Practical utility of thermodilution versus Doppler ultrasound to measure haemodialysis blood access flow
Aplicación práctica de la termodilución frente a la ecografía-Doppler en la medición del flujo del acceso vascular
Néstor Fontseréa, Néstor Fontseréb, Gaspar Mestresc, Gaspar Mestresd, Marta Barrufete, Marta Burrele, Manel Veraf, Marta Ariasf, Elisabeth Massof, Aleix Casesf, Francisco Maduellf, Josep M Campistolg, Josep M. Campistolf
a Nefrologia. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain,
b Servicio de Nefrología. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona,
c Cirugía Vascular. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain,
d Servicio de Cirugía Vascular. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona,
e Servicio de Radiología Vascular Intervencionista. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona,
f Servicio de Nefrología, Hospital Clínic de Barcelona. Universidad de Barcelona,
g Nefrologia, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain,
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"apellidos" => "Campistol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Nefrologia. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Cirugía Vascular. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía Vascular. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Servicio de Radiología Vascular Intervencionista. Unidad Funcional de Acceso Vascular, Hospital Clínic de Barcelona. Universidad de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] 5 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Clínic de Barcelona. Universidad de Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] 6 => array:3 [ "entidad" => "Nefrologia, Hospital Clínic de Barcelona. Universidad de Barcelona, Barcelona, Barcelona, Spain, " "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "affg" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicación práctica de la termodilución frente a la ecografía-Doppler en la medición del flujo del acceso vascular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46764_en_t111748.jpg" "Alto" => 594 "Ancho" => 2187 "Tamanyo" => 185019 ] ] "descripcion" => array:1 [ "en" => "General concordance results between vascular flow measurements obtained using thermodilution and Doppler ultrasound" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Studies have shown that patients on haemodialysis programmes with arteriovenous fistulas maintain patency for a longer period of time and incur fewer complications.<span class="elsevierStyleSup">1</span> In this context, the various clinical guidelines on vascular accesses (VA) recommend periodical application of different programmes of active follow-up and monitoring.<span class="elsevierStyleSup">2-4</span> The main objective of these programmes is the early application of the available range of endovascular and surgical corrective therapies designed to avoid the need for central venous catheters, which imply increased morbidity and mortality rates due to infectious complications.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Of the available second-generation monitoring methods for measuring VA flow (Qa), those considered as the “gold standard” include the saline-dilution method and colour Doppler ultrasound (UD).<span class="elsevierStyleSup">6</span> Despite this, modern haemodialysis monitors utilise other indirect and dilutional techniques for automatically estimating Qa through ionic dialysance<span class="elsevierStyleSup">7</span> and thermodilution (TD).<span class="elsevierStyleSup">8</span> Our group recently reported a study carried out in 50 stable patients on an ambulatory haemodialysis programme, concluding optimal concordance of Qa derived from the temperature monitor as compared to saline-dilution as a reference value.<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">No studies to date have evaluated the concordance of Qa values between TD and DU measurements. One of the primary limitations of the saline-dilution method and ultrasound for measuring Qa is that both techniques lack an external apparatus. In the case of ultrasound control, it is not possible to automatically determine flow during the dialysis session, and this method is also susceptible to possible biases in measurements related to the angle of insonation and variations in vessel diameter.