\r\n\tNotably, the book encourages academic scholars and researchers to contribute to the modern concepts of CSR. Fundamentally, it speaks for well-developed literature for entrepreneurs and managers, thus assisting them in the decision-making process. \r\n\tFurthermore, this book is of great value to policymakers, practitioners, and corporations, thus contributing to various disciplines (e.g., social science and management). \r\n\tThese proposed themes encourage future researchers and professionals to share their ideas, concepts and work concerning these subject domains. All these suggested topics had recommended under the rubrics of CSR. Perhaps, all the professionals, researchers, and scholars are welcome to submit their piece of work, in particular to the suggested topics. \r\n\tIndeed, the recommended topics include the following but are not limited to these only. \r\n\t• Corporate Governance and Sustainability \r\n\t• Green Innovation and CSR \r\n\t• Social Entrepreneurship \r\n\t• Green Economy and Social and Environmental Sustainability \r\n\t• Sustainable Development and Industrialization
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1. Introduction
A decade ago Sites and Marshall [1] described the empirical practice of species delimitation as “a Renaissance issue in systematic biology”. At the time there was an odd disconnect between the two frequently stated empirical goals systematic biology: the discovery of: (1) monophyletic groups (clades) and relationships within these at all hierarchical levels above species; and (2) lineages (species); compared to the actual practice of the discipline. While much of systematic biology had been devoted to the first goal, the second goal had until recently been largely ignored [2], despite the fact that species are routinely used as the basic units of analysis in biogeography, ecology, evolutionary biology, and conservation biology [3,4]. However, Sites and Marshall [1] noted “signs of a Renaissance” at the time of their review, which was precipitated in part by others emphasizing the need to distinguish between a non-operational, ontological definition of species, versus the empirical (operational) data needed to test their reality [5-7]. De Queiroz [7] (p. 60) noted that “All modern species definitions either explicitly or implicitly equate species with segments of population level evolutionary lineages.” De Queiroz also noted that this was a revised version of Simpson’s “evolutionary species concept”, which defines a species as “a lineage (an ancestral- descendent sequence of populations) evolving separately from others and with its own evolutionary role and tendencies” ([8], p. 153), and called this a General Lineage Concept (GLC) of species ([7], p. 65). De Queiroz [9] further emphasized that the multiple empirical criteria simply reflect the many contingent properties (differences in genetic or morphological features, adaptive zones or ecological niches, mate-recognition systems, reproductive compatibility, monophyly, etc.) of diverging populations associated with different evolutionary processes operating in various geographic contexts [10,11]. Sites and Marshall [1] noted that the emerging consensus among systematists and evolutionary biologists was based on the utility of this distinction (ontological definition vs. empirical species delimitation [SDL] methods), and as also noted by de Queiroz [12], due to the contingencies of speciation processes, any single criterion or data set will artificially reduce the complexity of evolving lineages.
The subject matter of these and other reviews [12,13] focused strictly on methods of detecting various lines of evidence for lineage independence (reproductive isolation, ecological distinctiveness, diagnosability, monophyly, etc.), and since then new methods continue to be described [14], as do studies comparing the performance of some of these [14,15]. In 2006, the Society of Systematic Biologists (SSB’06) organized the first symposium dedicated to the topic of species delimitation [2]; 11 papers were presented and six of those published, including an update by referenced de Queiroz [16], which emphasized the distinction between the GLC as “separately evolving metapopulation lineages, or more specifically, with segments of such lineages”, versus secondary biological attributes or properties of organisms that can be quantified to empirically test for species status. This is a crucial distinction because it clearly separates the conceptual issue of defining the species category from the methodological issues of delimiting species; previously these had been conflated with the result that properties used to infer species boundaries (the empirical test) were also sometimes regarded as necessary for defining a species (a conceptualization issue). The advantage of the unified GLC is that no specific biological attributes of a species are considered necessary properties – species may exist as segments of metapopulations lineages regardless of our ability to empirically delimit them. Prior to this clarification and the realization that many different properties are relevant to the issue of species delimitation [17], the alternative species “concepts” in which various biological attributes had accumulated in diverging lineages required these same attributes to be necessary properties of species. This led to a confusing situation in which a different property was considered necessary under each alternative concept (22 such “concepts” were identified by Mayden [6]), and a long and ultimately non-productive debate about species definitions. Now most of these earlier “concepts” can be viewed as secondary species criteria that provide evidence of lineage separation.
Recently, Hausdorf [17] argued for an up-dated ontological species concept, based in new insights into speciation processes, particularly evidence that reproductive barriers are semi-permeable to some gene flow, and that speciation may occur despite ongoing gene flow between diverging populations [18-23]. Two other lines of evidence are relevant to the point of re-visiting the GLC: (1) findings of polyphyletic species of animals, due to parallel speciation in which similar traits conferring reproductive isolation arise separately in closely related populations [24,25], or in plants, due to recurrent polyploidization in different populations of the ancestral species [26,27]; and (2) discoveries of uniparental organisms that can be characterized as distinct units resembling species of biparental organisms [28]. We cannot resolve all of these larger issues here, but we return to some of the general points raised by Hausdorf [17] in the discussion.
Empirically, species delimitation continues to be a topic of increasing interest in evolutionary biology. A reference search in the ISI Web of Science with the keyword ‘species delimitation’ retrieved 227 articles published since 2000, of which 60% were published after 2008. Less than 10 articles per year were published between 2000 and 2005; subsequently 10-20 articles per year between 2006 and 2008, and after 2008 the publication rate reached ~ 40 articles (Figure 1A). These increases include papers describing new SDL methods, or using existing methods with novel data sets and/or applications to new taxa. Because new SDL methods apply the same coalescent models developed for species tree estimation and usually lead to the discovery of morphologically ‘cryptic’ species, we also searched for references with the keywords ‘species tree’ and ‘cryptic species’. During the same period of time, papers about ‘species trees’ were few until 2007, increased between 2008 and 2010 to 5-10 articles per year, and nearly doubled to >20 papers last year (Figure 1B). Publications referring to ‘cryptic species’ show a constant increase from 20 papers/year in 2000 to 90 papers/year in 2011 with the larger annual increase between 2010 and 2011 (Figure 1C). These publication trends suggest that the recent paradigm shift in phylogenetic systematics to incorporate species trees (29) is having a positive impact on the development of new SDL methods, which are gradually being incorporated into integrative taxonomic practices for the discovery of cryptic species diversity [30].
2. Body
2.1. Short history of some early methods
Sites and Marshall [1,13] separated SDL methods into non-tree and tree-based approaches, and included among the former (1) pairwise genetic distances that could be tested for either correlations with reproductive isolation [31,32], morphological distances [33], or geographic distances [34]; (2) gene flow statistics to estimate the extent of gene flow across hybrid zones [35]; (3) fixed alternative character states as an indicator of no gene flow in a “population aggregation analysis” (PAA; [36]); (4) the presence of heterozygous genotypes as an indicator of a “field for recombination” [37]; and (5) genotypic clusters [38].
Early tree-based methods included: (1) three versions of the phylogenetic species “concept” based on apomorphy, or lineage splitting, or node-based criteria, following the terminology of Brooks and McLennan [39]; (2) cladistic haplotype aggregation [40]; (3) molecular-morphological assessments using dichotomous flow charts [41]; (4) genealogical exclusivity [42]; and (5) an extension of the nested clade analysis [43] that includes tests of species boundaries [44]. The data sets in these early studies most often included genotypes resolved from multilocus isozymes [15], morphological (usually meristic) characters, and with few exceptions [45,46], mitochondrial DNA (mtDNA) sequences. An innovative phylogenetic method described by Pons et al. [14] was based on a likelihood analysis of the mtDNA gene tree that estimates the inflection point between species-level (speciation-extinction) and population-level (coalescent) evolutionary processes, and demonstrated that groups delimited by this approach were generally concordant with geographic distributions and morphologically recognized species. This was one of a small number of early studies comparing the performance of multiple SDL methods (see also [15, 40, 45,46]).
Figure 1.
The number of papers with (A) “species delimitation”; (B) “species tree”, or (C) “cryptic species” in the title, published from 2000 – 2011.
The published contributions of SSB’06 symposium [2] included several novel SDL methods, the first method [47] described a coalescent approach to estimating species boundaries based on multiple unlinked gene trees, and that does not require species to be characterized by reciprocal monophyly. This is an explicitly model-based approach that accommodates stochastic variance of the gene sorting process by linking estimates of two key parameters, a range of estimates of effective population sizes relative to possible divergence times. This type of gene tree-coalescence approach also directly links population genetic SDL methods to phylogenetic inference at deeper levels of divergence, which has been identified as a “new paradigm” in systematics [29]. In this same issue, Shaffer and Thomson [48] introduced a population genetic SDL based on large sets of single nucleotide polymorphisms (SNPs), which would be most suited to delimiting very young species. Finally, this volume included two more novel SDL methods, both in this case using ecological and distributional data in novel ways to model “niche envelopes” that can augment molecular or morphological data in species delimitation [49-51].
2.2. Recent progress
2.2.1. New methods & new theory
New empirical SDL methods continue to be developed, based on multiple lines of evidence and multiple statistical methods. Among some of these is the approach of Bond and Stockman [52] that is especially relevant to highly geographically-structured populations in which traditional sequence-only data sets are likely to recover large numbers of well-defined, well-supported, and geographically concordant/genetically divergent-but-morphologically cryptic populations (species). These authors describe a framework for testing potential genetic and ecological exchangeability as a means of delimiting cohesion species [53], and present an example in trapdoor spiders of the Aptostichus atomarius complex. A completely different approach [54] is based on statistical tests of both population structure [48] and genealogical exclusivity [54] of nuclear loci, to test species provisionally identified from well-supported mtDNA haploclades; the focal taxa in this study were Malagasy mouse lemurs (55; genus Microcebus). As a third example, Puillandre et al. [56] described a four-step approach to “generating robust speciation hypotheses” in mollusk family Turridae (genus Gemmula) based on: (a) collection of the COI DNA barcode gene for GMYC [14] and ABGD (Automatic Barcode Gap Discovery; [57]) analyses; coupled with (b) nuclear gene (rRNA 28S), morphological, geographical and bathymetrical data, to redefine species boundaries in this clade. This protocol more than doubled the previously known species diversity in Gemmula, and may be useful for large-scale SDL in hyperdiverse groups. A few additional examples include genotype-based methods for dominant and co-dominant multi-locus markers [58], combined estimates of divergence times and gene flow to discriminate intraspecific from interspecific patterns [59], and an extension of the R package GENELAND to include genetic, phenotypic (morphometric), and geographic data for delimitation of populations and species [60].
The recent merge of coalescent theory with phylogenetics has driven a new generation of SDL methods and a new paradigm in systematics [29]. This new theoretical framework, and its derived analytical applications, was in part required as a solution for accommodating the observed conflict among genealogies from multiple loci (gene trees) with the underlying population-level genealogies (species trees) [61]. A multi-species or ‘censored’ model was formulated to account for this discordance by considering each branch of the species tree as a separate coalescent model and by connecting them into a population-level genealogy following the topology of the species tree [62,63]. Under this new approach, two major key innovations over the classic phylogenetic methods were achieved. First, multiple individual samples can be assigned to a single species and the estimated phylogeny represents the speciation history of ancestral and descendant species-level lineages, in contrast to the gene genealogies estimated with individual samples. Second, because the coalescent process of each gene tree is dependent upon parameters of its containing species tree, this approach can co-estimate gene and species tree simultaneously, by-passing the task of calculating a consensus tree or estimating a phylogeny from a concatenated dataset. This new theoretical framework allows prediction of the probability distribution of gene trees given the species tree, and consequently, several methods were developed for estimating species trees from a collection of multiple gene trees under different algorithms [64,65]. Based on these new methods, a generation of fully-coalescent SDL methods was introduced that consisted of selecting the best species-tree model from a set of alternative models that represent different hypotheses of species limits. For instance, one approach finds the maximum-likelihood for the full species tree (all species are hypothesized as separate lineages) and for alternative species trees (two or more species at a given node are collapsed into one), and then selects the best model using Akaike information criteria, assuming fixed gene trees and constant population sizes along the species tree (SpeDeSTEM; [66]).
Another SDL method consists of sampling from the Bayesian posterior distribution of species delimitation models using reversible-jump Markov chain Monte Carlo (rjMCMC) with the program BP&P 2.1 [67]. This approach accomodates gene tree uncertainty and variable population sizes, but a “known” species tree must be provided a priori. In addition, heuristic and/or semi-parametric approaches have been developed for: resolving the boundary between coalescent and speciation processes using single gene trees (generalized mixed Yule-coalescent, [14]), finding both the optimum species tree and species limits via minimization of gene tree conflict and intraspecific structure (Brownie; [68]), and selection of SDL models using approximate Bayesian computation (ABC) [69]. Other tree-based [54] and non-tree-based [58] SDL methods that can handle multiple loci with limited variation have been applied with success. In addition, there has been also a resurgence of morphology-based SDL using multivariate techniques in a hypothesis-driven statistical framework [60,70].
2.2.2. New kinds of data
The development of new multi-species/multi-locus SDL methods was also in part due to the demand of efficient analytical tools to handle the rapidly increasing amounts of molecular data collected with modern techniques. New SDL methods should be able to handle tens of loci for multiple individuals derived from the development and screening of anonymous nuclear loci (ANL), introns, and protein-coding loci using genomic resources [71-73]. However, these new SDL methods are inadequate to analyze the influx of whole-genome data that have started to be collected for non-model organisms via next-generation sequencing (NGS) technologies ([74-76]; e.g, genome of the lizard Anolis carolinensis; [77]). NGS technologies have been recently applied to development of thousands of gene regions spanning multiple divergence times [78], or loci targeted for “shallow-scale” phylogenetic/phylogeographic studies [79], and microsatellites [80] or SNPs [81] for extremely shallow phylogeographic histories [82]. The microsatellite or SNP data should be useful for genotyping individuals for SDL studies of very young species [48].
More efficient and less costly whole-genome sequencing is becoming available on a regular basis, a trend that started with the first-generation technology (Sanger capillary-sequencing), followed by the second-generation (i.e., SOLiD 454, Illumina, Solexa, etc; [83]), and continuing today with the recently introduced third-generation ‘nanopore’ sequencing [84,85]. A significant by-product of these single-molecule sequencing methods is their ability to automatically resolve the allelic phases of heterozygotes, in contrast to the time-consuming phase estimation and/or cloning required after direct dideoxy-sequencing [86]. In addition, the uniform sampling of hundreds of loci across the genome can help identifying “outlier” loci via genome scans, which can represent candidate genes with fitness value, subject to selection and linked to processes such as ecological speciation [87].
2.2.3. Advantages of Multi-Species Coalescent-Based Methods (MSCM)
Model-based.–Because these SDL are based in the multi-species coalescent model, the likelihood of the data can be evaluated to find maximum-likelihood and posterior probability estimates of parameters and testing alternative SDL models under different criteria (e.g., likelihood-ratio test, Akaike information criterion, Bayes factors [46,88]). More importantly, these methods implement SDL in a hypothesis-testing framework, and taking into account uncertainty due to genetic processes and insufficient sampling [89,90]. In addition, coalescent simulations generated under a null hypothesis of no-speciation and the alternative hypothesis of speciation can be used for evaluating the performance of these methods based on estimations of inferential errors (type I and II errors, see [91]). For example, the accuracy of three coalescent-based SDL (SpeDeSTEM, BP&P, and ABC) has been compared using simulations under a model of speciation for variable sampling densities and parameter values to estimate type II error (i.e., failing to reject no-speciation when it is false) across a range of conditions [66,69,92]. When there is no migration, SpeDeSTEM can delimit species that have diverged as recently as 0.5Ne generations ago using only 5 loci and 5 alleles per species [66] while BP&P could detect speciation at shorter divergence times (0.4Ne generations ago) with the same sampling design [67,92]. In agreement with these results, a comparison under identical simulation conditions showed that BPP outperformed SpeDeSTEM (and also ABC) when speciation takes place with or without gene flow [69]. In spite of these simulations covering different speciation scenarios, sampling designs, and SDLs, the practical question of the appropriate balance between number of loci and number of alleles sequenced has not been explicitly explored until now. Below, in the last section of this chapter, we performed some simulations for a preliminary evaluation of the relative benefits of sampling more alleles vs. loci for accurate species delimitation.
