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are the methods of choice for regular VA surveillance&#46;<span class="elsevierStyleSup">1 </span>Since 1995&#44; it have been described several of these methods and some of them have subsequently applied in daily clinical practice&#44; such as ultrasound dilution&#44; Delta-H or termodiluci&#243;n&#46;<span class="elsevierStyleSup">4 </span>Some Some of these techniques have been proven effective in providing an early diagnosis of significant stenosis and reducing the rate of VA thrombosis&#46;<span class="elsevierStyleSup">5&#44;6 </span></p><p class="elsevierStylePara">The temperature gradient method &#40;TGM&#41; was described and validated by Wijnen et al in 2007 by comparison against the ultrasound dilution method&#46;<span class="elsevierStyleSup">7 </span>This method allows us to calculate the Q<span class="elsevierStyleInf">A </span>from the temperature values obtained by means of the blood temperature monitor &#40;BTM&#41; with the HD blood lines in the normal and reversed positions&#46;<span class="elsevierStyleSup">7 </span>The use of a specialised device named Twister&#8482; &#40;Fresenius Medical Care&#41;&#44; which is placed between the HD needles and the blood lines&#44; can simplify the Q<span class="elsevierStyleInf">A </span>determination by shortening the time needed to reverse the HD blood lines &#40;Figure 1&#41;&#46; </p><p class="elsevierStylePara">On the other hand&#44; no reliable study on VA function can overlook a variable as important as the patient&#8217;s blood pressure&#46; In this regard&#44; some authors have highlighted the direct relationship between the mean arterial pressure &#40;MAP&#41; and the Q<span class="elsevierStyleInf">A </span>of the VA&#44; meaning that changes in the MAP can affect the VA function&#46;<span class="elsevierStyleSup">8&#44;9 </span></p><p class="elsevierStylePara">This is an observational&#44; cross-sectional&#44; comparative study of the TGM with the following objectives&#58; </p><p class="elsevierStylePara">1&#41; Evaluate TGM efficacy in measuring the Q<span class="elsevierStyleInf">A </span>at the AVF during HD&#46; </p><p class="elsevierStylePara">2&#41; Determine whether placement of the Twister<span class="elsevierStyleSup">TM </span>shortens the time needed to determine Q<span class="elsevierStyleInf">A</span>&#46; </p><p class="elsevierStylePara">3&#41; Undertake a comparative functional study of TGM and the Delta-H method&#46; </p><p class="elsevierStylePara">4&#41; Analyse the effect of blood pressure on AVF function&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients </span></p><p class="elsevierStylePara">The AVF was evaluated in 30 patients undergoing HD 3 times weekly in the Nephrology Department at Hospital de Mollet&#46; Inclusion criteria for patients were as follows&#58; 1&#41; Age &#62;18 years&#46; 2&#41; In chronic HD programme&#46; 3&#41; Use of the AVF as a permanent VA&#46; 4&#41; Puncture of the AVF with 2 needles during a minimum of 12 consecutive HD sessions&#46; 5&#41; Use of a Q<span class="elsevierStyleInf">B </span>greater than 250ml&#47;min during a minimum of 12 consecutive HD sessions&#46; 6&#41; Informed consent from the patient&#46; The following variables were analysed&#58; sex&#44; age&#44; time on HD&#44; diabetic nephropathy as a cause of renal failure&#44; Kt&#47;V index &#40;by Daugirdas second-generation single-pool model&#41;&#44; MAP &#40;diastolic blood pressure &#43;1&#47;3 pulse pressure&#41;&#44; type of AVF&#44; duration of AVF&#44; total number of VA and distance between needles&#46; Table 1 summarises the most important clinical characteristics of the patients included in the study&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Method </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">1&#41; Measuring the Q<span class="elsevierStyleInf">A </span>by means of TGM&#46; </span>The Q<span class="elsevierStyleInf">A </span>was measured by using the BTM sensor incorporated in the 4008 S machine manufactured by Fresenius Medical Care&#46; TGM allows us to calculate the Q<span class="elsevierStyleInf">A </span>from the temperature values obtained with the HD blood lines in the normal and reverse positions&#44; with no need for creating a bolus of temperature&#46; The Q<span class="elsevierStyleInf">A </span>was calculated using the following formula&#58; </p><p class="elsevierStylePara">Q<span class="elsevierStyleInf">A&#160;</span>&#61; &#40;Q<span class="elsevierStyleInf">B&#44;x</span>&#160;&#8211; UFR&#41;&#160;&#183;&#160;T<span class="elsevierStyleInf">art&#44;x</span>&#160;&#8211; T<span class="elsevierStyleInf">ven<span class="elsevierStyleBold">&#44;</span>x</span><span class="elsevierStyleBold">&#160;</span>&#47;<span class="elsevierStyleBold">&#160;</span>T<span class="elsevierStyleInf">art&#44;n </span>&#8211; T<span class="elsevierStyleInf">art&#44;x</span></p><p class="elsevierStylePara">Where <span class="elsevierStyleItalic">Q<span class="elsevierStyleInf">B&#44;x</span></span>is the effective blood flow with blood lines in reverse position &#40;ml&#47;min&#41;&#44; UFR is the ultrafiltration rate &#40;ml&#47;min&#41;&#44; <span class="elsevierStyleItalic">T</span>is the<span class="elsevierStyleItalic">rt&#44;n</span>temperature of the arterial line with blood lines in normal position&#44; <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">art&#44;x</span></span>is the temperature of the arterial line with blood lines in reverse position&#44; and <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">ven&#44;x</span></span>is the temperature of the venous line with blood lines in reverse position&#46; To correctly calculate the Q<span class="elsevierStyleInf">A</span>&#44; the Q<span class="elsevierStyleInf">B</span>&#44; the UFR and the dialysate temperature &#40;35&#46;5&#186;C&#41; must remain constant throughout the entire measurement process<span class="elsevierStyleSup">7</span>&#46; The Q<span class="elsevierStyleInf">A </span>was calculated twice during the first hour of 2 consecutive HD sessions&#44; and these two values were weighed&#46; The MAP was also measured also in both HD sessions along with the Q<span class="elsevierStyleInf">A</span>&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">2&#41; Twister&#8482; device&#46; </span>This accessory measuring 37&#46;5cm in length has a dial-shaped rotating mechanism in its centre&#46; On 1 side it connects to the blood lines&#44; and on the other side&#44; to the 2 needles puncturing the AVF&#46; By simply rotating the mechanism &#40;turning the dial halfway&#41;&#44; the blood lines reverse flow direction automatically with no need for disconnecting them from the needles or stopping the haemodialysis pump&#46; At the end of the procedure&#44; turning the dial once more in the opposite direction will instantly re-establish the normal flow direction of the blood lines &#40;Figure 1&#41;&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">3&#41; Measuring the Q<span class="elsevierStyleInf">A </span>by the Delta-H method&#46; </span>During the same week&#44; the Q<span class="elsevierStyleInf">A </span>was calculated using the Delta-H optodilutional method using the Crit-Line III monitor &#40;ABF-mode&#44; HemaMetrics&#44; USA&#41; in all patients&#46; This method&#44; described and validated by Yarar et al<span class="elsevierStyleSup">10 </span>is a photometric technique based on the inverse relationship existing between volaemia and haematocrit &#40;Hct&#41;&#46; The Q<span class="elsevierStyleInf">A</span>was also determined during the first hour of the HD session based on the changes recorded in Hct and the scheduled changes in ultrafiltration &#40;from 0&#46;1 to 1&#46;8l&#47;h&#41; with blood lines in normal and reversed positions&#46; Changes in Hct were registered continuously by an optical sensor coupled to a blood chamber inserted between the dialyser and the arterial line&#46; Q<span class="elsevierStyleInf">A </span>was calculated using the following formula&#58; </p><p class="elsevierStylePara">Q<span class="elsevierStyleInf">A</span>&#61; &#40;UF max&#46;&#8722;UF min&#46;&#41;<span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold">&#183;&#160;</span>Hct max&#46; rev&#46; <span class="elsevierStyleBold">&#47;&#160;</span>¿Hct rev&#46;&#8722;¿Hct nor&#46;</p><p class="elsevierStylePara">Where UF max&#46; is maximum ultrafiltration rate&#44; UF min&#46; is minimum ultrafiltration rate&#44; Hct max&#46; rev&#46; is maximum Hct with blood lines in reverse position&#44; ¿Hct rev&#46; is the change in Hct with the lines reversed and ¿Hct nor&#46; is the change in Hct with blood lines in normal position&#46; Reversing the blood lines was performed manually after momentarily stopping the haemodialysis pump &#40;the Twister<span class="elsevierStyleSup">TM </span>device was not used&#41;&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">Statistical study </span></p><p class="elsevierStylePara">Statistical analysis of the data was performed using the SPSS program version 12&#46;0 for Windows&#46; Values were expressed as percentages or mean &#177; standard deviation&#46; The mean coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was