Background: Arteriovenous Fistula (AVF) is the ideal method of vascular access for patients on maintenance hemodialysis (HD). Therefore it is an important part of treatment in HD. There are several observations that indicate the role of inflammation in failure of AVF. The aim of this study was to evaluate the hematologic and inflammatory biomarkers in early AVF failure. Methods: This case-control study included 110 ESRD patients, whom were undergone AVF creation, divided in two groups. About 700 radius-cephalic AVF were created during these two years. We found 55 cases with AVF failure. In this study, we compared those 55 failures with 55 functional AVF which were selected using randomized sampling from the rest of patients according to age, gender, and AVF location. Levels of serum C-reactive protein (CRP) were checked in both groups to evaluate the relation between AVF failure and CRP level before surgery. Results: The meanÂ±SD age of the patients was 49.7Â±17.28 years. CRP was positive in 34 patients (61.8) with unsuccessful fistula function, while only 4 (7.3) of those with successful AVF had positive CRP and the rest had negative CRP. The difference between the two groups of patients was strongly significant (p<0.001). Statistically, there was not any significant difference between the average of age (p: 0.580) of patients in the control and experimental groups. However, the gender (p: 0.832) discrepancies was not meaningful between the groups. Conclusion: AVF thrombosis is one of the main complications after AVF creation. Therefore, it is recommended to check CRP before AVF surgery to prevent possible failure of the fistula function

Mohammadipour, S.

Omrani, Z.

Zadeh, M.K.