Neutral loci.–These markers should be insensitive to ‘phenotypic plasticity’, the phenotypic response to environmental variation that is not genetically-based (in contrast to adaptive variation), which could bias morphological-based taxonomy. Environmental variation in different parts of the range can lead to a plastic phenotypic response, which can be revealed and distinguished from local adaptation via reciprocal transplant or ‘common garden’ experiments [93]. In these cases, morphological variation as a result of this plastic response could be used as a criterion to delimit species, while neutral markers would indicate that there is no genetic differentiation [94,95]. In contrast, in cases of morphologically-cryptic species due to for example to niche conservatism [96], genetic divergence and lineage sorting is expected to occur in neutral markers due to independent evolution in isolation, and those markers with higher mutation rates and smaller effective population size (e.g. mtDNA) should be ideal for species delimitation [97,98]. Moreover, it has been suggested that neutral loci will also differ in their usefulness for species delimitation since those with higher rates of intra-specific gene flow will be less sensitive to the effect of inter-specific introgression [99]. However, the mitochondrial locus does not always meet assumptions of neutrality [100], and it frequently introgresses across species boundaries [101], so in our view it should be used to identify “candidate species” [102], which can then be verified with independent lines of evidence [103].
Repeatability.–The results of a SDL analysis can be replicated exactly when using the same data and the same analytical methods, which eliminates much of the subjectivity and/or investigator bias for/against certain kinds of data (morphology vs. molecular, etc.). Because these methods rely on explicit predictions about genealogical patterns under alternative models of lineage divergence, it is possible to carry out species delimitation in a more objective and bias-free fashion compared to diagnosability-based SDL methods [90]. In addition, because inferences are dependent upon a specific sampling design and the method used, one can make explicit statements about how robust a given species delimitation method is to variation in these parameters, and to violations of the method’s assumptions.
Universality.–The same SDL method and the same kind of data (i.e, DNA sequences or gene trees from homologous regions of the genome) can be used for SDL across different taxa, making these approaches comparable across all parts of the Tree of Life, as long as the assumptions of the method are reasonable for the taxon under study (see below). Another advantage associated with the use of neutral markers in coalescent-based SDLs is related to the standard criterion used for assigning species status across a variety of taxa when using the same markers and analyses [90], assuming that these markers offer similar resolving power. This is a desirable property for a SDL method since a uniform criterion implies that the species level could be compared readily among different higher-level taxa, thereby allowing meaningful analyses of species diversity among communities typical of ecological studies [91].
2.2.4. Disadvantages of MSCM
Many of the advantages listed above also impose some limitations of MSCM and other SDL methods for different reasons. First, these are model-based methods, and any violations of assumptions of the standard coalescent are expected to introduce inference errors. For instance, and most relevant to the SDL problem, while the standard coalescent assumes panmixis within populations, it is clear that in most natural populations, there is almost always some degree of population structure (i.e, demes connected by limited gene flow). In fact, a recent study using the Brownie’s SDL method found that more dense sampling increased the chances of detecting population structure, supporting more species boundaries, and consequently, inflating estimates of the number of species [104]. Thus, MSCM could be more prone to split a single real species into multiple lineages due to intra-specific population structure alone, increasing type I error (i.e., rejecting a true hypothesis of a single species), and leading to ‘taxonomic inflation’ [91]. Fortunately, some flexible MSCM methods allow incorporating population structure within species via coalescent simulation of island, stepping-stone, and other potential models, and subsequent comparison of SDL hypotheses with ABC approaches [69].
Another frequent assumption of most MSCM is that species have diverged from a common ancestral species without gene flow even though speciation with gene flow seems to be rather common in nature, especially in cases of ecological speciation [22,95,105]. While these methods ignore the effects of gene flow, simulation testing has shown that some of them are relatively robust to low levels of gene flow [66,92], and that its impact on delimitation accuracy is ameliorated when gene flow is explicitly incorporated in the speciation model [69]. This result supports the suggestion that, in order to distinguish between species- and population-level differentiation, it is necessary to jointly consider the two components of the divergence process: time since splitting and gene flow after divergence [59].
Second, sampling effort is well known to strongly impact coalescent-based and other SDL methods. A number of studies evaluating the accuracy of several MSCM methods suggest that limited sampling of loci and sequences will decrease the probability of detecting speciation when this hypothesis is correct [66,69,92] and consequently, increasing type II error [91]. In addition, these simulation results also support the intuitive idea that the problem of insufficient sampling becomes more serious when SDL is more difficult: shorter divergence times, larger population size, and increasing inter-specific gene flow. However, more simulations are necessary to evaluate the appropriate balance between sampling intensity and design (e.g., geographic vs. genealogical dimensions, [91]) for different parameter configurations, in a power analysis context to provide further guidance to empirical studies [106]. In addition to limited geographic sampling, the collected sequence data also impose a limit to the amount of genetic data available for analysis. In the next section, we explore how accuracy in species delimitation responds to variable sampling of loci and alleles for a fixed sequencing effort.
Third, coalescent-based SDL approaches assume selective neutrality of gene regions used, but divergent selection on ecological traits, across habitats or along an environmental gradient, can lead to local adaptation and correlated reproductive isolation in a process of ecological speciation [95,107]. Phenotypic divergence can be so fast that mutation rates could produce little or no differentiation at all in neutral markers used in SDL approaches. Only those “outlier loci” under selection revealed by genomic scans, which are potentially associated with the selected traits, would be appropriate markers under these scenarios [87].
Fourth, as in other methods data conflict may be evident when multiple data sets are used. These SDL methods are not expected to resolve the discordance among different kinds of data sets (i.e., morphological, behavioral, ecological, molecular, etc.) since they typically use sequence data or gene trees from presumably neutral loci. However, Bayesian approaches have the potential of incorporating previous information about species limits derived from non-molecular data into prior distributions of genetic-based analyses [67].
Fifth, there may be conflicts with traditional taxonomic practices. The discovery of new cryptic species with coalescent-based SDL in a statistical framework, is still insufficient for formal taxonomic descriptions, since nomenclatural rules still require traditional morphology-based diagnoses [108,109]. While these methods will help diagnosing new cryptic diversity, many taxonomists will be reluctant to formally describe new species based on molecular-data alone, which ultimately will further expand the ‘taxonomy-phylogeny’ gap [91]. While the description of cryptic species is complicated by the lack of morphological diagnostic characters, another difficulty relies in the inability of MSCM to assign newly collected specimens to species (i.e., taxonomic determination) unless new analyses are carried out to re-evaluate species limits.
3. Future directions
Statistical testing of SDL.–The ongoing surge in the new generation of SDL methods will probably encourage many taxonomists to apply these methods empirically, especially for recently evolved, cryptic taxa that cannot be delimited with other data. The ability to frame species limits as statistical hypotheses that can be tested objectively with multi-locus and multi-species analyses make these new SDL methods very appealing for empirical systematists in the context of an ‘integrative taxonomy’ [4,110,111]. In addition to empirical application to real data sets, we also expect that more simulation studies will be carried out to compare the performance of different data sets, under different methods/assumptions, and for variable sampling designs, using statistical power analyses. Previous studies have compared methods for a limited set of parameter conditions (e.g., usually population size has been assumed to remain constant) and have examined the effect of increased sampling effort for loci or sequences separately. However, performance of these SDL methods has not been evaluated for a variable sampling design and a fixed sampling effort; in other words, what should be the optimal balance between number of loci and number of sequences when the total number of sequenced base pairs (bp) is the same?
In order to provide a preliminary evaluation of the impact of sampling design on performance of new SDM, we simulated coalescent genealogies with the program ms [112] and sequence data with the program Seq-Gen [113] for a speciation model between species A and B for three increasing divergence times: 0.25, 0.5, and 1Ne (Figure 2A). We assumed a constant θ per site = 0.01, 500 bp per locus, and ~50 variable sites per locus. For each divergence time, we simulated 5 combinations of number of loci (1, 2, 4, 10, and 20) and number of sequences per species (1, 2, 5, 10, and 20) while keeping the total sequencing effort constant (20 sequences per species). We simulated 100 replicates for each sampling treatment which were analyzed with BP&P to calculate the mean speciation probability between species A and B across replicates, which represents the accuracy of the method (i.e., the probability of detecting speciation when it is the true hypothesis). We also simulated a no-speciation model where sequences from species A and B were collapsed into a single lineage, and repeated the same sampling and analytical procedure to examine the performance of the method based on a plot of true positive and false positives rates (i.e., ROC plot; [114]).
The results show that under the conditions examined, more sequences per species is better than more loci at least in the range of 1-20 loci and sequences per species (Figure 2B). The ROC plots for the 5 sampling treatments at a divergence time of 0.5Ne show that performance is higher (i.e., area under ROC curve is larger) when sampling 20 sequences for 1 locus or 10 sequences for 2 loci, but performance gradually decreased with more loci and fewer sequences (Figure 2C). These results are congruent with the impact of sampling design on the accuracy of species-tree methods (STM) at shallow divergence times [115,116], which is an expected outcome because both STM and SDL methods share the same basic multispecies coalescent model [67,117]. However, our results are contingent upon the conditions simulated, in particular the assumptions of panmixia within species, and a constant θ across the species tree. This second assumption is a critical parameter of coalescent models, which can be estimated more accurately with a larger sample of loci [118]. Our attempt with this simulation example was to show how we can evaluate the performance of a SDL method under a variety of sampling conditions based on a power analysis, and that this same approach can be applied for comparisons across different SDL methods and more complex speciation scenarios than those that have been examined so far.
Population and species delimitation.–The application of coalescent-based SDM, which can delimit species at very shallow levels of divergence [66,69,92] should reduce the ‘taxonomy-phylogeny’ gap and help decrease the type I error of biological-species criteria that often fail to detect species, when reproductive isolation is not yet complete [91]. Thus, coalescent-based SDL methods will probably help to delimit entities, name taxonomic units, and give appropriate conservation priority to the increasing amounts of cryptic diversity being discovered in nature [91]. On the other hand, MLCM should be used with caution to avoid confusing species-level divergence with intra-specific population structure and therefore, over-splitting lineages, with serious consequences for conservation science since limited resources would be potentially wasted due to bad taxonomy [91].
A potential protocol for an informed species delimitation approach that takes into account population structure, could consist of first applying a clustering/population aggregation method to identify the smaller clusters of individuals under a population genetics criterion based on genotype or allele frequency data (\'e.g., Structure 48, 58, 60). Subsequently, a SDL method can be applied to test if these clusters also represent independent evolutionary lineages based on the pattern of allele coalescence in gene genealogies (e.g. BP&P). Because initial population divergence starts with differentiation in allele frequencies and secondly, with random lineage sorting and mutation that further differentiates lineages during speciation [59], population genetics approaches are expected to detect lineages earlier than SDL approaches. For example, an empirical analysis of West African forest geckos (Hemidactylus fasciatus) found ~10 populations with Structure, which were considered as ‘candidate’ species in a subsequent BPP analysis that collapsed them into 4 species [119]. This two-stage approach would provide a consistent and standard criterion for distinguishing between population- and species-level divergence, a threshold that has been difficult to resolve with genetic parameters measuring amounts of evolutionary differentiation [59].
Figure 2.
Simulation-based testing of the accuracy of BP&P to detect speciation between species A and B using five alternative sampling designs with the same sequencing effort and at three increasing divergence times (0.25, 0.5, and 1Ne) (A). Plot of accuracy and divergence time for each sampling design (B).ROC plot for each sampling design when divergence time = 0.5Ne (C).
The next generation of SDL methods.–We have emphasized that species delimitation should take into account the speciation processes that have shaped the patterns of trait divergence in genetic, morphological, and ecological data [89]. In a process-oriented classification of modes of speciation, we can distinguish between ‘passive’ modes driven by random divergence associated with the classic allopatric models, and the ‘adaptive’ modes of speciation. The formulation of a null hypothesis of speciation due to stochastic forces (i.e., ‘passive divergence’ or ‘drift-only’ model) should facilitate testing this mode of speciation, because rejecting this hypothesis is probably easier than demonstrating ‘adaptive’ speciation due to deterministic processes [120]. In nature, both speciation models appear to interact and work in concert during diversification of closely related lineages [121,122]. Adaptive speciation in turn can be subdivided into ‘ecological’ speciation, reproductive isolation due to disruptive natural selection operating on ecological traits [95], and speciation due to sexual selection that results in divergent mating preferences and assortative mating [123]. In theory, both kinds of selection seem to be necessary to drive speciation to completion [124], and limited empirical data supports the role of this interaction during diversification [125]. Due to this variety in speciation processes, we should expect different patterns of trait divergence, and consequently, different kinds of data would be more appropriate for species delimitation under each speciation scenario. Therefore, relying on any single kind of trait could potentially miss the detection of a speciation event, for example using exclusively morphological data will fail to recognize cryptic species. Similarly, if we use only the typical neutral genetic markers of phylogeography and population genetics, we could miss many instances of ecological speciation that takes place in contemporary time scales [126], and/or without divergence in neutral loci [127].
4. Conclusion
There is an ongoing genomics revolution for the study of adaptation in ecological and evolutionary non-model organisms derived from (NGS) technologies [76,128]. Decreasing sequencing costs and new protocols for discovering and screening thousands of markers scattered throughout the genome [79], is now allowing application of population genomics approaches to identifying the candidate loci underlying adaptive traits with ecological significance [87]. In fact, recent studies have found genomic regions and/or specific loci related to repeated local adaptation, population divergence, and reproductive isolation between ecotypes in different habitats or hosts [129,130]. We anticipate that these ‘speciation genomics’ approaches will become more common in non-model organisms and will provide a basis for species delimitation in scenarios of adaptive speciation SDL methods, complementing current SDL methods. Moreover, this plurality of criteria for species delimitation based on multiple kinds of traits is consistent with the GLC of species that views these organismal traits as evolving in different temporal order depending on how speciation has actually taken place [9,12]. In addition, it is also compatible with the more recent ‘differential fitness’ concept, which is based on those organismal features of one species that have negative fitness effects in other species and cannot be exchanged upon contact [17].
Acknowledgments
AC acknowledges a postdoctoral fellowship from CONICET (Argentina). For financial support we thank thank NSF awards OISE 0530267 and AToL 0334966 to JWS, as well as BYU graduate research and graduate mentoring awards, and student research awards from the Society of Systematic Biologists and the Society for the Study of Amphibians and Reptiles, to AC. We both also received support from the BYU Dept. of Biology and the Bean Life Science Museum.
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Sites, Jr.",slug:"jack-w.-sites-jr.",email:"jack_sites@byu.edu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Body",level:"1"},{id:"sec_2_2",title:"2.1. Short history of some early methods",level:"2"},{id:"sec_3_2",title:"2.2. Recent progress",level:"2"},{id:"sec_3_3",title:"2.2.1. New methods & new theory",level:"3"},{id:"sec_4_3",title:"2.2.2. New kinds of data",level:"3"},{id:"sec_5_3",title:"2.2.3. Advantages of Multi-Species Coalescent-Based Methods (MSCM)",level:"3"},{id:"sec_6_3",title:"2.2.4. Disadvantages of MSCM",level:"3"},{id:"sec_9",title:"3. Future directions",level:"1"},{id:"sec_10",title:"4. Conclusion",level:"1"},{id:"sec_11",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Sites JW, Jr., Marshall JC. Delimiting species: a Renaissance issue in systematic biology. 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Evolution, 2012;doi: 66:2723-2738'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Arley Camargo",address:null,affiliation:'
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Montag, Tiago Magalhães da S. Freitas, Ana Cristina Mendes-Oliveira and Ronaldo B. Barthem",authors:[{id:"50134",title:"Dr.",name:"Luciano",middleName:"Fogaça De Assis",surname:"Montag",fullName:"Luciano Montag",slug:"luciano-montag"},{id:"61751",title:"MSc.",name:"Tiago",middleName:null,surname:"Freitas",fullName:"Tiago Freitas",slug:"tiago-freitas"},{id:"61752",title:"Dr.",name:"Ronaldo",middleName:null,surname:"Barthem",fullName:"Ronaldo Barthem",slug:"ronaldo-barthem"},{id:"94793",title:"Dr.",name:"Ana Cristina",middleName:null,surname:"Mendes De Oliveira",fullName:"Ana Cristina Mendes De Oliveira",slug:"ana-cristina-mendes-de-oliveira"}]},{id:"21538",title:"Biodiversity Conservation Planning in Rural Landscapes in Japan: Integration of Ecological and Visual Perspectives",slug:"biodiversity-conservation-planning-in-rural-landscapes-in-japan-integration-of-ecological-and-visual",signatures:"Yoji Natori, Janet Silbernagel and Michael S. 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1. Background
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VA is an essential component of the life-sustaining therapy in end stage kidney disease patients relying on a sustained extracorporeal circulation for haemodialysis (HD) or haemodiafiltration (HDF) [1, 2]. Indeed, VA is often referred to as the lifeline or Achilles heel for a dialysis-dependent patient [3]. VA performance is a key factor to drive success or failure in all forms of extracorporeal renal replacement treatment [4]. Furthermore, VA dysfunction or complication is the major cause of morbidity requiring interventional procedures (angioplasty and revision) or hospitalisation [4, 5, 6]. Furthermore, VA morbidity represents a tremendous burden both for patient and health care system [7, 8]. VA management in chronic kidney disease patient is of tremendous importance in quality care of dialysis patients, since it represents a daily duty for care givers in the nephrology area to ensure success of renal replacement therapy, to improve patient outcome and to reduce burden of VA morbidity [1, 9].
