Surveillance of arteriovenous hemodialysis access: A systematic review and meta-analysis
Received 7 August 2008; accepted 9 August 2008.
Objectives
Hemodialysis centers regularly survey arteriovenous (AV) accesses for signs of dysfunction. In this review, we synthesize the available evidence to determine to what extent proactive vascular access monitoring affects the incidence of AV access thrombosis and abandonment compared with clinical monitoring.
Methods
We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and SCOPUS) and sought references from experts, bibliographies of included trials, and articles that cited included studies. Two reviewers independently assessed trial quality and extracted data. We used random effects meta-analysis to estimate the pooled relative risk (RR) and 95% confidence interval (CI) across studies and conducted subgroup analyses to explain heterogeneity. The I2 statistic was used to assess heterogeneity of treatment effect among trials.
Results
Nine studies (1363 patients) compared a strategy of surveillance vs clinical monitoring. A vascular intervention to maintain or restore patency was provided to both groups if needed. Surveillance followed by intervention led to a nonsignificant reduction of the risk of access thrombosis (RR, 0.82; 95% CI, 0.58-1.16; I2 = 37%) and access abandonment (RR, 0.80; 95% CI, 0.51-1.25; I2 = 60%). Three studies (207 patients) compared the effect of vascular interventions vs observation in patients with abnormal surveillance result. Vascular interventions after an abnormal AV access surveillance led to a significant reduction of the risk of access thrombosis (RR, 0.53; 95% CI, 0.36-0.76) and a nonsignificant reduction of the risk of access abandonment (RR, 0.76; 95% CI, 0.43-1.37).
Conclusion
Very low quality evidence yielding imprecise results suggests a potentially beneficial effect of AV access surveillance followed by interventions to restore patency. This inference, however, is weak and will require randomized trials of AV access surveillance vs clinical monitoring for rejection or confirmation.
aKnowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minn
bDivision of Nephrology, Mayo Clinic, Rochester, Minn
cDivision of Preventive Medicine, Mayo Clinic, Rochester, Minn
dDivision of Vascular Surgery, Mayo Clinic, Rochester, Minn
eDivision of Endocrinology, Mayo Clinic, Rochester, Minn
fDepartment of Surgery, VA Medical Center, Georgetown and George Washington Universities, Washington, DC
Correspondence: M. Hassan Murad, MD, MPH, Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905
This review was funded by a contract from the Society of Vascular Surgery.
STATEMENT OF CONFLICT OF INTEREST: These authors report that they have no conflicts of interest with the sponsor of this supplement article or products discussed in this article.
ABSTRACT