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The Cochrane Database of Systematic... Apr 2022Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous... (Review)
Review
BACKGROUND
Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters. Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access.
OBJECTIVES
To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD.
DATA COLLECTION AND ANALYSIS
Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE.
MAIN RESULTS
We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported.
AUTHORS' CONCLUSIONS
Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.
Topics: Adult; Catheter-Related Infections; Central Venous Catheters; Child; Heparin; Humans; Renal Dialysis; Sepsis
PubMed: 35363884
DOI: 10.1002/14651858.CD013554.pub2 -
JAMA Aug 2022The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear. (Comparative Study)
Comparative Study Meta-Analysis
IMPORTANCE
The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear.
OBJECTIVE
To compare the risks of vein graft failure and bleeding associated with ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy vs aspirin among patients undergoing coronary artery bypass graft surgery.
DATA SOURCES
MEDLINE, Embase, and Cochrane Library databases from inception to June 1, 2022, without language restriction.
STUDY SELECTION
Randomized clinical trials (RCTs) comparing the effects of ticagrelor DAPT or ticagrelor monotherapy vs aspirin on saphenous vein graft failure.
DATA EXTRACTION AND SYNTHESIS
Individual patient data provided by each trial were synthesized into a combined data set for independent analysis. Multilevel logistic regression models were used.
MAIN OUTCOMES AND MEASURES
The primary analysis assessed the incidence of saphenous vein graft failure per graft (primary outcome) in RCTs comparing ticagrelor DAPT with aspirin. Secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included RCTs comparing ticagrelor monotherapy with aspirin.
RESULTS
A total of 4 RCTs were included in the meta-analysis, involving 1316 patients and 1668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT (median age, 67 years [IQR, 60-72 years]; 65 women [14.9%]; 370 men [85.1%]) and 436 received aspirin (median age, 66 years [IQR, 61-73 years]; 63 women [14.5%]; 373 men [85.5%]). Ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%; difference, -8.7% [95% CI, -13.5% to -3.9%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001) and was associated with a significantly lower incidence of saphenous vein graft failure per patient (13.2% vs 23.0%, difference, -9.7% [95% CI, -14.9% to -4.4%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001). Ticagrelor DAPT (22.1%) was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events than was aspirin (8.7%; difference, 13.3% [95% CI, 8.6% to 18.0%]; OR, 2.98 [95% CI, 1.99 to 4.47]; P < .001), but not BARC type 3 or 5 bleeding events (1.8% vs 1.8%, difference, 0% [95% CI, -1.8% to 1.8%]; OR, 1.00 [95% CI, 0.37 to 2.69]; P = .99). Compared with aspirin, ticagrelor monotherapy was not significantly associated with saphenous vein graft failure (19.3% vs 21.7%, difference, -2.6% [95% CI, -9.1% to 3.9%]; OR, 0.86 [95% CI, 0.58 to 1.27]; P = .44) or BARC type 2, 3, or 5 bleeding events (8.9% vs 7.3%, difference, 1.7% [95% CI, -2.8% to 6.1%]; OR, 1.25 [95% CI, 0.69 to 2.29]; P = .46).
CONCLUSIONS AND RELEVANCE
Among patients undergoing coronary artery bypass graft surgery, adding ticagrelor to aspirin was associated with a significantly decreased risk of vein graft failure. However, this was accompanied by a significantly increased risk of clinically important bleeding.
Topics: Aged; Aspirin; Coronary Artery Bypass; Female; Graft Occlusion, Vascular; Hemorrhage; Humans; Male; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Saphenous Vein; Ticagrelor; Treatment Outcome
PubMed: 35943473
DOI: 10.1001/jama.2022.11966 -
International Journal of Surgery... Sep 2023The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus... (Meta-Analysis)
Meta-Analysis
Perioperative and oncologic outcomes of minimally-invasive surgery for renal cell carcinoma with venous tumor thrombus: a systematic review and meta-analysis of comparative trials.
BACKGROUND
The present study aimed to conduct a pooled analysis to compare the perioperative and oncologic outcomes of minimally-invasive radical nephrectomy with tumor thrombus (MI-RNTT) with open radical nephrectomy with tumor thrombus (O-RNTT).
METHODS
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to December 2022. The primary outcomes were perioperative results, complications, and oncologic outcomes. Review Manager 5.4 was used for this analysis.