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2. Overview on VA management in dialysis patients
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2.1. VA types
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VA for HD belongs to three main categories: (1) arteriovenous fistula (AVF) made of native or autologous vessel (aAVF) or heterologous vessel (hAVF) [10]; (2) arteriovenous graft (AVG) made of synthetic polymer or bioprosthesis; and (3) venous–venous access consisting mainly in tunnelled central venous catheter (tCVC) inserted preferably in the superior vena cava system [11]. A schematic representation of various VA types is in Figures 1 and 2. aAVF is still the preferred VA strongly recommended by best practice guidelines due to its long-term patency superiority, higher performances and fewer complications in majority of patients [11, 12, 13].
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Figure 1.
Autologous AV fistula.
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Figure 2.
Heterologous AV graft.
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Several autologous AVF types have been developed to fit with patient anatomic and physiologic characteristics. Briefly, according to their location on the upper arms, they are categorised either as distal (wrist) or proximal (elbow or upper arm); according to the type of anastomosis, they are categorised as side to side anastomosis or artery side to vein end anastomosis [14, 15] or vein transposition [16].
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If the end-stage kidney disease (ESKD) patient is not a suitable candidate for an AVF, the AVG is the second VA option. Compared to the AVF, the AVG has better mechanical strength, earlier use, decreased primary failure rates, development of graft stenosis, a fivefold increase in infection risk, a poorer long-term patency, higher levels of complications and more interventions than AVF [17]. AVG should be preferred over a CVC because of fewer complications and better survival rates [18]. AVG access is made usually of synthetic material (e.g., PTFE) or biomaterial and realise a conduit between artery and vein [17]. Recently, a new biologic human acellular vessel, as a potential solution to AVG disadvantages, has been evaluated with promising evidence [19]. Human acellular vessels were implanted into 60 patients. The vessels had no dilatation and rarely had post-cannulation bleeding. At 12 months, 28% had primary patency, 38% had primary assisted patency and 89% had secondary patency [19]. AVG may be constructed either on the forearm as straight conduit (radial artery to cephalic vein), or as looped conduit (brachial artery to cephalic vein), or on the upper arm as straight conduit (brachial artery to axillary vein) or looped conduit (axillary artery to axillary vein). Less commonly AVG looped is created on the lower extremity (femoral artery to axillary vein) or as transthoracic conduit (axillary artery to contralateral axillary vein).
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Although AVF is the preferred vascular access, double-lumen non-tunnelled catheter is the VA of choice when urgent or emergency HD is requested or when AVF/AVG becomes dysfunctional. Tunnelled dialysis catheters can be safely used as vascular access till the maturation of fistula and may be an alternative to arteriovenous fistula or graft for long-term VA if indicated. tCVC can be considered as permanent VA vein, in patients with recurrent access thrombosis, low blood pressure (cardiomyopathy), severe vascular disease (“steal” syndrome), trypanophobia (fear of needles), in case of premature exhaustion of veins needed for AVF creation and reduced life expectancy. Catheters are available in a variety of materials, configurations and tip designs, with the aim to maximise the blood flow, reducing recirculation preventing the catheter tip obstruction. There are well-established guidelines for selection of an insertion site for CVCs. The preferred site is the right internal jugular vein. In case, for different reasons, it is not possible to utilise the above vascular approach, and the second option is the left internal jugular vein. Other options are the subclavian veins keeping in mind the higher risk of subsequent stenosis or venous occlusion. The femoral vein for long-term CVC access should be avoided in patients waiting for kidney transplantation due the iliac vein risk stenosis.
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2.2. VA prevalence
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Interestingly, percentage of various VA types varies tremendously among HD population worldwide. Several factors contribute to heterogeneity of VA prevalent use and distribution that include dialysis vintage (incident vs. prevalent), age (young vs. old), gender (male vs. female), ethnicity, comorbidities (high vs. low risk), dialysis modality (HD vs. HDF) or dialysis setting (in centre vs. home or self-care).
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Furthermore, it is of utmost importance noting that practice patterns have likely a strong impact on VA choice and prevalent use [20]. In other words, VA choice is not only driven by patient conditions or treatment modalities but also depends strongly on local or regional practice patterns including referral time to nephrologist, CKD patient management, care access, VA expertise and commitment, also patient choice. As an example, prevalence of AVFs in incident patients (<6 months) may vary from 20 to 80% from one country to another considering comparable patient profile, while the use of CVCs may vary from less than 5–80% in the same condition [20, 21]. Comparing VA repartition in prevalent patients, the same heterogeneous distribution holds true, with prevalence of 30% to over 90% of AVFs from one country to another with comparable patient profile [22, 23].
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2.3. VA strategy planning
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VA creation strategy planning is important to ensure best outcome to dialysis patients. It is now well established that careful clinical assessment and non-invasive vascular network mapping (US Doppler) facilitate VA construction and increase success rate [24, 25, 26]. Best practices emphasise and recommend such an approach to reduce failure rate and optimise VA creation, maturation and management [11, 12].
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Early referral of advanced chronic kidney disease patient to nephrologist and to expert vascular surgeon may facilitate decision for VA choice and creation [27]. VA nurse coordinator has been shown to facilitate management of ESKD patients, to reduce CVCs use and to improve VA outcome in incident patients [28, 29, 30].
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Few general rules for VA creation are recommended from best clinical practice guidelines: first, start with native AVF distal position at the non-dominant wrist and move proximally to the elbow in case of failure, second, favour artery side to vein-end anastomosis with reduced and fixed anastomosis diameter, third, consider using synthetic graft conduct in case of multiple failed attempts and fourth, tCVC might be a suitable option, in case of repeated VA attempt failures, in elderly patients, in patients with limited life time expectancy or as mid or long-term bridging solution to facilitate creation and maturation of AVF or AVG [12].
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VA construction should be ideally performed within expert centres adequately staffed, imaging capacities and providing full clinical service to correct immediate or short-term VA dysfunction [31, 32].
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2.4. VA performance and outcome
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VA performance is crucial to ensure delivery of adequate renal replacement therapy. It relies on four main indicators: access flow, recirculation, pressure changes, and dialysis dose delivery. VA performance is more critical with short dialysis than in long or more frequent dialysis treatment schemes.
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VA flow is the main parameter that drives dialysis session efficiency [4, 33]. Ideally, access flow with AVF or AVG should be higher than 500–600 ml/min to ensure extracorporeal blood flow of 350–400 ml/min. Choice of dual lumen tCVC should aim to achieve 350–400 ml/min blood flow on a regular basis [34].
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In case of dialysis efficiency reduction due to VA dysfunction, that will be expressed by a Kt/V decline trend over time [35] (better if evaluated with online automated system and in continuous mode [36, 37]) and an increasing of serum potassium, phosphate, urea and creatinine levels. Dynamic pressure changes in vascular access either from venous or arterial side are reflecting VA dysfunction and suggesting a stenosis either on the distal vein or the proximal artery and impeding access flow reduction [38]. VA recirculation is usually very low and less than 1% with well-functioning AVF and AVG [39]. High recirculation (>10%) reflects VA dysfunction (e.g., stenosis of distal vein or proximal artery) and requires further investigation and intervention on VA if needed. It is important noting that tCVCs have by design and functional characteristics, higher recirculation than AVF or AVG. A well-functioning CVC has a recirculation closed to 10%, and higher recirculation is a strong signal of CVC dysfunction [34]. Recirculation is usually measured by dilution methods that sense either changes in US velocity (Transonic) [33], electrical impedance, optical (CritLine), ionic dialysance change [40] or thermal changes (BTM) [41] with relative good concordance [42]. Fresenius Medical Care (FMC), Europe Middle East Africa (EMEA) and NephroCare (NC) clinics commonly apply the thermodilution measurements [43]. The thermodilution method makes it possible to determine the total blood recirculation with a non-invasive temperature bolus technique, and thus detect vascular problems that could reduce the efficacy of dialysis. This method can be used to assess both grafts/fistula and cardiopulmonary recirculation. In case the VA recirculation is confirmed the colour, Doppler US can provide an accurate anatomical and haemodynamic information, also measuring the access flow. This examination can be performed as part of a routine surveillance program, to detect early VA problems, or suspected dysfunction. However, limitations for its use are lack of staff and/or knowledge in the HD unit. Imaging techniques as the angiography and magnetic resonance flow measurements can allow a better definition of blood flow and stenosis visualising inside the vessel lumens.
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In brief, reduced access flow, increased recirculation, low Kt/V and significant pressure changes are all indicating VA dysfunction that needs to be confirmed, explored and treated adequately [44].
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A dedicated quality assurance program to VA monitoring and management is strongly recommended in dialysis facilities, as part of best clinical practices, to improve dialysis patient outcome [45] (see Section 4). VA outcome is usually best summarised by three hard clinical endpoints: functionality (e.g., maturation and access flow), technical survival (e.g. primary patency and secondary patency) and VA-related morbidity (e.g., dysfunction, infection and intervention) [46]. In brief, VA outcome depends on three groups of factors: first, patient medical profile (e.g., age, gender, comorbidity, diabetes and vascular calcification); second, VA type (e.g., autologous AVF and synthetic graft); third, practice patterns (e.g., creation skills, monitoring and maintenance) [47]. It is not our intent to review factors implicated in these outcomes but only to provide some brief trends and facts. Autologous AVFs have better survival than synthetic AVGs considering both primary and secondary-assisted patency [48, 49, 50]. Median technical survival with AVFs ranges between 3 and 10 years compared to AVGs which range between 1 and 4 years. Substantial loss of AVFs (10–30%) occurs shortly after creation due to thrombosis or poor maturation. Late stenosis or aneurysm may be observed with AVFs in long-term run depending on cannulation technique. Loss of AVGs occurs later due to stenosis in relation with myointimal hyperplasia in almost 90% of cases. Patency of AVGs requires tight monitoring and frequent restoring and maintaining procedural interventions (e.g., percutaneous angioplasty and stenting) [51]. Infection risk is about three times higher with AVGs. Intervention rate (e.g., angioplasty) to keep VA patency is 3–10 times higher with AVGs than AVFs in long run.
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2.5. Complications in established VA
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VA-related morbidity represents a tremendous burden for patient (pain, anxiety and depression) and healthcare system (hospitalisation, technical procedures and interventions and cost). VA-related problems represent a common cause of hospitalisation in dialysis patients accounting for 10–15% of cases [5].
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VA complications vary according to VA type [52]. Arteriovenous accesses (AVF and AVG) are associated with less complications and risks as compared to tCVC [53]. AVF is still the “standard” for VA presenting significant less complications and longer survival patency than AVG [54].
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Most common complications of recently created AVFs and AVGs are inadequate flow, failure to mature and thrombosis [55]. This aspect is further developed in the next section.
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VA dysfunction in mature access requires further exploration and imaging (e.g., Doppler US, contrast media phlebography or arteriography and digital VA imaging) to identify the cause of poor flow or insufficient development. Based on the root cause analysis of the VA dysfunction, specific interventional procedures may be proposed. Usually they consist in percutaneous angioplasty with or without stenting. In the worst cases, surgical VA revision or new VA creation might be preferred.
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Thrombosis occurs rarely as an unexpected event but usually follows and/or complicates an underlying stenosis of the distal or proximal vein or proximal artery [56]. This well-established fact reinforces the need for regular VA monitoring to correct pre-emptively this causal factor. Treatment of thrombosis requires urgent action by VA interventional expert consisting usually in a combination of thrombolytics and thrombectomy techniques [57, 58, 59]. After successful declotting, it is important to treat underlying stenosis by percutaneous balloon angioplasty to prevent thrombosis recurrence [60].
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Aneurysms or more frequently false aneurysms may have developed on the vein segment of the VA either with AVFs or AVGs [61]. They result from repeated cannulation in the same area and high venous pressure. False aneurysms should be resected since they are exposed to further complications (e.g., infection and bleeding), and cause of high venous pressure (e.g., stenosis) should also be treated by balloon angioplasty.
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Steal syndrome is a rare but painful and severe condition that needs to be treated adequately [62]. Steal syndrome results from retrograde blood flow after AV access creation, and a condition that diverts blood flow to proximal segment creates functional ischaemia in distal arm segment. It is more likely to be observed in severely arteriopathic and vascular calcified patients. Severity of steal syndrome is graded from minor (pale, blue and cold hand) to major (ischaemic pain, ulceration and necrosis of digits or hand). Treatment of steal syndrome consists usually in venous banding (high flow steal syndrome) or distal revascularisation and interval ligation (DRIL procedure) (normal flow steal syndrome). In worst cases, closing AVF or AVG would be considered as a safer option.
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Infection of VA is not common in AVFs but more common in AVGs (2–3 times) and much more common (5–7 times) with tCVCs [63]. Infection results from specific risk of VA and chronic dialysis patient profile, but more likely from VA handling practices and hygienic rules of the dialysis facility [64].
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Complications are associated with CVC placement (puncture of the associated artery, bleeding, major venous laceration, atrial perforation, pneumothorax and air embolism) and use (malfunction and limitation of dialysis performances, central vein stenosis or thrombosis and catheter infection) [65, 66, 67]. For patients who are treated with HD, the risks of major cardiovascular events, fatal and non-fatal infections and overall mortality are far greater with catheters than with AVF.
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The NKF/DOQI guidelines define CVC dysfunction as the failure to attain a sufficient extracorporeal blood flow rate of ≥300 ml/min with a pre-pump arterial pressure lower than −250 mmHg [68]. Catheter dysfunction can lead to catheter thrombosis in the extreme. Early CVC dysfunction is defined as a catheter that never functioned adequately after placement and is mainly consequent to technical problems. Later, CVC dysfunction is related to partial or total catheter occlusions induced by intrinsic thrombus within the CVC, external fibrin sheath or extrinsic thrombus around the catheter in the vein leading to catheter adherence to the vessel wall or to the cardiac atrium. The majority of thrombi associated with CVC are asymptomatic. If the dialysis staff notices a decreasing Kt/V, an increasing level of serum potassium, phosphate, urea and creatinine and an increase of both negative arterial pressure and positive venous pressure during consecutive dialysis sessions, a CVC dysfunction could be suspected. If thrombosis involves the catheter tip, it may not be possible to withdraw blood and/or to infuse fluids and there may be leaking at the access site. In general, symptoms vary from local tenderness or pain at the site of entry to obstructive symptoms with swelling of the ipsilateral extremity, neck or face. Atrial thrombi may become symptomatic, with pulmonary or systemic (paradoxical) embolism or catheter dysfunction, or may be incidentally found as an atrial mass. In the experience of the authors of various studies, many patients who undergo an echocardiogram bring equivocal reports describing valve vegetation vs. tip catheters thrombi [69, 70, 71].
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3. Vascular access creation and maintenance
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3.1. Vascular access choice: selection bias
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Whenever a native AVF can be created and is able to mature in no more than 12 weeks, it is considered the first and best choice as a VA [72]. Higher long-term longevity, less thrombotic or infectious morbidity, needs less procedure for maintenance. Overall a native AVF is big life and money saver.
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The optimal VA is one that enables an adequate dialysis treatment, for as long as needed, keeping in mind that ultimately the natural history of a VA is failure. Its characteristics are a good blood inflow through the feeding artery, and an access flow (Qa) > 600 ml/min, without recirculation. It must be superficial (<0.6 cm skin deep), have a thick wall, a long straight segment to allow two needle punctures 2.5 cm away, a diameter > 0.6 cm, a good venous outflow, without causing distal ischemia in that limb.
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That perception lead health authorities, some agencies and big provider chains to influence access choice through incentives and performance indicators, as if it was a black & white issue. In fact, AVF should not be always first and CVC are not always last. VA type comprises two of the nine quality metrics in the US CMS’s five star rating of dialysis facilities a Quality Incentives Program (QIP) that rewards high AVF prevalence and penalises CVCs, without regard to patient case-mix.
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There has never been a RCT comparing different VA choices regarding mortality or other hard outcomes. All large observational trials compared accesses achieved as opposed to the accesses that were intended (as in intention to treat). As 30–60% of all AVFs created either fail or need several procedures to mature and the CVC group in most studies were people in whom AVF failed, or CVC was chosen because of a predictable bad prognosis (old age, congestive heart failure, short life expectancy…), then we really cannot answer the question on which VA is the best or correlate it with hard outcomes [73]. If we exclude patients that begin HD urgently, mortality between AVF and CVC patients become identical [73].
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VA is only one example of the paradox between patient-centred care and the tyranny of quality metrics based on population studies. Reconciling this paradox is what clinical judgement is all about and why physicians cannot be replaced by algorithms, care paths or protocol-driven medicine [74].
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The native AVF comes with its own set of disadvantages. There is a higher risk of primary failure (non-maturation), up to 60% failing prior to ever being cannulated, angiographic procedures frequently required to assist maturation. Attempt to maximise fistula use by increasing creation rates has led to the unintended consequence of higher primary failure rate and longer dependency on catheters [75, 76].