calculated by averaging the quotient of the standard deviation and the mean of the two measurements taken for each patient&#46; The comparative study between the mean Q<span class="elsevierStyleInf">A </span>obtained and the variables specific to both the patient and the AVF&#44; compared 2 by 2&#44; was performed using Student&#8217;s t-test for 2 independent samples and the non&#173;parametric Mann-Whitney U test&#46; Pearson&#8217;s correlation coefficient was calculated to analyse the correlation between the mean Q<span class="elsevierStyleInf">A </span>at the AVF and the different quantitative variables studied&#46; </p><p class="elsevierStylePara">The time required to determine Q<span class="elsevierStyleInf">A </span>was calculated as follows&#44; depending on the method used&#58; </p><p class="elsevierStylePara">1&#41; TGM&#58; Time needed to record the temperature of the arterial line&#44; which are necessary in order to calculate Q<span class="elsevierStyleInf">A&#44; </span>as shown on the BTM display upon beginning the examination&#44; with blood lines in the normal position &#43; time needed for instant reversal of blood lines by using the Twister<span class="elsevierStyleSup">TM </span>device &#43; time to stabilise temperature with blood lines in the reversed position &#40;time needed in order to maintain exactly the same temperature during a minimum of 1 minute&#41; &#43; time to record the temperature values shown on the BTM display&#44; which are necessary in order to calculate Q<span class="elsevierStyleInf">A</span>&#40;blood lines in reverse position&#41; &#43; time to automatically revert blood lines to normal blood flow direction using the Twister<span class="elsevierStyleSup">TM </span>device&#46; Unlike when the Delta-H method is used&#44; the Q<span class="elsevierStyleInf">A </span>value is not obtained automatically&#46; It must be calculated after completing the examination&#44; using the formula described above&#46; </p><p class="elsevierStylePara">2&#41; Delta-H method&#58; time elapsed during the first part of the examination&#44; when the measured haematocrit values in relation to scheduled changes in ultrafiltration are automatically recorded&#44; with blood lines in the normal position &#43; time to stop the haemodialysis pump &#43; time to manually invert the blood lines &#43; time to re-start the HD pump &#43; time elapsed during the second part of the examination&#44; when the measured haematocrit values in relation to scheduled changes in ultrafiltration are automatically recorded with blood lines reversed &#43; time to record the Q<span class="elsevierStyleInf">A </span>value displayed on the Crit-Line III monitor &#43; time to stop the HD pump &#43; time to manually revert the blood lines to their normal position &#43; time to re-start the haemodialysis pump&#46; </p><p class="elsevierStylePara">We completed a correlation analysis of the AVF blood flow values measured by Delta-H and by the TGM in the same patient sample&#46; The Bland-Altman graph was drawn so as to provide a visual display of concordance between the two methods&#46; <span class="elsevierStyleItalic">P</span>values &#60;0&#46;05 were considered to be statistically significant&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">The mean Q<span class="elsevierStyleInf">A </span>at the AVF obtained by TGM was 1132&#46;5&#177;515&#46;4ml&#47;min &#40;range&#58; 446-2233ml&#47;min&#41;&#46; The coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was 6&#46;8&#177;4&#46;7&#37;&#46; Table 2 shows the mean values of Q<span class="elsevierStyleInf">A </span>and MAP measured in the 2 consecutive HD sessions&#46; There are no differences between MAP values taken in the first and second sessions &#40;<span class="elsevierStyleItalic">P</span>&#61; not significant&#41;&#46; </p><p class="elsevierStylePara">No differences were found when comparing the mean Q<span class="elsevierStyleInf">A </span>in relation to variables of the patient and the AVF shown in Table 3&#46; The Q<span class="elsevierStyleInf">A </span>from the AVF of diabetic patients was less than 1000 ml&#47;min&#44; but this was not significantly different compared to the remaining patients&#46; The mean Q<span class="elsevierStyleInf">A </span>was similar when comparing patients with MAP above or below 100 mmHg&#46; The brachial AVF showed a higher mean Q<span class="elsevierStyleInf">A </span>than the radial AVF&#44; but the difference was not statistically significant&#46; We observed no correlations between mean Q<span class="elsevierStyleInf">A </span>and&#58; age &#40;r&#61;0&#46;09&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;62&#41;&#44; time on HD &#40;r&#61;0&#46;06&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;76&#41;&#44; MAP &#40;r&#61;&#8211;0&#46;21&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;27&#41;&#44; Kt&#47;V index &#40;r&#61;0&#46;12&#44; P&#61;&#46;51&#41;&#44; distance between needles &#40;r&#61;&#8211;0&#46;17&#44; P&#61;&#46;37&#41; or AVF duration &#40;r&#61;&#8211;0&#46;01&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;96&#41;&#46; </p><p class="elsevierStylePara">The mean time to obtain the temperature values needed to calculate the Q<span class="elsevierStyleInf">A </span>by the TGM using the Twister&#8482; device&#44; was 5&#46;9 &#177; 1&#46;9 minutes &#40;range 2-11 minutes&#41; and significantly lower in relation to the Delta method -H applied in this study &#40;Table 4&#41;&#46; As shown by the histogram in Figure 2&#44; the time required in most cases &#40;46&#47;60&#44; 76&#46;7&#37;&#41; using TGM ranged between 4 and 7 minutes&#46; </p><p class="elsevierStylePara">Mean Q<span class="elsevierStyleInf">A </span>calculated by using the TGM &#40;1132&#46;5&#177;515&#46;4ml&#47;min&#41; was similar to that measured using the Delta-H method &#40;1138&#46;4 &#177; 502&#46;3ml&#47;min&#41; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;83&#41;&#46; As shown in the histogram in Figure 3&#44; the absolute difference between mean Q<span class="elsevierStyleInf">A </span>values at the AVF taken using both measurement methods was less than 150ml&#47;min in 66&#46;7&#37; of the patients &#40;20&#47;30&#41;&#46; Blood flow values at the AVF measured using TGM showed a significant correlation with those taken using the Delta-H method &#40;r&#61;0&#46;963&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; &#40;Figure 4&#41;&#46; The Bland-Altman graph in Figure 5 shows concordance between both screening methods&#44; even where mean Q<span class="elsevierStyleInf">A </span>values are equal to or above 2000ml&#47;min &#40;n&#61;3&#41;&#46; </p><p class="elsevierStylePara">&#160; <br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">TGM has been proven an effective means of evaluating AVF function&#46; The Q<span class="elsevierStyleInf">A </span>value obtained by TGM in this study coincides with previously reported values obtained by other non-invasive screening methods for measuring Q<span class="elsevierStyleInf">A</span>&#46;<span class="elsevierStyleSup">3&#44;11-15 </span>In addition&#44; the Q<span class="elsevierStyleInf">A </span>result reported in the TGM validation cohort study carried out by Wijnen et al &#40;1000&#177;588ml&#47;min&#41; is very similar to the Q<span class="elsevierStyleInf">A </span>calculated in our study&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">In this study&#44; TGM demonstrated optimal reproducibility with a coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements of less than 10&#37;&#46; This result allows the TGM&#8217;s reproducibility to be compared favourably to that of other methods used in daily clinical practice&#44; such as the Delta-H or ultrasound dilution methods&#46;<span class="elsevierStyleSup">3&#44;16 </span></p><p class="elsevierStylePara">Our study found a significant functional correlation between the Delta-H method&#44; which is routinely used in our department&#44; and the TGM&#46; Comparison of Q<span class="elsevierStyleInf">A </span>values at the AVF obtained by both methods revealed no differences&#46; The previously mentioned cohort study by Wijnen et al also reported a significant correlation &#40;r&#61;0&#46;964&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41; between Q<span class="elsevierStyleInf">A </span>values obtained using the ultrasound dilution method &#40;mean Q<span class="elsevierStyleInf">A </span>960&#177;594ml&#47;min&#41; and TGM&#46;<span class="elsevierStyleSup">7 </span>Therefore&#44; considering their efficacy in obtaining reliable Q<span class="elsevierStyleInf">A </span>values&#44; the TGM and Delta-H methods are equivalent and can be used interchangeably for regular VA monitoring&#46; </p><p class="elsevierStylePara">Time is money&#44; especially when we consider the current dynamics in many HD units in Spain&#46; Therefore&#44; if we are to ensure the success of the VA surveillance programs&#44; we must to apply a quick method for VA monitoring in the HD room without excessive consumption of time&#46; In this regard&#44; the joint application of the TGM and the Twister&#8482; device allows to obtain the data necessary to calculate