Determinants of Hemodialysis AV Fistula Maturation

大约有47万美国人患有终末期肾脏疾病，大多数人接受了 血液透析。进行血液透析程序需要血管通路，并且可以提供血管通路 使用自体动静脉瘘、人造动静脉移植物或中心静脉导管。房室瘘是 首选的血管通路类型，因为血栓发生率、感染率、通路相关 瘘管患者的支出和总的医疗支出都低于 要么植入人造房室，要么置入中心静脉导管。然而，瘘管的优点是 与永远不能使用的移植物相比，瘘管的比例要高得多，这与之相平衡 用于透析，因为未能充分成熟以支持有效的血液透析。成熟失败是 瘘管患病率增加的主要障碍，对许多患者来说，会导致多次手术 手术或长时间使用中心静脉导管，这是最不可取的血管通路类型。 最近的研究表明，20%-50%的新瘘管无法成熟。 此申请是对NIDDK RFA建立设计和执行联合体的响应 一项对新发瘘管患者的观察性队列研究。我们正在申请成为参赛者之一 该联盟的临床中心。这项建议的总体目标是确定瘘管的决定因素。 成熟结局，以便能够早期识别失败的瘘管，阐明机制 评估潜在的瘘管成熟度，并确定促进成熟度干预的潜在靶点。我们的 该提案有五个具体目标。这些措施包括1)确定超声波作为早期诊断方法的实用性。 识别未成熟的瘘管，2)评估预先存在的血管功能对 瘘管成熟的结果，3)确定与瘘管成熟相关的手术因素 结果，4)建立以证据为基础的瘘管成熟标准，以及5)临床特征 瘘管成熟失败的后果。这些目标假设招收75-100名两岁以上的科目。 在我们的网站上进行了600名受试者的总体研究队列。我们的几个目标包括将 在受试者的子集中进行，以提供关于瘘管的额外机械信息 成熟过程。 我们在血液透析血管通路方面确立的研究重点和专业知识，我们的成功和 作为多学科NIDDK透析访问联盟(DAC)的临床中心的领导地位 这项提议的合作者的专业知识和波士顿大学可用的资源使我们 非常适合作为NIDDK计划的参与临床中心。

Approximately 470,000 Americans have end-stage renal disease and most are treated with hemodialysis. A vascular access is required for performing the hemodialysis procedure and can be provided with a native arteriovenous (AV) fistula, a synthetic AV graft; or a central venous catheter. The AV fistula is the preferred type of vascular access because thrombosis rates, infection rates, access-related expenditures, and total healthcare expenditures all are lower for patients with fistulas than for those with either synthetic AV grafts or central venous catheters. However, the advantages of fistulas are counterbalanced by the substantially higher proportion of fistulas than grafts that are never able to be used for dialysis because of failure to mature adequately to support effective hemodialysis. Maturation failure is the major barrier to increasing fistula prevalence, and, for many patients, leads to multiple surgical procedures or prolonged use of central venous catheters, the least desirable type of vascularaccess. Recent studies suggest that 20-50% of new fistulas fail to mature. This application is a response to an NIDDK RFA to establish a consortium for designing and performing an observational cohort study of patients with new fistulas. We are applying to be one of the Participating Clinical Centers of the Consortium. The overall objective of this proposal is to identify determinants of fistula maturation outcomes in order to enable early identification of failing fistulas, elucidate mechanisms underlying fistula maturation, and identify potential targets for maturation-enhancing interventions. Our proposal has five specific aims. These include 1) determining the utility of ultrasound as a method for early identification of fistulas that are failing to mature, 2) evaluating the impact of pre-existing vascular function on fistula maturation outcomes, 3) identifying surgical factors that are associated with fistula maturation outcomes, 4) creating evidence-based criteria for fistula maturation, and 5) characterizing the clinical consequences of fistula maturation failure. These aims assume an enrollment of 75-100 subjects over two years at our site for an overall study cohort of 600 subjects. Several of our aims include sub-studies that will be performed in a subset of the subjects to provide additional mechanistic information about the fistula maturation process. Our established research focus and expertise in hemodialysis vascular access, our success and leadership as a Clinical Center for the NIDDK Dialysis Access Consortium (DAC), the multidisciplinary expertise of the collaborators for this proposal, and the resources available at Boston University make us ideally suited to serve as a Participating Clinical Center for this NIDDK initiative.