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Studies have shown that the primary failure rate is two times greater for fistulas (40%) than AVG (19%), with similar cumulative patency, in addition, the number of catheter days before AV access use was more than double in those having a fistula (81 days) compared with AVGs (38 days). However, grafts require more angioplasties (1.4 vs. 3.2 events) and thrombolysis (0.05 vs. 0.98 events) interventions per 1000 patient-days [76, 77]. The risk of primary fistula failure is much higher for lower arm fistula (28%) than with upper arm fistula (20%) [75].
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According to the EDTA Registry, there is a trend for decreasing AVF in incident patients from 42% in 2005 to 32% in 2009, while there was an increment in CVCs from 58 to 68% (80% in the USA), with large international variation. In prevalent patients, AVFs went from 66 to 62% and CVCs from 28 to 32% [23, 78]. In a recent meta-analysis, CVCs (compared with AVF) have a higher risk of all-cause mortality (RR 1.53), fatal infection (RR 2.1), and cardiovascular events (RR 1.48) [18]. Grafts need twice as many angioplasties (1.4 vs. 3.2 events/1000 acc. days) than AVF, more thrombolysis (0.06 vs. 0.98 events/1000 acc. days). Although they need more procedures, their cumulative patency is the same when primary AVF failure is factored in [79].
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Applying a proportional hazard model to examine mortality in incident HD pts aged 65–90 years old in association with the type of VA, but accounting for case-mix and health status, the RR of AVF is 1.0, graft 1.18, CVC transformed in AVF 1.2, CVC transformed in a Graft 1.38 and CVC permanently 1.54 (both adjustments reduce RR in CVCs of 44%) [80].
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Using a decision analysis model (fed with data extracted from DOPPS 2, the REDUCE FTM study, the DAC study and CMS data) of the best option for patients initiating HD with a CVC, an AVF attempt strategy is associated with better survival and lower annual cost, but that advantage is progressively lost in patients above 60 years or diabetics [81]. The advantages of an AVF attempt strategy lessened considerably among older patients, particularly women with diabetes, reflecting the lower fistula success rates and lower life expectancy.
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Although upper-arm fistulas have a greater chance of maturation, the loss of multiple lower-arm possibilities will sooner exhaust VA sites. Also, the upper-arm option exposes patients to higher frequency of steal syndrome, potential adverse long-term complications of high-flow AVF on cardiac function and an incidence of cephalic arch stenosis that is dramatically higher when compared with the forearm choice [82].
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According to data from CMS, the first year cost in the common scenario of patients initiating haemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF vs. an AVG. In their first year, the average annual cost of an AVF is $10,642 vs. $6810 in an AVG. The CVC group had the highest median annual access-related cost of $28,709 largely attributed to high frequency hospitalisations due to bacteraemia, repeated use of thrombolytics, and frequent catheter replacement [83].
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3.2. Timing of referral for vascular access surgery
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It is consensual that once established, a native AVF is the preferred HD access, and all guidelines recommend placement of an AV access before dialysis initiation; however, that desideratum is achieved only in less than one third of all incident patients [84]. If we create it too early, the access may need extra procedures to keep its patency until dialysis initiation and many more CKD stages 4 and 5 patients will die of cardiovascular events than those who will progress to end-stage renal failure needing dialysis, and on the other hand, if we do it too late more than 60% of all patients will begin their treatment through CVC, without time for full maturation of their AV access [85].
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Hod examined the optimal timing of incident fistula placement in a population of elderly patients above 66 years old, showing that the odds ratio for successful fistula use was maximised when surgery was performed 6–9 months before dialysis was needed, with worst results in obese females, in diabetics and patients with congestive heart failure [86]. Unfortunately, even when a patient is being monitored in clinic by a nephrologist, the rate of progression of CKD to ESRF is not constant, the need for dialysis can be precipitated by random, unexpected clinical events and the correlation between measurements of renal function and uraemic clinical symptoms are poor; therefore, it may be quite difficult to plan the best timing. The best strategy would be to develop techniques that speed fistula maturation below 2 months’ time after surgical creation, what would make planning much easier and accurate [87]. Despite the tremendous heterogeneity in the decline of kidney function in stage 5 CKD patients, factoring in the presence of diabetes, the degree of proteinuria and the eGFR trajectory in the preceding year, significantly improved our prediction capability of dialysis commencement [88].
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3.3. Access creation and early complications
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Access malfunction is a source of tremendous emotional and physical suffering, dialysis treatments loss, low treatment adequacy, urgent need for a central catheter as a substitution access and referral for new angiography or surgical procedures.
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The most common first VA complications include haemorrhage, usually at the sutures level, infection, revealed in the first 15 days, local pain/inflammation, failure to mature producing poor dialysis adequacy and early thrombosis. Non-maturation and thrombosis, both have as an underlying mechanism the development of early stenosis along the arterial inflow, in the VA itself or in the access outflow.
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Stenosis is necessary for thrombosis, but it is not enough. Only 30% of stenosis above 50% of lumen compromise will cause thrombosis in the next 6 months, we just do not know which ones [89], and on the other hand, stenosis treatment based on morphology, percutaneous angioplasty, induces accelerated neointimal hyperplasia with recurrent stenosis [90]. In 20% of all cases, recurrent stenosis occurs in 1-week post-procedure and 40% in 1 month [51].
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We define VA maturation by our capability to cannulate it with two needles and deliver a minimum blood flow to the extracorporeal circuit of 350 ml/min for the whole dialysis, 4 months after its creation, for a minimum of eight dialysis in 1 month [91].
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Immediately after fistula creation, the blood flow increases from an average of approximately 20 ml/min in the radial artery to as much as 300 ml/min in a radio-cephalic fistula, 1 week later the mean blood flow rate increases further to an average of 540 ml/min and the mean shear stress from 5 to 10 dyne/cm2 to 24.5 dyne/cm2. Ultimately, the increase in flow in a well-developed fistula can reach 600–1200 ml/min [2].
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The functional ability of the artery and vein to dilate and achieve a rapid increase in blood flow are the most important determinants of fistula maturation [92] and declared that success correlated much better with Qa one day after surgery than with preoperative vessel diameter [91]. Increased shear stress sensed by the endothelium, related directly with flow rate and inversely with vessel radius, initiates the vascular response and secretion of vasodilators and anti-inflammatory mediators, to reduce neointimal hyperplasia and lower shear stress back toward baseline levels.
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At the pathogenic level, the stenosis seems to be caused by a combination of neointimal hyperplasia and an inadequate outward or positive remodelling [93]. The abundant presence of myofibroblasts within the neointima is consistent with a role for the adventitia as a source of cells for neointimal proliferation. New biologic interventions, delivered periadventitial during surgery may old promise in preventing fistula maturation failure [92, 94].
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3.4. Prevention of early complications
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The process of care to maximise AVF includes: (a) early referral to a nephrologist; (b) patient and hospital staff education to save peripheral veins, avoiding peripheral as well as central I.V. lines (in our experience, 75% of all patients in a renal ward have an I.V. line in the cephalic vein), as well as transvenous implantation of pace-makers to be substituted by epicardial leads; and (c) timely referral to the right surgeon (well trained and experienced in obtaining VAs), that will probably order, or preferably will do it himself a pre-operative vascular mapping. Remind him to avoid grafts, but, if no other choice, do not save in their length and that an AVF do not always have to be distal [95].
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Preoperative physical examination provides essential information in patients needing AVF construction but is rarely sufficient nowadays because an increasing proportion of HD patients has a compromised vasculature, the result of age, diabetes, many years of dialysis therapy and prior HD catheters. Non-invasive assessment by duplex sonography is very helpful in locating veins that are not clinically visible and also provides information about their functional characteristics, including venous outflow. Duplex sonography is the method of choice for evaluation of arteries. A calcified artery with a small lumen and thickened wall will never provide adequate fistula function [96].
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Vascular mapping (Figure 3) is a technique that leads to information on patient’s inflow and outflow anatomy as they relate to arteriovenous access creation. It can be done by using US evaluation, or angiographic mapping, both have pros and cons, the choice depends on local expertise and availability.
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Figure 3.
Vascular network mapping: arterial map and venous map.
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The US scanner should allow examination with B-mode and Doppler mode, using linear array probes with a frequency of 7 MHz for B-mode and 5 MHz for Doppler. Patients more likely to benefit from pre-operative US evaluation are those with: (a) difficult clinical examination (obese, absent pulses and multiple previous access surgery); (b) possible arterial disease (older age, diabetics and cardiovascular disease); and (c) venous disease (previous cannulation) [97]. Doppler US has a distinct advantage of being a non-invasive modality that can evaluate both structural and functional aspects of vessels that play a key role in access maturation [98].
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Preoperative mapping in some settings leads to marked increase in placement of AVF and a reduction in the use of catheters [24, 99]. Comparing pre-op US Doppler with physical examination, there was a dramatic increase in AVF creation 64 vs. 34% [24], reduction in graft placement from 62 to 30% and in tunnelled catheters insertion 24–7% [99]. Those were not universal findings, though.
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The success rate of fistula formation does not correlate with vessel diameter but with flow, mainly in the day after [92], and in some series, a preoperative Doppler US achieved 80% successful constructed AVFs. Average parameters in this success cases: artery internal diameter 2.6 mm (vs. 1.6), Qa 54.5 ml/min (vs. 24.1), and resistive index 0.5 (vs. 0.7). Risk of primary failure is much higher for lower arm fistula, and long-term patency is not better, increase in vein ID after compression 59% (vs. 12.4) and Qa increased to 300 ml/min in 1 week (vs. 4–8 weeks) [100].
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There is no systematic evidence that preoperative US mapping will induce an increase in the proportion of fistulas ultimately used for dialysis or a reduction in catheter use. It appears that the results from vessel mapping only influenced the decision as to the type or location of the AV access in surgeons with less than 15 years of experience [101]. In patients with pre-operative vascular mapping, on multiple variable logistic regression, factors associated with failure to mature were female gender, age > 65 years and forearm location (up to 78% if the three criteria were met), and the extracted mapping hemodynamic measurements could not differentiate patients with mature or immature forearm fistulas [102].
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There is clearly more to maturation than vessel diameter, non-anatomic factors likely to contribute to maturation failure include the underlying vascular pathology and impaired endothelial function associated with CKD, vein trauma from surgical manipulation and the haemodynamic stresses resulting from the creation of an AV anastomosis [94]. Preoperative duplex US scanning and venography increased first fistula creation rate from 66 to 83%, but maturation rates actually declined from 73 to 57%, probably due to basing decision mostly on the vessels diameter [103].
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4. Best VA outcome: role of a vascular access centre: quality assurance process
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Dialysis VA outcome relies on three main components: support of a referent vascular access centre (VAC) providing expertise and service 24/7/365 per year; implementation of a quality assurance process optimising use of VA; commitment and skills of trained nursing staff ensuring best use and management of VA. This last part will be addressed more specifically in the nurse perspective section.
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4.1. The vascular access centre in a dialysis network
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A VAC is a dedicated department specifically designed and equipped to deal with VA dysfunction. Its goals are to provide easy access in less than 24 hours to an experienced VA surgeon or interventional nephrologist, to increase the prevalent number of patients dialysed through native arteriovenous fistulas (AV fistulas) and above all to reduce the number of patients requiring a catheter as a transient or permanent VA. Place and role of VAC are summarised in Figure 4.
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Figure 4.
(A) Place of VAC in clinic network organisation; (B) role of VAC in coordinating VA care.
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The structure of a VAC is very similar to an ambulatory surgical unit, with continuous service from 9:00 am to 9:00 pm, 5 days a week, with a standard operating room and angiography suit functioning side by side, staffed by VA expert surgeons and interventional nephrologists. The perfect setup for a multidisciplinary approach to VA care is in a constant dialogue between surgeons and nephrologists.
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The equipment should include a portable C-arm with capability for digital subtraction and road mapping, US equipment for central vein access localisation and puncture, pre-procedure patients´ triage and procedure planning, sterilisation facilities and a common recovery room for both disciplines. Supplies are tailored to operator preferences, within economic considerations [31, 32]. The VAC must be licenced by the health authorities, and their physicians credentialed to perform the needed techniques.
Referrals to the VA are decided at the discretion of the attending nephrologist in the dialysis unit, and on arrival to the VAC patients are assessed to confirm referral correctness. Referral indications to the surgical pole of our VAC include: (a) construction and revision of AV fistulas or grafts; (b) exudative infection of the VA; (c) distal ischaemia of the access limb; (d) actively growing aneurysms; (e) haemorrhage or rupture of the VA; and (f) native AF thrombosis.
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Referral indications to the angiography suite include: (a) graft thrombosis; (b) growing oedema of the access limb; (c) pain in the access limb during treatment; (d) unexplained reduction of dialysis adequacy (Kt/V) and/or VA flow (Qa drop < 600 ml/min in a graft, or < 400 ml/min in a native AV fistula confirmed in a second measurement); (e) SVC syndrome; and (f) native AV fistula non-maturation. Local bylaws require that all central venous catheters be implanted in hospitals.
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Techniques performed in the operating room include: (a) construction or revision of native AV fistulas and grafts; (b) basilic vein transposition; (c) surgical treatment of VA infection; and (d) surgical treatment of ischemia or aneurysms of the VA limb. Techniques performed in the angiography suite include: (a) diagnostic angiography (mapping not achieved with ultrasound); (b) stenosis A=angioplasty; (c) pharmacomechanic thrombolysis; and (d) VA stenting.
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In our series, with around 3000 interventions per year in both VACs, the most common referral cause is by far a drop in Qa in 61.2% of all causes, meaning that a VA surveillance program like ours, using daily physical examination by trained dialysis nurses and monthly measurement of Qa in the dialysis unit, although of controversial benefit, will have a major impact in the workload of the VAC and in the costs of the whole operation.
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The most common site of stenosis, requiring intervention, was in the access itself in 31% of all cases, graft venous anastomosis in 29%, in the cephalic arch with 9.9% and the swing segment of the native AV fistula (the proximal segment immediately after the AV anastomosis) in 9.1%.
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The most common procedures in the angiography suite were isolated balloon angioplasty in 67.5% of all cases, thrombolysis + angioplasty in 14.3% (depending on the graft prevalence in each region) and 10.1% did not need any endovascular intervention (false positive referrals). We decrease the implantation of stents, extremely expensive and not suitable for reintervention once suffering a stenosis recurrence, to less than 0.5% of all procedures, substituted in the same indications by drug eluting balloons. We were not successful accomplishing needed endovascular treatment in 7.1% of all cases.
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Like the experience of others [104], in our centres, the procedures profile changed in the last years from a majority of interventions in grafts (angioplasties and thrombectomies) to one characterised primarily by angioplasties performed on AV fistulas. The number of interventional procedures did not decrease, and it was just the referral pattern and the percutaneous intervention required that changed in parallel with the increasing AV fistulas utilisation in prevalent patients.
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A VAC needs a quality assurance program, to continuously monitor its performance. In our network, we use: (a) in first accesses an AVF construction in 80% of all cases; (b) in subsequent VAs 60% of AVF; (c) primary AVF failure at 3 months in less than 40% of all cases; (d) percentage of function VAs 7 days post-thrombolysis > 75% and at 3 months > 50%; and (e) absence of VA infection 15 days post-intervention. We also monitor the dialysis unit, requiring less than 1 referral to the VAC per patient year. We closely follow our success and complication rate according to international standards [105, 106].
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In our experience, the major achievements of a VAC in our network are a substantial reduction in the waiting time for urgent procedures (28% of all referrals) to the same day response (elective referrals 4–6 days), the clear improvement of training and education of physicians and nurses in the dialysis units, now generating 0.3 surgeries/pt.Year, 0.37 angiographies/pt.Year, a precipitously drop of prevalent patients being dialysed through a tunnelled catheter from 24 to 14% and the total disappearance from our units of transient catheters. VA-related hospital admissions went from 1.3 to 0.6 episodes/pt.Year and they were 20% of all admissions and are now less than 10%. Our numbers compare favourably with the experience of others [107].
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So, the question is, do we need a VAC for our dialysis patients? It depends on how good and how prompt is VA care offered in your region, if you are working in a capitated system, as in our case, is VA management included in the care bundle, are you mainly serving your own patients, raising the quality and coordination of care they previously received, or is there a market for you to sell a service outside your network. Do dialysis units in your area implemented a VA surveillance program, and in that case, do we intend to act pre-emptively to correct apparent malfunction?
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To turn it into a success, it is important to monitor and influence the process of care delivered in our VAC, avoiding futile procedures such as AV fistulas that will never mature, diagnostic angiographies not needing therapeutic intervention (false positive referrals), useless angioplasties that will only accelerate more severe recurrences, or short-lived thrombolysis. It is imperative that we reach a consensus on how to define success and reward it (is it Δ Qa, Kt/V improvement, recurrence rate?). It is also of utmost importance to establish an accredited program for training young surgeons and nephrologists in VA care to guarantee future expertise in this field [108].