the Q<span class="elsevierStyleInf">A </span>of the AVF in significantly less time compared to the Delta-H method &#40;current study&#41; and to the methods that used the BTM to determine the Q<span class="elsevierStyleInf">A </span>such as the thermodilution method and the same TGM with manual switching of HD lines &#40;Table 4&#41;&#46;<span class="elsevierStyleSup">7&#44;17 </span></p><p class="elsevierStylePara">The direct relationship between the MAP and the Q<span class="elsevierStyleInf">A </span>of the AVF is well-known&#44; and it is expressed as follows&#58; Q<span class="elsevierStyleInf">A</span>&#61;MAP&#8211;central venous pressure&#47;AVF resistance<span class="elsevierStyleSup">18</span>&#46; For example&#44; in the multivariate study from Tonelli et al including 4084 Q<span class="elsevierStyleInf">A </span>measurements by ultrasound dilution in 294 patients with AVF&#44; it was observed that for each 1 mmHg of increase in systolic blood pressure&#44; the Q<span class="elsevierStyleInf">A </span>increased by 1&#46;8 and 2&#46;9 ml&#47;min in distal and proximal AVF&#44; respectively<span class="elsevierStyleSup">19 </span>Consequently&#44; the results from any study examining AVF function cannot be valid unless they consider blood pressure&#46; The current study analysed the effect of MAP on two fundamental aspects&#58; </p><p class="elsevierStylePara">&#160;1&#41; Reproducibility of the TGM&#46; No differences were found when comparing the MAP values obtained simultaneously with the first and second <span class="elsevierStyleInf">A </span>measurements&#46; Therefore&#44; the patient&#39;s blood pressure did not interfere with the study of the TGM reproducibility&#46; </p><p class="elsevierStylePara">2&#41; The Q<span class="elsevierStyleInf">A </span>of the AVF&#46; No correlations were found between the MAP and the Q<span class="elsevierStyleInf">A </span>of the AVF&#44; even when MAP values higher or lower than 100 mmHg are considered separately&#46; </p><p class="elsevierStylePara">Therefore&#44; it has shown a total independence between the AVF function &#40;assessed objectively by calculating the Q<span class="elsevierStyleInf">A</span>&#41; and the MAP in the current study&#46; This result may be explained by the fact that Q<span class="elsevierStyleInf">A </span>measurements were made at the beginning of the HD session&#44; when blood pressure was stable&#44; avoiding subsequent drops in blood pressure secondary to the ultrafiltration scheduled&#46; </p><p class="elsevierStylePara">In this regard&#44; according to Rehman et al&#46;&#44; the MAP is the main factor that determines the Q<span class="elsevierStyleInf">A </span>variations during HD so that&#44; after 90 minutes of the start of the HD session&#44; for every 10&#37; decrease in the MAP&#44; the QA is reduced by 8 &#37;&#46;<span class="elsevierStyleSup">20 </span></p><p class="elsevierStylePara">In summary&#44; the main objective of the VA surveillance programs in the HD units is to prevent thrombosis in prevalent patients&#46; To do this&#44; you must have in the HD room an objective screening method of simple application that allows us to know the AV function reliably in the shortest time possible&#46; The TGM associated with Twister&#8482; device meets all these requirements and can help us achieve the goal of reducing the current rate of VA thrombosis&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160; <span class="elsevierStyleBold">Acknowledgements </span></p><p class="elsevierStylePara">We would like to thank Fresenius Medical Care for providing the Twister<span class="elsevierStyleSup">TM </span>device&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160;&#160;<span class="elsevierStyleBold">Conflicts of interest </span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27931&#95;en&#95;f1&#95;11132&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27931_en_f1_11132.jpg" alt="The TwisterTM device"></img></a></p><p class="elsevierStylePara">Figure 1&#46; The TwisterTM device</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27932&#95;en&#95;f2&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27932_en_f2_111326_copia.jpg" alt="Time needed to calculate QA using TGM"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Time needed to calculate QA using TGM</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27933&#95;en&#95;f3&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27933_en_f3_111326_copia.jpg" alt="Absolute difference between mean QA obtained by TGM and by Delta-H"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Absolute difference between mean QA obtained by TGM and by Delta-H</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27934&#95;en&#95;f4&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27934_en_f4_111326_copia.jpg" alt="Correlation between QA values at the AVF obtained by TGM and by Delta-H &#40;n&#61;30&#41;"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Correlation between QA values at the AVF obtained by TGM and by Delta-H &#40;n&#61;30&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27935&#95;en&#95;f5&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27935_en_f5_111326_copia.jpg" alt="Bland-Altman graph representing the relationship between mean QA obtained by TGM and by Delta-H"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Bland-Altman graph representing the relationship between mean QA obtained by TGM and by Delta-H</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27936&#95;en&#95;t1&#95;11132&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27936_en_t1_11132_copia.jpg" alt="Characteristics of patients and AVF studied using TGM"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of patients and AVF studied using TGM</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27938&#95;en&#95;t3&#95;11132&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27938_en_t3_11132_copia.jpg" alt="Relationship between the obtained QA and the variables from the patient and the AVF"></img></a></p><p class="elsevierStylePara">Table 3&#46; Relationship between the obtained QA and the variables from the patient and the AVF</p><p class="elsevierStylePara"><a href="11132&#95;19157&#95;27937&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20692&#95;es&#95;11132&#95;tabla2&#95;en&#46;doc" class="elsevierStyleCrossRefs">11132&#95;19157&#95;27937&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20692&#95;es&#95;11132&#95;tabla2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 2&#46; QA and MAP values taken during 2 consecutive haemodialysis sessions</p><p class="elsevierStylePara"><a href="11132&#95;19157&#95;27939&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20694&#95;es&#95;11132&#95;tabla4&#95;en&#46;doc" class="elsevierStyleCrossRefs">11132&#95;19157&#95;27939&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20694&#95;es&#95;11132&#95;tabla4&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 4&#46; Required time to calculate the QA using three methods for AVF surveillance</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58;</span>&#160;La determinaci&#243;n peri&#243;dica del flujo sangu&#237;neo &#40;Q<span class="elsevierStyleInf">A</span>&#41; es el m&#233;todo de elecci&#243;n para monitorizar la f&#237;stula arteriovenosa &#40;FAVI&#41; de los pacientes en hemodi&#225;lisis &#40;HD&#41; cr&#243;nica&#46;&#160;<span class="elsevierStyleBold">Objetivos&#58;</span>&#160;1&#41; Valorar la eficacia de la t&#233;cnica de gradiente de temperatura &#40;TGT&#41; en la determinaci&#243;n de Q<span class="elsevierStyleInf">A</span> utilizando el dispositivo Twister<span class="elsevierStyleSup">&#174; </span>y comparar los resultados funcionales con el m&#233;todo Delta-H&#46; 2&#41; Analizar el efecto de la presi&#243;n arterial sobre la funci&#243;n de la FAVI&#46;&#160;<span class="elsevierStyleBold">Pacientes y m&#233;todo&#58;</span>&#160;Hemos determinado no invasivamente el Q<span class="elsevierStyleInf">A</span> de 30 FAVI &#40;24 radial y 6 humeral&#59; duraci&#243;n media 53&#44;4 &#177; 78&#44;5 meses&#41; en 30 pacientes &#40;edad media&#58; 59&#44;9 &#177; 14&#44;1 a&#241;os&#59; sexo H&#58; 60&#37;&#44; M&#58; 40&#37;&#59; tiempo medio en HD&#58; 37&#44;4 &#177; 40&#44;6 meses&#59; nefropat&#237;a diab&#233;tica&#58; 20&#37;&#41; estables durante la HD mediante la TGT&#44; descrita y validada por Wijnen et al&#46;<span class="elsevierStyleItalic">&#160;</span>&#40;Kidney Int&#160;2007&#59;72&#58;736&#41;&#46; El Q<span class="elsevierStyleInf">A</span> se calcul&#243; a partir de los valores de temperatura obtenidos mediante el monitor de temperatura sangu&#237;nea BTM&#44; integrado en la m&#225;quina Fresenius Medical Care 4008-S&#44; con las l&#237;neas sangu&#237;neas de HD en configuraci&#243;n normal e invertida&#44; y sin la necesidad de generar un bolus de temperatura&#46; El dispositivo Twister<span class="elsevierStyleSup">&#174;</span> se utiliz&#243; para revertir las l&#237;neas sangu&#237;neas sin necesidad de desconectarlas de las agujas ni de detener la bomba sangu&#237;nea&#46; El Q<span class="elsevierStyleInf">A</span> se determin&#243; durante la primera hora de 2 sesiones