RESULTS
In total, eight retrospective trials with a total of 563 patients were included. Compared to O-RNTT, MI-RNTT had shorter hospitalization time [weighted mean difference (WMD) -3.58 days, 95% CI: -4.56 to -2.59; P <0.00001), lower volumes of blood loss (WMD -663.32 ml, 95% CI: -822.22 to -504.42; P <0.00001), fewer transfusion rates (OR 0.18, 95% CI: 0.09-0.35; P <0.00001), fewer overall complications (OR 0.33, 95% CI: 0.22-0.49; P <0.00001), and fewer major complications s (OR 0.49, 95% CI: 0.24-1.00; P =0.05). However, operative time, intraoperative complications, mortality rate (intraoperative, within 30 days, and total mortality), overall survival, recurrence-free survival, and cancer-specific survival did not significantly differ between the two groups.
CONCLUSIONS
MI-RNTT possesses more benefits than O-RNTT in terms of length of hospital stay, blood loss, and complications and provides comparable mortality rates and oncologic outcomes. However, more comprehensive and rigorous research is warranted to further validate the outcomes, which should include a larger sample size and comprehensive data from high-volume medical centers.
Topics: Humans; Carcinoma, Renal Cell; Retrospective Studies; Treatment Outcome; Veins; Kidney Neoplasms; Postoperative Complications
PubMed: 37526108
DOI: 10.1097/JS9.0000000000000405 -
Cureus Jan 2017The pulmonary veins (PVs) are the most proximal source of arterial thromboembolism. Pulmonary vein thrombosis (PVT) is a rare but potentially lethal disease; its... (Review)
Review
The pulmonary veins (PVs) are the most proximal source of arterial thromboembolism. Pulmonary vein thrombosis (PVT) is a rare but potentially lethal disease; its incidence is unclear, as most of the literature includes case reports. It most commonly occurs as a complica-tion of malignancy, post lung surgery, or atrial fibrillation and can be idiopathic in some cases. Most patients with PVT are commonly asymptomatic or have nonspecific symptoms such as cough, hemoptysis, and dyspnea from pulmonary edema or infarction. The thrombi are typically detected using a variety of imaging modalities including transesophageal echocardiogram (TEE), computed tomography (CT) scanning, magnetic resonance imaging (MRI), or pulmonary angiog-raphy. Treatment should be determined by the obstructing pathological finding and can include antibiotic therapy, anticoagulation, thrombectomy, and/or pulmonary resection. The delay in diagnosing this medical entity can lead to complications including pulmonary infarction, pulmonary edema, right ventricular failure, allograft failure, and peripheral embolism resulting in limb ischemia, stroke, and renal infarction (RI).
PubMed: 28265529
DOI: 10.7759/cureus.993 -
Journal of Clinical Hypertension... Jul 2020The present meta-analysis aims to compare renal arterial and venous Doppler parameters in women with preeclampsia and healthy pregnant controls. Medline, Scopus,... (Meta-Analysis)
Meta-Analysis Review
The present meta-analysis aims to compare renal arterial and venous Doppler parameters in women with preeclampsia and healthy pregnant controls. Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Google Scholar databases were systematically searched from inception to December 04, 2019. All observational studies reporting renal resistive index, pulsatility index, renal interlobar vein impedance, or pulse transit time among preeclamptic and healthy pregnant women were held eligible. Subgroup analysis was conducted on the basis of disease onset and side of measurement. Both pair-wise and network meta-analysis were performed using Review Manager 5.3 and R-3.4.3 software. Fourteen studies were included, with a total of 1118 women. No difference of renal resistive (MD: 0.00, 95% CI: [-0.03, 0.04]) and pulsatility index (MD: -0.01, 95% CI: [-0.14, 0.12]) was evident between the two groups. Renal interlobar vein impedance was estimated to be significantly higher in preeclampsia (MD: 0.07, 95% CI: [0.06, 0.09]), while venous pulse transit time was significantly lower (MD: -0.10, 95% CI: [-0.14, -0.05]) in women with the disease. Subgroup analysis indicated that early-onset preeclampsia was associated with significantly elevated renal interlobar vein impedance and lower venous pulse transit time than late-onset disease. The outcomes of the present meta-analysis suggest that preeclampsia is characterized by venous hemodynamic dysfunction as it is associated with significantly elevated renal interlobar vein impedance and shorter venous pulse transit time. Future large-scale prospective studies should introduce cutoff values and determine the optimal timing of measurement in order to achieve optimal predictive accuracy.
