HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) All Versions of this Article: CJN.01320307v1 2/6/1163    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Portolés, J. Search for Related Content PubMed PubMed Citation Articles by Portolés, J.

Course of Vascular Access and Relationship with Treatment of Anemia

José Portolés^*, Juan Manuel López-Gómez, Enrique Gruss^*, Pedro Aljama; for the MAR Study Group

^* Nephrology Service, Fundación Hospital Alcorcón, and Nephrology Service, Hospital Universitario Gregorio Marañón, Madrid, and Nephrology Service, Hospital Universitario Reina Sofía, Córdoba, Spain

Address correspondence to: Dr. José Portolés, Nephrology Service, Fundación Hospital Alcorcón, Avda. Villaviciosa 1, Alcorcón 28922, Madrid, Spain. Phone: +34-91-6219513; Fax: +34-91-66419368; E-mail: jmportoles{at}fhalcorcon.es

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
Background and objectives: Maintenance of the vascular access is a crucial factor in hemodialysis, but large studies of factors that are predictive of thrombosis are lacking.

Design, setting, participants, & measurements: This prospective, multicenter study investigated a cohort to describe the management of vascular access and establish the influence of anemia as a risk factor. The cohort included 1710 patients (aged 64.4 yr; 60% men) who were followed every 3 mo at 119 centers during 12 mo. On inclusion, 9.6% had a catheter, 80.3% had a native arteriovenous fistula, and 10.1% had a polytetrafluoroethylene graft.

Results: Low baseline hemoglobin increased the risk for vascular access events. The risk was higher with a polytetrafluoroethylene graft and a catheter versus arteriovenous fistula. The multivariate model included type of vascular access, previous cardiovascular events, and noncorrected anemia. The likelihood of remaining free of vascular access events 12 mo later was 0.727 (baseline hemoglobin <10.0 g/dl), 0.801 (10.01 to 11.0 g/dl), 0.814 (11.01 to 12.0 g/dl), and 0.833 (>12.0 g/dl), figures similar to those obtained with hemoglobin from the trimester before the event. The Cox model included type of vascular access.

Conclusions: Correcting anemia did not increase the risk for vascular access–related events, and anemia that was resistant to treatment identified a subgroup of patients with higher comorbidity and higher likelihood of a vascular access event.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
The construction and maintenance of vascular access (VA) constitutes one of the habitual problems in hemodialysis (HD). A suboptimal VA can compromise the effectiveness of HD and lead to malnutrition, infections, tolerance-related problems, hospitalization, and other complications with the potential to affect the quality of life of our patients (1). In Europe and the United States, these complications account for 15 to 36% of all hospitalizations, at a cost of >$700 million in the United States (2–4). The magnitude of the problem is such that since 1999, expert committees have proposed in their guidelines for clinical practice that studies be carried out to search for solutions (1,5). The guidelines of the Spanish Society of Nephrology propose as a possible target the reduction in the use of central venous catheters in favor of attempting to create a native arteriovenous fistula (AVF) whenever possible. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines recommend efforts to reduce the rates of thrombosis to 0.5 episodes per year in patients with a polytetrafluoroethylene (PTFE) graft and 0.25 episodes per year in patients with an AVF (1,5). Currently, however, little information is available on the distribution of the various types of VA, rates of thrombosis, and triggering factors because of the scarcity of large, national-level, prospective studies involving hospital and ambulatory centers (6–8).

Clinical guidelines note the factors that may be involved in VA thrombosis, including patient-related (e.g., age, gender, diabetes), management-related (e.g., prospective follow-up, rotation of puncture sites), and treatment-related characteristics such as anticoagulation, degree of control of hyperparathyroidism, and angiotensin-converting enzyme inhibitor use (1). Some authors have proposed that correcting anemia to achieve normal values may favor the appearance of thrombosis (9); however, this issue remains controversial (8).

Moreover, policies that guide the choice of type of VA and its management vary widely across countries. In the United States, the use of PTFE access is much more prevalent than in Spain, and the rates of thrombosis are as high as one episode per year with PTFE grafts (2,9). However, native AVF is the most frequently used option in Spain, and that estimated thrombosis rate is lower (10).