English

PubMed

eprints Iran University of Medical Sciences

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)Iran University of Medical Sciences____________________________________________________________________________________________________________________1. (Corresponding author) MD, Assistant Professor of Surgery, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran,Iran. Khavaninzadeh.m@iums.ac.ir2. MD, General Surgeon, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran. samanmp@yahoo.com3. MD, General Surgeon, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran. Zahraomrani@yahoo.comCorrelation between CRP and early failure of arteriovenousfistula (AVF)Morteza Khavanin Zadeh*1, Saman Mohammadipour2, Zahra Omrani3Received: 13 October 2014 Accepted: 7 February 2015 Published: 8 June 2015AbstractBackground: Arteriovenous Fistula (AVF) is the ideal method of vascular access for patients onmaintenance hemodialysis (HD). Therefore it is an important part of treatment in HD. There are sev-eral observations that indicate the role of inflammation in failure of AVF. The aim of this study wasto evaluate the hematologic and inflammatory biomarkers in early AVF failure.Methods: This case-control study included 110 ESRD patients, whom were undergone AVF crea-tion, divided in two groups. About 700 radius-cephalic AVF were created during these two years.We found 55 cases with AVF failure. In this study, we compared those 55 failures with 55 functionalAVF which were selected using randomized sampling from the rest of patients according to age,gender, and AVF location. Levels of serum C-reactive protein (CRP) were checked in both groups toevaluate the relation between AVF failure and CRP level before surgery.Results: The mean±SD age of the patients was 49.7±17.28 years. CRP was positive in 34 patients(61.8%) with unsuccessful fistula function, while only 4 (7.3%) of those with successful AVF hadpositive CRP and the rest had negative CRP. The difference between the two groups of patients wasstrongly significant (p<0.001). Statistically, there was not any significant difference between the av-erage of age (p: 0.580) of patients in the control and experimental groups. However, the gender (p:0.832) discrepancies was not meaningful between the groups.Conclusion: AVF thrombosis is one of the main complications after AVF creation. Therefore, it isrecommended to check CRP before AVF surgery to prevent possible failure of the fistula function.Keywords: Vascular Access, Arteriovenous Fistula, CRP, Failure.Cite this article as: Khavanin Zadeh M, Mohammadipour S, Omrani Z. Correlation between CRP and early failure of arteriovenous fistula(AVF). Med J Islam Repub Iran 2015 (8 June). Vol. 29:219.IntroductionWith large advances during recent yearsin medicine and general heath, the life spanof ESRD patients has been increased (1).New studies show that the prevalence ofESRD patients is increasing 7-9% eachyear (2, 3)Hemodialysis (HD) is the most commonrenal replacement procedure performed forend stage renal disease (ESRD) patients(4). Vascular Access is the most importantmedical procedure in these cases.Nowadays, AVF is one of the most com-mon Vascular Access for HD (5). Vascularaccess failure and its complications are themost frequent hospital admission cause inthese patients. In overall, dialysis grafts,that are not frequent in Iran, last shorterthan AVF and are more prone to infectionand thrombosis (6).At clinical level, early failure has beendefined as an AVF that never develops ad-equately for dialysis (failure to mature), orwhich fails within one month of startingdialysis. As identified, increased age, fe-male gender, high blood pressure, presenceof diabetes, Caucasian race, vasculaturediseases and hemodynamic profile mayCRP and AV fistula failure2 MJIRI, Vol. 29.219. 8 June 2015http://mjiri.iums.ac.ircomplicate the prognosis of AVF (7).Technical errors in AVF creation are themain causes of early AVF failure (8). Fac-tors such as low hemoglobin levels andhigh calcium and phosphorous concentra-tions have been demonstrated as othercauses of early AVF failure. Likewise heartfailure, distal ischemia, aneurysm for-mation, median nerve injury, local bleed-ing, venous hypertension and Steal’s syn-drome can be some other probable sourcesof the complications (9-10).Thrombosis in the arteriovenous anasto-mosis is a common complication. (11-12)In addition, there are some other risk fac-tors that can influence physiopathology ofvascular access destruction (13). So far,there are not many studies relating clinicalfactors and biomarkers to AVF failure, andfurthermore, there are many controversiesin these studies. A study in the UK hadconcluded that low Albumin levels couldbe a risk factor for AVF failure (14). An-other study demonstrated low hemoglobinlevels as a destructive factor (9). However,all studies have suspected the importance ofinflammatory process. Furthermore, thereare not many studies regarding inflammato-ry biomarkers and AVF failure. The rela-tion between hemoglobin, Albumin, in-flammation and other biomarkers are stillunclear (9, 11-13). Thus, finding clinicaland para clinical factors that can indicateearly and late failure of the fistula is essen-tial (14-16). In our study, we evaluated therelationship between inflammation bi-omarker (CRP) and early rejection of AVFin ESRD patients.MethodsSubjectsThis is a case-control study of patientswho were all candidates of fistula creationand hospitalized at Hasheminejad KidneyCenter as a referral kidney hospital betweenDecember 2010 and October 2012. About700 radius-cephalic AVF were done duringthese two years and we had 55 failure. Inthis study we compared those 55 failures toanother 55 functional AVF which were se-lected using randomized sampling from therest of patients according to their age, gen-der, and AVF site.The study and analysis included 55 ESRDpatients with functional AVF and 55 otherswho experienced failure due to AVFthrombosis during one month after surgery.Therefore, we classified the 55 patientswith AVF dysfunction as ‘Failure’ andthose 55 with successful AVF creation as‘Survived’ groups. Data related to age,gender and AVF complication was also an-alyzed.The demographic data and other relatedinformation were recorded on a checklistpaper. CRP levels were recorded as well.Other complications related to the AVFwere also assessed in the study.Blood sample assaysBlood samples were obtained before theAVF surgery from antecubital vein of theopposite hand. All Biochemical assayswere carried out in the Hasheminejad Kid-ney Center laboratory. CRP levels weremeasured with high sensitive CRP (hs-CRP) assay based on the principle of a sol-id phase Enzyme-linked immunosorbentassay (ELISA) using goat anti Human CRPantibody (hs-CRP ELISA kit, DRG Instru-ment GmbH, Germany). The intra- and in-ter-assay coefficients of variation (CV) areboth under 5%. All CRP levels higher than200 nm/L were considered as positive val-ues.Statistical analysisDescriptive statistics such as mean andstandard deviation were used. IndependentT-test was used to analyze quantitative da-ta. Chi-square test was used for qualitativedata.Ethical issuesPatients were given information on thegoal and subject of the study; oral approvalfor their participation as a subject of studywere also gained. The participants’ infor-mation kept confidential. The protocol ofthe study gained the approval of the TehranM. Khavanin Zadeh, et al.3MJIRI, Vol. 29.219. 