Statin Therapy and Hemodialysis Vascular Access-Were We Bringing a Knife to a Gunfight and Were Hoping to Win?
Nephrology Department, University of Nebraska Medical Center, Omaha, Nebraska Internal Medicine Department, Nebraska-Western Iowa V. A. Medical Center, Omaha, Nebraska. Seminars in Dialysis
(Impact Factor: 1.75).
03/2012; 25(6). DOI: 10.1111/j.1525-139X.2012.01059.x
Vascular access dysfunction is a major contributor to end stage renal disease patient morbidity, and the cost of maintaining it is staggering. Any intervention able to improve the vascular access maturation rate and/or patency would be significant progress. Based on the anti-inflammatory and vascular beneficial effects demonstrated in non-end stage renal disease patients, we were hoping that statin use might provide the much needed improvement in the hemodialysis vascular access outcome. The reality proved disappointing. The statins failed to improve every aspect of hemodialysis vascular access studied. The present editorial discusses the current data regarding the effect of statins on vascular access and attempts to explain their lack of success.
Available from: William Herrington
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ABSTRACT: Reducing LDL cholesterol (LDL-C) with statin-based therapy reduces the risk of major atherosclerotic events among patients with CKD, including dialysis patients, but the effect of lowering LDL-C on vascular access patency is unclear.
The Study of Heart and Renal Protection (SHARP) randomized patients with CKD to 20 mg simvastatin plus 10 mg ezetimibe daily versus matching placebo. This study aimed to explore the effects of treatment on vascular access occlusive events, defined as any access revision procedure, access thrombosis, removal of an old dialysis access, or formation of new permanent dialysis access.
Among 2353 SHARP participants who had functioning vascular access at randomization, allocation to simvastatin plus ezetimibe resulted in a 13% proportional reduction in vascular access occlusive events (355 [29.7%] for simvastatin/ezetimibe versus 388 [33.5%] for placebo; risk ratio [RR], 0.87; 95% confidence interval [95% CI], 0.75 to 1.00; P=0.05). There was no evidence that the effects of treatment differed for any of the separate components of this outcome. To test the hypothesis raised by SHARP, comparable analyses were performed using the AURORA (A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events) trial cohort. AURORA did not provide independent confirmation (vascular access occlusive events: 352 [28.9%] for rosuvastatin versus 337 [27.6%] for placebo; RR, 1.06, 95% CI, 0.91 to 1.23; P=0.44). After combining the two trials, the overall effect of reducing LDL-C with a statin-based regimen on vascular access occlusive events was not statistically significant (707 [29.3%] with any LDL-C-lowering therapy versus 725 [30.5%] with placebo; RR, 0.95, 95% CI, 0.85 to 1.05; P=0.29).
Exploratory analyses from SHARP suggest that lowering LDL-C with statin-based therapy may improve vascular access patency, but there was no evidence of benefit in AURORA. Taken together, the available evidence suggests that any benefits of lowering LDL-C on vascular access patency are likely to be modest.
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Stenosen von arteriovenösen (AV-)Fisteln sind die häufigste Ursache für eine Dysfunktion oder den Verlust des Dialysezugangs. Das pathologische Korrelat der AV-Fistelstenose ist i. d. R. die neointimale Hyperplasie. Ihre Entstehung ist multifaktoriell. Hämodynamische Reize und mechanische Traumen induzieren einen komplexen Prozess von Inflammation, Regeneration und Degeneration, der letztlich zur Stenose führt.
Basierend auf der Lokalisation der Einengung hat sich eine Einteilung in 4 Typen etabliert. Typ-1-Stenosen finden sich anastomosenah, Typ-2-Stenosen im Bereich der Punktionsareale. Typ-3-Stenosen sind an Einmündungen in das tiefe Venensystem lokalisiert und Typ-4-Stenosen in den zentralen Venenabschnitten.
Für die Verhinderung der Entstehung von Shuntvenenstenosen sind in den letzten Jahren pharmakologische, zellbasierte und physikalische Strategien entwickelt worden. Die Therapieoptionen sind sowohl endovaskulär als auch chirurgisch. Die Wahl des Verfahrens erfordert eine individuelle Betrachtung verschiedenster lokaler, systemischer und prognostischer Faktoren und sollte möglichst in einem interdisziplinären Konzept erfolgen.
Available from: Yahya Makkeyah
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ABSTRACT: Background: Thrombosis of hemodialysis vascular access represents a major medical and economic burden. Omega-3 fatty acids play an important modulatory role in the immune and inflammatory responses and the progression of arteriosclerosis. Fish oils have been demonstrated to have anti-platelet effects, and reduce intimal hyperplasia in autogenous grafts. Such effects may improve arteriovenous fistula (AVF) and arteriovenous graft (AVG) patency. Objective: To determine the effect of fish oil on native AVF and synthetic graft patency in chronic hemodialysis patients. Patients and Methods: Prospective Case control study conducted on 80 chronic hemodialysis patients selected from El-Maadi Liver & Kidney Transplantation Hospital in Egypt. The study was conducted through a period of time spanning 6 months. Patients were divided randomly into two groups, group (1) composed of 40 hemodialysis patients receiving four Omega-3 fatty acids capsules/day (1-g per capsule) for the 6-months duration of the study and group (2) composed of 40 hemodialysis patients not receiving omega-3 fatty acids. Full clinical examination of AVF and grafts was done to all patients in every hemodialysis session during the six months period of the study. Angiography was done whenever indicated. Results: 82.5% out of our patients were having AVF as their vascular access while the remaining 17.5% were having AVG. There was highly significant statistical decrease in serum triglyceride, total cholesterol and LDL levels in group (1) compared to group (2) over the 6 months period (p<0.001). Highly significant statistical increase in HDL level and URR in group (1) compared to group (2) over the 6 months period (p <0.001). Angiography was done to 8 indicated patients (10%), 3 patients in group (1) (7.5%) and 5 patients in group (2) (12.5%).Conclusion: Fish oil leads to significant decrease in serum triglyceride level, total cholesterol level and LDL together with increase in HDL level in chronic hemodialysis patients. Vascular access blood flow also changed but not in a significant manner. [Howayda El-Shinnawy, Walid Bichari, Yahya Makkeyah, Maha Behairy, Ahmed Shabaan. Effect Of Omega-3 Fatty Acids On Vascular Access Patency In Chronic Hemodialysis Patients. Life Sci J 2015;12(1):82-88]. (ISSN:1097-8135). http://www.lifesciencesite.com. 12
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