Topics: Female; Hemodynamics; Humans; Kidney; Pre-Eclampsia; Pregnancy; Prospective Studies
PubMed: 32644302
DOI: 10.1111/jch.13940 -
Journal of Vascular Surgery. Venous and... Mar 2018Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for... (Review)
Review
OBJECTIVE
Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for intervention. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS.
METHODS
We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups.
RESULTS
The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation.
CONCLUSIONS
NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.
Topics: Endovascular Procedures; Hemodynamics; Humans; Laparoscopy; Postoperative Complications; Renal Artery; Renal Circulation; Renal Nutcracker Syndrome; Stents; Time Factors; Treatment Outcome; Vascular Grafting; Vascular Patency
PubMed: 29292117
DOI: 10.1016/j.jvsv.2017.11.005 -
Journal of Human Hypertension Oct 2022The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were... (Meta-Analysis)
Meta-Analysis Review
The study aims to compare clinical outcomes following renal denervation (RDN) in hypertensive patients with atrial fibrillation (AF). Three online databases were searched (MEDLINE, EMBASE and PubMed) for literature related to outcomes of RDN on hypertension and AF, between January 1, 2010, and June 1, 2021. Where possible, risk ratios (RR) and mean differences (MD) were combined using a random effects model. Significance was set at p ≤ 0.05. Seven trials were included that assessed the effect of adding RDN to pulmonary vein isolation (PVI) in patients with hypertension and AF. A total of 711 patients (329 undergoing PVI + RDN and 382 undergoing PVI alone), with an age range of 56 ± 6 to 68 ± 9 years, were included. Pooled analysis showed a significant lowering of AF recurrence in the PVI + RDN (31.3%) group compared to the PVI-only (52.9%) group (p < 0.00001). Pooled analysis of patients with resistant hypertension showed a significant mean reduction of systolic blood pressure (SBP) (-9.42 mm Hg, p = 0.05), but not diastolic blood pressure (DBP) (-4.11 mm Hg, p = 0.16) in favor of PVI + RDN. Additionally, the pooled analysis showed that PVI + RDN significantly improved estimated glomerular filtration rate (eGFR) (+10.2 mL/min per 1.73 m, p < 0.001) compared to PVI alone. RDN procedures in these trials have proven to be both safe and efficacious with an overall complication rate of 6.32%. Combined PVI and RDN is beneficial for patients with hypertension and AF. Combined therapy showed improvement in SBP and eGFR, reducing the risk of AF recurrence. RDN may serve as an innovative intervention in the treatment of AF.
Topics: Atrial Fibrillation; Catheter Ablation; Humans; Hypertension; Recurrence; Renal Artery; Sympathectomy; Treatment Outcome
PubMed: 35094013
DOI: 10.1038/s41371-022-00658-0 -
Journal of Arrhythmia Jun 2020This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone...
Efficacy and safety of renal denervation in addition to pulmonary vein isolation for atrial fibrillation and hypertension-Systematic review and meta-analysis of randomized controlled trials.
INTRODUCTION
This systematic review and meta-analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension.
METHODS
A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12-month follow-up and the secondary outcome was procedure-related complications.
RESULTS
There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], < .001; : 0%). Pooled analysis of HR showed that RDN + PVI was associated with reduced AF recurrence (HR 0.51 [0.38, 0.70], < .001; : 0%). Complications were 7/241 (2.9%) in the RDN + PVI group and 8/237 (3.4%) in the PVI group. The rate of complications between the groups was similar (RR 0.87 [0.33, 2.29], = .77; : 0%). In the subgroup analysis of paroxysmal AF, RDN + PVI was shown to reduce AF recurrence (RR 0.64 [0.49, 0.82], < .001; : 0% and HR 0.56 [0.38, 0.82], = .003; : 0%) compared to PVI alone. RDN + PVI has a moderate certainty of evidence in the reducing AF recurrence with an absolute reduction of 197 fewer per 1000 (from 254 fewer to 124 fewer).