consecutivas de HD &#40;ambos valores se promediaron&#41;&#46; La presi&#243;n arterial media &#40;PAM&#41; &#40;presi&#243;n diast&#243;lica &#43; 1&#47;3 de la presi&#243;n del pulso&#41; se calcul&#243; simult&#225;neamente con el Q<span class="elsevierStyleInf">A</span>&#46; Paralelamente&#44; el flujo sangu&#237;neo de la FAVI se determin&#243; durante la misma semana en todos los pacientes mediante el m&#233;todo Delta-H utilizando el monitor Crit-Line III &#40;HemaMetrics&#44; USA&#41; durante la HD &#40;inversi&#243;n manual de las l&#237;neas&#41;&#46;&#160;<span class="elsevierStyleBold">Resultados&#58;&#160;</span>El Q<span class="elsevierStyleInf">A </span>medio fue 1132&#44;5 &#177; 515&#44;4 ml&#47;min &#40;intervalo&#44; 446-2233 ml&#47;min&#41;&#46; El coeficiente de variaci&#243;n para medidas duplicadas de Q<span class="elsevierStyleInf">A</span> fue 6&#44;8 &#177; 4&#44;7&#37;&#59; la PAM no influy&#243; en la reproductibilidad de la TGT &#40;96&#44;1 &#177; 13&#44;7 vs&#46;&#160;96&#44;6 &#177; 12&#44;8 mmHg&#44; p &#61; 0&#44;72&#41;&#46; Sin diferencias al comparar el Q<span class="elsevierStyleInf">A</span> de pacientes diab&#233;ticos &#40;n &#61; 6&#44; 966&#44;4 &#177; 340&#44;7 ml&#47;min&#41; y no diab&#233;ticos &#40;n &#61; 24&#44; 1174&#44;4 &#177; 548&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;39&#41;&#46; El Q<span class="elsevierStyleInf">A</span> fue similar tanto para los &#160;pacientes con PAM &#60; 100 mmHg &#40;n &#61; 18&#44; 1101&#44;0 &#177; 552&#44;7 ml&#47;min&#41; como para<span class="elsevierStyleItalic"> </span>los pacientes con PAM &#8805; 100 mmHg &#40;n &#61; 12&#44; 1180&#44;4 &#177; 473&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;69&#41;&#46; No hemos objetivado ninguna correlaci&#243;n entre el Q<span class="elsevierStyleInf">A</span> medio y&#58; edad &#40;r &#61; 0&#44;09&#44; p &#61; 0&#44;62&#41;&#44; tiempo en HD &#40;r &#61; 0&#44;06&#44; p &#61; 0&#44;76&#41;&#44; PAM &#40;r &#61; &#8211;0&#44;21&#44; p &#61; 0&#44;27&#41;&#44; &#237;ndice Kt&#47;V &#40;r &#61; 0&#44;12&#44; p &#61; 0&#44;51&#41;&#44; distancia entre las agujas &#40;r &#61; &#8211;0&#44;17&#44; p &#61; 0&#44;37&#41; y duraci&#243;n de la FAVI &#40;r &#61; &#8211;0&#44;01&#44; p &#61; 0&#44;96&#41;&#46; El tiempo medio empleado para determinar el Q<span class="elsevierStyleInf">A</span> por la TGT utilizando el accesorio Twister<span class="elsevierStyleSup">&#174;</span> &#40;5&#44;9 &#177; 1&#44;9 min&#41; fue significativamente inferior en relaci&#243;n con el m&#233;todo Delta-H &#40;26&#44;8 &#177; 1&#44;9 min&#41; o con la TGT &#40;n &#61; 35&#44; 8&#44;9 &#177; 3&#44;5 min&#44; inversi&#243;n manual de las l&#237;neas&#41; aplicada por Wijnen et al&#46;&#160;&#40;Kidney Int&#160;2007&#59;72&#58;736&#41; &#40;para ambas comparaciones&#44; p &#60; 0&#44;001&#41;&#46; El Q<span class="elsevierStyleInf">A</span> medio obtenido mediante la TGT fue similar al flujo sangu&#237;neo medio determinado con el m&#233;todo Delta-H &#40;1138&#44;4 &#177; 502&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;83&#41;&#46; Los valores del flujo sangu&#237;neo de la FAVI obtenidos mediante la TGT se correlacionaron significativamente con los determinados por el m&#233;todo Delta-H &#40;r &#61; 0&#44;963&#44; p &#60; 0&#44;001&#41;&#46;&#160;<span class="elsevierStyleBold">Conclusiones&#58;</span>&#160;1&#41; La TGT es un m&#233;todo v&#225;lido y reproducible para calcular el Q<span class="elsevierStyleInf">A</span> durante la HD&#46; 2&#41; El dispositivo Twister<span class="elsevierStyleSup">&#174;</span> es eficaz para reducir el tiempo empleado en determinar el Q<span class="elsevierStyleInf">A</span> mediante la TGT&#46; 3&#41; Los valores de flujo sangu&#237;neo de la FAVI obtenidos mediante la TGT y el m&#233;todo Delta-H se correlacionaron significativamente&#46; 4&#41; Se ha evidenciado una independencia entre la funci&#243;n de la FAVI y la presi&#243;n arterial del paciente&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#46; </span>Periodic blood flow &#40;Q<span class="elsevierStyleInf">A</span>&#41; measurement is the preferred way for arteriovenous fistula &#40;AVF&#41; surveillance in chronic hemodialysis &#40;HD&#41; patients&#46; <span class="elsevierStyleBold">Objectives&#46; </span>1&#41; Assess the efficacy of the temperature gradient method &#40;TGM&#41; on the Q<span class="elsevierStyleInf">A </span>determinations using the Twister<span class="elsevierStyleSup">&#8482; </span>device and to compare the functional results with the Delta-H method&#46; 2&#41; Evaluate the effect of blood pressure on the AVF function&#46; <span class="elsevierStyleBold">Patients and method&#46; </span>We measured the Q<span class="elsevierStyleInf">A </span>non invasively in 30 AVF &#40;24 radial and 6 brachial&#59; mean duration 53&#46;4 &#177; 78&#46;5 months&#41; during HD in 30 stable patients &#40;mean age 59&#46;9 &#177; 14&#46;1 years&#44; males 60 &#37;&#44; females 40 &#37;&#59; mean time on HD 37&#46;4 &#177; 40&#46;6 months&#44; diabetic nephropathy 20 &#37;&#41; by the TGM&#44; described and validated by Wijnen et al &#40;Kidney Int 2007&#59;72&#58;736&#41;&#46; The Q<span class="elsevierStyleInf">A </span>was calculated from the temperature values obtained by means of the blood temperature monitor &#40;BTM&#41;&#44; integrated into the Fresenius Medical Care 4008-S machine&#44; at normal and reverse configurations of the HD blood lines&#44; with no need for a thermal bolus&#46; The Twister<span class="elsevierStyleSup">&#8482; </span>device was used for reversing the blood lines without the need to disconnect them from the AVF lines nor to stop the blood pump&#46; The Q<span class="elsevierStyleInf">A </span>was measured within the first hour of two consecutive HD sessions &#40;the values were averaged&#41;&#46; The mean arterial pressure MAP &#40;diastolic pressure &#43; 1&#47;3 pulse pressure&#41; was calculated simultaneous with the Q<span class="elsevierStyleInf">A</span>&#46; In addition&#44; the AVF blood flow was also determined during the same week in all patients by the Delta-H method using the Crit-Line III Monitor &#40;ABF-mode&#44; HemaMetrics&#44; USA&#41; during HD &#40;manually switching lines&#41;&#46; <span class="elsevierStyleBold">Results&#46; </span>The mean Q<span class="elsevierStyleInf">A </span>was 1132&#46;5 &#177; 515&#46;4 ml&#47;min &#40;range&#44; 446-2233 ml&#47;min&#41;&#46; The mean coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was 6&#46;8 &#177; 4&#46;7 &#37;&#59; the MAP was not different when the reproducibility tests were performed &#40;96&#46;1 &#177; 13&#46;7 versus 96&#46;6 &#177;12&#46;8 mmHg&#44; p &#61; &#46;72&#41;&#46; No significant difference was found when comparing the mean Q<span class="elsevierStyleInf">A </span>between diabetic &#40;n &#61; 6&#44; 966&#46;4 &#177; 340&#46;7 ml&#47;min&#41; and nondiabetic &#40;n &#61; 24&#44; 1174&#46;4 &#177; 548&#46;3 ml&#47;min&#41; patients &#40;p &#61; &#46;39&#41;&#46; The mean Q<span class="elsevierStyleInf">A </span>was similar for patients with mean MAP &#60; 100 mmHg &#40;n &#61; 18&#44; 1101&#46;0 &#177; 552&#46;7 ml&#47;min&#41; and for patients with mean MAP &#62;&#95; 100 mmHg &#40;n &#61; 12&#44; 1180&#46;4 &#177; 473&#46;3 ml&#47;min&#41; &#40;p &#61; &#46;69&#41;&#46; No correlation was found between the mean Q<span class="elsevierStyleInf">A </span>and&#58; age &#40;r &#61; 0&#46;09&#44; p &#61; &#46;62&#41;&#44; time on HD &#40;r &#61; 0&#46;06&#44; p &#61; &#46;76&#41;&#44; MAP &#40;r &#61; &#8211; 0&#46;21&#44; p &#61; &#46;27&#41;&#44; Kt&#47;V index &#40;r &#61; 0&#46;12&#44; p &#61; &#46;51&#41;&#44; distance between needles &#40;r &#61; &#8211; 0&#46;17&#44; p &#61; &#46;37&#41; and AVF duration &#40;r &#61; &#8211; 0&#46;01&#44; p &#61; &#46;96&#41;&#46; The mean time required to measure Q<span class="elsevierStyleInf">A </span>with the TGM using the Twister<span class="elsevierStyleSup">&#8482; </span>device &#40;5&#46;9 &#177; 1&#46;9 min&#41; was significantly shorter compared with the Delta-H technique &#40;26&#46;8 &#177; 1&#46;9 min&#41; or with the TGM &#40;n &#61; 35&#44; 8&#46;9 &#177; 3&#46;5 min&#44; manually reversing lines&#41; reported by Wijnen et al &#40;Kidney Int 2007&#59;72&#58;736&#41;&#46;&#41; &#40;for both comparisons&#44; p &#60; &#46;001&#41;&#46; The mean Q<span class="elsevierStyleInf">A </span>obtained by the TGM was not different when compared to mean ABF determined by the Delta-H method &#40;1138&#46;4 &#177; 502&#46;3 ml&#47;min&#41; &#40;p&#61;&#46;83&#41;&#46;The calculated values of AVF blood flow obtained by TGM were highly correlated with those determined by the Delta-H technique &#40;r &#61; 0&#46;963&#44; p &#60; &#46;001&#41;&#46; <span class="elsevierStyleBold">Conclusions&#46; </span>1&#41; The TGM is a valuable and reproducible indicator of Q<span class="elsevierStyleInf">A </span>during HD&#46; 2&#41; The Twister&#8482; device is useful to reduce the time for Q<span class="elsevierStyleInf">A </span>measurement by the TGM&#46; 3&#41; The AVF blood flow values obtained by the TGM and the Delta-H technique correlated highly with each other&#46; 4&#41; It has been shown the lack of relationship between the AVF function and the patient&#8217;s blood pressure&#46; </p>"
