Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts.
BACKGROUND
End-stage renal disease (ESRD) patients often require either the formation of an arteriovenous (A-V) fistula or an A-V interposition prosthetic shunt for haemodialysis.


OBJECTIVE
To determine the effects of adjuvant drug treatment on the patency of fistulae and grafts in patients with ESRD who are undergoing haemodialysis by assessing the number of thrombotic episodes.


METHODS
The Cochrane Peripheral Vascular Diseases Group (PVD) searched their Specialised Register (last searched May 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 2).


METHODS
RCTs of active drug versus placebo in patients with ESRD undergoing haemodialysis via an A-V fistula or prosthetic interposition A-V graft.


METHODS
For the update, two review authors (ADS, GO) independently assessed trial quality and ADS, XE, and GO extracted data. Information on adverse events was collected from the trials. The outcome measure analysed was the long-term fistula or graft patency rate.


RESULTS
The overall results of the meta-analysis (three RCTs) comparing aspirin versus placebo favoured treatment with aspirin (odds ratio (OR) 0.42, 95% confidence interval (CI) 0.20 to 0.86; P = 0.02).The overall result of the meta-analysis ( three RCTs) comparing ticlopidine (a platelet aggregation inhibitor) versus placebo favoured active treatment (OR 0.47, 95% CI 0.26 to 0.85; P = 0.01).The overall result from one trial comparing the effect of dipyridamole versus placebo and dipyridamole plus aspirin versus placebo favoured treatment (OR 0.57, 95% CI 0.13 to 2.51; OR 0.77, CI 0.19 to 3.19, respectively).One trial compared fish oil (4 g/daily) versus placebo with 24 participants, follow-up 12 months. The overall result favoured treatment (OR 0.07, 95% CI 0.01 to 0.49).One trial compared low-dose warfarin with placebo, 107 patients were followed for 37 months but the trial was terminated prematurely due to increased bleeding events in the treatment group. The overall result favoured placebo (OR 1.76, 95% CI 0.78 to 3.99).One trial compared sulfinpyrazone versus placebo. Sixteen patients, follow-up three months, and the overall result favoured treatment (OR 0.14, 95% CI 0.01 to 1.99).Finally, one trial compared clopidogrel (75 mg/once daily) with placebo. Twenty-four patients, follow-up over a three-year period until their first episode of thrombosis. The overall result favoured treatment (OR 0.01, 95% CI 0.00 to 0.15).


CONCLUSIONS
The meta-analysis confirmed the beneficial effect of anti-platelet treatment as an adjuvant used to increase the patency of A-V fistulae and grafts in the short term.
Department of General Surgery, Singleton Hospital, Swansea NHS Trust, Sketty Lane, Swansea, Wales, UK, SA2 8QA.
Gary
G
Osborn
Xavier
X
Escofet
Anthony
A
Da Silva
D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods; D017024:Chemotherapy, Adjuvant; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis / Q000379:methods; D014654:Vascular Patency / Q000187:drug effects
D010975:Platelet Aggregation Inhibitors