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Meta-analysis and Commentary: Preemptive Correction of Arteriovenous Access Stenosis

View ORCID ProfileJochen G. Raimann, View ORCID ProfileLevi Waldron, Elsie Koh, Gregg A. Miller, Murat H. Sor, Richard J. Gray, Peter Kotanko
doi: https://doi.org/10.1101/179580
Jochen G. Raimann
1Renal Research Institute, NY, NY, United States
2City University New York School of Public Health, NY, USA
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Levi Waldron
2City University New York School of Public Health, NY, USA
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Elsie Koh
3Azura Vascular Care, Waltham, MA, USA
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Gregg A. Miller
3Azura Vascular Care, Waltham, MA, USA
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Murat H. Sor
3Azura Vascular Care, Waltham, MA, USA
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Richard J. Gray
3Azura Vascular Care, Waltham, MA, USA
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Peter Kotanko
1Renal Research Institute, NY, NY, United States
4Icahn School of Medicine at Mount Sinai Health System, NY, USA
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Abstract

Background A recent meta-analysis by Ravani and colleagues (Ravani, P., et al., Am J Kidney Dis, 2016. 67(3): p. 446-60.) studied the effect of pre-emptive correction of arterio-venous dialysis vascular access versus deferred care, based on data from 11 trials. The authors reported a non-significant protective treatment effect of pre-emptive correction on access loss, while showing a significant protective effect on thrombosis rates conferred by pre-emptive correction. We revisit this analysis, including data extraction and effects of a heterogenous study population.

Methods We repeated data extraction from all referenced publications in the meta-analysis by Ravani et al. and corrected event counts where applicable. We repeated the meta-analyses with access loss as the outcome for studies that recruited patients with arterio-venous fistulae (AVF) and grafts (AVG), respectively, using a random effects model with relative risk (RR) and risk difference (RD) of access loss as the outcomes of interest. We repeated data extraction from all referenced publications, and corrected event counts where applicable.

Results Our conclusions differ from the original findings in two ways. First, after some amendment of the event counts extracted from Mayer et al. (Vascular and Endovascular Surgery 1993), we find a significant overall positive effect of pre-emptive correction on arterio-venous access loss in the overall study population [RR 0.80 (95% CI 0.64 to 0.99), RD −0.07 (95% CI −0.12 to −0.02); Figure 1]. Secondly, we highlight the impact of heterogeneous study populations on the meta-analysis. Whereas the data do not conclusively show a benefit of pre-emptive correction for arteriovenous grafts (AVG; RR = 0.87, 95% CI: 0.69 – 1.11), they show a strong protective effect for arteriovenous fistulae (AVF; RR = 0.5, 95% CI: 0.29 to 0.86).

Figure 1:
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Figure 1:

Meta-analysis of access loss, overall and by access type using risk ratio (RR) as the measure of association.

Discussion and Conclusion These findings corroborate clinical arguments such as superior long-term patency of AVF and the nature of AVG failure that often involve infectious causes. The available data indicate mild or no benefit of pre-emptive correction for AVG, but strongly support tight monitoring of dialysis accesses and preemptive intervention and correction upon the slightest suspicion of access stenosis for AVF.

Copyright 
The copyright holder for this preprint is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license.
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Posted August 23, 2017.
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Meta-analysis and Commentary: Preemptive Correction of Arteriovenous Access Stenosis
Jochen G. Raimann, Levi Waldron, Elsie Koh, Gregg A. Miller, Murat H. Sor, Richard J. Gray, Peter Kotanko
bioRxiv 179580; doi: https://doi.org/10.1101/179580
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Meta-analysis and Commentary: Preemptive Correction of Arteriovenous Access Stenosis
Jochen G. Raimann, Levi Waldron, Elsie Koh, Gregg A. Miller, Murat H. Sor, Richard J. Gray, Peter Kotanko
bioRxiv 179580; doi: https://doi.org/10.1101/179580

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