The Morbidity-and-mortality Anemia Renal (MAR) study has followed a cohort of patients on HD to establish the influence of anemia as a risk factor for mortality and morbidity (11,12). As a secondary objective, this study offers a descriptive analysis of VA-related problems and their course and relationship with anemia management.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
Study Design
This was a descriptive, prospective, open, multicenter study of a representative cohort of patients who had chronic kidney disease from any cause, were on HD, and were followed for 12 mo for this analysis. Representativeness of the sample was based on the sampling strategy, which included patients’ being followed in both hospitals and other centers from all parts of continental Spain, and was established in earlier publications that compared our sample with other series and with data from the national dialysis registry (11,12). The main objective of this analysis was to establish the influence of anemia as a risk factor for VA events and to describe the management of VA and its course and factors that influence the appearance of complications.

The reference population was prevalent patients who were on HD, were older than 18 yr, began treatment during the period from January 1999 to March 2001, and had not received a kidney transplant. The 4-mo recruitment period lasted from March 2001 to July 2001, and the follow-up period lasted for 12 mo. The final sample consisted of 1710 patients (929 hospital patients and 781 patients followed at dialysis centers), for which we estimated an absolute sampling error of ±0.03 at a 95% confidence interval (CI). Centers were urged to apply the recommendations of the European Clinical Guidelines for the optimal management of anemia in patients with chronic kidney failure (13), although not all patients in this study were receiving treatment with erythropoietin (EPO).

This study was conducted in accordance with the recommendations of the Declaration of Helsinki, and informed consent was obtained from all participating patients. Data were recorded in case report form notebooks by staff physicians every 3 mo for events, changes in treatment, and results. Patient data included age, gender, comorbidity, date when HD was started, cause, and cardiovascular risk factors. Disease management data included HD parameters, management of anemia, cardiovascular risk factors, and HD targets (monocompartmental kT/V) (14). Vascular access events noted were hospitalizations and events that did not require hospitalization (12). For this analysis we considered "combined events" to include thrombosis, graft repair, and hospitalization for a diagnosis related with VA. We used the EPO resistance index (ERI), as an indicator of the response to treatment of anemia with EPO. ERI was calculated every 3 mo as current dosage in U/kg per wk divided by hemoglobin (Hb) in g/dl.

Sample Characteristics
The final sample comprised 1710 patients who were followed at 119 centers and had a mean time on HD of 15.9 ± 11.1 mo. These patients represented 18% of all incident patients during 1999 and 2000, according to the national register. Slightly more than half (54.3%) of the patients received HD at a hospital; the remaining patients were treated at private centers supported by the national health system. Mean age was 64.4 ± 13.6 yr (range 18 to 92 yr), and 60% were men. Cause of chronic kidney disease was diabetes (22.3%), glomerular (15.8%), vascular (13.0%), interstitial (9.9%), polycystic (8.6%), unknown (21.8%), and other causes (7.1%). Mean Charlson comorbidity index (15) was 6.53 ± 2.3, with 30.7% scoring 5 or lower, 36.9% scoring 6 or 7, and 32.4% scoring 8 or more. Slightly more than one third (36.7%) of the patients were on the waiting list for kidney transplantation. All patients received three weekly sessions lasting a total of 11.1 ± 1.3 h/wk, and a high-flux membrane (coefficient >20 ml/h per mmHg) was used for 39.8% of the patients. At the time of inclusion, 75.8% of the patients had hypertension, 16.7% had coronary disease, 13.9% had some degree of heart failure, 11.6% had arrhythmia, 2.0% and antecedents of acute cerebrovascular accident, and 5.5% had peripheral artery disease. The sample has been described in detail elsewhere (11), and we summarize in Table 1 the characteristics of our cohort.

	Results

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
Description of VA and Course
At the time of inclusion, 9.6% of the patients had a catheter, 80.3% had a native AVF, and 10.1% had a PTFE graft. At the end of the study period, these proportions were 9.4, 79.7, and 10.8%, respectively. The most relevant characteristics of the sample, grouped according to type of VA at the start of the study, are shown in Table 1.