<span class="elsevierStyleSup">10</span> Based on the available scientific evidence, controversy persists regarding which is the best location for measuring Qa with ultrasound in patients with an internal arteriovenous fistula (IAVF), especially in radio-cephalic side-to-end anastomoses (SE). In this context, Wiese et al.<span class="elsevierStyleSup">11</span> suggested that measurements in the radial artery could underestimate flow due to feedback from the ulnar arterial access and palmar arch.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">OBJECTIVES</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Primary objective: to analyse the level of concordance of Qa measurements between TD and DU.</p><p class="elsevierStylePara">Secondary objectives:</p><li>An analysis of the validity of Qa measurements in the different available anatomical locations in comparison with the brachial artery in patients with radio-cephalic IAVF with SE anastomoses.</li><li>An analysis of haemodynamic parameters and haemodialysis adequacy between the group of patients with significant VA dysfunction and the rest of the study patients.</li><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">Observational and cross-sectional cohort study involving 64 stable patients (41 males) on a haemodialysis programme with a mean age of 59.9±15.4 years, with 54 IAVF (28 radio-cephalic and 26 brachial) and 10 polytetrafluoroethylene (PTFE) prosthetic grafts (5 brachio-axillary and 5 femoro-femoral). Median time on the dialysis programme was 30.5 months (P<span class="elsevierStyleInf">25-75</span>: 11.7-92.2 months), using 5008S monitors (Fresenius Medical Care<span class="elsevierStyleSup">®</span>) with bicarbonate and 1.5 or 1.8m<span class="elsevierStyleSup">2</span> polysulfone or helixone high-flux filters using post-dilutional online haemodiafiltration; Qb: 410.3±28.1ml/min; Qd: 534.3±117.1ml/min; Qi: 99.4±17.4ml/min. At the end of each haemodialysis session, we determined dosage through ionic dialysance (Kt).<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">As regards causes of renal failure, 15 patients had vascular nephropathy, 13 had diabetic nephropathy, 16 were of an unknown cause, 10 had glomerular diseases, 9 had polycystic kidney disease, and 1 had tubulo-interstitial nephropathy.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Vascular flow rate measurement</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Doppler ultrasound</span></span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">DU was considered as the “gold standard” for measuring Qa. We took the mean value from three consecutive measurements taken one week after taking the TD measurement. The reference ultrasound value was obtained at the brachial artery in IAVF<span class="elsevierStyleSup">13</span> (4-5cm from the anastomosis) and at the arterial puncture site for prosthetic grafts. We used the colour Doppler ultrasound modality on the MyLab 25 ultrasound machine (Esaote<span class="elsevierStyleSup">®</span>) for B-mode and haemodynamic analyses. In order to minimise bias when taking measurements, we adjusted PRF and gain, and measured along the transverse-longitudinal axis of the central part of the vein, with a wide spectral window and an insonation angle >60º. In order to measure Qa, we traced the curve of one cycle, taking reference values for maximum velocity (peak systolic velocity) and minimum velocity. The ultrasound automatically provides mean velocity, the area based on the diameter measurement, and the value of Qa using the following formula:</p><p class="elsevierStylePara">DU-Qa = ∏ r<span class="elsevierStyleSup">2 </span>(area) x Vm x 60<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">R is the radius of the vessel and Vm is the mean velocity (cm/sec)</p><p class="elsevierStylePara">In the group of patients with radio-cephalic IAVF and SE anastomoses, we also determined Qa in the radial artery, sum of the radial-ulnar artery, and cephalic vein.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Thermodilution</span></span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">TD is one of the non-invasive techniques available for the monitoring and follow-up of Qa, using recirculation values obtained using the blood temperature monitor (BTM<span class="elsevierStyleSup">®</span>) with normal and reversed-position haemodialysis lines.