CONCLUSION
RDN in addition to PVI, is associated with reduced 12-month AF recurrence and similar procedure-related complications compared to PVI alone.
PubMed: 32528562
DOI: 10.1002/joa3.12353 -
Frontiers in Cardiovascular Medicine 2023Autogenous arteriovenous fistula (AVF) is an efficient hemodialysis access for patients with end-stage kidney disease (ESKD). The specific threshold of vein diameter... (Review)
Review
BACKGROUND
Autogenous arteriovenous fistula (AVF) is an efficient hemodialysis access for patients with end-stage kidney disease (ESKD). The specific threshold of vein diameter still not reached a consensus.
METHOD
We conducted a comprehensive search in PubMed, Embase, and Web of Science databases for articles which comparing the treatment outcomes of AVF with 2 mm as vein diameter threshold. Fixed and random effect model were used for synthesis of results. Subgroup analysis was designed to assess the risk of bias.
RESULT
Eight high-quality articles were included finally. Among a total of 1,075 patients (675 males and 400 females), 227 and 809 patients possessed <2 mm and ≥2 mm vein respectively. Apart from gender and coronary artery disease ( < 0.05), there was no significant difference in age, diabetes, hypertension or radial artery between maturation and non-maturation groups. The functional maturation rate was lower in patients with <2 mm vein according to fixed effect model [OR = 0.19, 95% CI (0.12, 0.30), < 0.01]. There was no significant difference in primary [OR = 0.63, 95% CI (0.12, 3.25), = 0.58] or cumulative patency rates [OR = 0.40, 95% CI (0.13, 1.19), = 0.10].
CONCLUSION
Vein diameter less than 2 mm has a negative impact on the functional maturation rate of AVF, while it does not affect the primary and cumulative patency rates (12 months).
PubMed: 37808887
DOI: 10.3389/fcvm.2023.1226136 -
Journal of Vascular Surgery Mar 2015Basilic vein transposition is recommended in patients who are not candidates for a radial or brachial artery to cephalic vein fistula for dialysis access. Both one-stage... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Basilic vein transposition is recommended in patients who are not candidates for a radial or brachial artery to cephalic vein fistula for dialysis access. Both one-stage and two-stage procedures have their advantages and disadvantages. Which procedure results in improved outcomes remains unclear.
METHODS
A systematic review was conducted of the MEDLINE and EMBASE databases for studies that compared one-stage and two-stage brachial-basilic vein transpositions. Abstracts and full-text studies were screened independently by two reviewers with data abstraction done in duplicate. Random-effects meta-analysis was used to identify differences in primary failure rates and 1-year primary and secondary patency rates. Study quality was assessed by a previously described tool designed for observational studies reporting on dialysis access outcomes.
RESULTS
Of 1662 abstracts screened, 97 were selected for full-text review. Of these, eight studies (one randomized trial, seven observational studies) involving 882 patients met the inclusion criteria. The pooled odds ratio estimate for primary failure was 1.21 (95% confidence interval [CI], 0.73-1.98; P = .46), suggesting no difference in failure rate between one-stage and two-stage transpositions. Similarly, the estimated odds ratio for 1-year primary patency rate of 1.39 (95% CI, 0.71-2.72; P = .33) and 1-year secondary patency rate of 1.02 (95% CI, 0.36-2.87; P = .98) indicated no difference between the two groups. Study quality was limited by unclear outcome definitions, minimal control for confounding, and variable selection criteria. The decision to pursue a one-stage vs a two-stage procedure was often based on size of the basilic vein, with a two-stage procedure reserved for patients with smaller veins.
CONCLUSIONS
Meta-analysis of the existing literature comparing one-stage and two-stage basilic vein transposition suggests no difference in failure and patency rates, despite the two-stage procedure's being used in patients with smaller basilic veins. These findings are limited by the small size, observational design, and inconsistent quality of included studies. Reserving a two-stage procedure for patients with smaller basilic veins appears justified, although the strength of the evidence is limited.
Topics: Arteriovenous Shunt, Surgical; Chi-Square Distribution; Graft Occlusion, Vascular; Humans; Odds Ratio; Renal Dialysis; Retreatment; Risk Factors; Time Factors; Treatment Failure; Upper Extremity; Vascular Patency; Veins
PubMed: 25720934
DOI: 10.1016/j.jvs.2014.11.083