The mortality rate was 12%, and 45% of the patients were hospitalized during the 12-mo study period (1.42 admissions per hospitalized patient). The cumulative rate of admission per year for VA problems was 18.2% for patients with a catheter, 6.3% for those with an AVF, and 23.1% for those with a PTFE graft (P < 0.01). Figure 1 shows survival to the first VA event according to type of access. The rate of thrombosis was 0.09 episodes per year at risk for patients with a native AVF and 0.44 episodes per year at risk for patients with a PTFE graft. The rate of any event (thrombosis or reparation by any cause) was 0.29 episodes per year at risk for patients with a native AVF and 1.04 episodes per year at risk for patients with a PTFE graft.

View larger version (28K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Kaplan-Meier survival curves to first vascular access (VA) event, according to type of VA on inclusion. PTFE, polytetrafluoroethylene graft.

Our survival analysis also showed that type of VA was the best predictor of VA events, with a likelihood of remaining free of events after 12 mo of 0.564 for patients with a catheter, 0.508 for patients with a PTFE graft, and 0.858 for those with a native AVF (log rank test = 152.33, Kaplan-Meier test P < 0.001; Figure 1). Survival analysis according to baseline Hb value established a likelihood of remaining free of events after 12 mo of 0.727 for Hb <10.0 g/dl, 0.801 for Hb 10.01 to 11.0 g/dl, 0.814 for Hb 11.01 to 12.0 g/dl, and 0.833 for Hb >12.0 g/dl (log rank test = 9.09, Kaplan-Meier test P < 0.04). Survival analysis according to Hb value measured in the trimester before the event yielded a similar pattern, as shown in Figure 2. Because type of VA was associated with other prognostic factors and management of anemia, we used multivariate analysis to obtain the corresponding Cox model, which included type of VA, cardiovascular events before creation of the access, and Hb value in the trimester before the VA event. The OR (95% CI) were 3.63 (2.65 to 4.98) for PTFE graft and 3.29 (2.34 to 4.63) for catheter versus native AVF, 1.63 (1.23 to 2.16) for previous cardiovascular event, and 1.11 (1.02 to 1.21) per 1-g/dl decrease in Hb concentration before the event.

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Kaplan-Meier survival curves before VA event, according to hemoglobin (Hb) concentration.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

The rate of access thrombosis was 0.14 per year in patients who were at risk with an AVF, and 0.44 per year in patients who were at risk with a PTFE graft. These figures are within the target values recommended by the National Kidney Foundation K/DOQI guidelines and are lower than the rates published for the US Renal Data System register (2). Despite these encouraging results, much remains to be done to achieve the ideal VA that yields appropriate dialysis performance, comfort, and convenience for the patient and a good prognosis throughout the period when the patient needs HD.

Anemia and Other Prognostic Factors in the Maintenance of VA
We found that the type of VA (PTFE versus native fistula) had the greatest influence on the prognosis for survival, as found in previous studies (1,3,16,17). This analysis looked specifically into the role of anemia and its treatment in the incidence of thrombosis and found that Hb level was associated with the course of the VA. The better the control of anemia, the more favorable the course of VA during the subsequent 12 mo. However, some clinical trials have reported a higher rate of thrombosis when target of Hb reaches normal value levels (9). The study by Besarab et al. (9) was a clinical trial in a selected population, with two treatment objectives (normalization of hematocrit versus maintenance of hematocrit at 30%), and their intention-to-treat analysis showed a higher rate of thrombosis in the normalization group. The authors suggested that the mechanism could include high blood viscosity as a result of the hemoconcentration (with higher post-HD hematocrit) and low blood flow as a result of the postdialysis hypotension. Both may favor VA thrombosis, especially in patients with a PTFE graft. However, patients who had thrombosis did not have higher Hb levels. A recent Cochrane systematic review of controlled trials that compared various targets of Hb in EPO treatment concluded that there were no significant differences in the risk for VA thrombosis between low and high Hb groups (18).

Our study was observational in nature and involved a nonselected population for whom clinical guidelines for the treatment of anemia were recommended. The patients were later stratified according to the results. Thus patients who remained anemic may represent a subgroup in which the response to treatment was smaller, comorbidity was greater, and inflammation was more frequent. In fact, the subgroup of patients whose anemia responded least favorably to treatment received EPO and iron therapy (at high dosages in some patients) but comprised patients who had more comorbidity and more often had a catheter (and least often had a native AVF). Moreover, efficacy of HD and nutritional status were compromised often in this subgroup. These comorbidity factors, along with possible inflammation associated with catheter use, might have resulted in suboptimal access performance and a less favorable course of the VA, as suggested in a previous study (19).