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Study of arteriovenous fistula function by the temperature gradient method using the Twister' device
Estudio de la función de la fístula arteriovenosa mediante la técnica de gradiente de temperatura y utilizando el dispositivo Twister®
Ramon Roca-Teya, Rosa Samona, Omar Ibrika, Amparo Rodaa, Juan C. González-Olivaa, Jordi Viladomsa
a Servicio de Nefrología, Hospital de Mollet, Mollet del Vallès, Barcelona,
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are the methods of choice for regular VA surveillance&#46;<span class="elsevierStyleSup">1 </span>Since 1995&#44; it have been described several of these methods and some of them have subsequently applied in daily clinical practice&#44; such as ultrasound dilution&#44; Delta-H or termodiluci&#243;n&#46;<span class="elsevierStyleSup">4 </span>Some Some of these techniques have been proven effective in providing an early diagnosis of significant stenosis and reducing the rate of VA thrombosis&#46;<span class="elsevierStyleSup">5&#44;6 </span></p><p class="elsevierStylePara">The temperature gradient method &#40;TGM&#41; was described and validated by Wijnen et al in 2007 by comparison against the ultrasound dilution method&#46;<span class="elsevierStyleSup">7 </span>This method allows us to calculate the Q<span class="elsevierStyleInf">A </span>from the temperature values obtained by means of the blood temperature monitor &#40;BTM&#41; with the HD blood lines in the normal and reversed positions&#46;<span class="elsevierStyleSup">7 </span>The use of a specialised device named Twister&#8482; &#40;Fresenius Medical Care&#41;&#44; which is placed between the HD needles and the blood lines&#44; can simplify the Q<span class="elsevierStyleInf">A </span>determination by shortening the time needed to reverse the HD blood lines &#40;Figure 1&#41;&#46; </p><p class="elsevierStylePara">On the other hand&#44; no reliable study on VA function can overlook a variable as important as the patient&#8217;s blood pressure&#46; In this regard&#44; some authors have highlighted the direct relationship between the mean arterial pressure &#40;MAP&#41; and the Q<span class="elsevierStyleInf">A </span>of the VA&#44; meaning that changes in the MAP can affect the VA function&#46;<span class="elsevierStyleSup">8&#44;9 </span></p><p class="elsevierStylePara">This is an observational&#44; cross-sectional&#44; comparative study of the TGM with the following objectives&#58; </p><p class="elsevierStylePara">1&#41; Evaluate TGM efficacy in measuring the Q<span class="elsevierStyleInf">A </span>at the AVF during HD&#46; </p><p class="elsevierStylePara">2&#41; Determine whether placement of the Twister<span class="elsevierStyleSup">TM </span>shortens the time needed to determine Q<span class="elsevierStyleInf">A</span>&#46; </p><p class="elsevierStylePara">3&#41; Undertake a comparative functional study of TGM and the Delta-H method&#46; </p><p class="elsevierStylePara">4&#41; Analyse the effect of blood pressure on AVF function&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients </span></p><p class="elsevierStylePara">The AVF was evaluated in 30 patients undergoing HD 3 times weekly in the Nephrology Department at Hospital de Mollet&#46; Inclusion criteria for patients were as follows&#58; 1&#41; Age &#62;18 years&#46; 2&#41; In chronic HD programme&#46; 3&#41; Use of the AVF as a permanent VA&#46; 4&#41; Puncture of the AVF with 2 needles during a minimum of 12 consecutive HD sessions&#46; 5&#41; Use of a Q<span class="elsevierStyleInf">B </span>greater than 250ml&#47;min during a minimum of 12 consecutive HD sessions&#46; 6&#41; Informed consent from the patient&#46; The following variables were analysed&#58; sex&#44; age&#44; time on HD&#44; diabetic nephropathy as a cause of renal failure&#44; Kt&#47;V index &#40;by Daugirdas second-generation single-pool model&#41;&#44; MAP &#40;diastolic blood pressure &#43;1&#47;3 pulse pressure&#41;&#44; type of AVF&#44; duration of AVF&#44; total number of VA and distance between needles&#46; Table 1 summarises the most important clinical characteristics of the patients included in the study&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Method </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">1&#41; Measuring the Q<span class="elsevierStyleInf">A </span>by means of TGM&#46; </span>The Q<span class="elsevierStyleInf">A </span>was measured by using the BTM sensor incorporated in the 4008 S machine manufactured by Fresenius Medical Care&#46; 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UFR is the ultrafiltration rate &#40;ml&#47;min&#41;&#44; <span class="elsevierStyleItalic">T</span>is the<span class="elsevierStyleItalic">rt&#44;n</span>temperature of the arterial line with blood lines in normal position&#44; <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">art&#44;x</span></span>is the temperature of the arterial line with blood lines in reverse position&#44; and <span class="elsevierStyleItalic">T<span class="elsevierStyleInf">ven&#44;x</span></span>is the temperature of the venous line with blood lines in reverse position&#46; To correctly calculate the Q<span class="elsevierStyleInf">A</span>&#44; the Q<span class="elsevierStyleInf">B</span>&#44; the UFR and the dialysate temperature &#40;35&#46;5&#186;C&#41; must remain constant throughout the entire measurement process<span class="elsevierStyleSup">7</span>&#46; The Q<span class="elsevierStyleInf">A </span>was calculated twice during the first hour of 2 consecutive HD sessions&#44; and these two values were weighed&#46; The MAP was also measured also in both HD sessions along with the Q<span class="elsevierStyleInf">A</span>&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">2&#41; Twister&#8482; device&#46; </span>This accessory measuring 37&#46;5cm in length has a dial-shaped rotating mechanism in its centre&#46; On 1 side it connects to the blood lines&#44; and on the other side&#44; to the 2 needles puncturing the AVF&#46; By simply rotating the mechanism &#40;turning the dial halfway&#41;&#44; the blood lines reverse flow direction automatically with no need for disconnecting them from the needles or stopping the haemodialysis pump&#46; At the end of the procedure&#44; turning the dial once more in the opposite direction will instantly re-establish the normal flow direction of the blood lines &#40;Figure 1&#41;&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">3&#41; Measuring the Q<span class="elsevierStyleInf">A </span>by the Delta-H method&#46; </span>During the same week&#44; the Q<span class="elsevierStyleInf">A </span>was calculated using the Delta-H optodilutional method using the Crit-Line III monitor &#40;ABF-mode&#44; HemaMetrics&#44; USA&#41; in all patients&#46; This method&#44; described and validated by Yarar et al<span class="elsevierStyleSup">10 </span>is a photometric technique based on the inverse relationship existing between volaemia and haematocrit &#40;Hct&#41;&#46; The Q<span class="elsevierStyleInf">A</span>was also determined during the first hour of the HD session based on the changes recorded in Hct and the scheduled changes in ultrafiltration &#40;from 0&#46;1 to 1&#46;8l&#47;h&#41; with blood lines in normal and reversed positions&#46; Changes in Hct were registered continuously by an optical sensor coupled to a blood chamber inserted between the dialyser and the arterial line&#46; Q<span class="elsevierStyleInf">A </span>was calculated using the following formula&#58; </p><p class="elsevierStylePara">Q<span class="elsevierStyleInf">A</span>&#61; &#40;UF max&#46;&#8722;UF min&#46;&#41;<span class="elsevierStyleBold">&#160;</span><span class="elsevierStyleBold">&#183;&#160;</span>Hct max&#46; rev&#46; <span class="elsevierStyleBold">&#47;&#160;</span>¿Hct rev&#46;&#8722;¿Hct nor&#46;</p><p class="elsevierStylePara">Where UF max&#46; is maximum ultrafiltration rate&#44; UF min&#46; is minimum ultrafiltration rate&#44; Hct max&#46; rev&#46; is maximum Hct with blood lines in reverse position&#44; ¿Hct rev&#46; is the change in Hct with the lines reversed and ¿Hct nor&#46; is the change in Hct with blood lines in normal position&#46; Reversing the blood lines was performed manually after momentarily stopping the haemodialysis pump &#40;the Twister<span class="elsevierStyleSup">TM </span>device was not used&#41;&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">Statistical study </span></p><p class="elsevierStylePara">Statistical analysis of the data was performed using the SPSS program version 12&#46;0 for Windows&#46; Values were expressed as percentages or mean &#177; standard deviation&#46; The mean coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was calculated by averaging the quotient of the standard deviation and the mean of the two measurements taken for each patient&#46; The comparative study between the mean Q<span class="elsevierStyleInf">A </span>obtained and the variables specific to both the patient and the AVF&#44; compared 2 by 2&#44; was performed using Student&#8217;s t-test for 2 independent samples and the non&#173;parametric