<span class="elsevierStyleSup">15</span> This method, first described and validated by Schneditz et al.,<span class="elsevierStyleSup">8</span> is easy to apply since the BTM sensor is integrated into modern haemodialysis machines.</p><p class="elsevierStylePara">The measurement process begins by generating a “temperature bolus” by self-limiting the temperature of the dialysate fluid (-2ºC for 2 minutes). Initially, this thermal decrease is picked up by the venous line temperature sensor and, after mixing with the bloodstream and cardiopulmonary circulation of the patient, returns to the dialyser and is detected by the arterial line sensor. The difference between these two values obtained by the two sensors allows us to quantify the percentage of recirculation. This procedure is carried out with normal and reverse-position dialysis lines.</p><p class="elsevierStylePara">DU-Qa = Qs x (1-Rx) (1-Rn) / (Rx-Rn),</p><p class="elsevierStylePara">TD-Qa = Qs x (1-Rx) (1-Rn) / (Rx-Rn),</p><p class="elsevierStylePara">Qs represents effective blood flow (ml/min), Rn is the rate of recirculation with lines in the normal position (%), and Rx is the rate of recirculation obtained with lines in the reverse position (%).</p><p class="elsevierStylePara">All measurements taken using TD were obtained during the first 60 minutes of the dialysis sessions, with a minimum 5cm distance between puncture sites using a high-efficacy modality of haemodialysis with a Qb of 300ml/min and Qd of 500ml/min.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The values obtained were expressed in percentages or mean ± standard deviation. We used the Bland-Altman method<span class="elsevierStyleSup">16</span> and intra-class correlation coefficients (ICC) to analyse concordance between the two measurement methods. We used the non-parametric Mann-Whitney U-test to compare differences between quantitative variables. We considered a <span class="elsevierStyleItalic">P</span>-value of <.05 to be statistically significant in all cases. We used PASW statistical software, version 18, for all statistical analyses (SPSS Inc., Chicago, IL, USA).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The mean Qa value obtained using DU was 1389±758ml/min. The DU-Qa value resulted in 1426±753ml/min for the group of patients with IAVF, and 1186±789ml/min in the PTFE group. Table 1 summarises the results in terms of concordance between TD and DU, and Figure 1 presents a graphical representation of the Bland-Altman mathematical model. The measurement bias between the two methods was defined as the difference in Qa values obtained between TD and DU. Figure 2 summarises the number of patients with IAVF or PTFE divided into categories based on the Qa values obtained from both methods using the current clinical VA guideline recommendations for cut-off values. DU measurements classified 92.2% of patients with IAVF as having a Qa≥500ml/min, and 7.8% as having a Qa<500ml/min. The results from TD were 90.6% and 9.4%, respectively. As regards the group of patients with PTFE prostheses, DU classified 70% as having a Qa≥600ml/min and 30% as having a Qa <600ml/min. The results obtained for Qa using TD in this group were 60% and 40%, respectively.</p><p class="elsevierStylePara">In the group of 28 patients with radio-cephalic IAVF with SE anastomoses, the mean Qa value obtained using ultrasound measurements in the brachial artery was 1232±767ml/min. The measurements taken from the radial artery with respect to the brachial artery resulted in a mean value of 942±595ml/min, with a mean bias of -290ml/min and an ICC of 0.805 (<span class="elsevierStyleItalic">P</span><.01). The sum value of the radial and ulnar arteries for Qa was 1103±583ml/min, with a bias of -129ml/min and an ICC of 0.973 (<span class="elsevierStyleItalic">P</span><.01). The mean value taken from the cephalic vein was 788±423ml/min, with a bias of -44ml/min and an ICC of 0.772 (<span class="elsevierStyleItalic">P</span><.01). The results obtained using TD were 1026±431ml/min, with a bias of -206ml/min and an ICC of 0.971 (<span class="elsevierStyleItalic">P</span><.01). Using the Qa value obtained from the brachial artery as a reference point, the radial artery corresponded to 76.5%, the sum radial-ulnar artery was at 89.5%, the cephalic vein at 63.9%, and the TD method yielded a value at 83.3% of the reference point.