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If we manage to be responsible for the full cycle of VA care, without sharing responsibilities with other providers, we may expect to keep costs control below the reimbursement rate, reduce the hospitalisation rate due to VA morbidity and limit the number of dialysis treatments lost. Reducing the number of patients with catheters we will avoid morbidity due inadequate dialysis, and the extra costs of supplies for in-treatment catheter handling as well the cost of thrombolytics to treat recurrent catheter obstruction and antibiotics to treat frequent catheter infections.
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In the U.S. to break even a VAC in their current reimbursement environment, requires at least 800 patients, I suspect we would need a larger patient base in Europe; however, the feasibility of a VAC is quite variable and depends on unique payment structure in different geographic locations, specific needs of the patient population being covered and the availability of trained operators.
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4.2. Quality assurance process
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Patients with ESKD are fragile and vulnerable. For those who depend on HD, the ongoing success requires access to blood vessels capable of providing high volume extracorporeal blood flow to execute efficient HD treatments. Indeed, a properly functioning and reliable VA is one of the key successes of the HD adequacy. Unfortunately, the vascular access for HD continues to be referred to as the “Achilles Heel” of the HD procedure. Complications have a negative effect on the quality of life and continue to be a leading cause for morbidity and mortality of ESKD patients, with dysfunction being a major cause of morbidity and mortality in HD patients [109, 110].
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VA options for HD include the placement of endogenous AVF, AVG and tCVC. The AVF is the preferred choice for chronic HD VA, rather than AVG and CVC, due the better outcomes (morbidity and mortality) and lower need for interventions and complications that could reduce both efficiency and efficacy of HD treatments which also increase the overall HD costs [111, 112, 113, 114]. The selection of access should be individualised based on life expectancy and comorbidities and in consultation with a vascular surgeon with experience in the creation of HD VA. However, AVF is not always the ideal VA choice for certain ESKD patient categories such as the elderly: for those patients, the selection of VA should be individualised based on life expectancy and comorbidities. AVF, AVG and CVC are all used in older patients for permanent VA.
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The HD VA long patency depends on several factors and minimises its complications, and failure has high priority in dialysis therapy and is a significant challenge for nephrologist, nurse and surgeon. The multidisciplinary team approach with agreement on a common set of targets [115], the surgeon experience [116] and adopting specific prevention measures such as, time referral for surgery with preliminary vascular mapping, specific VA surveillance strategies, AVF and AVG cannulation techniques with specific hygiene procedures are mandatory measures to prevent the VA both early and late failure or complications such as stenosis, thrombosis and infection.
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The first challenge is the time referral to the vascular surgeon allowing to the AVF to mature adequately (1–6 months) and to be used for HD, remaining useable for many years with minimal intervention. Early referral of patients with CKD is strongly recommended. This approach helps to preserve access sites and provides adequate time for planning the creation and allowing maturation of the VA [68]. The most experienced surgeon of the HD vascular access team should be responsible, or supervise the AVF creation. Fassiadis [117] demonstrated that the primary success and primary and secondary patency rates of a series of consecutive radio-cephalic fistulae were affected by the experience of the surgeon. The risk of AVF primary failure related to ESKD patient increasing age, gender (female) and comorbidities (cardiac disease, pulmonary disease, peripheral arterial disease, diabetes and obesity) should be improved by careful patient evaluation and vascular mapping prior AVF creation. Patient evaluation (medical history and physical examination) and preoperative mapping of arm vessels allow a higher percentage AVF placements as well as an increased fistula success rate [24, 118]. Physical and US examination are intended to evaluate both the arterial and the venous system: vascular lesions, classified as inflow or outflow problems, should be identified allowing the surgeon the best AVF option protecting as much possible the arm vessel paucity for native AVF. The goals of the arterial evaluation are to find an artery capable of delivering the blood flow at rate to allow the HD treatment correctly. The axillary, brachial, radial and ulnar pulses should be examined as well as the blood pressure between the two arms to assure that the vessels are patent. By modified duplex Allen test is evaluated the hand arterial blood circulation if the radial or the ulnar arteries will be utilised in the AVF creation. The artery used must be of sufficient size (diameter > 2 mm) [119]. A forearm cephalic vein AVF (radial artery–cephalic vein) (brachial artery–cephalic vein) is preferred. The entire extent of the vein, its drainage, the diameter, depth and assessment of the ability to dilate should be assessed. The upper arm cephalic vein AVF (brachial artery–cephalic vein) is evaluated in case no suitable vein is found in the forearm. The non-dominant forearm is preferable for dialysis access placement, and the first choice used is the radio-cephalic AVF [111]. In case the first choice is not available, the other options from the most to least desirable are the following [113]: (a) dominant forearm radio-cephalic AVF; (b) non-dominant, or dominant upper arm brachiocephalic AVF; (c) non-dominant or dominant upper arm Brachiobasilic vein transposition AVF; (d) forearm loop graft rate; (e) upper arm straight graft; and (f) upper arm loop graft (axillary artery to axillary vein).
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After AVF creation immediate thrombosis, failing to mature, or early fistula failure, may develop [120], and after the maturation late failure and other complications can occur [120]. VA monitoring and surveillance are crucial to ensure best outcome of VA and success to renal replacement program [121, 122, 123]. The AVF monitoring and the early identification of complications contribute to maintain the long-term patency of the AVF. Once the HD treatment is started, skilled nurses should evaluate the VA at each dialysis session. VA monitoring is performed on a regular basis synchronised with dialysis sessions to detect early dysfunction or complication. A routinely weekly physical examination of mature AVF is recommended by 2006 National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines and 2008 Society for Vascular Surgery [68, 119]. The nurse should inform the nephrologist in case of abnormal noise intensity [12], oedema, redness, swelling, bruising, haematoma, rash or break in skin, bleeding, other exudate, aneurysm or pseudo-aneurysm. The AVF blood flow is in the range of 800–2000 mL, and the thrill is associated with a blood flow >450 ml/min: in case the patient notices that the pulse or the thrill is reduced or it cannot be felt he/she should immediately inform the clinical staff. Patients should be instructed to keep the access extremity clean and to avoid wearing any cloths or wristwatches that restrict flow.
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VA surveillance is intended to assess objectively and to follow over time VA performance and dialysis treatment delivery efficacy. It requires specific non-invasive tests and special instruments. Three main key parameter indicators are usually monitored: effective dialysis dose delivered, recirculation of VA [124, 125] and VA flow.
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Time trend behaviour monitoring of VA performance based on selected indicators is crucial to detect early VA dysfunction (e.g., stenosis). Pre-emptive intervention has been shown very effective in correcting stenosis (percutaneous angioplasty) and preventing further risk of thrombosis and dysfunction. Precise knowledge of individual VA performances, threshold values (e.g., access flow 500–600 ml/min) and time trend analyses are required to optimise and personalise VA maintenance strategy [126, 127].
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Time of first use or first cannulation varies according to VA type, maturation degree and local expertise: native AVF may be cannulated within 4–8 weeks after creation; AVG may be cannulated earlier 2–6 weeks; tunnelled CVC may be used immediately after insertion. Timing of VA cannulation (early <2 weeks or late >3–4 weeks) does not seem to impact VA outcome, and this is a particular feature of dialysis policy units [128].
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The correct cannulation technique is mandatory for preventing AVF injury that might cause infiltration/haematoma or intimal damage with subsequent stenosis that might lead AVF thrombosis. Recommendations for the AVF cannulation procedures are few and mainly focused on needle size, angle of needle insertion and direction of needle bevel. Experienced dialysis staff only should be allowed to cannulate a newly created fistula. For first cannulations, local anaesthesia performed with topic anaesthetic cream or patch (Emla) is recommended [129].
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In FMC EMEA NC clinics, the following cannulation procedures are applied [43]. The arterial needle should be placed in the direction of the blood flow and bevel down, but in case of anatomical restrictions, the needle is placed against blood flow and bevel up. The venous needle is always placed in the direction of the blood flow. The needle should be inserted at an angle of 20–35°, and when flashback is observed, the needle should be lowered and advanced into the centre of the vessel. Sites on the AVF which display evidence of aneurysm formation should be avoided. In mature AVF, 15- or 14-G needles are needed to support a blood flow rate of >350 ml/min needed for high efficiency dialysis or convective treatments. In 2006, NKF KDOQI guidelines recommended the use of arterial needles with a back-eye, to reduce the need for flipping or twisting the needle [68]. Parisotto showed in a cohort of 7058 patients from nine countries, that area cannulation technique (repeated cannulations concentrated over a small vessel area (2–3 cm)) was associated with a significantly higher risk of access failure than rope-ladder or buttonhole. Retrograde direction of the arterial needle with bevel down was also associated with an increased failure risk [130]. Moreover, patient application of pressure during cannulation appeared more favourable for VA longevity than not applying pressure or using a tourniquet [130].
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The buttonhole needling is postulated to be associated with a reduction in haematoma and might increase long-term survival of AVF with less complication. The buttonhole technique is a cannulation method where the AVF is cannulated in the exact same spot, at the same angle and depth of penetration every time [131, 132, 133, 134]. By using the exact same spot, a scar tissue tunnel track will be created. The procedure should be performed by the same cannulator until the track tunnel has been created. After track creation, this technique should always be performed by highly experienced staff. Using a sharp needle, it takes approximately 6–12 cannulations (depending on the individual patient) to create a track at a given site. The creation of a scar tissue tunnel track allows the use of a blunt needle [43].
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The needle removal procedure is as important as the cannulation. Needle withdrawal must be done carefully in order to prevent tearing of the vessel, to minimise access trauma and to achieve optimal haemostasis. Each needle should be withdrawn slowly, keeping the same angle as that of insertion, until the entire needle has been removed. Digital pressure should be applied only after the needle is completely removed to prevent damage to the vessel wall and should be sufficient to stop bleeding but not so great as to stop the flow of blood through the VA [43, 135].
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Cannulation and needle removal techniques are similar in patients with either AVF or AVG with the exception of the buttonhole technique that cannot be utilised to cannulate the AVG. It is suggested to avoid “flip” or rotate the bevel of the needle 180°. Flipping can lead to stretching of the needle insertion site, which can cause bleeding from the needle site and oozing, during dialysis treatment and can damage the graft [135].
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Some medications, including statins, antiplatelet agents, anticoagulants, and dipyridamole have been reported to potentially affect VA outcome. Saran evaluated the association between VA failure and the use of specific drugs [136]. Calcium channel blockers improved the primary graft patency (relative risk [RR] for failure, 0.86; P = 0.034). Aspirin therapy was associated with better secondary graft patency (RR, 0.70; P < 0.001). Treatment with angiotensin-converting enzyme inhibitors was associated with significantly better secondary fistula patency (RR, 0.56; P = 0.010). Patients administered warfarin showed worse primary graft patency (RR, 1.33; P = 0.037). Statin treatment could be associated with reduced neointimal proliferation, vascular inflammation, and improved AVF dysfunction [137, 138, 139]. A Cochrane review reported that antiplatelet treatment can improve the 1-month patency rates of AVFs and AVGs [140]. Dipyridamole demonstrated to reduce ePTFE graft occlusion reducing the vascular smooth muscle proliferation and the neointimal hyperplasia [141].
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Infection is the second most common cause of AVF-AVG loss after stenosis/thrombosis [9]. An effective hygiene and infection control policy is essential, and healthcare staff must be trained appropriately. Standard precautions prevent healthcare-associated transmission of infectious agents among patients and healthcare workers, and they must be applied to all patients. Appropriate sterile technique should be used [43]. The patient’s skin must be disinfected with an appropriate solution (before needle insertion for approximately 30–60s) starting at the chosen cannulation site and moving outward in a circular rubbing motion. If the skin is touched by the patient or staff after the skin prep has been applied but the cannulation has not been completed, repeat the preparation.
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The CVC exit-site infection can be defined as a culture-positive inflammation external to the cuff of the catheter and localised to the exit site and not extending beyond the cuff. It is characterised by local redness, crusting and a variable amount of exudate. In most of these cases, the patients respond well with local measures, like topical antibiotic application (without fever). The CVC tunnel infection is defined as a culture-positive inflammation within the catheter tunnel but beyond the catheter cuff, with negative blood culture. Usually it is characterised by erythema, tenderness and induration in tissues overlying the catheter and > 2 cm from the exit site. CVC-related bloodstream infection (CRBSI) is defined as the presence of bacteraemia originating from an intravenous catheter. The diagnosis of CRBSI is often suspected clinically in a patient using a CVC who presents fever or chills, unexplained hypotension, and no other local sign. Severe sepsis and metastatic infectious complications, such as infective endocarditis, septic arthritis, osteomyelitis, spinal epidural abscess and septic emboli, can prolong the course of CRBSI and should be considered in patients who do not respond appropriately to treatment. Specific connection and disconnection procedures to prevent the CVC infections are applied in FMC EMEA NC [69].
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5. Patient perspective
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5.1. Patient information and education
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Patient information and education are powerful means for keeping VA functional and safe and to guarantee successful dialysis therapy. These needs extend to patient’s family and relatives. Awareness and learning processes should start as soon as the patient is diagnosed with chronic kidney disease. VA creation is a significant milestone in the life cycle of CKD patient that marks almost the final step of kidney disease progression and announce the start of replacement therapy. VA planning and creation are usually associated with a severe psychological trauma in renal patient that needs to be adequately prepared. Therefore, regarding VA education, it is important to differentiate in the life cycle of CKD patient two stages: before and after VA construction.
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Preservation of vessels is an essential message and task that should be given to any CKD patients and relatives [11]. It is of utmost importance that CKD patients are aware of how they can preserve their vessels in both arms. They need to realise very early that vessels are essential for VA creation as a line to life-sustaining therapy and superficial vein resources are not endless. Patient education should include information to avoid and/or to refrain using major vessels located in the forearm for blood sampling, intravenous (IV) injections and infusions or invasive arterial procedures and to avoid the use of upper arms veins for catheterisation (e.g., angiography) or radio-logical procedures (e.g., contrast media imaging). Such message should be repeated at each hospital or clinical admission. Instead the use of superficial veins of the hand and minor vessels of upper arm should be preferred for exploration or imaging.
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Patient education means more than providing information, CKD patients will benefit from counselling to actively participate in the choice of their treatment modality, to act on their own care and in successfully self-managing certain tasks needed by their treatment [11]. Patient education is needed to increase patients’ skills and confidence in managing their own disease. Education should be part of CKD management program during outpatient clinic consultation as a continuous training process. Long-term follow-up of renal patient gives caregivers and patient a better understanding of the choice regarding the type of renal replacement therapy and VA option. Obviously, patient education does not mean simply handing over information. Appropriate materials and personalised education (e.g., adapted to age, educational level, cultural and language barriers), that consist both in providing written documents, pictures, movies, social media and discussions, but also in regular checking of patient understanding and knowledge. This regular interaction between patient and care giver is one of the most efficient components of the educational and training process.
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When the creation of VA is planned or performed, the patient must be informed about and what to be expected after the surgery. Also, he must be asked to report immediately to the VA reference centre if side effects or important changes occur. Important and practical advices after VA surgery include for example: to keep the arm warm and dry; to monitor the surgical wound for changes; to elevate the arm slightly to prevent swelling; to use the other hand to feel VA thrill; to avoid sleeping on the fistula arm, wearing tight sleeve, carrying heavy weights, violent sports or activity that may cause a trauma to the AVF; to avoid blood pressure measurements, blood sampling and IV injections on the VA; to ask dialysis nurse to check AV patency if patient is already on dialysis via a CVC.
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Maturation of AV access is an important period for long-term VA outcome corresponding to the non-use of the VA. This time may last 4–8 weeks dependent on the VA type, medical patient profile and vascular network characteristics. After wound healing, patient needs to start appropriate exercise program for enhancing flow in the VA arm (e.g., open and close hand, squeeze soft ball and touch fingertips with thumb) that will foster VA maturation. Long-term monitoring of VA is needed for dialysis patient. In the patient’s life, VA patency and local skin aspect should be checked at least daily. The easiest way is to put their hand or fingers on the fistula to feel a buzzing sensation (thrill) and to detect abnormal pain or temperature.
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Patients with a dysfunctioning VA may require at some points imaging and/or interventional procedures. It is necessary to explain planned procedures or examinations to the patient. Patients should be informed about the contrast media use for the examination and be aware of allergy or other potential side effects. Expected results of investigation and potential required intervention should be carefully explained to the patient.
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Hygienic rules should be applied any time on the VA arm to prevent skin colonisation and migration of bacteria from the skin to the blood circulation system at the time of needling (e.g., AVF or AVG) or VA connection (e.g., CVC). General recommendations consist in washing access arm with water and soap every day, before and after each dialysis session, avoid coughing or sneezing on the VA, keep the haemostatic and adhesive dressing for up to 3–4 hours after VA disconnection. Teach patients of the importance of preserving VA from special risky practices (e.g., sauna and steam bath, swimming, extreme sport and gardening with gloves).