Other authors have reported findings similar to ours (7,18). Foley et al. (20) investigated the role of anemia in patients with left ventricular hypertrophy and reported as an ancillary finding that normalization of Hb levels (13.0 to 14.0 g/dl) did not increase the risk for thrombosis compared with a group of patients with low Hb levels (9.5 to 10.5 g/dl). A recent study by Garrancho et al. (8) analyzed a large cohort of patients who were on HD and followed exclusively at outpatient centers and found similar rates of access survival in patients with mean a Hb of 12.0 to 13.0 g/dl and in the reference group of patients with a mean Hb of 10.0 to 12.0 g/dl. Moreover, these authors found a NS trend toward a higher rate of thrombosis at Hb levels <10.0 g/dl. However, their analysis was based on mean Hb value for the entire study period, which might have confounded the results because of reverse causality bias. In patients who have a VA event, suboptimal dialysis, hospitalization, and surgical procedures that can contribute to lower Hb values are often associated.

To avoid this confounding factor (cause by effect), we analyzed our data with three different approaches. First, we used mean Hb level for the entire study period (as described previously) and found that appropriate correction of anemia was not associated with a worse course of the VA. In previous analyses, we found a linear association between appropriate control of anemia and lower mortality and between the former and lower global hospitalization rate—results that confirmed some of the findings of the Dialysis Outcomes and Practice Patterns Study (DOPPS) (21). Second, the results were similar when Hb levels on inclusion were used instead of mean Hb for the entire study period, because we detected no increase in the risk for a VA event in patients with Hb >12.0 g/dl. Finally, we repeated the analysis with a time-dependent variable—Hb concentration measured in the trimester before the VA event—with the same results.

The factors that contribute to poor survival of VA are frequently associated. Type of VA was the most powerful predictor of VA survival, and the choice of type of VA depends on these comorbidity factors. As we have shown, patients with a PTFE graft were older, had a higher prevalence of diabetes and obesity, had more frequent comorbidity factors, and were more often women than patients with a native AVF. Multivariate analysis with type of VA and comorbidity (recalling that age was included in the comorbidity index) essentially ruled out the influence on survival of all other factors. Other studies have established a low serum albumin value as a marker of increased risk for thrombosis (19), through the role of inflammation in the obstruction of PTFE grafts. However, serum albumin is also a nutritional marker associated with greater comorbidity and other risk factors; consequently, albumin dropped out of our multivariate model (the greater the comorbidity, the lower the albumin concentration). Recent studies have confirmed the influence of age and diabetes (both included in the Charlson index) on VA prognosis but have also found a role for hyperparathyroidism or angiotensin-converting enzyme inhibitor. In our cohort, we were not able to confirm the influence of these last two factors on VA prognosis.

Type of VA and Treatment of Anemia
The type of VA seems to act as a risk marker for inadequate response to treatment for anemia. This effect was clearest in patients with a central venous catheter, who needed larger dosages of EPO to achieve smaller corrections in anemia. The ERI was higher in patients with a catheter than in those with a PTFE graft and was higher in the latter group when compared with patients with a native AVF. Our data showed that the effect was maintained despite that ferrokinetics values were within the normal range. We found less favorable dialysis outcomes, nutritional indicators, and serum albumin levels in the group of patients with a catheter. These patients had factors predictive of a poor response to treatment of anemia, and these factors, together with the inflammatory stimulus of the catheter itself, contributed to the partial or complete resistance to treatment with EPO.

	Conclusions

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
Correcting anemia within the limits proposed by current guidelines did not seem to increase the risk for VA events. Moreover, anemia that was refractory to treatment in observational studies identified a subgroup of patients with more comorbidity, in whom the likelihood of VA events was greater. This analysis provides an estimate of the distribution of types of VA in a Spanish population of patients on dialysis and the difference in clinical course between various types of VA. In addition, we were able to identify age and comorbidity as the main prognostic factors of VA events. HD with a central venous catheter required the use of more EPO-stimulating agents and was associated with a less satisfactory correction of anemia and less favorable nutrition and dialysis parameters. The most beneficial VA for patients, in terms of clinical course, rate of events, efficacy, and response to treatment of anemia, was the native AVF, and this type of access should be encouraged with appropriate preparation and follow-up to minimize the rate of events.

