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Mathematical Model Demonstrates Influence of Luminal Diameters on Venous Pressure Surveillance

John J. White^*, Steven A. Jones, Sunanda J. Ram, Steve J. Schwab, and William D. Paulson^*

^* Augusta VA Medical Center, and Section of Nephrology, Hypertension, and Renal Transplantation, Medical College of Georgia, Augusta, Georgia; Biomedical Engineering, Louisiana Tech University, Ruston, Louisiana; Division of Nephrology and Hypertension, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and Department of Medicine, College of Medicine, University of Tennessee, Memphis, Tennessee

Correspondence: Dr. William D. Paulson, BA 9413, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912. Phone: 706-721-9655; Fax: 706-721-7136; E-mail: wpaulson{at}mcg.edu

Background: The reliability of dialysis venous pressure (VP) in detecting stenosis is controversial. A mathematical model may help to resolve the controversy by providing insight into the factors that influence static VP.

Design, setting, participants, and measurements: This study used inflow artery and outflow vein luminal diameters from duplex ultrasound studies of 94 patients. These diameters were applied to a mathematical model, and how they affect the relation among VP, mean arterial pressure (MAP), blood flow, and stenosis was determined. Whether VP/MAP is a valid adjustment for the influence of MAP on VP, and whether the standard VP/MAP referral threshold of 0.50 is valid, were also determined.

Results: It was found that there is an approximate one-to-one relation between MAP and VP, so VP/MAP is a valid adjustment. Also, the 0.50 threshold successfully identifies most grafts with stenosis of 65% or more. However, the ratio of artery/vein diameters varied widely between patients, and the ratio independently influences VP/MAP. When the inflow artery is relatively narrow, the VP/MAP increase is delayed followed by a more rapid increase as critical stenosis is reached.

Conclusions: VP/MAP is a valid adjustment for the influence of MAP on VP, and the standard VP/MAP threshold of 0.50 warns of the transition to critical stenosis. However, relatively narrow arteries cause a delay followed by a rapid increase in VP/MAP that may not be detected before thrombosis unless measurements are very frequent. Clinical trials that emphasize trend analysis with frequent measurements are needed to evaluate the efficacy of VP surveillance.

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				M. F. Kheda, L. E. Brenner, M. J. Patel, J. J. Wynn, J. J. White, L. M. Prisant, S. A. Jones, and W. D. Paulson Influence of arterial elasticity and vessel dilatation on arteriovenous fistula maturation: a prospective cohort study Nephrol. Dial. Transplant., September 15, 2009; (2009) gfp462v1. [Abstract] [Full Text] [PDF]

				W. D. Paulson, S. J. Ram, J. Work, S. A. Conrad, and S. A. Jones Inflow stenosis obscures recognition of outflow stenosis by dialysis venous pressure: analysis by a mathematical model Nephrol. Dial. Transplant., December 1, 2008; 23(12): 3966 - 3971. [Abstract] [Full Text] [PDF]