. Winkler K. Drechsler C. Lilienthal J. Marz W. Wanner C. Association of LDL cholesterol and inflammation with cardiovascular events and mortality in hemodialysis patients with type 2 diabetes mellitus.Am J Kidney Dis. 2009; 54: 902-911Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 6Wang A.Y. Lam C.W. Chan I.H. Wang M. Lui S.F. Sanderson J.E. Sudden cardiac death in end-stage renal disease patients: a 5-year prospective analysis.Hypertension. 2010; 56: 210-216Crossref PubMed Scopus (128) Google Scholar Increasingly, cardiac devices such as implantable cardioverter-defibrillators (ICDs) and pacemakers are inserted for both prevention of sudden cardiac death and nonlethal arrhythmias. Because of the high incidence of cardiovascular disease, decreased ejection fraction, and arrhythmia, it has been proposed that dialysis patients may derive benefits from more frequent ICD use.7Herzog C.A. Li S. Weinhandl E.D. Strief J.W. Collins A.J. Gilbertson D.T. Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators.Kidney Int. 2005; 68: 818-825Abstract Full Text Full Text PDF PubMed Google Scholar During the past decade, the number of dialysis patients with an ICD or cardiac resynchronization therapy with a defibrillator within a year of initiating dialysis therapy has increased from 0.06% of hemodialysis patients in 1995 to 0.75% in 2005.1US Renal Data SystemExcerpts from the United States Renal Data System 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.Am J Kidney Dis. 2009; 53 (1): S257-S270Google Scholar A recent retrospective study confirms this rapid increase in cardiac device use in dialysis patients and suggests a possible small temporary mortality benefit associated with device placement.8Charytan D. Patrick A. Liu J. et al.Trends in the use and outcomes of implantable cardioverter defibrillators in patients undergoing dialysis in the United States.Am J Kidney Dis. 2011; (In press)Google Scholar ICDs and pacers most often use transvenous wires that travel through the subclavian vein. It has been observed both anecdotally and in small studies that transvenous wires may predispose to central vein stenoses.9Sticherling C. Chough S.P. Baker R.L. et al.Prevalence of central venous occlusion in patients with chronic defibrillator leads.Am Heart J. 2001; 141: 813-816Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 10Teruya T.H. Abou-Zamzam Jr, A.M. Limm W. Wong L. Symptomatic subclavian vein stenosis and occlusion in hemodialysis patients with transvenous pacemakers.Ann Vasc Surg. 2003; 17: 526-529Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar In dialysis patients, for whom vascular access represents their lifeline, this may have severe consequences, affecting access patency and access options. Other options for cardiac devices include the use of epicardial leads, but placement requires cardiothoracic surgery, a higher-risk and more expensive procedure. In this study, we assess the impact of transvenous cardiac devices on central vein patency in hemodialysis patients and determine the effect of device placement on current and future vascular access. Charts were reviewed for all patients who received long-term hemodialysis therapy at Dialysis Clinic Inc (DCI) Boston in 1995-2010. Access history was obtained from electronic medical records at DCI Boston and Tufts Medical Center, taking advantage of the fact that most DCI Boston patients receive other care at Tufts Medical Center. All access procedures, chest radiographs, and cardiology and electrophysiology records were reviewed. Notes from dialysis access rounds, a weekly multidisciplinary conference, also were reviewed for mention of device-associated stenoses. Cardiac device presence was defined as any mention in DCI Boston records, radiology records (with the last chest radiograph visually evaluated for all uncertain cases), and Tufts Medical Center charts. Study outcomes included central vein stenosis and catheter dependence due to central vein stenosis. Central vein stenosis was defined as either demonstration of central venous stenosis or occlusion on venography requiring intervention or access abandonment, or occlusion seen on ultrasound. Catheter dependence was defined as use of a catheter after device insertion without subsequent use of a fistula or graft in patients with documented stenosis. Catheter dependence was determined based on clinical assessment of each patient by a multidisciplinary group that included nephrologists, interventional radiologists, and access surgeons. Over 15 years, there were 590 maintenance dialysis patients, of whom 43 had a transvenous cardiac device (0.7%; Fig 1). At the time of device insertion, mean age was 70.2 ± 9.7 years (Table 1). In 23 (53.5%) patients, the cardiac device was placed before dialysis therapy initiation, whereas 13 of the 20 patients in whom the device was placed after dialysis therapy initiation had a fistula at the time of insertion.Table 1Characteristics of Patients With Cardiac Devices at Device InsertionCharacteristicValueAge (y)aIn 2 patients with no documentation of date of device in whom insertion preceded dialysis therapy initiation, age at dialysis therapy initiation was used.70.2 ± 9.7Men20 (46.5)Dialysis access Fistula13 (30.2) Graft5 (11.6) Catheter1 (2.3) PD1 (2.3) Predialysis23 (53.5)ESRD cause Diabetes17 (39.5) Hypertension15 (34.9) GN5 (11.6) Other4 (9.3) PKD1 (2.3) Unknown1 (2.3)Diabetes18 (41.8)Note: Values shown are mean ± standard deviation or number (percentage).Abbreviations: ESRD, end-stage renal disease; GN, glomerulonephritis; PD, peritoneal dialysis; PKD, polycystic kidney disease.a In 2 patients with no documentation of date of device in whom insertion preceded dialysis therapy initiation, age at dialysis therapy initiation was used. Open table in a new tab Note: Values shown are mean ± standard deviation or number (percentage). Abbreviations: ESRD, end-stage renal disease; GN, glomerulonephritis; PD, peritoneal dialysis; PKD, polycystic kidney disease. Of these 43 patients, 34 (79%) underwent imaging of the central veins; 21 of the 34 patients (62%) had demonstrable central vein stenoses, 17 of which were ipsilateral to the cardiac device. The mean number of accesses, including access present at the time of device insertion, was 3.9 ± 2.7 for patients with versus 2.8 ± 2.3 for those without central stenoses. Of patients without devices, 297 of 547 (54%) underwent imaging of central veins and 94 of the 297 (32%) had an identified central stenosis (P = 0.001 compared with those with imaging). Ten of 21 (48%) patients with a cardiac device and central vein stenosis were deemed catheter dependent after device insertion. Hemodialysis patients with cardiac devices appear to have a high rate of central vein stenoses, potentially resulting from vein injury by transvenous leads. Importantly, a high proportion of individuals with transvenous wires were deemed catheter dependent. Despite the limitations of this report, which include nonsystematic ascertainment of central vein stenosis and the retrospective chart review design, it is unlikely that we are underestimating the prevalence of central vein stenoses. Accordingly, we believe that these data suggest it is prudent to weigh the risks and benefits of these devices, including consideration of epicardial leads, in patients with advanced kidney disease. Further research clearly is required to better delineate the true risk of device-associated central stenosis and the safety of endovascular treatment of these stenoses in the presence of device wires. Because an author of this manuscript is an editor for AJKD, the peer-review and decision-making processes were handled entirely by an Associate Editor (Kevan R. Polkinghorne, MBChB, MClinEpi, FRACP, PhD, Monash Medical Centre) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website. The corresponding author, Dr Weiner, may be contacted at [email protected] . Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests." @default.
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• W2000650473 title "Transvenous Cardiac Device Wires and Vascular Access in Hemodialysis Patients" @default.
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