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Cochrane Database of Systematic Reviews

Pre‐emptive correction for haemodialysis arteriovenous access stenosis

Overview of attention for article published in Cochrane database of systematic reviews, January 2016
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Title
Pre‐emptive correction for haemodialysis arteriovenous access stenosis
Published in
Cochrane database of systematic reviews, January 2016
DOI 10.1002/14651858.cd010709.pub2
Pubmed ID
Authors

Pietro Ravani, Robert R Quinn, Matthew J Oliver, Divya J Karsanji, Matthew T James, Jennifer M MacRae, Suetonia C Palmer, Giovanni FM Strippoli

Abstract

Guidelines recommend routine arteriovenous (AV) graft and fistula surveillance (technology-based screening) in addition to clinical monitoring (physical examination) for early identification and pre-emptive correction of a stenosis before the access becomes dysfunctional. However, consequences on patient-relevant outcomes of pre-emptive correction of a stenosis in a functioning access as opposed to deferred correction, i.e. correction postponed to when the access becomes dysfunctional, are uncertain. We aimed to evaluate 1) whether pre-emptive correction of an AV access stenosis improves clinically relevant outcomes; 2) whether the effects of pre-emptive correction of an AV access stenosis differ by access type (fistula versus graft), aim (primary and secondary prophylaxis), and surveillance method for primary prophylaxis (Doppler ultrasound for the screening of functional and anatomical changes versus measurement of the flow in the access); and 3) whether other factors (dialysis duration, access location, configuration or materials, algorithm for referral for intervention, intervention strategies (surgical versus radiological or other), or study design) explain the heterogeneity that might exist in the effect estimates. We searched the Cochrane Kidney and Transplant Specialised Register to 30 November 2015 using search terms relevant to this review. We included all studies of any access surveillance method for early identification and pre-emptive treatment of an AV access stenosis. We extracted data on potentially remediable and irremediable failure of the access (i.e. thrombosis and access loss respectively); infection and mortality; and resource use (hospitalisation, diagnostic and intervention procedures). Analysis was by a random effects model and results expressed as risk ratio (RR), hazard ratio (HR) or incidence rate ratio (IRR) with 95% confidence intervals (CI). We identified 14 studies (1390 participants), nine enrolled adults without a known access stenosis (primary prophylaxis; three studies including people using fistulas) and five enrolled adults with a documented stenosis in a non-dysfunctional access (secondary prophylaxis; three studies in people using fistulas). Study follow-up ranged from 6 to 38 months, and study size ranged from 58 to 189 participants. In low- to moderate-quality evidence (based on GRADE criteria) in adults treated with haemodialysis, relative to no surveillance and deferred correction, surveillance with pre-emptive correction of an AV stenosis reduced the risk of thrombosis (RR 0.79, 95% CI 0.65 to 0.97; I² = 30%; 18 study comparisons, 1212 participants), but had imprecise effect on the risk of access loss (RR 0.81, 95% CI 0.65 to 1.02; I² = 0%; 11 study comparisons, 972 participants). In analyses subgrouped by access type, pre-emptive stenosis correction did not reduce the risk of thrombosis (RR 0.95, 95% CI 0.8 to 1.12; I² = 0%; 11 study comparisons, 697 participants) or access loss in grafts (RR 0.9, 95% CI 0.71 to 1.15; I² = 0%; 7 study comparisons; 662 participants), but did reduce the risk of thrombosis (RR 0.5, 95% CI 0.35 to 0.71; I² = 0%; 7 study comparisons, 515 participants) and the risk of access loss in fistulas (RR 0.5, 95% CI 0.29 to 0.86; I² = 0%; 4 studies; 310 participants). Three of the four studies reporting access loss data in fistulas (199 participants) were conducted in the same centre. Insufficient data were available to assess whether benefits vary by prophylaxis aim in fistulas (i.e. primary and secondary prophylaxis). Although the magnitude of the effects of pre-emptive stenosis correction was considerable for patient-centred outcomes, results were either heterogeneous or imprecise. While pre-emptive stenosis correction may reduce the rates of hospitalisation (IRR 0.54, 95% CI 0.31 to 0.93; I² = 67%; 4 study comparisons, 219 participants) and use of catheters (IRR 0.58, 95% CI 0.35 to 0.98; I² = 53%; 6 study comparisons, 394 participants), it may also increase the rates of diagnostic procedures (IRR 1.78, 95% CI 1.18 to 2.67; I² = 62%; 7 study comparisons, 539 participants), infection (IRR 1.74, 95% CI 0.78 to 3.91; I² = 0%; 3 studies, 248 participants) and mortality (RR 1.38, 95% CI 0.91 to 2.11; I² = 0%; 5 studies, 386 participants).In general, risk of bias was high or unclear in most studies for many domains we assessed. Four studies were published after 2005 and only one had evidence of registration within a trial registry. No study reported information on authorship and/or involvement of the study sponsor in data collection, analysis, and interpretation. Pre-emptive correction of a newly identified or known stenosis in a functional AV access does not improve access longevity. Although pre-emptive stenosis correction may be promising in fistulas existing evidence is insufficient to guide clinical practice and health policy. While pre-emptive stenosis correction may reduce the risk of hospitalisation, this benefit is uncertain whereas there may be a substantial increase (i.e. 80%) in the use of access-related procedures and procedure-related adverse events (e.g. infection, mortality). The net effects of pre-emptive correction on harms and resource use are thus unclear.

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Mendeley readers

Mendeley readers

The data shown below were compiled from readership statistics for 225 Mendeley readers of this research output. Click here to see the associated Mendeley record.

Geographical breakdown

Country Count As %
Unknown 225 100%

Demographic breakdown

Readers by professional status Count As %
Student > Master 38 17%
Researcher 26 12%
Student > Bachelor 22 10%
Student > Ph. D. Student 18 8%
Other 11 5%
Other 44 20%
Unknown 66 29%
Readers by discipline Count As %
Medicine and Dentistry 73 32%
Nursing and Health Professions 32 14%
Psychology 8 4%
Computer Science 4 2%
Engineering 4 2%
Other 26 12%
Unknown 78 35%
Attention Score in Context

Attention Score in Context

This research output has an Altmetric Attention Score of 4. This is our high-level measure of the quality and quantity of online attention that it has received. This Attention Score, as well as the ranking and number of research outputs shown below, was calculated when the research output was last mentioned on 27 June 2019.
All research outputs
#7,746,035
of 26,467,269 outputs
Outputs from Cochrane database of systematic reviews
#9,011
of 13,230 outputs
Outputs of similar age
#110,359
of 404,047 outputs
Outputs of similar age from Cochrane database of systematic reviews
#208
of 268 outputs
Altmetric has tracked 26,467,269 research outputs across all sources so far. This one has received more attention than most of these and is in the 69th percentile.
So far Altmetric has tracked 13,230 research outputs from this source. They typically receive a lot more attention than average, with a mean Attention Score of 35.7. This one is in the 30th percentile – i.e., 30% of its peers scored the same or lower than it.
Older research outputs will score higher simply because they've had more time to accumulate mentions. To account for age we can compare this Altmetric Attention Score to the 404,047 tracked outputs that were published within six weeks on either side of this one in any source. This one has gotten more attention than average, scoring higher than 71% of its contemporaries.
We're also able to compare this research output to 268 others from the same source and published within six weeks on either side of this one. This one is in the 22nd percentile – i.e., 22% of its contemporaries scored the same or lower than it.