	Disclosures

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 
None.

	Acknowledgments

 
This study was supported by Janssen-Cilag.

We thank M. de la Fuente for advice on statistics and the statistical analysis and K. Shashok for translating the original manuscript into English.

Members of the MAR Study Group (institution and co-investigators): ASHDO el Rosario: A. Garcia Rubiales, R. Canabal; ASHDO Talavera: N. Ajage; Cediat Lliria: J. Lacueva; Cedicas Catellón: M. Orts; Centro de HD (C. HD.) Aljarafe: A. Lara; C. HD. Arroyo: A. Carreño; C. HD. Bonanova: B. de la Torre; C. HD. Burgalés: B. Gónzalez Díez; C. HD. Dr. Criado: J.R. Criado; C. HD. Los Arcos: S. García Marcos; C. HD. Montequinto: M. Parallé; C. HD. Nuestra Señora del Prado: A. Martínez Calero; C. HD. Salve Care Canarias: C. Mora; C. HD. Sierra Este: J. Madrigal; C. HD. Torremolinos: M.M. Castilla, J.L. Pizarro; C. HD. Verdún: E. Poch; C. HD. Villagarcía de Arousa: T. Cordal; C. HD. Virgen de los Reyes-Gambro Healthcare: J.M. Soler; C. de Nefrología de Mataró: M. Casals, M. Romero; C. HD. Bellavista: A. Ruiz; Complejo Hospitalario (C. H.) Unitat Coronària de Manresa: J. Sole; C. HD. Los Llanos: P. Hernando, H. Santana; Centro Médico (C. M.) Jesús: A. Fernández; C. M. La Roselada: P. Abad; C. M. Santa Bárbara: C. Vozmediano; C. P. de HD Cilu, Jerez de la Frontera: M.L. Alcalá, G. Silgado; C. HD. Santa Engracia: M. Albalate, J. Hernández Pérez; C. HD. Virgen de la Fuensanta: N. Ridao, M. Rodríguez Ferrero; C. HD. Axarquía: R. Franquelo; Clinica (C.) la Milagrosa: G. del Pozo; Clinica Ruber: R. Delgado; C. San Carlos: I. Merello; C. Santa Isabel de Sevilla: G. Fernández; Club HD. Los Enebros: F. Valderrábano; Club HD. Ponfedial: R. Alcázar; Comp. H. de León: Rosa Ordóñez; Comp. H. Pontevedra: Javier Fernández Muiños; C. Parc Taulí: M. García García, J.C. Martínez Ocaña; Dialcentro: M. Sánchez Sancho, M.T. Villaverde; Fundación Hospital (F. H.) Alcorcón: G. Fernández-Juarez, A. Tato; F. H. Manacor: J. Calls; F. H. de Mollet: O. Ibrik; F. Sociosanitaria de Barcelona: J. Bartolomé; Fundación (F.) Puigvert: E. Andrés; Gamapal: A. López Ramos; Hospital (H.) Clínico University S. Cecilio: D. Prados; Hemodial: A. Cubas, E. Sierra; H. La Mancha Cto.: M. Arranz, J.M. Garrancho; H. "Ernest Lluch": M.J. Aladrén, P. Vives; H. 12 de Octubre: J.M. Alcázar, E. Gutiérrez Martínez; H. Arnau de Vilanova: L. Craver; H. Can Misses: M. Saiz, A. Vázquez; H. Clínico Valladolid: J. Bustamante, J. Núñez García; H. Clínico San Carlos: J.A. Herrero; H. Clínico University