</p><p class="elsevierStylePara">In our morphological and haemodynamic analysis of the study group, we detected 5 cases of significant VA dysfunction (3 IAVF and 2 PTFE). Table 2 and Figure 3 summarise the primary characteristics of this group of patients, as well as values for haemodialysis dosage (Kt) and Qa measured using TD post-revascularisation with percutaneous transluminal angioplasty (PTA). The post-PTA Kt value was 79l (61l in the pre-PTA measurement; <span class="elsevierStyleItalic">P</span>=.043), and the post-PTA Qa-TD was 895ml/min (663ml/min pre-PTA measurement; <span class="elsevierStyleItalic">P</span>=.043). Table 3 summarises the values obtained for the haemodynamic parameters using ultrasound control in patients with significant VA dysfunction and the rest of the group.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">According to our results, TD is a useful automated and non-invasive method for measuring Qa, as compared to DU. The major clinical guidelines for VA recommend the active application of various multi-disciplinary programmes in order to facilitate early detection of significant vascular dysfunction.<span class="elsevierStyleSup">2-4</span> The main objective of these strategies is to promote optimal functioning of endovascular and surgical treatment measures with the goal of maintaining access patency and minimising the risk of thrombosis. Despite using second-generation Qa measurement methods, we must never forget the importance of a systematic physical examination. In the study by Asif et. al,<span class="elsevierStyleSup">17</span> involving 145 consecutive patients with dysfunctional IAVF, exploring the VA allowed for detecting and localising the stenosis in a high percentage of cases.</p><p class="elsevierStylePara">Qa estimation represents one of the most important predictive factors of significant dysfunction (stenosis or partial thrombosis). The criteria used for imaging tests include a reduction in absolute Qa values of <600ml/min in PTFE grafts or <500ml/min in IAVF.<span class="elsevierStyleSup">18,19</span> A temporary reduction of Qa>20%-25% with respect to baseline values must also be included among the criteria associated with high clinical suspicion. As shown in the study by Tessitore et al.,<span class="elsevierStyleSup">20</span> which involved a 5-year follow-up of 159 patients on haemodialysis with IAVF (62 monitored using the saline-dilution method), monitoring Qa was associated with an increase in the rate of detection of stenoses, reduced rates of thrombosis and central venous catheter placement, a greater economic benefit, and superior patency values during the first three years of follow-up after implantation of the vascular access point.</p><p class="elsevierStylePara">Currently, we can automatically obtain Qa estimates at no additional economic cost using techniques based on TD. In the study reported by Wang et al.,<span class="elsevierStyleSup">21</span> this dilutional method resulted in a sensitivity value of 81.8% and a specificity of 98.6% for detecting dysfunctional IAVF. According to the results reported by our research group, TD yields a strong correlation with the saline-dilution method in an intra-method validation test (Qb: 300ml/min; Qd: 500ml/min).<span class="elsevierStyleSup">9</span> Despite this, TD methods have certain limitations in measuring Qa with standard prescription parameters in high-flux haemodialysis and post-dilutional online haemodiafiltration.<span class="elsevierStyleSup">22</span> The mean Qa values obtained by TD in recent publications that included patients with IAVF were 1034ml/min and 1170ml/min, with no significant differences as compared to the saline-dilution and Delta-H methods, respectively.<span class="elsevierStyleSup">23,24</span> As shown in Table 1 and Figure 1, our results show that TD also presents a strong correlation with Qa values taken using ultrasound techniques, with an ICC>0.90 and a bias of 54.6ml/min and 10.2ml/min in patients with IAVF and prosthetic PTFE grafts. However, the confidence intervals (Table 1) and Bland-Altman graphical representation (Figure 1) show a greater degree of dispersion of values for Qa>1000ml/min. This phenomenon was also described in the study by Merino et al.