Mann-Whitney U test&#46; Pearson&#8217;s correlation coefficient was calculated to analyse the correlation between the mean Q<span class="elsevierStyleInf">A </span>at the AVF and the different quantitative variables studied&#46; </p><p class="elsevierStylePara">The time required to determine Q<span class="elsevierStyleInf">A </span>was calculated as follows&#44; depending on the method used&#58; </p><p class="elsevierStylePara">1&#41; TGM&#58; Time needed to record the temperature of the arterial line&#44; which are necessary in order to calculate Q<span class="elsevierStyleInf">A&#44; </span>as shown on the BTM display upon beginning the examination&#44; with blood lines in the normal position &#43; time needed for instant reversal of blood lines by using the Twister<span class="elsevierStyleSup">TM </span>device &#43; time to stabilise temperature with blood lines in the reversed position &#40;time needed in order to maintain exactly the same temperature during a minimum of 1 minute&#41; &#43; time to record the temperature values shown on the BTM display&#44; which are necessary in order to calculate Q<span class="elsevierStyleInf">A</span>&#40;blood lines in reverse position&#41; &#43; time to automatically revert blood lines to normal blood flow direction using the Twister<span class="elsevierStyleSup">TM </span>device&#46; Unlike when the Delta-H method is used&#44; the Q<span class="elsevierStyleInf">A </span>value is not obtained automatically&#46; It must be calculated after completing the examination&#44; using the formula described above&#46; </p><p class="elsevierStylePara">2&#41; Delta-H method&#58; time elapsed during the first part of the examination&#44; when the measured haematocrit values in relation to scheduled changes in ultrafiltration are automatically recorded&#44; with blood lines in the normal position &#43; time to stop the haemodialysis pump &#43; time to manually invert the blood lines &#43; time to re-start the HD pump &#43; time elapsed during the second part of the examination&#44; when the measured haematocrit values in relation to scheduled changes in ultrafiltration are automatically recorded with blood lines reversed &#43; time to record the Q<span class="elsevierStyleInf">A </span>value displayed on the Crit-Line III monitor &#43; time to stop the HD pump &#43; time to manually revert the blood lines to their normal position &#43; time to re-start the haemodialysis pump&#46; </p><p class="elsevierStylePara">We completed a correlation analysis of the AVF blood flow values measured by Delta-H and by the TGM in the same patient sample&#46; The Bland-Altman graph was drawn so as to provide a visual display of concordance between the two methods&#46; <span class="elsevierStyleItalic">P</span>values &#60;0&#46;05 were considered to be statistically significant&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">The mean Q<span class="elsevierStyleInf">A </span>at the AVF obtained by TGM was 1132&#46;5&#177;515&#46;4ml&#47;min &#40;range&#58; 446-2233ml&#47;min&#41;&#46; The coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was 6&#46;8&#177;4&#46;7&#37;&#46; Table 2 shows the mean values of Q<span class="elsevierStyleInf">A </span>and MAP measured in the 2 consecutive HD sessions&#46; There are no differences between MAP values taken in the first and second sessions &#40;<span class="elsevierStyleItalic">P</span>&#61; not significant&#41;&#46; </p><p class="elsevierStylePara">No differences were found when comparing the mean Q<span class="elsevierStyleInf">A </span>in relation to variables of the patient and the AVF shown in Table 3&#46; The Q<span class="elsevierStyleInf">A </span>from the AVF of diabetic patients was less than 1000 ml&#47;min&#44; but this was not significantly different compared to the remaining patients&#46; The mean Q<span class="elsevierStyleInf">A </span>was similar when comparing patients with MAP above or below 100 mmHg&#46; The brachial AVF showed a higher mean Q<span class="elsevierStyleInf">A </span>than the radial AVF&#44; but the difference was not statistically significant&#46; We observed no correlations between mean Q<span class="elsevierStyleInf">A </span>and&#58; age &#40;r&#61;0&#46;09&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;62&#41;&#44; time on HD &#40;r&#61;0&#46;06&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;76&#41;&#44; MAP &#40;r&#61;&#8211;0&#46;21&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;27&#41;&#44; Kt&#47;V index &#40;r&#61;0&#46;12&#44; P&#61;&#46;51&#41;&#44; distance between needles &#40;r&#61;&#8211;0&#46;17&#44; P&#61;&#46;37&#41; or AVF duration &#40;r&#61;&#8211;0&#46;01&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;96&#41;&#46; </p><p class="elsevierStylePara">The mean time to obtain the temperature values needed to calculate the Q<span class="elsevierStyleInf">A </span>by the TGM using the Twister&#8482; device&#44; was 5&#46;9 &#177; 1&#46;9 minutes &#40;range 2-11 minutes&#41; and significantly lower in relation to the Delta method -H applied in this study &#40;Table 4&#41;&#46; As shown by the histogram in Figure 2&#44; the time required in most cases &#40;46&#47;60&#44; 76&#46;7&#37;&#41; using TGM ranged between 4 and 7 minutes&#46; </p><p class="elsevierStylePara">Mean Q<span class="elsevierStyleInf">A </span>calculated by using the TGM &#40;1132&#46;5&#177;515&#46;4ml&#47;min&#41; was similar to that measured using the Delta-H method &#40;1138&#46;4 &#177; 502&#46;3ml&#47;min&#41; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;83&#41;&#46; As shown in the histogram in Figure 3&#44; the absolute difference between mean Q<span class="elsevierStyleInf">A </span>values at the AVF taken using both measurement methods was less than 150ml&#47;min in 66&#46;7&#37; of the patients &#40;20&#47;30&#41;&#46; Blood flow values at the AVF measured using TGM showed a significant correlation with those taken using the Delta-H method &#40;r&#61;0&#46;963&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41; &#40;Figure 4&#41;&#46; The Bland-Altman graph in Figure 5 shows concordance between both screening methods&#44; even where mean Q<span class="elsevierStyleInf">A </span>values are equal to or above 2000ml&#47;min &#40;n&#61;3&#41;&#46; </p><p class="elsevierStylePara">&#160; <br></br></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">TGM has been proven an effective means of evaluating AVF function&#46; The Q<span class="elsevierStyleInf">A </span>value obtained by TGM in this study coincides with previously reported values obtained by other non-invasive screening methods for measuring Q<span class="elsevierStyleInf">A</span>&#46;<span class="elsevierStyleSup">3&#44;11-15 </span>In addition&#44; the Q<span class="elsevierStyleInf">A </span>result reported in the TGM validation cohort study carried out by Wijnen et al &#40;1000&#177;588ml&#47;min&#41; is very similar to the Q<span class="elsevierStyleInf">A </span>calculated in our study&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">In this study&#44; TGM demonstrated optimal reproducibility with a coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements of less than 10&#37;&#46; This result allows the TGM&#8217;s reproducibility to be compared favourably to that of other methods used in daily clinical practice&#44; such as the Delta-H or ultrasound dilution methods&#46;<span class="elsevierStyleSup">3&#44;16 </span></p><p class="elsevierStylePara">Our study found a significant functional correlation between the Delta-H method&#44; which is routinely used in our department&#44; and the TGM&#46; Comparison of Q<span class="elsevierStyleInf">A </span>values at the AVF obtained by both methods revealed no differences&#46; The previously mentioned cohort study by Wijnen et al also reported a significant correlation &#40;r&#61;0&#46;964&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41; between Q<span class="elsevierStyleInf">A </span>values obtained using the ultrasound dilution method &#40;mean Q<span class="elsevierStyleInf">A </span>960&#177;594ml&#47;min&#41; and TGM&#46;<span class="elsevierStyleSup">7 </span>Therefore&#44; considering their efficacy in obtaining reliable Q<span class="elsevierStyleInf">A </span>values&#44; the TGM and Delta-H methods are equivalent and can be used interchangeably for regular VA monitoring&#46; </p><p class="elsevierStylePara">Time is money&#44; especially when we consider the current dynamics in many HD units in Spain&#46; Therefore&#44; if we are to ensure the success of the VA surveillance programs&#44; we must to apply a quick method for VA monitoring in the HD room without excessive consumption of time&#46; In this regard&#44; the joint application of the TGM and the Twister&#8482; device allows to obtain the data necessary to calculate the Q<span class="elsevierStyleInf">A </span>of the AVF in significantly less time compared to the Delta-H method &#40;current study&#41; and to the methods that used the BTM to determine the Q<span class="elsevierStyleInf">A </span>such as the thermodilution method and the same TGM with manual switching of HD lines &#40;Table 4&#41;&#46;<span class="elsevierStyleSup">7&#44;17 </span></p><p class="elsevierStylePara">The