Analysis of risk factors for failure of autologous arteriovenous endovascular fistula in patients on maintenance hemodialysis

doi:10.21203/rs.3.rs-2074285/v1

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Analysis of risk factors for failure of autologous arteriovenous endovascular fistula in patients on maintenance hemodialysis

https://doi.org/10.21203/rs.3.rs-2074285/v1

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Objective: To look at the risk factors for autologous arteriovenous endovascular fistula dysfunction in hemodialysis patients (MHD).

Methods: As of July 2022, of the 49 patients who received MHD treatment in 1 our hemodialysis facility, 25 were classified as normal and 24 were classified as dysfunction. To examine the risk variables influencing the dysfunction of internal fistula in MHD patients, general clinical data and laboratory test results were gathered from both groups.

Results: Patients in the dysfunctional group had higher hemoglobin levels, higher red blood cell counts, were more likely to smoke, and had more combined diabetics than those in the normal group; however, iPTH levels were lower (P 0.05) than those in the normal group. Multifactorial logistic regression study showed that high erythrocyte levels, iPTH levels, age, smoking, and concomitant diabetes were independent risk factors for endovascular failure in patients with MHD (P < 0.05).

Conclusion: High erythrocyte level, iPTH level, age, smoking, and coupled diabetes mellitus are all strongly associated with the failure of autologous arteriovenous fistula in MHD patients. To decrease the likelihood of autologous arteriovenous endovascular fistula failure by raising awareness of endovascular fistula maintenance, using a rope ladder puncture technique to puncture from a distance to a close proximity, and encouraging patients to quit smoking.

Hemodialysis

arteriovenous endovascular fistula

endovascular failure

risk factors

For patients with end-stage renal illness around the world, maintenance hemodialysis is a common choice for renal replacement therapy, and excellent vascular access is essential to its success^[1]. The best type of vascular access, autologous arteriovenous fistula (AVF), has the advantages of low infection rates and adequate flow rates, but failure of AVF can affect the quality of dialysis in MHD patients and lead to various complications, causing physical and psychological pain and affecting their quality of life^[2-4]. In order to offer a theoretical foundation for enhancing the standard of dialysis and extending the use of AVF in MHD patients, we examined the risk variables influencing the failure of AVF in maintenance hemodialysis patients in this study.

Ethical Approvals: This study has passed the ethical review(Ethical review No.: 2022-ky-086).

1.1 Research Subjects

As of July, 2022, maintenance hemodialysis patients in the hemodialysis center of a tertiary general hospital in Beijing were selected by convenient sampling method. Inclusion criteria: ①age ≥ 18 years; ②regular use of AVF for hemodialysis treatment for more than 3 months; ③those who had a failure of autologous arteriovenous internal fistula from January 2021 to July,2022; ④clear consciousness and consent to participate in this study. Exclusion criteria: ① use of artificial blood vessels and central venous catheters; ② immature AVF; ③ malignant disease, malignant tumor; ④ severe infection

1.2 Research Methodology

1.2.1 General Information Collection

Patients' hemodialysis treatment records were retrospectively reviewed to collect information on gender, age, dry weight, age on dialysis, primary disease, and smoking and alcohol consumption.

1.2.2 Biochemical index monitoring

Retrospective review of laboratory index data of patients within one month before the loss of function. Specifically, the patients had fasting venous blood before dialysis and were sent to our laboratory to determine the levels of red blood cell count, hemoglobin, total leukocytes, white blood cells, platelets, blood phosphorus, triglycerides, total cholesterol, β2 microglobulin, and iPTH.

1.2.3 Diagnostic criteria for AVF loss of function

Failure to perform is diagnosed when at least one of the following conditions occurs after the fistula has matured and been in use for 3 months: (1) the fistula fails to palpate tremor and fails to detect a vascular murmur; (2) the blood flow is <180 ml/min and cannot meet the needs of dialysis; (3) the anastomosis diameter is ≤0.4㎝ on vascular ultrasound^[5].

1.3 Statistical Methods

SPSS20.0 statistical software was used for analysis, and the measurement data were expressed as (`x±s), and the comparison of means between groups was performed by independent sample t-test; the non-normally distributed data were expressed as median; the comparison of rank data was performed by two independent samples Wilcoxon rank-sum test, and the count data were expressed as the number of cases and percentage, and the comparison of count data was performed by χ2 test. The factors influencing internal fistula failure were analyzed by logistic regression analysis, and the odds ratio (OR) and its 95% confidence interval were calculated. p < 0.05 indicates a statistical difference.

Meaning.

A total of 49 cases were included in the study, 29 (59.2%) males and 20 (40.8%) females; ages ranged from 34 to 86 years, with a mean age of (58.94±13.12) years. Dialysis age ranged from 1 to 27 years, with a median of 4 years; renal primary diseases: chronic glomerular 20 cases (40.82%), hypertensive nephropathy 12 cases (24.49%), and diabetic nephropathy 17 cases (34.69%).