Zaragoza: R. Álvarez Lipe, F. Martín Marín; H. Clínico University de Santiago: V. Arcocha; H. Costa del Sol: A. Marañes, J. Payán; Hospital Clínico (H. C.) de Sant Antoni Abad: R. Ramos; H.C. del Bierzo: Z. Ghais; H.C. do Barbanza: D Güimil; H. Cristal Piñor de Orense: E. Armada; H. de Alcañiz: L.M. Lou; H. de Basurto: R. Ortiz de Vigón; H. de la Cruz Roja de Oviedo: P. Ruiz de Alegría; H. de la Ribera: M. Candel; H. de La Santa Creu: P. Angelet, M.T. Compte; H. de Vic: E. Castellote; H. del Aire: E. González Parra; H. Galdakao: R. Muñoz González; H. General Albacete: I. Lorenzo; H. General de Asturias: J. Herrera; H. General de Castellón: J. Hernández Jaras; H. General de La Palma: A. Macía; H. General de Manresa: A. Sans Boix; H. General de Segovia: M.J. Fernández Reyes; H. General Juan Cardona-El Ferrol: R. Mouzo; H. General Yagüe: G. Estefan, G. Torres; H. Gregorio Marañón: R. Jofre; H. Juan Canalejo: M. Pérez Fontán; H. Juan Ramón Jiménez: J. González Martínez; H. La Paz: J. Martínez Ara, J.L. Miguel; H. Las Américas-Hospiten Sur: M.L. Domínguez Gallego; H. Lluis Alcanys: F. Sigüenza; H. Marqués de Valdecilla: R. Escallada; H. Meixoeiro deVigo: J.M. Lamas; H. Militar Gómez Ulla: B. Fanlo; H. Nuestra (Nta.) Sra Sonsoles de Ávila: A. Fidalgo; H. Perpetuo Socorro: M.D. Arenas; H. Puerta del Mar de Cádiz: M. Ceballos; H. Regional Carlos Haya: J. Fernández-Gallego, B. Ramos; H. Río Carrión: F. Sousa; H. Río Hortega: A. de Paula, A. Molina; H. San Agustín de Avilés: J. Guerediaga; H. San Jorge de Huesca: J.M. Logroño; H. San Pedro de Alcántara: R. Novillo; H. Severo Ochoa: I. Rodríguez Villareal; H. Tamaragua: B. Martín Urcuyo, J.E. Sánchez Álvarez; H. Txagorritxu: B. Aurrekoetxea; H. University Ciudad de Jaén: M.J. García Cortés, C. Sánchez Perales; H. University Getafe: J.M. Arche; H. Virgen de la Concha: J. Grande; H. Virgen de la Luz: E. Ruiz La Iglesia; H. Virgen de la Macarena: J.A. Milán, J.R. Molas; H. Virgen de la Salud: E. García Díaz, T. Sierra; H. Xeral Calde de Lugo: R. Ranero Díaz; ICN-Unidad Nefrológica El Pilar: R. Gota Ángel, C. Hevia; ICN-Unidad Nefrológica Moncloa: F. Coronel, J. Torrente; Instituto Médico Badalona: P. Fernández Crespo; Instituto Médico Barcelona: J. Casellas, M. Mas; Instituto Médico Quirúrgico San Rafael: J. Calviño, M. Rodríguez Lozano; Nefroclub Cartago: T. Ortuño; Nefroplana Castellón: R. Pons; Nefroubeda: P. Serrano; Phermodiayisis: M.T. Hernández Moreno; Sanatorio Souto Boo: A. Pérez Freiría; Unidad HD. Madrid Oeste: C. Gámez, P. Mateos; H. Virgen de los Lirios: C. del Pozo.