direct relationship between the MAP and the Q<span class="elsevierStyleInf">A </span>of the AVF is well-known&#44; and it is expressed as follows&#58; Q<span class="elsevierStyleInf">A</span>&#61;MAP&#8211;central venous pressure&#47;AVF resistance<span class="elsevierStyleSup">18</span>&#46; For example&#44; in the multivariate study from Tonelli et al including 4084 Q<span class="elsevierStyleInf">A </span>measurements by ultrasound dilution in 294 patients with AVF&#44; it was observed that for each 1 mmHg of increase in systolic blood pressure&#44; the Q<span class="elsevierStyleInf">A </span>increased by 1&#46;8 and 2&#46;9 ml&#47;min in distal and proximal AVF&#44; respectively<span class="elsevierStyleSup">19 </span>Consequently&#44; the results from any study examining AVF function cannot be valid unless they consider blood pressure&#46; The current study analysed the effect of MAP on two fundamental aspects&#58; </p><p class="elsevierStylePara">&#160;1&#41; Reproducibility of the TGM&#46; No differences were found when comparing the MAP values obtained simultaneously with the first and second <span class="elsevierStyleInf">A </span>measurements&#46; Therefore&#44; the patient&#39;s blood pressure did not interfere with the study of the TGM reproducibility&#46; </p><p class="elsevierStylePara">2&#41; The Q<span class="elsevierStyleInf">A </span>of the AVF&#46; No correlations were found between the MAP and the Q<span class="elsevierStyleInf">A </span>of the AVF&#44; even when MAP values higher or lower than 100 mmHg are considered separately&#46; </p><p class="elsevierStylePara">Therefore&#44; it has shown a total independence between the AVF function &#40;assessed objectively by calculating the Q<span class="elsevierStyleInf">A</span>&#41; and the MAP in the current study&#46; This result may be explained by the fact that Q<span class="elsevierStyleInf">A </span>measurements were made at the beginning of the HD session&#44; when blood pressure was stable&#44; avoiding subsequent drops in blood pressure secondary to the ultrafiltration scheduled&#46; </p><p class="elsevierStylePara">In this regard&#44; according to Rehman et al&#46;&#44; the MAP is the main factor that determines the Q<span class="elsevierStyleInf">A </span>variations during HD so that&#44; after 90 minutes of the start of the HD session&#44; for every 10&#37; decrease in the MAP&#44; the QA is reduced by 8 &#37;&#46;<span class="elsevierStyleSup">20 </span></p><p class="elsevierStylePara">In summary&#44; the main objective of the VA surveillance programs in the HD units is to prevent thrombosis in prevalent patients&#46; To do this&#44; you must have in the HD room an objective screening method of simple application that allows us to know the AV function reliably in the shortest time possible&#46; The TGM associated with Twister&#8482; device meets all these requirements and can help us achieve the goal of reducing the current rate of VA thrombosis&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160; <span class="elsevierStyleBold">Acknowledgements </span></p><p class="elsevierStylePara">We would like to thank Fresenius Medical Care for providing the Twister<span class="elsevierStyleSup">TM </span>device&#46; </p><p class="elsevierStylePara"><br></br></p><p class="elsevierStylePara">&#160;&#160;<span class="elsevierStyleBold">Conflicts of interest </span></p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27931&#95;en&#95;f1&#95;11132&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27931_en_f1_11132.jpg" alt="The TwisterTM device"></img></a></p><p class="elsevierStylePara">Figure 1&#46; The TwisterTM device</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27932&#95;en&#95;f2&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27932_en_f2_111326_copia.jpg" alt="Time needed to calculate QA using TGM"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Time needed to calculate QA using TGM</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27933&#95;en&#95;f3&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27933_en_f3_111326_copia.jpg" alt="Absolute difference between mean QA obtained by TGM and by Delta-H"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Absolute difference between mean QA obtained by TGM and by Delta-H</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27934&#95;en&#95;f4&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27934_en_f4_111326_copia.jpg" alt="Correlation between QA values at the AVF obtained by TGM and by Delta-H &#40;n&#61;30&#41;"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Correlation between QA values at the AVF obtained by TGM and by Delta-H &#40;n&#61;30&#41;</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27935&#95;en&#95;f5&#95;111326&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27935_en_f5_111326_copia.jpg" alt="Bland-Altman graph representing the relationship between mean QA obtained by TGM and by Delta-H"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Bland-Altman graph representing the relationship between mean QA obtained by TGM and by Delta-H</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27936&#95;en&#95;t1&#95;11132&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27936_en_t1_11132_copia.jpg" alt="Characteristics of patients and AVF studied using TGM"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of patients and AVF studied using TGM</p><p class="elsevierStylePara"><a href="grande&#47;11132&#95;16025&#95;27938&#95;en&#95;t3&#95;11132&#95;copia&#46;jpg" class="elsevierStyleCrossRefs"><img src="11132_16025_27938_en_t3_11132_copia.jpg" alt="Relationship between the obtained QA and the variables from the patient and the AVF"></img></a></p><p class="elsevierStylePara">Table 3&#46; Relationship between the obtained QA and the variables from the patient and the AVF</p><p class="elsevierStylePara"><a href="11132&#95;19157&#95;27937&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20692&#95;es&#95;11132&#95;tabla2&#95;en&#46;doc" class="elsevierStyleCrossRefs">11132&#95;19157&#95;27937&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20692&#95;es&#95;11132&#95;tabla2&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 2&#46; QA and MAP values taken during 2 consecutive haemodialysis sessions</p><p class="elsevierStylePara"><a href="11132&#95;19157&#95;27939&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20694&#95;es&#95;11132&#95;tabla4&#95;en&#46;doc" class="elsevierStyleCrossRefs">11132&#95;19157&#95;27939&#95;en&#95;ref&#46;1113212193&#95;11132&#95;19115&#95;20694&#95;es&#95;11132&#95;tabla4&#95;en&#46;doc</a></p><p class="elsevierStylePara">Table 4&#46; Required time to calculate the QA using three methods for AVF surveillance</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n&#58;</span>&#160;La determinaci&#243;n peri&#243;dica del flujo sangu&#237;neo &#40;Q<span class="elsevierStyleInf">A</span>&#41; es el m&#233;todo de elecci&#243;n para monitorizar la f&#237;stula arteriovenosa &#40;FAVI&#41; de los pacientes en hemodi&#225;lisis &#40;HD&#41; cr&#243;nica&#46;&#160;<span class="elsevierStyleBold">Objetivos&#58;</span>&#160;1&#41; Valorar la eficacia de la t&#233;cnica de gradiente de temperatura &#40;TGT&#41; en la determinaci&#243;n de Q<span class="elsevierStyleInf">A</span> utilizando el dispositivo Twister<span class="elsevierStyleSup">&#174; </span>y comparar los resultados funcionales con el m&#233;todo Delta-H&#46; 2&#41; Analizar el efecto de la presi&#243;n arterial sobre la funci&#243;n de la FAVI&#46;&#160;<span class="elsevierStyleBold">Pacientes y m&#233;todo&#58;</span>&#160;Hemos determinado no invasivamente el Q<span class="elsevierStyleInf">A</span> de 30 FAVI &#40;24 radial y 6 humeral&#59; duraci&#243;n media 53&#44;4 &#177; 78&#44;5 meses&#41; en 30 pacientes &#40;edad media&#58; 59&#44;9 &#177; 14&#44;1 a&#241;os&#59; sexo H&#58; 60&#37;&#44; M&#58; 40&#37;&#59; tiempo medio en HD&#58; 37&#44;4 &#177; 40&#44;6 meses&#59; nefropat&#237;a diab&#233;tica&#58; 20&#37;&#41; estables durante la HD mediante la TGT&#44; descrita y validada por Wijnen et al&#46;<span class="elsevierStyleItalic">&#160;</span>&#40;Kidney Int&#160;2007&#59;72&#58;736&#41;&#46; El Q<span class="elsevierStyleInf">A</span> se calcul&#243; a partir de los valores de temperatura obtenidos mediante el monitor de temperatura sangu&#237;nea BTM&#44; integrado en la m&#225;quina Fresenius Medical Care 4008-S&#44; con las l&#237;neas sangu&#237;neas de HD en configuraci&#243;n normal e invertida&#44; y sin la necesidad de generar un bolus de temperatura&#46; El dispositivo Twister<span class="elsevierStyleSup">&#174;</span> se utiliz&#243; para revertir las l&#237;neas sangu&#237;neas sin necesidad de desconectarlas de las agujas ni de detener la bomba sangu&#237;nea&#46; El Q<span class="elsevierStyleInf">A</span> se determin&#243; durante la primera hora de 2 sesiones consecutivas de HD &#40;ambos valores se promediaron&#41;&#46; La presi&#243;n arterial media &#40;PAM&#41; &#40;presi&#243;n diast&#243;lica &#43; 1&#47;3 de la presi&#243;n del pulso&#41; se calcul&#243; simult&#225;neamente con el Q<span class="elsevierStyleInf">A</span>&#46; Paralelamente&#44; el flujo sangu&#237;neo