2.1 Comparison of general information between the two groups of patients

There were differences in age, smoking, and diabetes between the two groups (P > 0.05), as detailed in Table 1.

Table 1 Comparison of general information between the two groups of patients

Factors	Loss of work group (n=24)	Normal group (n=25)	Statistical quantities	P-value
Gender (example)			1.268^（¹^）	0.263
Male	14	15
Female	10	10
Age (example)	55.94±11.88	60.88±13.51	-1.985^（²^）	0.0498^*
Age of dialysis (cases)			0.711^（¹^）	0.401
1-10 years	17	16
11-30 years	7	9
Smoking			5.582^（¹^）	0.020^*
Yes	3	8
No	21	17
Drinking			1.169^（¹^）	0.282
Yes	3	6
No	21	19
Diabetes			5.667^（¹^）	0.019^*
Yes	11	17
No	13	8

Note: (1) χ2 values, (2) t values, * is P < 0.05

2.2 Comparison of biochemical indexes between two groups of patients

Compared with the normal group, patients in the dysfunctional group had higher hemoglobin levels and red blood cell count levels, and lower iPTH levels, with statistically significant differences (P < 0.05), as detailed in Table 2.

Table 2 Comparison of biochemical indexes between two groups of patients

Factors	Loss of work group (n=24)	Normal group (n=25)	Statistical quantities	P-value
Hemoglobin (g/L)	131.43±13.80	117.76±12.75	5.187^（¹^）	<0.001^*
Red blood cell count (×10¹² /L)	4.59±0.60	3.87±0.45	6.89^（²^）	<0.001^*
White blood cell count (×10⁹ /L)	6.62±1.69	6.97±1.86	-0.97^（¹^）	0.334
Platelet count (×10⁹ /L)	180.79±42.10	196.37±47.14	-1.76^（¹^）	0.081
Blood phosphorus	1.88±0.47	1.84±0.39	0.524^（¹^）	0.601
Triglycerides (mmol/L)	1.66±0.74	1.57±0.85	0.552^（¹^）	0.582
Total cholesterol (mmol/L)	3.65±0.72	3.92±1.08	-1.464^（²^）	0.147
Β2 microglobulin (μg/L)	28.36±8.15	26.42±5.79	1.394^（²^）	0.167
iPTH (pg/ml)	187.10	292.60	-2.385^（¹^）	0.019^*

Note: (1) t-value, (2) u-value,^* is P < 0.05

2.3 Multi-factor logistic regression analysis of internal fistula loss of function in the two groups

The relevant influencing factors were assigned: age: <60 years = 0, ≥60 years = 1; smoking: no = 0, yes = 1; diabetes mellitus: no = 0, yes = 1; hemoglobin, red blood cell count, and iPTH levels were expressed in metric units. Multifactorial logistic regression analysis showed that high erythrocyte levels, low iPTH levels, age, smoking, and combined diabetes were independent risk factors for endovascular failure in patients (P < 0.05), as shown in Table 3.

Table 3 Results of multifactorial binary logistic regression analysis of patients' internal fistula loss of function

Projects	B	S.E.	Wald	P	Exp(B)	95% CI for EXP(B)
Projects	B	S.E.	Wald	P	Exp(B)	Lower	Upper
Hemoglobin	-5.692	3.615	2.480	0.645	0.982	0.911	1.059
Red blood cell count	3.476	1.135	9.389	0.002	32.343	3.500	298.876
iPTH	-0.006	0.002	11.357	0.001	0.994	0.991	0.998
Age	1.471	0.744	3.912	0.048	4.353	1.013	18.698
Smoking	-4.180	1.626	6.611	0.010	0.015	0.001	0.370
Diabetes	-2.254	0.890	6.420	0.011	0.105	0.018	0.600

Advances in medical technology have led to increasing diversity in dialysis access, but K-DOQI continues to use autologous arteriovenous fistulas as the preferred access for hemodialysis patients^[6] . Once a patient experiences endovascular fistula failure, it will directly affect the quality of dialysis and the survival of the patient. In this study, high erythrocyte levels, high iPTH levels, age, and comorbid diabetes were found to be independent risk factors for endovascular fistula failure in MHD patients.

