Determinanten der Shuntoffenheit

Determinanten der Shuntoffenheit 8. Symposium Dialyseshuntchirurgie Fortbildungsveranstaltung der IAD, Hotel Elephant, Weimar 11.12.2015 D. Döbrich, Th. Röder, Y. Al-Shargabi HELIOS Klinik Blankenhain

Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 2

Einflussfaktoren der Shuntoffenheit Alter Geschlecht Body Mass Index Herzinsuffizienz Antikoagulanzien Andere Medikamente (z. B. Ca ++ - Kanal Blocker, Statine) Vaskuläre Risikofaktoren Arterielle Hypertonie Hyperlipidämie Diabetes mellitus Nikotinabusus Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372-374. Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849-855. Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medical journal, 2002, 306-11. Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787-1792 Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 3

Einflussfaktoren der Shuntoffenheit Gefäßparameter Durchmesser Arterial Resistance Index Venous Distensibility Shuntart Operateur / OP-Technik Anastomosenart Präoperativer Ultraschall Postoperative Flussmessung Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372-374. Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849-855. Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medical journal, 2002, 306-11. Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787-1792 Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 4

Eigene Patienten Erstanlagen Radiocephale Shunts Terminale Niereninsuffizienz n = 133 Primäre Shuntoffenheit Zeitintervall von der Shuntanlage bis zu jeder ersten Intervention/Operation um die Shuntfunktion zu erhalten oder zu verbessern Sidawy AN, Gray Richard Besarab A, Henry Mitchell Ascher E et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. Journal of Vascular Surgery. 2002; 35:603-610. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 5

Demographische Daten Geschlechtsverteilung n = 133 Altersverteilung Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 6

Body Mass Index https://en.wikipedia.org/wiki/body_mass_index#/media/file:body_mass _index_chart.svg Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 7

Comorbiditäten 56% 56% 96% 30% Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 8

Comorbiditäten Herzinsuffizienz Diabetes mellitus Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 9

Alter Einfluss Shuntreifung Shuntoffenheit Quelle Ø + Ø Ø Ø + Olsha, Oded, Hijazi, Jamal, Goldin, Ilya und Shemesh, David, "Vascular access in hemodialysis patients older than 80 years," Journal of Vascular Surgery, 2015, 177-183. Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Swindlehurst, Nicola, Swindlehurst, Andrew, Lumgair, Heather et al., "Vascular access for hemodialysis in the elderly," Journal of Vascular Surgery, 2011, 1039 1043 Tordoir, J. H. M., Bode, A. S. und van Loon, M. M., "Preferred Strategy for Hemodialysis Access Creation in Elderly Patients," European Journal of Vascular and Endovascular Surgery, 2015, 738-743. Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787-1792. Allon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascular calcification, intimal hyperplasia, and arteriovenous fistula maturation," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43 Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 10

Alter LogRank-Test (5%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 11

Geschlecht Einfluss Shuntreifung Shuntoffenheit Ø + Quelle Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Bashar, Khalid, Zafar, Adeel, Elsheikh, Sawsan et al., "Predictive parameters of arteriovenous fistula functional maturation in a population of patients with end-stage renal disease," PloS one, 2015, e0119958. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 12

Geschlecht keine Herzinsuffizienz (n w = 37, n m = 56) LogRank-Test (10%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 13

Diabetes mellitus Typ II Einfluss Shuntreifung Shuntoffenheit Quelle Ø Ø Ø + + Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Conte, Michael S., Nugent, Helen M., Gaccione, Peter, Roy-Chaudhury, Prabir und Lawson, Jeffrey H., "Influence of diabetes and perivascular allogeneic endothelial cell implants on arteriovenous fistula remodeling," Journal of vascular surgery, 2011, 1383-9. Sedlacek, M., Teodorescu, V., Falk, A., Vassalotti, J. A. und Uribarri, J., "Hemodialysis access placement with preoperative noninvasive vascular mapping: comparison between patients with and without diabetes," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2001, 560-4. Allon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascular calcification, intimal hyperplasia, and arteriovenous fistula maturation," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43. Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787-1792. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 14

Diabetes mellitus Typ II LogRank-Test (9%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 15

Body Mass Index Einfluss Shuntreifung Shuntoffenheit Quelle + Ø + Evans, Richard P. T., Meecham, Lewis, Buxton, Pauline et al., "Vascular access in the obese: superficialisation of native radio-cephalic and brachio-cephalic fistulae," The journal of vascular access, 2015, 126-9. Kim, Jwa-Kyung, Jeong, Jae Han, Song, Young Rim et al., "Obesity-related decrease in intraoperative blood flow is associated with maturation failure of radiocephalic arteriovenous fistula," Journal of vascular surgery, 2015, 1010-1017.e1. Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 16