<span class="elsevierStyleSup">25</span> when comparing ionic dialysance with the saline-dilution method. In these clinical situations, we believe that a significant reduction in baseline Qa values is more valuable as a screening method for patients that should undergo imaging tests in order to facilitate the early detection of significant VA dysfunction.</p><p class="elsevierStylePara">According to our results for the group of patients with radio-cephalic IAVF and SE anastomoses, values taken from the sum of the ulnar and radial arteries presented the greatest level of concordance with respect to reference Qa values taken from the brachial artery. The mean bias obtained was -129ml/min, 89.5% of the total brachial flow. Even so, measuring these values in practice may lead to bias, since this involves ultrasound evaluation of small-diameter arterial vessels. In this context, it would be interesting to apply TD as an automated indirect method with strong correlation to values taken from the brachial artery. Measurements taken from the efferent vein also are associated with errors related to variations in diameter, turbulence, and vibrations.<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">DU represents a second-generation method that allows us to monitor VA through measurements of Qa, but also facilitates the assessment of other morphological and haemodynamic parameters. The morphological criteria that suggest the presence of a stenosis include a B-mode vascular reduction >50% accompanied by turbulent flow (aliasing) in the colour Doppler modality. Functional criteria include an elevation in peak systolic velocity or maximum velocity >400cm/sec (PSV), a PSV ratio between the stenotic and pre-stenotic areas >2 for IAVF or >3 for PTFE, an elevation in the brachial artery resistance index >0.6, or the aforementioned alterations in Qa values.<span class="elsevierStyleSup">11,26</span> As summarised in Table 3 and Figure 3, patients in our study with significant VA stenosis presented these haemodynamic abnormalities, as well as receiving a lower dose of haemodialysis (Kt). After endovascular revascularisation using an angioplasty balloon catheter, we observed a recovery of Qa as measured by TD (895ml/min vs 663ml/min; <span class="elsevierStyleItalic">P</span>=.043) and Kt (79l vs 61l; <span class="elsevierStyleItalic">P</span>=.043). The diagnostic sensitivity of DU for the diagnosis of significant stenoses ranges between 80% and 90%.<span class="elsevierStyleSup">27-29</span> Various studies have shown a greater rate of survival, fewer hospitalisations, and a significant reduction in health costs for patients under active monitoring with ultrasound techniques.<span class="elsevierStyleSup">30,31</span></p><p class="elsevierStylePara">One limitation of our study was the fact that we did not evaluate the impact of TD as a prospective monitoring programme for VA. As such, we find it necessary to design future studies focused on evaluating the efficacy of methods based on TD as a useful tool for the early detection of vascular dysfunction and for reducing thrombosis rates.</p><p class="elsevierStylePara">To conclude, TD is a useful automated indirect method for measuring Qa, with comparable results to those produced using DU. In patients with radio-cephalic IAVF and SE anastomoses, the most precise measurements were those derived from the sum of radial and ulnar arterial flow rates. However, in this clinical situation, TD produces excellent correlation with reference values taken from the humeral artery.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/11748_16025_46764_en_t111748.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46764_en_t111748.jpg" alt="General concordance results between vascular flow measurements obtained using thermodilution and Doppler ultrasound"></img></a></p><p class="elsevierStylePara">Table 1. General concordance results between vascular flow measurements obtained using thermodilution and Doppler ultrasound</p><p class="elsevierStylePara"><a href="grande/11748_16025_46765_en_t2117484.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46765_en_t2117484.jpg" alt="General characteristics of patients with significant vascular access dysfunction"></img></a></p><p class="elsevierStylePara">Table 2. General characteristics of patients with significant vascular access dysfunction</p><p class="elsevierStylePara"><a href="grande/11748_16025_46766_en_t3117486.