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5.2. Pain management of VA cannulation
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Pain and discomfort caused by VA cannulation and needling are of major concern for dialysis patient. Pain assessment is a primary task and responsibility of nursing staff when caring dialysis patient [142]. Dialysis patients are exposed to pain with VA cannulation more than 300 times per year. Such repetitive exposure to pain and discomfort causes anxiety and depression, reduces quality of life, and interferes with daily life enjoyment.
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Pain is an unpleasant emotional and sensory experience due to an actual or potential tissue injury that is tremendously enhanced by anxiety. This is a quite stressful condition that can lead to severe and uncontrollable fear of needles known as “needle phobia” or “trypanophobia” leading eventually to “dialysis phobia.” In this sense, the pain control during VA cannulation by nursing staff should be considered as a top priority in dialysis units. Pain intensity during VA cannulation may benefit from regular monitoring relying either on subjective assessment (nurse feeling) or better and more objective assessment using visual analogue scale (VAS).
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To prevent fear of needles and pain caused by the VA cannulation, dialysis nursing team should be adequately trained in pain management. Effective pain control improves patient satisfaction with dialysis nursing care, helps patient to accept haemodialysis and enhances their quality of life. Effective and personalised plans are needed to manage VA needling pain in dialysis patients. There are different pharmacological and non-pharmacological pain management strategies for VA needling. General approaches include topical heat or cold therapy, rhythmic breathing, distraction, transcutaneous electrical nerve stimulation, aromatherapy, acupressure, massage, active listening and music therapy. Topical treatment approaches aiming to reduce pain via local anaesthesia that include Emla (cream or patch) and lidocaine (cream or intradermic injection) or local analgesia such as Arnica topical cream or diclofenac sodium topical gel are now more frequently proposed. Other approaches may be advised such as hypnosis or gas anaesthesia with inhalation of nitrous oxide depending on the psychological component and on the local setting.
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6. A value-based approach relying on best nursing practices learned from NephroCare
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6.1. VA cannulation
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VA cannulation method is still an “art” and procedure that reflects local unit practices and personal nursing skills [130]. Interestingly, despite the impact needling has on VA survival and patient outcome, there is no universal or standardised method proposed for proper cannulation [143].
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There are three cannulation methods used by nursing staff: rope-ladder, area cannulation and buttonhole [144]. The rope-ladder (site-rotation) method appears to be the most used worldwide being considered as the safest one. It consists of alternating puncture sites at a defined distance from the previous one along the VA vessel as an attempt to prevent aneurysm formation, stenosis and repeated trauma by multiple punctures. The area (one-site-itis) puncture is the insertion of the needles in the same general area of 2–3 cm, session after session [145]. This method exposes to weakness VA wall with progressive dilation leading to false aneurysm. The buttonhole (constant-site) method is less used in centre but seems of great interest for patient self-cannulating their own VA. It consists in creating a track by cannulating repeatedly the same spot and angle with sharp needle over 6–9 weeks. Once the track is formed, then a blunt needle can be used for subsequent cannulation. Buttonhole cannulation appears to be less painful and create less anxiety than rope-ladder but exposes to a more risk of infection. Nursing vascular access procedures are detailed in a separate document accessible and downloadable from the website: https://www.edtnaerca.org/academy/publications.
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6.2. Patients bearing chronic tunnelled central venous catheter (tCVC)
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Despite strong recommendations from best clinical practice guidelines, the use of tCVC is very common and tends to increase over time in almost all countries either in incident (10–80%) and prevalent (2–48%) dialysis patients [20]. Such trend most likely reflects change in medical profile of dialysis patients (e.g., advanced age, comorbidities, short life expectancy and repeated failures of VA creation), change in medical practices (e.g., easy access to CVC and shortage of motivated vascular surgeon) and poor or fragmented management of CKD patients (e.g., late referral). Interestingly, prevalence of tCVC in prevalent patients varies from 20 to 40% in Europe.
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6.3. Nurse perspective: skills, training and responsibilities
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Nurses play a crucial role in the management of all VAs. VA assessment, cannulation and care are mandatory skills for dialysis nurses: failure to correctly perform this operation may result in serious complications for the patients [145].
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6.3.1. Competencies and responsibilities
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A highly-skilled dialysis nurse is required to ensure that each cannulation/connection procedure is carried out with minimal or no complications. At every dialysis session, and before each cannulation/connection, ensure that the patient’s VA is functional and has no problems in obtaining the optimal blood flow ensuring an adequate dialysis [43]. The competencies and responsibilities to achieve this are as follows:
The nurses should have competence in:
AVF/AVG and CVC assessment
AVF/AVG cannulation techniques and care
CVC connection and care
Management of complications
Patient education related to VA care
The nurses should have responsibility for:
Ensuring patient comfort and safety
Reporting and documenting all complications relating to VA
Liaising with the dialysis medical team to early identify and manage complications
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Before starting the cannulation procedure for AVF/AVG or the connection of the CVC, the Registered Nurse (RN) must assure the preparation of the environment, material and patient following strictly the hygienic rules.
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6.3.2. Hand hygiene
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The impact of health care-associated infections implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional financial burden, high costs for patients and their families and excess deaths [146]. In accordance with the WHO hand hygiene should routinely be performed.
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6.3.3. Personal protective equipment (PPE) and work uniform
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PPE (hand and face protection, aprons and gowns) serves to protect HCW from hazards and preventable injuries in the workplace. Some PPE items, such as gloves and masks, protect HCWs and patients.
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Uniforms are not considered as PPE. Nonetheless they provide the HCW with professional attire that supports the HCW in carrying out her or his work in the dialysis unit, while at the same time preventing cross-contamination between the workplace and the home.
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6.3.4. Patients general condition assessment
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Prior to any HD treatment, assessment of patient’s general condition to identify potential problems that may arise during the treatment should be performed: temperature (as a routine, only for CVC), diet, loss of appetite, vomiting, diarrhoea and any other intercurrences between treatments like cramps, bleeding or some other signs or symptoms of complications.
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The nurse needs to weigh the patient and compare the value with the last post dialysis weight and to the prescribed dry weight. Blood pressure and pulse must be evaluated and all treatment parameters should be validated. When using a CVC, the catheter exit site must be examined thoroughly for the presence of any signs of infection. A physical assessment of the VA must be carried out before every treatment.
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6.3.5. AVF/AVG assessment
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Using the eyes, ears and fingertips, AVF/AVG are assessed for complications. Inspection (observe and look for):
Signs and symptoms of inflammation/infection: redness, drainage, abscess, warmth, oedema and rash over the fistula.
Infiltration/haematoma: needle infiltration of new AVF is a relatively frequent complication, and haematoma can develop easily in patients on chronic anticoagulation therapy.
Pseudo-aneurysms are frequently seen on the fistula arm: pseudo-aneurysms develop because of trauma from cannulating the same site or due to a significant proximal stenosis in the outflow tract.
Skin colour: changes in the skin colour could point to stenosis of infection, discoloured or cyanotic fingers could be an early sign of steal syndrome.
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Palpation (touch and feel):
Thrill: normally a very prominent thrill is present at the anastomosis and the fistula is soft and easily compressible, the thrill diminishes evenly along access length.
Skin temperature: warmth could be a sign of infection; cold could be a sign of decreased blood supply (possible steal syndrome).
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Auscultation (listen to the fistula):
Listen for bruit: listen to entire access every treatment and note changes in sound characteristics.
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AVF/AVG physical examination is crucial to evaluate the proper function and to detect possible signs of complications. If any sign of complication is present, the VA should not be used and the patients should be evaluated by the nephrologist [43].
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6.3.6. CVC assessment
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CVC, despite being considered the worst HD VA, is used in a considerable number of patients, up to 80%, either due to the need to start HD following emergency catheter placement or due to lack of native vessel to create an AVF or place an AVG. The goal of performing a HD treatment via a CVC should be the achievement of the best patient outcome as possible, while keeping all possible complications under control. For this purpose, it is fundamental that all team members are familiar with the principles of CVC care, which include assessment, usage, surveillance and maintenance.
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6.3.6.1. Exit site
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The exit site of the CVC must always be inspected at each HD treatment for any signs of irritation, infection or development of allergy to dress or disinfectant solution, including tenderness, skin peeling, rash, swelling, exudate and redness. European Renal Best Practice (ERBP) recommends to always ensure the area being cleansed around the exit site is slightly larger than the final dressing and include the section of the catheter that will be underneath the dressing [147].
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6.3.6.2. Type of dressing
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There is a wide variety of different types of products for dressing and securing CVCs, but the superiority of one over another has not yet been demonstrated. According to ERBP, for long-term catheters sterile gauze is preferable, for enabling maximal natural airing of the exit site.
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6.3.6.3. Patency
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Before starting the HD treatment, the patency of the catheter should be evaluated. The locking solution use in the previous treatment should be removed by withdrawing 3–5 ml, locking solution mixed with blood. Using a 10 ml syringe filled with 0.9% NaCl, a small amount of blood should be aspirate into the syringe and observed for clots containment. If yes, flush should not be done. If unable to flush the physician should be alerted to assess and, if necessary, provide intervention.
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6.3.6.4. Patient’s skin preparation for cannulation
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Before needle insertion in an AVF/AVG, proper needle-site preparation should be done to reduce infection rates. Site selection should be done prior to the final skin preparation.
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6.3.6.5. Cannulation
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The most important procedure is the cannulation of an AVF/AVG, and over the course of a day, it is carried out on numerous occasions by the dialysis nurse. Choice of the correct cannulation site and technique are fundamental factors for an optimal dialysis session (more information at Section 6.1).
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6.3.6.6. Needle taping
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Tape the needle in place on completion of insertion, secure it using a minimum of three strips of tape: one to fix the wings, a second on top of it to secure the needle and a third one to secure the needle tubing.
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6.3.6.7. Needle removal and haemostasis (HS)
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The procedure of needle removal by the nurse is as important as the cannulation of the AVF. Needle withdrawal must be done carefully to prevent tearing of the vessel, to minimise access trauma and to achieve optimal HS. The needle should be removed using the same inclination as the insertion angle. Appropriate pressure should be applied after complete needle removal (thrill should be felt above and below the site of pressure). The pressure must be hold for 8–12 min without checking.
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6.3.6.8. Haemostasis
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HS of the first cannulation must always be performed by skilled nursing staff, since the vessel wall is fragile and there is an increased risk of haematoma formation. Manual compression applied by the nurse, health care assistant, or patient is the standard of care following withdrawal of HD needles. For the patients who cannot or are unwilling to hold pressure for sufficient time for HS the use of a HS clamp or band is required.
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6.3.6.9. Patient education to care for VA
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One of the most important responsibilities of the nurses is patient education. To achieve shared decision making, improve understanding and adherence, motivate, and encourage self-management, effective patient education is crucial [20] (more information at Section 5).
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A good knowledge on VA management is necessary to enable the nurse to assess, plan, implement and evaluate the care given to patients before, during and after cannulation (AVF/AVG) or connection (CVC) and to deal with complications. The first use of a VA is an important opportunity for the expert nurse to demonstrate and transfer her/his knowledge and expertise to novice HD nurse. This will ensure the continuing education of healthcare staff engaged in patient care within the HD unit.
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7. VA future outlook
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As stated in the background section, VA is an essential component of a life-sustaining therapy in ESKD patients with a significant effect on both patient outcomes and associated costs [3, 8]. Therefore, taking a value-based approach and identifying opportunities for VA that would provide the right balance between optimal patient outcomes and total spending would be the ultimate goal [148].
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The clinical/medical evidence basis clearly shows from a value-based perspective that it is obvious that native arteriovenous fistula is still the best VA option providing the highest survival expectation and the lowest complication risk [149]. However, patient profiles have become more complex including an increase of co-morbidities that affect the success rates of AVF [150]. Therefore, several attempts have been made to substitute failing native AVF by new VA devices including vascular graft (synthetic and biomaterial), implantable devices (graft, venous catheter and port catheter) or hybrid system (graft port or venous port catheter) with limited success [151, 152].
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What are the new VA perspectives to improve outcome and/or to expand VA possibilities in difficult cases. Several opportunities are currently under clinical investigation:
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First, better management and use of existing VA from installation (VA network mapping) to maintenance permitted by use of non-invasive imaging (US-based) including monitoring technologies (online monitoring HD) [149, 153, 154] or connected technologies offering 24/7 continuous monitoring of VA patency [155]. The idea behind is to facilitate maturation of newly created AVF and/or to intervene earlier on failing VA to permit percutaneous interventional procedures for restoring patency [156].
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Second, make better use and improve outcome of tCVC or implanted venous access port devices by implementing strict rules of handling and generalisation of catheter locking solutions [157].
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Third, assess clinical value of minimally invasive procedures such as percutaneous creation of VA [158, 159].
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Fourth, use medication either with systemic or local action to prevent thrombosis, to reduce neointimal proliferation leading to stenosis [160, 161, 162].
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Fifth, evaluate performance and outcome of bioengineered VA conduit based on vascular matrix formation and autologous cell seeding as part of regenerative medicine [19, 163].
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Next to the medical future outlook, the economic perspective should also be considered, reviewing the bottom part of the value-based healthcare equation where value “is defined as the health outcomes achieved per dollar spent” [148]. Two systematic reviews (one focused on VA creation and the other on VA maintenance) identified a total of ~15 economic evaluations and/or cost and resource use analyses. As from a medical perspective, AVF is concluded to be the most cost-effective VA type for HD patients [164]. Nevertheless, the number of studies identified, and the level of evidence currently available shows a clear gap in knowledge to come to a solid conclusion from a health economic point of view. Especially, the total patient life cycle with regards to costs is not clearly mapped including the identification of: downstream costs, costs of adverse events, associated costs of patency rates and long-term consequences in effectiveness of the HD treatment.
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Finally, there is one additional component that would need to be tackled which is the health system set up in general around transition management for CKD patients including VA placement and maintenance. According to Porter, healthcare needs to be structured based on meaningful outcomes to patients to maximise the value that is delivered in the end [165]. As part of this structure, episodic treatment should be transferred to bundling therapies under the responsibility of one provider [165]. Translating this to renal care would entail to include VA placement and management in the dialysis reimbursement bundle, which is already the case in, for example, USA, Portugal and Spain.
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The reason for this reorganisation is especially needed as currently approximately 32–73% of the CKD patient population experiences an unplanned start of dialysis [166, 167, 168, 169]. This unplanned start leads to the use of the least optimal VA type (CVC) rather than AVF as this requires a 6-month maturity phase. This suboptimal start is caused by a lack of screening and diagnosis of CKD patients in time, as these patients are first seen by a general practitioner (GP) rather than a nephrologist [170]. Hence, awareness/educational measures toward GPs could also be one of the future outlooks from a health policy perspective to improve VA practice and consequently the lifecycle of HD patients.
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In conclusion, the outlook for the future for VA practice is promising and has potential to improve significantly from multiple perspectives (medical, economic, health system, etc.). A collaboration and partnership between these disciplines would create an understanding and clear roadmap for next steps to put these into practice.
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8. Conclusion
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VA is an essential component of renal replacement therapy in ESKD patients. VA is currently referred to the life line of dialysis-dependent patient. Dialysis access relies on two main options: arteriovenous shunt (autologous AVF and AV graft); veno-venous access (tunnelled catheter and venous port device). AVFs are still the preferred VA option associated with best outcomes, higher performances and lower morbidity. Various innovative and quite interesting options, including minimally invasive percutaneous creation of AVFs and implantation of bioengineered vascular conduit deserve further clinical studies to enter in the VA armamentarium. VA performance is a key factor to drive success of extracorporeal renal replacement treatment. Furthermore, VA dysfunction and/or morbidity (stenosis, thrombosis and infection) are a source of frequent hospitalisation and corrective procedures. VA management in CKD patient is of tremendous importance in the overall quality care of dialysis patients. VA care and outcome are greatly improved in a large dialysis care provider network by means of a referent VAC and continuous quality improvement program [171].
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Acknowledgments
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We thank Jörg Rammo for conceptualising, designing the project and providing editorial assistance on the manuscript, Iain Morris for carefully reviewing the manuscript. All authors participated in critically revising the manuscript for important intellectual content and approved the final manuscript to be published.
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Conflict of interest
All authors are employees of Fresenius Medical Care.