de la FAVI se determin&#243; durante la misma semana en todos los pacientes mediante el m&#233;todo Delta-H utilizando el monitor Crit-Line III &#40;HemaMetrics&#44; USA&#41; durante la HD &#40;inversi&#243;n manual de las l&#237;neas&#41;&#46;&#160;<span class="elsevierStyleBold">Resultados&#58;&#160;</span>El Q<span class="elsevierStyleInf">A </span>medio fue 1132&#44;5 &#177; 515&#44;4 ml&#47;min &#40;intervalo&#44; 446-2233 ml&#47;min&#41;&#46; El coeficiente de variaci&#243;n para medidas duplicadas de Q<span class="elsevierStyleInf">A</span> fue 6&#44;8 &#177; 4&#44;7&#37;&#59; la PAM no influy&#243; en la reproductibilidad de la TGT &#40;96&#44;1 &#177; 13&#44;7 vs&#46;&#160;96&#44;6 &#177; 12&#44;8 mmHg&#44; p &#61; 0&#44;72&#41;&#46; Sin diferencias al comparar el Q<span class="elsevierStyleInf">A</span> de pacientes diab&#233;ticos &#40;n &#61; 6&#44; 966&#44;4 &#177; 340&#44;7 ml&#47;min&#41; y no diab&#233;ticos &#40;n &#61; 24&#44; 1174&#44;4 &#177; 548&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;39&#41;&#46; El Q<span class="elsevierStyleInf">A</span> fue similar tanto para los &#160;pacientes con PAM &#60; 100 mmHg &#40;n &#61; 18&#44; 1101&#44;0 &#177; 552&#44;7 ml&#47;min&#41; como para<span class="elsevierStyleItalic"> </span>los pacientes con PAM &#8805; 100 mmHg &#40;n &#61; 12&#44; 1180&#44;4 &#177; 473&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;69&#41;&#46; No hemos objetivado ninguna correlaci&#243;n entre el Q<span class="elsevierStyleInf">A</span> medio y&#58; edad &#40;r &#61; 0&#44;09&#44; p &#61; 0&#44;62&#41;&#44; tiempo en HD &#40;r &#61; 0&#44;06&#44; p &#61; 0&#44;76&#41;&#44; PAM &#40;r &#61; &#8211;0&#44;21&#44; p &#61; 0&#44;27&#41;&#44; &#237;ndice Kt&#47;V &#40;r &#61; 0&#44;12&#44; p &#61; 0&#44;51&#41;&#44; distancia entre las agujas &#40;r &#61; &#8211;0&#44;17&#44; p &#61; 0&#44;37&#41; y duraci&#243;n de la FAVI &#40;r &#61; &#8211;0&#44;01&#44; p &#61; 0&#44;96&#41;&#46; El tiempo medio empleado para determinar el Q<span class="elsevierStyleInf">A</span> por la TGT utilizando el accesorio Twister<span class="elsevierStyleSup">&#174;</span> &#40;5&#44;9 &#177; 1&#44;9 min&#41; fue significativamente inferior en relaci&#243;n con el m&#233;todo Delta-H &#40;26&#44;8 &#177; 1&#44;9 min&#41; o con la TGT &#40;n &#61; 35&#44; 8&#44;9 &#177; 3&#44;5 min&#44; inversi&#243;n manual de las l&#237;neas&#41; aplicada por Wijnen et al&#46;&#160;&#40;Kidney Int&#160;2007&#59;72&#58;736&#41; &#40;para ambas comparaciones&#44; p &#60; 0&#44;001&#41;&#46; El Q<span class="elsevierStyleInf">A</span> medio obtenido mediante la TGT fue similar al flujo sangu&#237;neo medio determinado con el m&#233;todo Delta-H &#40;1138&#44;4 &#177; 502&#44;3 ml&#47;min&#41; &#40;p &#61; 0&#44;83&#41;&#46; Los valores del flujo sangu&#237;neo de la FAVI obtenidos mediante la TGT se correlacionaron significativamente con los determinados por el m&#233;todo Delta-H &#40;r &#61; 0&#44;963&#44; p &#60; 0&#44;001&#41;&#46;&#160;<span class="elsevierStyleBold">Conclusiones&#58;</span>&#160;1&#41; La TGT es un m&#233;todo v&#225;lido y reproducible para calcular el Q<span class="elsevierStyleInf">A</span> durante la HD&#46; 2&#41; El dispositivo Twister<span class="elsevierStyleSup">&#174;</span> es eficaz para reducir el tiempo empleado en determinar el Q<span class="elsevierStyleInf">A</span> mediante la TGT&#46; 3&#41; Los valores de flujo sangu&#237;neo de la FAVI obtenidos mediante la TGT y el m&#233;todo Delta-H se correlacionaron significativamente&#46; 4&#41; Se ha evidenciado una independencia entre la funci&#243;n de la FAVI y la presi&#243;n arterial del paciente&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#46; </span>Periodic blood flow &#40;Q<span class="elsevierStyleInf">A</span>&#41; measurement is the preferred way for arteriovenous fistula &#40;AVF&#41; surveillance in chronic hemodialysis &#40;HD&#41; patients&#46; <span class="elsevierStyleBold">Objectives&#46; </span>1&#41; Assess the efficacy of the temperature gradient method &#40;TGM&#41; on the Q<span class="elsevierStyleInf">A </span>determinations using the Twister<span class="elsevierStyleSup">&#8482; </span>device and to compare the functional results with the Delta-H method&#46; 2&#41; Evaluate the effect of blood pressure on the AVF function&#46; <span class="elsevierStyleBold">Patients and method&#46; </span>We measured the Q<span class="elsevierStyleInf">A </span>non invasively in 30 AVF &#40;24 radial and 6 brachial&#59; mean duration 53&#46;4 &#177; 78&#46;5 months&#41; during HD in 30 stable patients &#40;mean age 59&#46;9 &#177; 14&#46;1 years&#44; males 60 &#37;&#44; females 40 &#37;&#59; mean time on HD 37&#46;4 &#177; 40&#46;6 months&#44; diabetic nephropathy 20 &#37;&#41; by the TGM&#44; described and validated by Wijnen et al &#40;Kidney Int 2007&#59;72&#58;736&#41;&#46; The Q<span class="elsevierStyleInf">A </span>was calculated from the temperature values obtained by means of the blood temperature monitor &#40;BTM&#41;&#44; integrated into the Fresenius Medical Care 4008-S machine&#44; at normal and reverse configurations of the HD blood lines&#44; with no need for a thermal bolus&#46; The Twister<span class="elsevierStyleSup">&#8482; </span>device was used for reversing the blood lines without the need to disconnect them from the AVF lines nor to stop the blood pump&#46; The Q<span class="elsevierStyleInf">A </span>was measured within the first hour of two consecutive HD sessions &#40;the values were averaged&#41;&#46; The mean arterial pressure MAP &#40;diastolic pressure &#43; 1&#47;3 pulse pressure&#41; was calculated simultaneous with the Q<span class="elsevierStyleInf">A</span>&#46; In addition&#44; the AVF blood flow was also determined during the same week in all patients by the Delta-H method using the Crit-Line III Monitor &#40;ABF-mode&#44; HemaMetrics&#44; USA&#41; during HD &#40;manually switching lines&#41;&#46; <span class="elsevierStyleBold">Results&#46; </span>The mean Q<span class="elsevierStyleInf">A </span>was 1132&#46;5 &#177; 515&#46;4 ml&#47;min &#40;range&#44; 446-2233 ml&#47;min&#41;&#46; The mean coefficient of variation for duplicate Q<span class="elsevierStyleInf">A </span>measurements was 6&#46;8 &#177; 4&#46;7 &#37;&#59; the MAP was not different when the reproducibility tests were performed &#40;96&#46;1 &#177; 13&#46;7 versus 96&#46;6 &#177;12&#46;8 mmHg&#44; p &#61; &#46;72&#41;&#46; No significant difference was found when comparing the mean Q<span class="elsevierStyleInf">A </span>between diabetic &#40;n &#61; 6&#44; 966&#46;4 &#177; 340&#46;7 ml&#47;min&#41; and nondiabetic &#40;n &#61; 24&#44; 1174&#46;4 &#177; 548&#46;3 ml&#47;min&#41; patients &#40;p &#61; &#46;39&#41;&#46; The mean Q<span class="elsevierStyleInf">A </span>was similar for patients with mean MAP &#60; 100 mmHg &#40;n &#61; 18&#44; 1101&#46;0 &#177; 552&#46;7 ml&#47;min&#41; and for patients with mean MAP &#62;&#95; 100 mmHg &#40;n &#61; 12&#44; 1180&#46;4 &#177; 473&#46;3 ml&#47;min&#41; &#40;p &#61; &#46;69&#41;&#46; No correlation was found between the mean Q<span class="elsevierStyleInf">A </span>and&#58; age &#40;r &#61; 0&#46;09&#44; p &#61; &#46;62&#41;&#44; time on HD &#40;r &#61; 0&#46;06&#44; p &#61; &#46;76&#41;&#44; MAP &#40;r &#61; &#8211; 0&#46;21&#44; p &#61; &#46;27&#41;&#44; Kt&#47;V index &#40;r &#61; 0&#46;12&#44; p &#61; &#46;51&#41;&#44; distance between needles &#40;r &#61; &#8211; 0&#46;17&#44; p &#61; &#46;37&#41; and AVF duration &#40;r &#61; &#8211; 0&#46;01&#44; p &#61; &#46;96&#41;&#46; The mean time required to measure Q<span class="elsevierStyleInf">A </span>with the TGM using the Twister<span class="elsevierStyleSup">&#8482; </span>device &#40;5&#46;9 &#177; 1&#46;9 min&#41; was significantly shorter compared with the Delta-H technique &#40;26&#46;8 &#177; 1&#46;9 min&#41; or with the TGM &#40;n &#61; 35&#44; 8&#46;9 &#177; 3&#46;5 min&#44; manually reversing lines&#41; reported by Wijnen et al &#40;Kidney Int 2007&#59;72&#58;736&#41;&#46;&#41; &#40;for both comparisons&#44; p &#60; &#46;001&#41;&#46; The mean Q<span class="elsevierStyleInf">A </span>obtained by the TGM was not different when compared to mean ABF determined by the Delta-H method &#40;1138&#46;4 &#177; 502&#46;3 ml&#47;min&#41; &#40;p&#61;&#46;83&#41;&#46;The calculated values of AVF blood flow obtained by TGM were highly correlated with those determined by the Delta-H technique &#40;r &#61; 0&#46;963&#44; p &#60; &#46;001&#41;&#46; <span class="elsevierStyleBold">Conclusions&#46; </span>1&#41; The TGM is a valuable and reproducible indicator of Q<span class="elsevierStyleInf">A </span>during HD&#46; 2&#41; The Twister&#8482; device is useful to reduce the time for Q<span class="elsevierStyleInf">A </span>measurement by the TGM&#46; 3&#41; The AVF blood flow values obtained by the TGM and the Delta-H technique correlated highly with each other&#46; 4&#41; It has been shown the lack of relationship between the AVF function and the patient&#8217;s blood pressure&#46; </p>"
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Article information
ISSN: 20132514
Original language: English
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Idiomas
Nefrología (English Edition)