Development Of A Nomogram For Failure Of Arteriovenous Fistula And Prognostic Analysis Of Interventional Therapy

Part I Development of a nomogram for failure of mature arteriovenous fistula and clinical evaluation.Research purposes:The purpose of this study is to analyze the risk factors for failure of mature arteriovenous fistula(AVF),then develop and validate a nomogram for predictive value in failure of mature AVF.Patient and Methods:This nomogram was based on a training cohort consist of 280 patients undergoing maintenance hemodialysis through arteriovenous fistula at Chang Zheng hospital in Shanghai from January 2014 to July 2018.Patients’ medical history and clinical data were collected and grouped according to whether AVF ever lost.Candidate risk factors included sex,age,diabetes,hypotension,dialysis mode,ratio of ultrafiltration volume to dry weight(ultrafiltration weight ratio),and some of laboratory tests.Possible risk factors were selected by univariate analysis firstly.Then the nomogram established by multivariate logistic regression was evaluated discriminative ability and calibration by the concordance index(C-index)and calibration curve respectively.The results were assessed on a validation cohort contained 64 patients.Results:1.In the primary cohort,280 patients(169 males and 111 females,with an average age of 50.32±12.20 years)who undergoing hemodialysis through AVF,57(20.4%)have occurred AVF failure during a retrospective period.In the validation cohort which contained 64 patients(36 males and 28 females,with an average age of 54.81±12.97 years),the incidence of failure of mature AVF is 14.1%.2.Univariate logistic regression analysis of the candidate variables showed that 5 variables,including age(P=0.030),hypotension(P=0.001),ultrafiltration weight ratio(P=0.007),Total cholesterol(TC)(P=0.040)and Low density lipoprotein(LDL)(P=0.027),met the inclusion requirements.3.On the basis of multivariate logistic regression and combined with the Akaike Information Criterion(AIC),we found that independent factors for failure of mature AVF were age(OR=3.103,95% CI:1.336-7.209),hypotension(OR=4.503,95% CI:1.590-12.751),ultrafiltration weight(OR=1.335,95% CI:1.079-1.651)ratio,LDL(OR=1.666,95% CI:1.089-2.548),and incorporate these factors into the nomogram.The C-index of the nomogram for predicting AVF failure was 0.714(95% CI,0.639 to 0.789).Application of the nomogram in the validation cohort still received similar discrimination,the C-index was 0.747(95% CI,0.581 to 0.914).Conclusion:This study provided a nomogram combined with clinical risk factors was proposed to preliminarily predict failure of mature AVF in patients with maintenance hemodialysis.In order to identify high-risk patients early,and intervention early.Part II Outcome and prognostic factors of stenosis after ultrasound-guided percutaneous transluminal angioplasty of arteriovenous fistulasResearch purposes:To assess primary patency after ultrasound-guided percutaneous transluminal angioplasty(PTA)of stenosis in AVF and to explore independent risk factors of primary patency after intervention.Patient and Methods:Patients who were admitted to the department of nephrology of Shanghai Chang Zheng hospital from November 2017 to January 2019 and were diagnosed with AVF stenosis by Doppler ultrasound or other imaging examinations and met the indications for PTA were selected.The PTA was performed under the guidance of color Doppler ultrasound.The degree of stenosis,brachial artery blood flow and brachial artery resistance index(RI)were reviewed one day after the operation to learn the therapeutic effect.At least 12 months of follow-up were performed to know the primary patency rate.The candidate risk factors included gender,age,diabetes,dialysis mode,age of AVF,stenosis degree,stenosis length,RI of brachial artery,flow volume of brachial artery,and laboratory tests.Categorical variables and continuous variables were analyzed through Kaplan-Meier method and univariate Cox regression,respectively.The multivariate Cox proportional-hazards model was used to analyze the independent risk factors related to the primary patency of AVF after PTA.Result:1.Technical success of ultrasound-guided PTA occurred in 96.6%(56 of 58)of interventions.2.Primary patency rate after intervention at 3months,6months and 12 months were 87.50%,78.57%,60.20%,respectively.3.According to the Kaplan-Meier survival analysis,age(P=0.046),stenosis length(P=0.002)and AVF duration(P=0.010)were found to be possible risk factors affecting primary patency.It was conclusion that the length of stenosis(RR=3.544,95% CI:1.495-8.613)and age of AVF(RR=0.411,95% CI:0.173-0.975)were independent risk factors influencing the primary patency after ultrasound-guided PTA.Diabetes,stenosis degree and dialysis mode had no significant influence on postoperative primary patency.Conclusion:Ultrasound-guided PTA is an effective method to treat AVF stenosis despite modest primary patency rates in 12 months.The detrimental determinant were length of stenosis and and age of AVF,which may be the independent risk factors for the primary patency rate after PTA treatment.