	Footnotes

 
Published online ahead of print. Publication date available at www.cjasn.org.

Received March 17, 2007. Accepted June 25, 2007.

	References

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Disclosures References

 

1. NKF-K/DOQI clinical practice guidelines for vascular access: Update 2000. Am J Kidney Dis37[Suppl 1] :S137 –S181,2001
2. US Renal Data System: USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases,2001
3. Rayner HC: Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, Piera L, Bragg-Gresham JL, Feldman HI, Goodkin DA, Gillespie B, Wolfe RA, Held PJ, Port FK: Mortality and hospitalization in haemodialysis patients in five European countries: Results from the Dialysis Outcome and Practice Patterns Study (DOPPS). Nephrol Dial Transplant19 :108 –120,2004[Abstract/Free Full Text]
4. Manns B, Tonelli M, Yilmaz S, Lee H, Laupland K, Klarenbach S, Radkevich V, Murphy B: Establishment and maintenance of vascular access in incident hemodialysis patients: A prospective cost analysis. J Am Soc Nephrol16 :201 –209,2005[Abstract/Free Full Text]
5. Rodriguez Hernandez JA, Gonzalez Parra E, Julian Gutierrez JM, Segarra Medrano A, Almirante B, Martinez MT, Arrieta J, Fernandez Rivera C, Galera A, Gallego Beuter J, Gorriz JL, Herrero JA, Lopez Menchero R, Ochando A, Perez Banasco V, Polo JR, Pueyo J, Ruiz CI, Segura Iglesias R; Sociedad Espanola de Nefrologia: Vascular access guidelines for hemodialysis [in Spanish]. Nefrologia25[Suppl 1] :3 –97,2005
6. Rodriguez JA, Lopez J, Cleries M, Vela E: Vascular access for haemodialysis: An epidemiological study of the Catalan Renal Registry. Nephrol Dial Transplant14 :1651 –1657,1999[Abstract/Free Full Text]
7. Rodriguez JA: Hemodialysis vascular access in incident patients in Spain. Kidney Int62 :1475 –1476, author reply 1476–1477,2002[Medline]
8. Garrancho JM, Kirchgessner J, Arranz M, Klinker G, Rentero R, Ayala JA, Marceli D: Haemoglobin level and vascular access survival in haemodialysis patients. Nephrol Dial Transplant20 :2453 –2457,2005[Abstract/Free Full Text]
9. Besarab A, Bolton WK, Browne JK, Egrie JC, Nissenson AR, Okamoto DM, Schwab SJ, Goodkin DA: The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med339 :584 –590,1998[Abstract/Free Full Text]
10. Pisoni RL, Young EW, Dykstra DM, Greenwood RN, Hecking E, Gillespie B, Wolfe RA, Goodkin DA, Held PJ: Vascular access use in Europe and the United States: Results from the DOPPS. Kidney Int61 :305 –316,2002[CrossRef][Medline]
11. Portoles J, Lopez-Gomez JM, Aljama P, Tato A: Cardiovascular risk in hemodialysis in Spain: Prevalence, management and target results (MAR Study). Nefrología24 :83 –92,2005
12. Portoles J, Lopez-Gomez JM, Aljama P: Anemia management and treatment response in patients on hemodialysis: The MAR Study. J Nephrol19 :352 –360,2006[Medline]
13. European best practice guidelines on anemia management. Nephrol Dial Transplant14[Suppl 4] :1 –50.1999
14. Daughirdas JT: Second generation logarithmic estimates of single-pool variable volume KT/V: an analysis of error. J Am Soc Nephrol56 :1928 –1933,1993
15. Beddhu S, Bruns FJ, Saul M, Seddon P, Zeidel M: A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. Am J Med108 :609 –613,2000[CrossRef][Medline]
16. Astor BC, Eustace J, Powe N, Klag MJ, Fink N, Coresh J: Type of vascular access and survival among incident hemodialysis patients: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. J Am Soc Nephrol16 :1449 –1455,2005[Abstract/Free Full Text]
17. Gruss E, Portoles J, Jimenez T, Rueda JA, del Cerro J, Lasala M, Tato A, Gago MC: Prospective monitoring of vascular access in HD by a multidisciplinary team. Nefrologia26 :703 –710,2006[Medline]
18. Strippoli GF, Navaneethan SD, Craig JC: Haemoglobin targets for the anemia of chronic kidney disease. Cochrane Database Syst Rev(4) : CD003967,2006
19. Miller PE, Carlton D, Deierhoi MH, Redden DT, Allon M: Natural history of arteriovenous grafts in hemodialysis patients. Am J Kidney Dis36 :68 –74,2000[Medline]
20. Foley RN, Parfrey PS, Morgan J, Barre PE, Campbell P, Cartier P, Coyle D, Fine A, Handa P, Kingma I, Lau CY, Levin A, Mendelssohn D, Muirhead N, Murphy B, Plante RK, Posen G, Wells GA: Effect of hemoglobin levels in hemodialysis patients with asymptomatic cardiomyopathy. Kidney Int58 :1325 –1335,2000[CrossRef][Medline]
21. Locatelli F, Pisoni RL, Combe C, Bommer J, Andreucci VE, Piera L, Greenwood R, Feldman HI, Port FK, Held PJ: Anaemia in haemodialysis patients of five European countries: Association with morbidity and mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant19 :121 –132,2004[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) All Versions of this Article: CJN.01320307v1 2/6/1163    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Portolés, J. Search for Related Content PubMed PubMed Citation Articles by Portolés, J.