\n',keywords:"haemodialysis, vascular access, vascular access centre, arteriovenous fistula, arteriovenous graft, central venous catheter, vascular access complications, best nursing practice, value-based haemodialysis",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/66364.pdf",chapterXML:"https://mts.intechopen.com/source/xml/66364.xml",downloadPdfUrl:"/chapter/pdf-download/66364",previewPdfUrl:"/chapter/pdf-preview/66364",totalDownloads:2541,totalViews:977,totalCrossrefCites:1,dateSubmitted:"October 15th 2018",dateReviewed:"February 6th 2019",datePrePublished:"April 3rd 2019",datePublished:"April 24th 2019",dateFinished:"March 25th 2019",readingETA:"0",abstract:"A good functioning vascular access (VA) is a prerequisite to obtain a successful dialysis treatment. This chapter reviews VA management in advanced chronic kidney disease (CKD) patients drawn from the experience of a large network dialysis care provider with the following sections: overview on VA management in advanced CKD that follows patient pathway and patient profile, current practice patterns in line with best clinical practices; VA creation addressing crucial themes: when and what type of VA to construct, how to assess patient pre-emptively, how to proceed for the construction and monitoring to prevent early failures and complications; VA management with particular focus on clinical monitoring, surveillance and interventional procedures required to preserve patency and functionality of VA; the often-forgotten patient perspective is VA usage. What information to share, how to proceed for preventing pain, and fears related with VA needling? What should patients know about their VA and how to manage in daily life? Competences, skills and responsibilities of nursing staff when using and managing VA; and future of VA in terms of innovative concept for creating and maintaining VA conduits in dialysis patients.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/66364",risUrl:"/chapter/ris/66364",signatures:"Bernard Canaud, Pedro Ponce, Maria Teresa Parisotto, Ellen Busink,\nChristian Apel, Jörg Rammo and Stefano Stuard",book:{id:"8334",type:"book",title:"Vascular Access Surgery",subtitle:"Tips and Tricks",fullTitle:"Vascular Access Surgery - Tips and Tricks",slug:"vascular-access-surgery-tips-and-tricks",publishedDate:"April 24th 2019",bookSignature:"Alexander E. Berezin",coverURL:"https://cdn.intechopen.com/books/images_new/8334.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83880-172-4",printIsbn:"978-1-83880-171-7",pdfIsbn:"978-1-83962-143-7",isAvailableForWebshopOrdering:!0,editors:[{id:"256942",title:"Prof.",name:"Alexander",middleName:null,surname:"Berezin",slug:"alexander-berezin",fullName:"Alexander Berezin"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Background",level:"1"},{id:"sec_2",title:"2. Overview on VA management in dialysis patients",level:"1"},{id:"sec_2_2",title:"2.1. VA types",level:"2"},{id:"sec_3_2",title:"2.2. VA prevalence",level:"2"},{id:"sec_4_2",title:"2.3. VA strategy planning",level:"2"},{id:"sec_5_2",title:"2.4. VA performance and outcome",level:"2"},{id:"sec_6_2",title:"2.5. Complications in established VA",level:"2"},{id:"sec_8",title:"3. Vascular access creation and maintenance",level:"1"},{id:"sec_8_2",title:"3.1. Vascular access choice: selection bias",level:"2"},{id:"sec_9_2",title:"3.2. Timing of referral for vascular access surgery",level:"2"},{id:"sec_10_2",title:"3.3. Access creation and early complications",level:"2"},{id:"sec_11_2",title:"3.4. Prevention of early complications",level:"2"},{id:"sec_13",title:"4. Best VA outcome: role of a vascular access centre: quality assurance process",level:"1"},{id:"sec_13_2",title:"4.1. The vascular access centre in a dialysis network",level:"2"},{id:"sec_14_2",title:"4.2. Quality assurance process",level:"2"},{id:"sec_16",title:"5. Patient perspective",level:"1"},{id:"sec_16_2",title:"5.1. Patient information and education",level:"2"},{id:"sec_17_2",title:"5.2. Pain management of VA cannulation",level:"2"},{id:"sec_19",title:"6. A value-based approach relying on best nursing practices learned from NephroCare",level:"1"},{id:"sec_19_2",title:"6.1. VA cannulation",level:"2"},{id:"sec_20_2",title:"6.2. Patients bearing chronic tunnelled central venous catheter (tCVC)",level:"2"},{id:"sec_21_2",title:"6.3. Nurse perspective: skills, training and responsibilities",level:"2"},{id:"sec_21_3",title:"6.3.1. Competencies and responsibilities",level:"3"},{id:"sec_22_3",title:"6.3.2. Hand hygiene",level:"3"},{id:"sec_23_3",title:"6.3.3. Personal protective equipment (PPE) and work uniform",level:"3"},{id:"sec_24_3",title:"6.3.4. Patients general condition assessment",level:"3"},{id:"sec_25_3",title:"6.3.5. AVF/AVG assessment",level:"3"},{id:"sec_26_3",title:"6.3.6. CVC assessment",level:"3"},{id:"sec_26_4",title:"6.3.6.1. Exit site",level:"4"},{id:"sec_27_4",title:"6.3.6.2. Type of dressing",level:"4"},{id:"sec_28_4",title:"6.3.6.3. Patency",level:"4"},{id:"sec_29_4",title:"6.3.6.4. Patient’s skin preparation for cannulation",level:"4"},{id:"sec_30_4",title:"6.3.6.5. Cannulation",level:"4"},{id:"sec_31_4",title:"6.3.6.6. Needle taping",level:"4"},{id:"sec_32_4",title:"6.3.6.7. Needle removal and haemostasis (HS)",level:"4"},{id:"sec_33_4",title:"6.3.6.8. Haemostasis",level:"4"},{id:"sec_34_4",title:"6.3.6.9. Patient education to care for VA",level:"4"},{id:"sec_38",title:"7. VA future outlook",level:"1"},{id:"sec_39",title:"8. Conclusion",level:"1"},{id:"sec_40",title:"Acknowledgments",level:"1"},{id:"sec_43",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Beathard GA. Integrated vascular access management. Blood Purification. 2003;21(1):89-98\n'},{id:"B2",body:'Konner K, Nonnast-Daniel B, Ritz E. The arteriovenous fistula. Journal of the American Society of Nephrology. 2003;14(6):1669-1680\n'},{id:"B3",body:'Riella MC, Roy-Chaudhury P. Vascular access in haemodialysis: Strengthening the Achilles\' heel. Nature Reviews. Nephrology. 2013;9(6):348-357\n'},{id:"B4",body:'Cortez AJ, Paulson WD, Schwab SJ. Vascular access as a determinant of adequacy of dialysis. 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Journal of Vascular Surgery. 2003;38(3):439-445; discussion 45\n'},{id:"B104",body:'Beathard GA, Urbanes A, Litchfield T. Changes in the profile of endovascular procedures performed in freestanding dialysis access centers over 15 years. Clinical Journal of the American Society of Nephrology. 2017;12(5):779-786\n'},{id:"B105",body:'Vesely TM, Beathard G, Ash S, Hoggard J, Schon D. Classification of complications associated with hemodialysis vascular access procedures. A position statement from the American Society of Diagnostic and Interventional Nephrology. The Journal of Vascular Access. 2008;9(1):12-19\n'},{id:"B106",body:'Beathard GA. Management of complications of endovascular dialysis access procedures. Seminars in Dialysis. 2003;16(4):309-313\n'},{id:"B107",body:'Mishler R, Sands JJ, Ofsthun NJ, Teng M, Schon D, Lazarus JM. Dedicated outpatient vascular access center decreases hospitalization and missed outpatient dialysis treatments. Kidney International. 2006;69(2):393-398\n'},{id:"B108",body:'Saad TF. Training, certification, and reimbursement for nephrology procedures. Seminars in Nephrology. 2002;22(3):276-285\n'},{id:"B109",body:'Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney International. 2001;60(4):1443-1451\n'},{id:"B110",body:'Pisoni RL, Arrington CJ, Albert JM, Ethier J, Kimata N, Krishnan M, et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: An instrumental variable analysis. American Journal of Kidney Diseases. 2009;53(3):475-491\n'},{id:"B111",body:'Hemodialysis Adequacy Work G. Clinical practice guidelines for hemodialysis adequacy, update 2006. American Journal of Kidney Diseases. 2006;48(Suppl 1):S2-S90\n'},{id:"B112",body:'Huber TS, Carter JW, Carter RL, Seeger JM. 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Dressings and securement devices for central venous catheters (CVC). Cochrane Database of Systematic Reviews;(2015, 9):CD010367\n'},{id:"B148",body:'Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press; 2006\n'},{id:"B149",body:'Hu H, Patel S, Hanisch JJ, Santana JM, Hashimoto T, Bai H, et al. Future research directions to improve fistula maturation and reduce access failure. Seminars in Vascular Surgery. 2016;29(4):153-171\n'},{id:"B150",body:'Fraser SD, Roderick PJ, May CR, McIntyre N, McIntyre C, Fluck RJ, et al. The burden of comorbidity in people with chronic kidney disease stage 3: A cohort study. BMC Nephrology. 2015;16:193\n'},{id:"B151",body:'Work J. Hemodialysis catheters and ports. Seminars in Nephrology. 2002;22(3):211-220\n'},{id:"B152",body:'Konner K. History of vascular access for haemodialysis. Nephrology, Dialysis, Transplantation. 2005;20(12):2629-2635\n'},{id:"B153",body:'Whittier WL. Surveillance of hemodialysis vascular access. Semin Intervent Radiology. 2009;26(2):130-138\n'},{id:"B154",body:'Sato T, Tsuboi M, Onogi T, Miwa N, Sakurai H, Ookubo K, et al. Standard procedures of endovascular treatment for vascular access stenosis in our facility—Clinical usefulness of ultrasonography. The Journal of Vascular Access. 2015;16(Suppl 10):S34-S37\n'},{id:"B155",body:'Majerus S, Dunning J, Potkay JA, Bogie KM. Flexible, structured MWCNT/PDMS sensor for chronic vascular access monitoring. 2016 IEEE Sensors Conference. Orlando, FL: Oral presentation. 30 Oct-2 Nov, 2016\n'},{id:"B156",body:'Aragoncillo I, Abad S, Caldes S, Amezquita Y, Vega A, Cirugeda A, et al. Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: A randomized controlled trial. The Journal of Vascular Access. 2017;18(4):352-358\n'},{id:"B157",body:'Arechabala MC, Catoni MI, Claro JC, Rojas NP, Rubio ME, Calvo MA, et al. Antimicrobial lock solutions for preventing catheter-related infections in haemodialysis. Cochrane Database of Systematic Reviews. 2018;4:CD010597\n'},{id:"B158",body:'Rajan DK, Ebner A, Desai SB, Rios JM, Cohn WE. Percutaneous creation of an arteriovenous fistula for hemodialysis access. Journal of Vascular and Interventional Radiology. 2015;26(4):484-490\n'},{id:"B159",body:'Hull JE, Jennings WC, Cooper RI, Waheed U, Schaefer ME, Narayan R. The pivotal multicenter trial of ultrasound-guided percutaneous arteriovenous fistula creation for hemodialysis access. Journal of Vascular and Interventional Radiology. 2018;29(2):149-158. e5\n'},{id:"B160",body:'Collins MJ, Li X, Lv W, Yang C, Protack CD, Muto A, et al. Therapeutic strategies to combat neointimal hyperplasia in vascular grafts. Expert Review of Cardiovascular Therapy. 2012;10(5):635-647\n'},{id:"B161",body:'Pradhan-Nabzdyk L, Huang C, LoGerfo FW, Nabzdyk CS. Current siRNA targets in the prevention and treatment of intimal hyperplasia. Discovery Medicine. 2014;18(98):125-132\n'},{id:"B162",body:'Xu K, Al-Ani MK, Pan X, Chi Q , Dong N, Qiu X. Plant-derived products for treatment of vascular intima hyperplasia selectively inhibit vascular smooth muscle cell functions. Evidence-based Complementary and Alternative Medicine. 2018;2018:3549312\n'},{id:"B163",body:'Gage SM, Lawson JH. Bioengineered hemodialysis access grafts. The Journal of Vascular Access. 2017;18(Suppl 1):56-63\n'},{id:"B164",body:'Leermakers JJ, Bode AS, Vaidya A, van der Sande FM, Evers SM, Tordoir JH. Cost-effectiveness of vascular access for haemodialysis: Arteriovenous fistulas versus arteriovenous grafts. European Journal of Vascular and Endovascular Surgery. 2013;45(1):84-92\n'},{id:"B165",body:'Porter ME. What is value in health care? 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The importance of early referral for the treatment of chronic kidney disease: A Danish nationwide cohort study. BMC Nephrology. 2012;13:108\n'},{id:"B171",body:'Canaud B, Tetta C, Marcelli D, Giordana G, Stuard S, Koehler K, et al. Implementation and Management of Strategies to Set and to Achieve Clinical Targets. Chapter 21. 2013. DOI: 10.5772/53041 [Accessed: January 24, 2019]\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Bernard Canaud",address:"bernard.canaud@fmc-ag.com",affiliation:'
Department of Nephrology, University of Montpellier, School of Medicine, Montpellier
Medical Office, Fresenius Medical Care Deutschland GmbH, Germany
Care Value Management, NephroCare, Fresenius Medical Care Deutschland GmbH, Germany
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Evans",authors:[{id:"96409",title:"Prof.",name:"Carla",middleName:null,surname:"Evans",slug:"carla-evans",fullName:"Carla Evans"},{id:"96472",title:"Prof.",name:"Budi",middleName:null,surname:"Kusnoto",slug:"budi-kusnoto",fullName:"Budi Kusnoto"},{id:"172854",title:"Dr.",name:"Emilia Taneva",middleName:null,surname:"Taneva",slug:"emilia-taneva-taneva",fullName:"Emilia Taneva Taneva"}]},{id:"18426",doi:"10.5772/18746",title:"Factors Affecting the Success of Dental Implants",slug:"factors-affecting-the-success-of-dental-implants",totalDownloads:17424,totalCrossrefCites:8,totalDimensionsCites:34,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Carlos Nelson Elias",authors:[{id:"32438",title:"Prof.",name:"Carlos",middleName:null,surname:"Elias",slug:"carlos-elias",fullName:"Carlos Elias"}]},{id:"32161",doi:"10.5772/38059",title:"Caries Through Time: An Anthropological Overview",slug:"caries-archaeological-and-historical-record",totalDownloads:6486,totalCrossrefCites:4,totalDimensionsCites:33,abstract:null,book:{id:"1742",slug:"contemporary-approach-to-dental-caries",title:"Contemporary Approach to Dental Caries",fullTitle:"Contemporary Approach to Dental Caries"},signatures:"Luis Pezo Lanfranco and Sabine Eggers",authors:[{id:"115399",title:"Dr.",name:"Luis",middleName:null,surname:"Pezo-Lanfranco",slug:"luis-pezo-lanfranco",fullName:"Luis Pezo-Lanfranco"}]}],mostDownloadedChaptersLast30Days:[{id:"61046",title:"Optical Diagnostics to Improve Periodontal Diagnosis and Treatment",slug:"optical-diagnostics-to-improve-periodontal-diagnosis-and-treatment",totalDownloads:6864,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The performance of clinicians undertaking periodontal assessment or periodontal therapy can be improved by using optical methods as adjuncts to visual inspection and periodontal probing. Subtle changes that occur over time in periodontal tissues that are below the detection limit of visual examination or periodontal probing can be found and tracked accurately over time using 3D imaging, fluorescence spectroscopy, and optical coherence tomography. During debridement of teeth and dental implants, the effective removal of subgingival microbial biofilms and dental calculus deposits can be enhanced using magnifying loupes and operating microscopes and by novel methods based on the interactions of light with bacterial deposits, such as differential reflectometry and light-induced fluorescence. While such techniques can also be used using initial case assessment, their primary purpose is for checking debridement procedures, since the point when bacterial deposits are no longer present represents an endpoint for treatment. The concept of real-time feedback has been developed, using fluorescence readings to control the removal of deposits. Overall, optical methods can support traditional periodontal diagnosis and improve treatment planning and clinical periodontal care.",book:{id:"7244",slug:"periodontology-and-dental-implantology",title:"Periodontology and Dental Implantology",fullTitle:"Periodontology and Dental Implantology"},signatures:"Fardad Shakibaie and Laurence Walsh",authors:[{id:"179467",title:"Prof.",name:"Laurence",middleName:null,surname:"Walsh",slug:"laurence-walsh",fullName:"Laurence Walsh"},{id:"235443",title:"Dr.",name:"Fardad",middleName:null,surname:"Shakibaie",slug:"fardad-shakibaie",fullName:"Fardad Shakibaie"}]},{id:"24363",title:"Biomechanics of Tooth-Movement: Current Look at Orthodontic Fundamental",slug:"biomechanics-of-tooth-movement-current-look-at-orthodontic-fundamental",totalDownloads:26524,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"277",slug:"principles-in-contemporary-orthodontics",title:"Principles in Contemporary Orthodontics",fullTitle:"Principles in Contemporary Orthodontics"},signatures:"Joanna Antoszewska and Nazan Küçükkeles",authors:[{id:"50158",title:"Prof.",name:"Joanna",middleName:null,surname:"Antoszewska",slug:"joanna-antoszewska",fullName:"Joanna Antoszewska"}]},{id:"71271",title:"Flap Techniques in Dentoalveolar Surgery",slug:"flap-techniques-in-dentoalveolar-surgery",totalDownloads:2438,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Most dentoalveolar procedures involve the reflection of mucosal flaps. This step is crucial for exposure or removal of impacted teeth, implant bed preparation, exposure of the alveolar bone for augmentation, periodontal surgeries, and repair of mucosal soft tissue defects, such as oroantral fistula. Because of the rich vascularity of the oral mucosa, great freedom is allowed for flap design, but it tends to result in carelessness and lack of thoughtful planning, which may lead to uneventful outcomes or/and complications. In this chapter, we review oral anatomy, classification, indications, and complications of common oral flap techniques; common flap designs are illustrated, and their fundamental principles are highlighted. The review has covered various flap designs based on their indications. Yet the common flap’s principles are fundamental for all types of flaps regardless of their application, namely, it should provide wide exposure, clear vision, good access, and assure rich vascularity and good final aesthetic outcome.",book:{id:"9387",slug:"oral-diseases",title:"Oral Diseases",fullTitle:"Oral Diseases"},signatures:"Randa Abdulmoein AlFotawi",authors:[{id:"308701",title:"Dr.",name:"Randa",middleName:"Abdulmoein",surname:"Alfotawi",slug:"randa-alfotawi",fullName:"Randa Alfotawi"}]},{id:"65088",title:"Evaluation and Management of Mandibular Fracture",slug:"evaluation-and-management-of-mandibular-fracture",totalDownloads:2834,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The mandibular bone is an important component of the facial bone, which has a unique role in digestive system, speech, and facial esthetics. For these important functions of mandibular bone, it is vital that surgeons should not only treat function but also consider the esthetics together. Mandibular fractures are among the most common traumatic injuries of the maxillofacial region. Even though treatment modalities are well established and being practiced for a long time, untreated and postoperative