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46766_en_t3117486.jpg" alt="Comparative analysis of the different haemodynamic parameters obtained using Doppler ultrasound (pre-PTA) between cases with dysfunction and all other patients"></img></a></p><p class="elsevierStylePara">Table 3. Comparative analysis of the different haemodynamic parameters obtained using Doppler ultrasound (pre-PTA) between cases with dysfunction and all other patients</p><p class="elsevierStylePara"><a href="grande/11748_16025_46767_en_f1117482.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46767_en_f1117482.jpg" alt="Graphical representation using the Bland-Altman method for comparing measurements of vascular flow using Doppler ultrasound and thermodilution"></img></a></p><p class="elsevierStylePara">Figure 1. Graphical representation using the Bland-Altman method for comparing measurements of vascular flow using Doppler ultrasound and thermodilution</p><p class="elsevierStylePara"><a href="grande/11748_16025_46768_en_f2117483.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46768_en_f2117483.jpg" alt="Patient classification based on type of vascular access and vascular flow rate as measured using Doppler ultrasound and thermodilution"></img></a></p><p class="elsevierStylePara">Figure 2. Patient classification based on type of vascular access and vascular flow rate as measured using Doppler ultrasound and thermodilution</p><p class="elsevierStylePara"><a href="grande/11748_16025_46769_en_f3117485.jpg" class="elsevierStyleCrossRefs"><img src="11748_16025_46769_en_f3117485.jpg" alt="Progression of haemodialysis doses (Kt) and vascular flow rates determined using pre- and post-PTA TD with a balloon catheter in patients with significant vascular access dysfunction."></img></a></p><p class="elsevierStylePara">Figure 3. Progression of haemodialysis doses (Kt) and vascular flow rates determined using pre- and post-PTA TD with a balloon catheter in patients with significant vascular access dysfunction.</p>" "pdfFichero" => "P1-E550-S4065-A11748-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:5 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436029" "palabras" => array:1 [ 0 => "FAVI radio-cefálicas latero-terminales" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436031" "palabras" => array:1 [ 0 => "Termodilución" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436033" "palabras" => array:1 [ 0 => "Ecografía-Doppler" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436035" "palabras" => array:1 [ 0 => "Flujo del acceso vascular (Qa)" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436037" "palabras" => array:1 [ 0 => "Hemodiálisis" ] ] ] "en" => array:5 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436030" "palabras" => array:1 [ 0 => "Radiocephalic AVFs latero-terminal" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436032" "palabras" => array:1 [ 0 => "Thermodilution" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436034" "palabras" => array:1 [ 0 => "Doppler ultrasound" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436036" "palabras" => array:1 [ 0 => "Access blood flow (Qa)" ] ] 4 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436038" "palabras" => array:1 [ 0 => "Haemodialysis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducción: </span>Las actuales guías recomiendan la medición periódica del flujo vascular (Qa). Los métodos actualmente validados son la ecografía-Doppler (ED) y la ultrasonografía dilucional. <span class="elsevierStyleBold">Objetivo: </span>Analizar la aplicación práctica de la termodilución (TD) en la medición del Qa respecto a la ED. <span class="elsevierStyleBold">Material y métodos: </span>Estudio transversal realizado en 64 pacientes (41 varones) en programa de hemodiálisis; 59,9 años con 54 FAVI y 10 politetrafluoroetileno (PTFE). El Qa de referencia se determinó por ED en la arteria humeral (fístula arteriovenosa [FAVI]) y en el tramo de punción arterial (PTFE). Para el análisis de concordancia se utilizó el método de Bland-Altman y el coeficiente de correlación intraclase (CCI). <span class="elsevierStyleBold">Resultados: </span>El Qa