TITLE:The association of erythropoietin-stimulating agents and increased risk for AV-fistula dysfunction in hemodialysis patients. A retrospective analysis.

BACKGROUND:Patients in maintenance hemodialysis (HD) need a patent vascular access for optimal treatment. The recommended first choice is a native arteriovenous fistula (AVF). Complications of AVF are frequent and include thrombosis, stenosis and infections leading to worsening of dialysis efficacy. Some known risk factors are age, gender and the presence of diabetes mellitus. The aim was to investigate if further risk variables are associated with dysfunctional AVF.

METHODS:This retrospective observational study included 153 chronic HD patients (Cases) referred to a total of 473 radiological investigations due to clinically suspected complications of their native AVF. Another group of chronic HD patients (n = 52) who had a native AVF but were without history of previous complications for at least 2 years were controls. Statistical analyses included ANOVA, logistic regression, parametric and non-parametric methods such as Student's T-test and Mann-Whitney test.

RESULTS:Among Cases, at least one significant stenosis (> 50% of the lumen) was detected in 348 occasions. Subsequent PTA was performed in 248 (71%). Median erythropoiesis-stimulating agent (ESA) weekly doses were higher in Cases than in Controls (8000 vs 5000 IU, p < 0.001). Cases received higher doses of intravenous iron/week than the Controls before the investigation (median 50 mg vs 25 mg, p = 0.004) and low molecular weight heparin (LMWH, p = 0.028). Compared to Controls, Cases had a lower level of parathyroid hormone (median 25 vs 20 ρmol/L, p = 0.009). In patients with diabetes mellitus, HbA1c was higher among Cases than Controls (50 vs 38 mmol/mol, p < 0.001). Multiple regression analysis revealed significant associations between Cases and female gender, prescription of doxazocin, and doses of ESA and LMWH. There was no difference between the groups regarding hemoglobin, CRP or ferritin.

CONCLUSION:In conclusion, the present study indicated that the factors associated with AVF problems were high doses of ESA, iron administration, and tendency of thromboembolism (indicated by high LMWH doses); the use of doxazocin prescription, however, requires further investigation.

SOURCE: Wärme A, Hadimeri H, Nasic S, et al. The association of erythropoietin-stimulating agents and increased risk for AV-fistula dysfunction in hemodialysis patients. A retrospective analysis[J]. BMC Nephrol, 2021, 22(1):30. DOI: 10.1186/s12882-020-02209-6.

背景：维持性血液透析（HD）的患者需要获得有效的血管通路以进行最佳治疗。推荐的首选是自体动静脉瘘（AVF）。 AVF的并发症很常见，包括血栓形成，狭窄和感染，导致透析效果恶化。一些已知的危险因素是年龄，性别和糖尿病的存在。本目的是研究是否进一步的风险变量与机能障碍有关。

方法：这项回顾性观察研究纳入了153例慢性HD患者（病例），由于其临床AVF的临床可疑并发症，因此总共进行了473项放射学检查。另一组拥有自体动静脉内瘘、至少有2年无既往并发症史的慢性HD患者（n = 52）为对照组。统计分析包括方差分析，逻辑回归，参数化和非参数化方法，例如Student T检验和Mann-Whitney检验。

结果：在病例中，至少有1例显着狭窄（> 50％的管腔）有348例次。其中248例次随后进行了PTA（71％）。病例中，促红细胞生成素刺激剂（ESA）的每周剂量高于对照组（8000 vs 5000 IU，p <0.001）。在研究前，病例组每周接受的静脉铁剂剂量高于对照组（中值分别为50mg和25mg，p = 0.004），以及高剂量的低分子量肝素（LMWH，p = 0.028）。与对照组相比，病例组的甲状旁腺激素水平较低（中位数为25 vs 20 ρmol / L，p = 0.009）。在糖尿病患者中，病例中的HbA1c高于对照组（50 vs 38mmol / mol，p <0.001）。多元回归分析显示，病例与女性，阿霉素的处方以及ESA和LMWH的剂量之间存在显着相关性。两组之间在血红蛋白，CRP或铁蛋白方面没有差异。

结论：总的来说，本研究表明与AVF问题相关的因素包括高剂量的ESA，铁剂的使用和血栓栓塞的趋势（高LMWH剂量表明）；然而，使用多沙唑星处方尚需进一步研究。

启发：国内使用的ESA明显高于本文献报道水平，会不会是与狭窄有关，以及程度如何，皆有待进一步研究。