8 June 2015 http://mjiri.iums.ac.irUniversity of Medical Sciences Institution-al board review.ResultsIn this study, 110 ESRD patients under-went AVF creation surgery. The mean±SDage of the patients was 50.62 ±16.7 years.The case group included 55 patients whoexperienced AVF failure because of throm-bosis. The control (survived) group includ-ed 55 patients, whose AVF installationswere successful. Variables such as age,gender and CRP levels were also studied inboth groups.Thirty one cases (28.2%) were female and79 (71.8%) were male. Among all the pa-tients, 54 (49.1%) had diabetes and 60 pa-tients (54.5%) had hypertension. Of all cas-es, 38 (34.5%) were CRP positive and 72(65.5%) were CRP negative.Surgery was performed at the radius-cephalic area, including 11.5% side to sideand 88.5% end to side anastomosis. 93% ofthe AVFs were created in the left hand.None of the patients showed infection,hemorrhage or pseudo aneurysm. Site ofAVF (left or right hand) also had no differ-ence in both groups (p: 1.000).Mean±SD of age and hemoglobin level(Hb) were 49.75±17.28 and 8.7 ±1.33, re-spectively. According to the t-test analysis,Hb level and age had no statistical differ-ence between the failure and survivedgroups (p: 1.000 &0.549 respectively).Thirty nine cases (70.1%) of thefailuregroup were male and 29.1% were female.However, the gender of participantsshowed no meaningful difference in thesuccess or failure of their AVFs (p: 0.832).Diabetes and hypertension had no statisticaldifference between the failure and survivedgroups (p: 1.000 in both groups) (Table 1).Chi Square analysis showed meaningfulrelation between failure of AVF and CRPstatus of the patients (sig: 0.000) in thefailure group (55 patients).Within the 55 patients who experiencedfailure in the AVF function, 34 (61.8%)were CRP positive; Only 4 (7.3%) withpositive CRP had successful AVF creation(p<0.001) (Table 2).In the logistic regression analysis, age,sex, diabetes, Hb level, hypertension andCRP status effects on failure of AVF wereevaluated; CRP (+/-) had statistical signifi-cance (p<0.001) in this analysis (Table 3).Table 1. Comparison  of  different  variables  between  survived  and  control  groupsVariable CaseN(%)ControlN(%)pGender (male) 39/55(70.9%) 40/55(72.7%) 0.832DM positive 27/55(49.1%) 27/55(49.1%) 1.000Hypertension 30/55(54.5%) 30/55(54.5%) 1.000CRP + 34/55(61.8%) 4/55(7.3%) 0.000Table 2. Frequency  distribution of  CRP  status  in  survived  and  failure  groupFailure Category N %No (survived Group) no 51 92.7yes 4 7.3Total 55 100.0Yes (Failure Group) no 21 38.2yes 34 61.8Total 55 100.0Table 3. Results from logistic regressionVariable B SE p OR 95% CI for ORLower UpperAge -0.003 0.015 0.818 0.997 0.968 1.026Sex -0.358 0.522 0.493 0.699 0.251 1.947diabetes 0.220 0.493 0.656 1.246 0.474 3.277hb -0.163 0.184 0.377 0.850 0.592 1.219htn -0.110 0.480 0.818 0.896 0.349 2.295CRP 3.174 0.615 <0.001 23.896 7.161 79.735CRP and AV fistula failure4 MJIRI, Vol. 29.219. 8 June 2015http://mjiri.iums.ac.irDiscussionGeneral findings: In our study, the meanage of our subjects was 53.27±17.47 years,generally lower than other studies in west-ern countries (17-18).In a study in the 90s, 11% of patients hadsuffered from AVF thrombosis (19). An-other study in 2011 showed that 23% ofthrombosis was occurred in malnutritionpatients, which points to the probability oflower albumin level association with higherAVF loss in that study. There has beensome higher rates of unsuccessful AVFs insome other studies, in which they have re-ported much larger rates of other complica-tions, such as infection and psuedoaneu-rysm (7-9, 13, 20). Another study in Croa-tia demonstrated that high blood pressure,history of diabetes and HD duration is re-lated to long term AVF inefficiency (17).The difference between those results andour finding is probably due to shorter dura-tion of follow-up and smaller sample sizein our study. However, in most of previousstudies (7-9), no significant difference wasseen within age, gender and history of dia-betes groups, under the condition of earlyAVF failure.Inflammatory biomarker: In our study,patients with AVF failure showed signifi-cantly higher CRP levels. Roy-Chaudhurywas the first who found the role of inflam-mation, following an invasive proceduresuch as angiography, in AVF failure. Thestudy demonstrated the aggressive intimalhyperplasia in anastomotic vessels is asso-ciated with thrombotic closure of AVF, re-sulting in AVF failure (21).Another study showed an association be-tween fibrinolytic/ endothelial cell functionand increased inflammatory biomarkers(fibrinogen and CRP) in ESRD patients(22).There are some other studies with con-sistent results, which can work as positiveproof to our study. In a study, catheter in-sertion and AV graft creation resulted in atransient state of high CRP within firstpostoperative week, while this was not ob-served after AVF surgery (23, 24). In an-other study, significantly lower hemoglobinlevels related to AVF failure in patientswas identified as a prognostic factor (25).Furthermore, there are some studiesdemonstrating association between lowhemoglobin levels and AVF failure (26,27). Based on these evidences, it is verylikely that in ESRD patients low hemoglo-bin levels induce local low grade inflamma-tion, which can accelerate the thrombosisformation in AVF site. Thus, seems likelythat patient with anemia to be more proneto AVF thrombosis with high CRP as apredictor biomarker, than other non-anemicones.ConclusionOur study suggests that inflammatory fac-tors inducing thrombosis might be im-portant causes of early AVF failure inESRD patients. CRP level is high in failedAVF cases. Probably larger sample sizewould further clarify the role of inflamma-tory biomarkers in prognosis of AVF fail-ure.AcknowledgementsThis paper is the thesis of Dr. SamanMohammadipour’s General Surgery Spe-cialty dissertation, supervised by DR Mor-teza Khavanin Zadeh. The authors wouldalso like to thank Dr. Katayoun Sedaghat &Miss Mohadese Pishgah Roudsari.References1. Ghods AJ, Savaj S. Iranian model of paid andregulated living-unrelated kidney donation. 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Correlation between CRP and early failure of arteriovenous fistula (AVF)

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Correlation between CRP and early failure of arteriovenous fistula (AVF)

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