complications still decrease the patient’s quality of life. This chapter aims to describe the cause, clinical presentations, diagnoses, and current treatment methods on the basis of resent literature.",book:{id:"7572",slug:"trauma-in-dentistry",title:"Trauma in Dentistry",fullTitle:"Trauma in Dentistry"},signatures:"Guhan Dergin, Yusuf Emes and Buket Aybar",authors:[{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin"},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes"},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar"}]},{id:"56461",title:"Permanent Maxillary and Mandibular Incisors",slug:"permanent-maxillary-and-mandibular-incisors",totalDownloads:2535,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The permanent incisors are the front teeth that erupt between 6 and 8 years of age. They are eight in number, four upper and four lower, two centrals and two laterals. They have sharp biting surfaces designed for shearing and cutting of food materials into small chewable pieces. They are the teeth most visible to the others during eating, smiling and talking, and thus, they have high aesthetic value for the individuals. The unique characteristics, arch position, function, development and chronological age of each tooth will be highlighted. In addition, the different aspects with their geometric outlines, outlines and surface anatomy of these teeth will be described. A brief explanation about the pulp cavity, tooth socket and normal occlusion for each tooth will be included.",book:{id:"5814",slug:"dental-anatomy",title:"Dental Anatomy",fullTitle:"Dental Anatomy"},signatures:"Mohammed E. Grawish, Lamyaa M. Grawish and Hala M. Grawish",authors:[{id:"82989",title:"Prof.",name:"Mohammed",middleName:"E",surname:"Grawish",slug:"mohammed-grawish",fullName:"Mohammed Grawish"}]}],onlineFirstChaptersFilter:{topicId:"174",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80964",title:"Upper Airway Expansion in Disabled Children",slug:"upper-airway-expansion-in-disabled-children",totalDownloads:28,totalDimensionsCites:0,doi:"10.5772/intechopen.102830",abstract:"Breathing is essential for life in all of its stages. Cellular, mitochondrial respiration requires an adequate supply of oxygen, provided by the air we breathe, after airway conduction, treatment by the lungs, and transport to tissues. At different stages of life, pediatric dentists and orthodontists can intervene in the upper airway, expanding it, which helps with ventilation. The greater airway space, if used, contributes in different ways to the child’s development and the recovery of respiratory problems and should always be present as a weapon that physicians and the population should know. The value of the techniques becomes even more important when applied to children and young people with disabilities who can significantly improve their development and performance. Rapid Maxillary Expansion and Extraoral Traction Appliances are two important pediatric resources to treat these children. Clinical practice of the authors, is discussed, emphasizing the importance of early intervention and the need for multi and interdisciplinary collaboration in the follow-up of disabled people.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"David Andrade, Joana Andrade, Maria-João Palha, Cristina Areias, Paula Macedo, Ana Norton, Miguel Palha, Lurdes Morais, Dóris Rocha Ruiz and Sônia Groisman"},{id:"80963",title:"Pain Perception in Patients Treated with Ligating/Self-Ligating Brackets versus Patients Treated with Aligners",slug:"pain-perception-in-patients-treated-with-ligating-self-ligating-brackets-versus-patients-treated-wit",totalDownloads:20,totalDimensionsCites:0,doi:"10.5772/intechopen.102796",abstract:"This study compared the perception of pain experienced by patients undergoing orthodontic treatment with conventional, self-ligating brackets and aligners, and investigated the impact that pain had on their daily lives. 346 consecutive patients were included in the study: 115 patients treated with conventional brackets, 112 Patients treated with self-ligating brackets, and 119 patients treated with aligners. The quantitative aspect of pain was assessed using the Visual Analogue Scale, while the qualitative aspect of pain was evaluated using the Moroccan Short Form of McGILL Pain questionnaire. In all three groups experienced pain after activation tended to decrease in the following week. This pain was greater in patients with conventional braces and less in patients with aligners. Using the M-SF-MPQ to describe the qualitative aspect of the pain revealed that the “cramping مزير,” “aching تيألم ” aspect was most accentuated in the 3 groups. Medication intake was correlated with the intensity of pain experienced in all 3 systems. As for the impact of pain on daily activities, patients in groups of conventional and self-ligating braces showed more pain than those in the aligners group. Overall, aligners were less painful than conventional and self-ligating appliances. Patients did not suffer from an alteration in their quality of life due to orthodontic treatment.",book:{id:"10780",title:"Current Trends in Orthodontics",coverURL:"https://cdn.intechopen.com/books/images_new/10780.jpg"},signatures:"Farid Bourzgui, Rania Fastani, Salwa Khairat, Samir Diouny, Mohamed El Had, Zineb Serhier and Mohamed Bennani Othmani"},{id:"80839",title:"Herbs and Oral Health",slug:"herbs-and-oral-health",totalDownloads:45,totalDimensionsCites:0,doi:"10.5772/intechopen.103715",abstract:"Herbal medicine has long been used to prevent and control disease, and it can minimize the potential side effects of chemical products. However, side effects from herbs do exist. Most of the challenges with herbal medicine revolves around inadequate information about the effect of herbs in the oral cavity, the mechanism of action, and potential side effects. There are several herbs described in this chapter have anti-inflammatory, anti-bacterial, anti-viral, anti-fungal in oral micro-organisms. It includes aloe vera, ginger, clove, cinnamon, garlic, neem, miswak, turmeric, tulsi, green tea, chamomile, fenugreek, anise plant, peppermint, bloodroot, caraway, eucalyptus, phyllanthus emblica, black seed, myrrh, rosemary, sage, and thyme; some may act as an alternative management option to current treatments for oral conditions such as caries prevention, gingivitis, periodontitis, oral burn, ulcers and inflammation, after extraction, dry mouth, pain reduction, anesthesia, intracanal medications, ill-fitting dentures, peri-implant mucositis and peri-implantitis. It can be used in several forms such as mouthwashes, toothpastes, topical agents or local drug delivery devices. However, more research is needed to understand their mechanisms and potential side effects.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Zuhair S. Natto"},{id:"80441",title:"Periodontitis and Heart Disease: Current Perspectives on the Associative Relationships and Preventive Impact",slug:"periodontitis-and-heart-disease-current-perspectives-on-the-associative-relationships-and-preventive",totalDownloads:49,totalDimensionsCites:0,doi:"10.5772/intechopen.102669",abstract:"Due to the important advancement and the accumulation of new evidence on the periodontitis-cardiovascular disease (CVD) relationship as well as the major medical, economic and social burden caused by both diseases this chapter aims to review existing epidemiological and pathogenetic links related to this topic. Also, this chapter aims to highlight the impact of the periodontitis-CVD relationships on clinical practice and on the preventive approaches targeting to decrease the impact of periodontitis on CVD. Periodontitis is an infectious disease eliciting local and general inflammation, which leads to periodontal destruction and systemic involvement. Several pathways could explain the link between periodontitis and CVD such as bacteraemia, chronic persistent systemic inflammation and oxidative stress. The first step in the treatment of periodontitis addresses the elimination of microbial components, which lead to a decrease in local and systemic inflammation. Periodontal therapy seems to positively impact CVD. Specialists should inform patients with CVD on the negative impact of periodontitis on their systemic status and refer patients to the periodontist for an extensive examination as routine management of CVD. Some possible risks of periodontal therapy should be considered in patients undergoing antithrombotic medication.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Alexandra Roman, Andrada Soancă, Bogdan Caloian, Alexandru Bucur, Gabriela Valentina Caracostea, Andreia Paraschiva Preda, Dora Maria Popescu, Iulia Cristina Micu, Petra Șurlin, Andreea Ciurea, Diana Oneț, Mircea Viorel Ciurea, Dragoș Alexandru Țermure and Marius Negucioiu"},{id:"79498",title:"Oral Aspects and Dental Management of Special Needs Patient",slug:"oral-aspects-and-dental-management-of-special-needs-patient",totalDownloads:59,totalDimensionsCites:0,doi:"10.5772/intechopen.101067",abstract:"Individuals with special needs are the most underserved regarding healthcare needs in almost all populations. Special needs patients with intellectual disability have muscle coordination disorder, impaired oral motor function, drooling, weak muscles that cause chewing and swallowing problems. Also, soft diet consumption makes this population more prone to dental disease. They have more caries, missing teeth, orthodontic and periodontal problems. Besides more difficulties obtaining professional dental care than other segments of the population. Though many countries developed community-based systems to improve oral health for people with special needs, providing good oral health mainly depends on the effort of the families. Therefore the education of the caregiver about oral hygiene provision is also critical for the special needs patient to enjoy a lifetime of oral health the same as other members of the society.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Pinar Kiymet Karataban"},{id:"79699",title:"Metabolomics Distinction of Cigarette Smokers from Non-Smokers Using Non-Stationary Benchtop Nuclear Magnetic Resonance (NMR) Analysis of Human Saliva",slug:"metabolomics-distinction-of-cigarette-smokers-from-non-smokers-using-non-stationary-benchtop-nuclear",totalDownloads:47,totalDimensionsCites:0,doi:"10.5772/intechopen.101414",abstract:"Implementations of high-field nuclear magnetic resonance (NMR) facilities into metabolomics studies are unfortunately restricted by their large dimensions, high costings, and specialist technical staff requirements. Therefore, here the application and practical advantages offered by low-field (60 MHz), compact NMR spectrometers for probing the metabolic profiles of human saliva was explored, as was their value in salivary metabolomics studies. Saliva samples were collected from cigarette smoking (n = 11) and non-smoking (n = 31) human participants. 1H NMR spectra were acquired on both low-field (60 MHz) and medium-field (400 MHz) spectrometers. Metabolomics analyses were employed to evaluate the consistencies of salivary metabolite levels determined, and their abilities to distinguish between smokers and non-smokers. Low-field 1H NMR analysis detected up to 15, albeit permitted the reliable quantification of 5, potentially key diagnostic biomolecules simultaneously (LLOQ values 250–400 μmol/L), although these were limited to those with the most prominent resonances. Such low-field profiles were also found to be suitable for salivary metabolomics investigations, which confirmed the successful discrimination between smoking and non-smoking participant sample donors. Differences observed between these groups were largely ascribable to upregulated salivary levels of methanol, and its metabolite formate, in the smoking group, but higher smoking-mediated concentrations of acetate, propionate and glycine may arise from a diminished salivary flow-rate in these participants. In conclusion, determination of salivary biomolecules using low-field, benchtop 1H NMR analysis techniques were found to be valuable for bioanalytical and metabolomics investigations. Future perspectives for the applications of this non-stationary NMR technique, for example for the on-site ‘point-of-care’ testing of saliva samples for diagnostic oral disease screening purposes at dental surgeries and community pharmacies, are considered.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Benita C. Percival, Angela Wann, Sophie Taylor, Mark Edgar, Miles Gibson and Martin Grootveld"}],onlineFirstChaptersTotal:36},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:8,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:286,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:9,numberOfPublishedChapters:101,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:null,scope:"
\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
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\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
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\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
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\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
",coverUrl:"https://cdn.intechopen.com/series/covers/24.jpg",latestPublicationDate:"April 24th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:0,editor:{id:"262440",title:"Prof.",name:"Usha",middleName:null,surname:"Iyer-Raniga",slug:"usha-iyer-raniga",fullName:"Usha Iyer-Raniga",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRYSXQA4/Profile_Picture_2022-02-28T13:55:36.jpeg",biography:"Usha Iyer-Raniga is a professor in the School of Property and Construction Management at RMIT University. Usha co-leads the One Planet Network’s Sustainable Buildings and Construction Programme (SBC), a United Nations 10 Year Framework of Programmes on Sustainable Consumption and Production (UN 10FYP SCP) aligned with Sustainable Development Goal 12. The work also directly impacts SDG 11 on Sustainable Cities and Communities. She completed her undergraduate degree as an architect before obtaining her Masters degree from Canada and her Doctorate in Australia. Usha has been a keynote speaker as well as an invited speaker at national and international conferences, seminars and workshops. Her teaching experience includes teaching in Asian countries. She has advised Austrade, APEC, national, state and local governments. She serves as a reviewer and a member of the scientific committee for national and international refereed journals and refereed conferences. She is on the editorial board for refereed journals and has worked on Special Issues. Usha has served and continues to serve on the Boards of several not-for-profit organisations and she has also served as panel judge for a number of awards including the Premiers Sustainability Award in Victoria and the International Green Gown Awards. Usha has published over 100 publications, including research and consulting reports. Her publications cover a wide range of scientific and technical research publications that include edited books, book chapters, refereed journals, refereed conference papers and reports for local, state and federal government clients. She has also produced podcasts for various organisations and participated in media interviews. She has received state, national and international funding worth over USD $25 million. Usha has been awarded the Quarterly Franklin Membership by London Journals Press (UK). Her biography has been included in the Marquis Who's Who in the World® 2018, 2016 (33rd Edition), along with approximately 55,000 of the most accomplished men and women from around the world, including luminaries as U.N. Secretary-General Ban Ki-moon. 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Several international research projects has been performed with European partners from France, Netherlands, Norway and the UK. He is currently Professor of Communications Systems at the Harz University of Applied Sciences, Germany.\n\nPublications and Publishing\nHe has edited one book, a special interest book about ‘Optoelectronic Packaging’ (VDE, Berlin, Germany), and has published over 100 papers and is owner of several international patents for WDM over POF key elements.\n\nKey Research and Consulting Interests\nUlrich’s research activity has always been related to Spectroscopy and Optical Communications Technology. Specific current interests include the validation of complex instruments, and the application of VR technology to the development and testing of measurement systems. He has been reviewer for several publications of the Optical Society of America\\'s including Photonics Technology Letters and Applied Optics.\n\nPersonal Interests\nThese include motor cycling in a very relaxed manner and performing martial arts.",institutionString:null,institution:{name:"Charité",country:{name:"Germany"}}},{id:"341622",title:"Ph.D.",name:"Eduardo",middleName:null,surname:"Rojas Alvarez",slug:"eduardo-rojas-alvarez",fullName:"Eduardo Rojas Alvarez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/341622/images/15892_n.jpg",biography:null,institutionString:null,institution:{name:"University of Cuenca",country:{name:"Ecuador"}}},{id:"215610",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sarfraz",slug:"muhammad-sarfraz",fullName:"Muhammad Sarfraz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/215610/images/system/215610.jpeg",biography:"Muhammad Sarfraz is a professor in the Department of Information Science, Kuwait University, Kuwait. 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He is also an editor and editor in chief for various international journals.",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"32650",title:"Prof.",name:"Lukas",middleName:"Willem",surname:"Snyman",slug:"lukas-snyman",fullName:"Lukas Snyman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/32650/images/4136_n.jpg",biography:"Lukas Willem Snyman received his basic education at primary and high schools in South Africa, Eastern Cape. He enrolled at today's Nelson Metropolitan University and graduated from this university with a BSc in Physics and Mathematics, B.Sc Honors in Physics, MSc in Semiconductor Physics, and a Ph.D. in Semiconductor Physics in 1987. After his studies, he chose an academic career and devoted his energy to the teaching of physics to first, second, and third-year students. 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