obtenido por ED resultó 1426 ± 753 ml/min FAVI y 1186 ± 789 ml/min PTFE. Los valores obtenidos por TD fueron 1372 ± 770 FAVI (sesgo 54,6; CCI 0,923) y 1176 ± 758 PTFE (sesgo 10,2; CCI 0,992). En el subgrupo de 28 pacientes portadores de FAVI radio-cefálicas latero-terminales el Qa obtenido por ED resultó 1232 ± 767 ml/min. A nivel de la arteria radial 942 (CCI 0,805); arteria radial-cubital 1.103 (CCI 0,973); vena cefálica 788 (CCI 0,772) y TD 1026 (CCI 0,971). Se detectaron 5 estenosis significativas; Kt posrevascularización mediante catéter balón de angioplastia (ATP): 79 l (61; p = 0,043) y Qa-TD post-ATP 895 ml/min (663; p = 0,043). <span class="elsevierStyleBold">Conclusiones: </span>La TD resultó un método indirecto automatizado útil en la medición del Qa. En el subgrupo de pacientes con FAVI radio-cefálicas resultó más preciso el sumatorio de flujo obtenido en arteria radial y cubital. Sin embargo, la TD también presentó una excelente correlación con la arteria humeral. </p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Introduction: </span></span><span class="elsevierStyleItalic">The current clinical guidelines recommend indirect measurement of vascular access blood flow </span><span class="elsevierStyleItalic">(Qa)</span><span class="elsevierStyleItalic"> as one of the most important components in vascular access maintenance programmes. The best-known methods are doppler ultrasound (DU) and saline dilution method. <span class="elsevierStyleBold">Objective: </span>This study evaluates the efficiency of Qa measurement using the thermodilution method (TD) in comparison with DU. <span class="elsevierStyleBold">Material and Method: </span>Cross-sectional study in 64 patients on haemodialysis (41 males); mean age: 59.9 years, with 54 AVFs and 10 PTFE. Qa reference values were obtained with DU in the brachial artery (AVFs) or at the zone of arterial puncture (PTFE). Bland-Altman and interclass correlation coefficients (ICC) were used to study accuracy. <span class="elsevierStyleBold">Results: </span>Mean values obtained with DU-Qa were 1426 ± 753 mL/min for AVFs and 1186 ± 789mL/min for PTFE grafts. The mean Qa with TD was 1372 ± 770 for AVFs (bias: 54.6; ICC: 0.923) and 1176 ± 758 for PTFE (bias 10.2; ICC 0.992). In the 28 patients with radiocephalic side-to-end AVFs, the mean DU-Qa was 1232 ± 767mL/min. Qa values were measured in the radial artery: 942 (ICC 0.805); radial-ulnar artery: 1103 (ICC 0.973); cephalic vein: 788 (ICC 0.772), and with TD: 1026 (ICC 0.971). We detected 5 cases of significant stenosis. After endovascular treatment, mean Kt was 79 liters (61; </span>P<span class="elsevierStyleItalic">=.043) and mean TD-Qa was 895mL/min (663; </span>P<span class="elsevierStyleItalic">=.043). <span class="elsevierStyleBold">Conclusions: </span>TD represents a good indirect method of Qa measurement. In patients with radiocephalic AVFs, Qa measurements in the radial and ulnar artery are more accurate. Therefore, in this situation the TD method obtained an excellent correlation with values taken from the brachial artery.</span></p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46764_en_t111748.jpg" "Alto" => 594 "Ancho" => 2187 "Tamanyo" => 185019 ] ] "descripcion" => array:1 [ "en" => "General concordance results between vascular flow measurements obtained using thermodilution and Doppler ultrasound" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46765_en_t2117484.jpg" "Alto" => 409 "Ancho" => 2174 "Tamanyo" => 236225 ] ] "descripcion" => array:1 [ "en" => "General characteristics of patients with significant vascular access dysfunction" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46766_en_t3117486.jpg" "Alto" => 392 "Ancho" => 2192 "Tamanyo" => 210317 ] ] "descripcion" => array:1 [ "en" => "Comparative analysis of the different haemodynamic parameters obtained using Doppler ultrasound (pre-PTA) between cases with dysfunction and all other patients" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46767_en_f1117482.jpg" "Alto" => 1925 "Ancho" => 2114 "Tamanyo" => 526878 ] ] "descripcion" => array:1 [ "en" => "Graphical representation using the Bland-Altman method for comparing measurements of vascular flow using Doppler ultrasound and thermodilution" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46768_en_f2117483.jpg" "Alto" => 771 "Ancho" => 1017 "Tamanyo" => 114600 ] ] "descripcion" => array:1 [ "en" => "Patient classification based on type of vascular access and vascular flow rate as measured using Doppler ultrasound and thermodilution" ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11748_16025_46769_en_f3117485.jpg" "Alto" => 1490 "Ancho" => 1012 "Tamanyo" => 214843 ] ] "descripcion" => array:1 [ "en" => "Progression of haemodialysis doses (Kt) and vascular flow rates determined using pre- and post-PTA TD with a balloon catheter in patients with significant vascular access dysfunction." ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003300000003/v0_201502091549/X2013251413003236/v0_201502091549/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003300000003/v0_201502091549/X2013251413003236/v0_201502091549/en/P1-E550-S4065-A11748-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251413003236?idApp=UINPBA000064" ]
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| 2024 February | 34 | 40 | 74 |
| 2024 January | 28 | 21 | 49 |
| 2023 December | 30 | 32 | 62 |
| 2023 November | 32 | 38 | 70 |
| 2023 October | 46 | 39 | 85 |
| 2023 September | 62 | 38 | 100 |
| 2023 August | 39 | 20 | 59 |
| 2023 July | 47 | 37 | 84 |
| 2023 June | 47 | 25 | 72 |
| 2023 May | 39 | 46 | 85 |
| 2023 April | 25 | 36 | 61 |
| 2023 March | 40 | 15 | 55 |
| 2023 February | 28 | 26 | 54 |
| 2023 January | 36 | 19 | 55 |
| 2022 December | 56 | 29 | 85 |
| 2022 November | 61 | 32 | 93 |
| 2022 October | 63 | 44 | 107 |
| 2022 September | 45 | 29 | 74 |
| 2022 August | 40 | 39 | 79 |
| 2022 July | 30 | 39 | 69 |
| 2022 June | 31 | 60 | 91 |
| 2022 May | 40 | 43 | 83 |
| 2022 April | 30 | 75 | 105 |
| 2022 March | 25 | 54 | 79 |
| 2022 February | 32 | 39 | 71 |
| 2022 January | 33 | 45 | 78 |
| 2021 December | 41 | 34 | 75 |
| 2021 November | 27 | 42 | 69 |
| 2021 October | 53 | 64 | 117 |
| 2021 September | 34 | 36 | 70 |
| 2021 August | 45 | 42 | 87 |
| 2021 July | 28 | 43 | 71 |
| 2021 June | 35 | 32 | 67 |
| 2021 May | 37 | 34 | 71 |
| 2021 April | 46 | 47 | 93 |
| 2021 March | 64 | 37 | 101 |
| 2021 February | 61 | 20 | 81 |
| 2021 January | 37 | 15 | 52 |
| 2020 December | 26 | 17 | 43 |
| 2020 November | 35 | 16 | 51 |
| 2020 October | 22 | 20 | 42 |
| 2020 September | 22 | 8 | 30 |
| 2020 August | 41 | 9 | 50 |
| 2020 July | 43 | 11 | 54 |
| 2020 June | 26 | 23 | 49 |
| 2020 May | 41 | 13 | 54 |
| 2020 April | 29 | 16 | 45 |
| 2020 March | 21 | 9 | 30 |
| 2020 February | 52 | 20 | 72 |
| 2020 January | 44 | 24 | 68 |
| 2019 December | 54 | 17 | 71 |
| 2019 November | 29 | 19 | 48 |
| 2019 October | 19 | 10 | 29 |
| 2019 September | 30 | 19 | 49 |
| 2019 August | 24 | 16 | 40 |
| 2019 July | 37 | 24 | 61 |
| 2019 June | 35 | 24 | 59 |
| 2019 May | 40 | 30 | 70 |
| 2019 April | 57 | 35 | 92 |
| 2019 March | 48 | 22 | 70 |
| 2019 February | 31 | 19 | 50 |
| 2019 January | 40 | 25 | 65 |
| 2018 December | 108 | 38 | 146 |
| 2018 November | 153 | 25 | 178 |
| 2018 October | 125 | 25 | 150 |
| 2018 September | 89 | 16 | 105 |
| 2018 August | 58 | 21 | 79 |
| 2018 July | 41 | 17 | 58 |
| 2018 June | 61 | 18 | 79 |
| 2018 May | 59 | 12 | 71 |
| 2018 April | 69 | 11 | 80 |
| 2018 March | 66 | 4 | 70 |
| 2018 February | 55 | 12 | 67 |
| 2018 January | 46 | 7 | 53 |
| 2017 December | 58 | 12 | 70 |
| 2017 November | 58 | 17 | 75 |
| 2017 October | 52 | 12 | 64 |
| 2017 September | 41 | 9 | 50 |
| 2017 August | 36 | 24 | 60 |
| 2017 July | 38 | 9 | 47 |
| 2017 June | 33 | 13 | 46 |
| 2017 May | 53 | 9 | 62 |
| 2017 April | 39 | 15 | 54 |
| 2017 March | 55 | 8 | 63 |
| 2017 February | 47 | 19 | 66 |
| 2017 January | 25 | 14 | 39 |
| 2016 December | 68 | 8 | 76 |
| 2016 November | 80 | 14 | 94 |
| 2016 October | 105 | 10 | 115 |
| 2016 September | 128 | 4 | 132 |
| 2016 August | 211 | 9 | 220 |
| 2016 July | 228 | 14 | 242 |
| 2016 June | 160 | 0 | 160 |
| 2016 May | 145 | 0 | 145 |
| 2016 April | 111 | 0 | 111 |
| 2016 March | 86 | 0 | 86 |
| 2016 February | 124 | 0 | 124 |
| 2016 January | 94 | 0 | 94 |
| 2015 December | 135 | 0 | 135 |
| 2015 November | 119 | 0 | 119 |
| 2015 October | 92 | 0 | 92 |
| 2015 September | 93 | 0 | 93 |
| 2015 August | 75 | 0 | 75 |
| 2015 July | 80 | 0 | 80 |
| 2015 June | 46 | 0 | 46 |
| 2015 May | 64 | 0 | 64 |
| 2015 April | 6 | 0 | 6 |
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