It was found^[7^、^8] that elevated erythrocyte levels stimulate a nonlinear increase in blood viscosity and stimulate platelet aggregation toward the vascular endothelium, especially in the direction of damaged cells; also erythrocytes can induce platelet aggregation by activating adenine nucleoside diphosphate, thereby accelerating thrombosis. In this study, it was found that 8.3% of patients in the dysfunctional group had high red blood cell count levels compared to none in the normal group, and 56% of patients had lower than normal red blood cell levels. logistic regression analysis revealed that patients with high red blood cell count levels had a higher risk of developing endovascular dysfunction. This may be because an increased red blood cell count causes an increase in erythrocyte-specific volume and blood viscosity, which increases the risk of thrombosis and aggravates the thrombus load, leading to higher risk stratification^[9]. Patients treated with endovascular fistulas for dialysis require puncture at each dialysis session. When patients have high red blood cell levels, they may be more likely to stimulate platelet aggregation to the endothelium, leading to the development of endovascular failure. Therefore, when performing endovascular fistula punctures, nurses should avoid regional punctures as much as possible and use a rope ladder to puncture from far to near to reduce the occurrence of endovascular malfunction.

Studies have shown^[10] that the incidence of endovascular fistula failure is greater in older hemodialysis patients, however, it is not consistent with the results of the present study. The results of this study showed that endovascular fistula failure occurred more often in younger patients, so it is assumed that this is related to the increasing incidence of uremia at a younger age and the increase of chronic kidney disease due to diabetes mellitus in recent years. At the same time, the results of this study also showed that patients with combined diabetes mellitus were more likely to have autogenous arteriovenous fistula failure. Several domestic and international studies have shown that diabetes is one of the risk factors affecting the functional status of arteriovenous fistulas and that dialysis patients with combined diabetes are prone to fistula failure^[11] . The results of our study are consistent with this, with a higher proportion of diabetic patients in the endovascular fistula malfunction group. Diabetic patients can suffer from vasculopathy through abnormally active polyol pathways, non-enzymatic glycosylation of proteins, oxidative stress, and protein kinase C activation, which can lead to the presence of extensive atherosclerosis. Patients with poor vascular conditions, chronic hyperglycemia, and deposition of glycosylation products lead to disruption of secretion of many metabolic substances in the body, and a combination of factors leads to damage of the intima. In addition, the enhanced biological activity of platelets also aggravates intimal hyperplasia and remodeling, vascular endothelial cell damage, arterial lumen narrowing, and thrombosis in diabetic MHD patients^[12] . Therefore, the presence of combined diabetes mellitus is an independent risk factor for AVF malfunction.

Some foreign studies have confirmed^[13] that long-term smoking may impair the anticoagulant properties of vascular endothelial cells and reduce their fibrinolytic activity, leading to an increased risk of thrombosis. Also, smoking modulates endothelium-dependent vasodilation, causing significant changes in nitric oxide synthesis and release, leading to increased contraction of vascular smooth muscle cells, which can also cause increased proliferation and migration, ultimately leading to the development of endovascular fistula failure, and several studies have also reported a direct association between smoking and AVF thrombosis^[14,15] . This is consistent with the results of this study, so health care workers should strengthen the management of smoking cessation in MHD patients, do a good job of educating them about smoking cessation, and involve their family members in the process of quitting smoking in patients to improve the success rate of quitting smoking.

In conclusion, the failure of autologous arteriovenous fistula in maintenance hemodialysis patients is closely related to high erythrocyte level, iPTH level, age, smoking, and diabetes mellitus. The patients' survival quality can be improved by strengthening the management of smoking cessation and enhancing patients' awareness of smoking cessation.

Ethics approval and consent to participate

This was an observational study, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of China-Japan Friendship Hospital. We have received informed consent from the participants. Ethics review number is 2022-KY-086.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

China Provincial Project Fund: Clinical scientific research business fee for Central High -level Hospital: Arteriovenous Fistula Exercise Appliance

Authors' contributions

Wanning Jia: Conceptualization, Methodology, Software, Data curation, Writing- Original draft preparation.

Liu Yang: Supervision, Software, Validation.

Wenwen He: Visualization, Investigation.

Liqian Gao: Writing- Reviewing and Editing.

Acknowledgements

The authors would like to thank the reviewers for their constructive feedback and all the users who participated in this study.

Authors' information (optional)

the name by which each author is known, with his or her highest academic degree(s) and institutional affiliation:

Wanning Jia: bachelor,China-Japan Friendship Hospital.

Liu Yang: master,China-Japan Friendship Hospital.

Wenwen He: bachelor,China-Japan Friendship Hospital.

Liqian Gao: bachelor,China-Japan Friendship Hospital.

the name and address of the author responsible for correspondence and proof about the manuscript:

Liu Yang:, China-Japan Friendship Hospital, No. 2, Yinghua East Street, Chaoyang District, Beijing, China.

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No competing interests reported.

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Analysis of risk factors for failure of autologous arteriovenous endovascular fistula in patients on maintenance hemodialysis

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Abstract

Introduction

1 Data And Methods

2 Results

3 Discussion

Declarations

References

Additional Declarations

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