Body Mass Index LogRank-Test (41%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 17

Hyperlipidämie Einfluss Shuntreifung Shuntoffenheit + Ø Quelle De Marchi, S., Falleti, E., Giacomello, R. et al., "Risk factors for vascular disease and arteriovenous fistula dysfunction in hemodialysis patients," Journal of the American Society of Nephrology : JASN, 1996, 1169-77. Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 18

Hyperlipidämie LogRank-Test (78%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 19

Arterielle Hypertonie Die Variabilität des systolischen Blutdrucks korreliert signifikant mit dem Risiko einer Shuntdysfunktion. Mutmaßlich erhöht der hohe systolische Blutdruck die Entzündungsaktivität in der Venenwand. Cheng, Yue, Zhang, Fan, Zhu, Jun et al., "Influence of blood pressure variability on the life of arteriovenous fistulae in maintenance hemodialysis patients," Clinical hemorheology and microcirculation, 2015,. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 20

Herzinsuffizienz Die Wahrscheinlichkeit, die Dialyse mit einem suffizienten Shunt zu beginnen ist bei Patienten mit Herzinsuffizienz 34% niedriger. Lilly, Michael P., Lynch, Janet R., Wish, Jay B. et al., "Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2012, 541-9. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 21

Herzinsuffizienz LogRank-Test (20%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 22

Durchmesser Arterie Der Mindestdurchmesser der A. radialis für eine optimale Shuntreifung und lange primäre Offenheit ist 2 mm. Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein and radial artery diameter in formation of radiocephalic arteriovenous fistula: a systematic review," The journal of vascular access, 2015, 506-11. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 23

Durchmesser Arterie LogRank-Test (28%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 24

Herzinsuffizienz und arterieller Gefäßdurchmesser Keine Herzinsuffizienz LogRank-Test (87%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 25

Herzinsuffizienz und arterieller Gefäßdurchmesser NYHA III-IV LogRank-Test (1%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 26

Durchmesser Vene Einfluss Shuntreifung Shuntoffenheit + + + + Quelle Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein and radial artery diameter in formation of radiocephalic arteriovenous fistula: a systematic review," The journal of vascular access, 2015, 506-11. Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the major predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499-1504. Dageforde, Leigh Anne, Harms, Kelly A., Feurer, Irene D. und Shaffer, David, "Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fistula maturation and secondary patency," Journal of Vascular Surgery, 2015, 170-176. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 27

Durchmesser Vene LogRank-Test (13%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 28

Herzinsuffizienz und venöser Gefäßdurchmesser Keine Herzinsuffizienz LogRank-Test (59%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 29

Herzinsuffizienz und venöser Gefäßdurchmesser Herzinsuffizienz NYHA III / IV LogRank-Test (6%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 30

Thrombozytenaggregationshemmer Einfluss Shuntreifung Shuntoffenheit Ø + Ø + Ø + Quelle Jackson, Andrew J., Coats, Paul und Kingsmore, David B., "Pharmacotherapy to improve outcomes in vascular access surgery: a review of current treatment strategies," Nephrology Dialysis Transplantation, 2012, 2005-2016. Dember, Laura M., Beck, Gerald J., Allon, Michael et al., "Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial," JAMA, 2008, 2164-71. Palmer, Suetonia C., Di Micco, Lucia, Razavian, Mona et al., "Antiplatelet Therapy to Prevent Hemodialysis Vascular Access Failure: Systematic Review and Meta-analysis," American Journal of Kidney Diseases, 2013, 112-122. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 31

Thrombozytenaggregationshemmer Keine Herzinsuffizienz LogRank-Test (59%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 32

Thrombozytenaggregationshemmer Herzinsuffizienz NYHA III-IV LogRank-Test (20%) Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 33

Fazit Bei Patienten mit einer relevanten Herzinsuffizienz keine Shuntanlagen mit grenzwertig kleinen Gefäßen Die bestmögliche Behandlung der kardiovasculär relevanten Begleiterkrankungen dient auch der Shuntoffenheit. Determinanten der Shuntoffenheit D. Döbrich, Th. Röder, Y. Al-Shargabi Weimar 11.12.2015 HELIOS Klinik Blankenhain 34

Für Fragen und Hinweise stehe ich in der Diskussion sowie danach gerne zur Verfügung, auch via dinah.doebrich@helios-kliniken.de Vielen Dank! Dr. med. Dinah Döbrich HELIOS Klinik Blankenhain www.helios-kliniken.de