Far Infrared Therapy on Arteriovenous Fistulas in Hemodialysis Patients

Effect of Far Infrared Therapy on Arteriovenous Fistulas Maturation, Survival and Stenosis. A Randomized, Controlled Open-labeled Multicenter Study

The number of hemodialysis patients in the world are increasing. In order to receive a sufficient dialysis, the patients needs a well functioning and stable vascular access - preferably an arteriovenous fistula (AVF). Unfortunately, the AVF has a high incidence of stenosis with percutaneous trans luminal angioplasty (PTA) as the only treatment option and a short lifetime. Little do we know of how to improve the survival of the AVF. With this study we want to explore the effect of far infrared therapy on the stenosis, maturation and survival of the arteriovenous fistula. The investigators will divide the patients into 2 groups: A treatment group and a control group. The treatment group will receive infrared therapy on their fistula during their dialysis session. The control group will not receive any infrared therapy. The investigators hope to reduce the risk of stenosis in the fistula and improve the fistula survival with this treatment. Furthermore, the investigators want to explore the change in several biochemical markers during the treatment with infrared therapy.

Background: The number of hemodialysis patients in the world are increasing. In order to receive an efficient dialysis, the patient needs a well-functioning and stable vascular access. Presently there is three options: an arteriovenous fistula (AVF), an arteriovenous graft (AVG) and a central venous catheter (CVC). CVCs are associated with an increased risk of stenosis of the central vessels, thrombosis in the AVF, infections and death. AVGs are associated with increased risk of infections, stenosis in the AVG and loss of access. This is why, the AVF is the preferred vascular access. But this vascular access does not come without risks. After the creation of an AVF there is a risk of 50 % for never maturing, which means the AVF cannot be used. Furthermore, the risk of stenosis in the AVF is also high, up to 67 % of the AVFs will have a stenosis, that needs an intervention. During this time the patient needs an alternative vascular access, such as a central venous catheter, which is related to an increased risk of infection, more hospital days and death. The maturation of the AVF depends on several patient related, but also surgically related factors. Factors such as comorbidity, female sex, length of end stage renal disease, anatomy of the vessel, surveillance after AVF placement and the operations itself have all been shown to affect the AVF maturation. Fistula stenosis emerges from an endothelial dysfunction, inflammation and smooth muscle cell proliferation leading to intimal hyperplasia and in the end stenosis. Factors such as increased blood flow, inflammation, uremia and percutaneous transluminal angioplasty has been shown to affect the stenosis, It is not well understood, which molecular mechanism are responsible for the intimal hyperplasia. There are few and not well established studies on how to improve the AVF survival and maturation. Far infrared radiation (FIR) is an electromagnetic radiation (heat therapy), that is given directly on the skin above the AVF. In a few single center studies in Taiwan it has been shown to decrease the risk of stenosis and increase the fistula survival and maturation. However another study is disputing this. The mechanism behind FIR and better fistula survival is not fully understood. The infrared light is supposed to have a thermal effect, which leads to vasodilatation and a non-thermal effect, which influence the endothelial function and vasodilation and thereby it may decrease the inflammation and proliferation in the fistula, primarily through the releasing of several anti-inflammatory and vasodilating factors. This is not well documented. Hypothesis: Treatment with FIR for 40 minutes three times a week on the patients AVF will improve the AVF survival and maturation Method: This study is a randomized, controlled multicenter study on western patients There will be 2 patient categories: A group (82 patients) of dialysis patients with a newly created AF A group (104 patients) of dialysis patients with an existing AVF The patients will randomly be randomized 1:1 to either the treatment group or a control group. For group 2 the patients will be block randomized according to their access flow (AF) (above or below 950 ml/min). Furthermore these patients will be stratified according to interventions in there AVF (no interventions >/= 1 intervention) For the FIR treatment Ws Far Infrared Therapy Unit, model TY-102F (Medical device Class 11a CE0434) is being used. The patients will receive 40 minutes of infrared radiation on the skin of their fistula during each dialysis treatment for one year. The control group will not receive any FIR treatment, but will be followed according to the protocol and in line with the treatment group. The patients will be followed until end of study or lost-to-follow-up (death, transplantations, change of renal replacement therapy, abandoned AVF, change of vascular access to CVC, consent withdrawal or if the patients moves away). In order to explore the long term effects of FIR the patients will be followed for an extra 6 months according to the endpoints. In a subset of 2x20 patients of the randomized controlled trial we further wish to explore the influence of infrared therapy on endothelial function and inflammation during a FIR treatment session. Blood samples will be collected before and immediately after infrared treatment directly from the treatment site, since 2 needles are placed in the fistula during the dialysis treatment. The same samples will be collected in the control group and in the intervention group during the dialysis before the first infrared intervention in order to reduce the interindividual variation in the biomarkers.The changes in markers of endothelial dysfunction and inflammation during treatment and control dialysis session will be examined and compared. Furthermore a blood sample from each patient will be collected at study start. The predictive value of the biomarkers of endothelial dysfunction and inflammation for the treatment response to infrared therapy and the prognosis for fistula maturation, stenosis and survival will be evaluated after the randomised controlled trial has ended. Arterial stiffness (measured by Mobil-O-Graph) will also be evaluated as a marker for fistula survival and maturation. A total of 186 participants will be recruited from 9 dialysis centres. If the study shows positive results, the implication of FIR in the clinic will have a huge beneficial effect for the hemodialysis patients vascular access and perhaps also patient survival. FIR is an easy treatment with a low cost-effectiveness and minimal or no side effects for the patient.

Far infrared radiation will be given for 40 minutes on the skin above the patients fistula in each dialysis session for one year

The control group will not receive any intervention, but will be followed with the same data as the treatment group

The treatment group will receive FIR for 40 minutes on the skin above the fistula during each dialysis session for one year.

Time from placement of the fistula to successful cannulation with 2 needles and successful hemodialysis treatment

For the fistulae with or without previous interventions we expect to find a decrease in the number of interventions in the treatment group compared to the control group

Is there a difference in the diameter measured by ultrasound between the 2 groups with patients with a newly places fistula

For patients with a new fistula and patients with a fistula with/without interventions how many will loose their fistula and receive a new vascular access

How many of the fistulas in the group with a new fistula needs an intervention in order to get a functioning fistula

Baseline value in adhesion molecules, heme-oxygenase and ADMA and selectin as a predictor for AVF survival stenosis

Before study start the following change in markers will be explored: vascular cell adhesion molecule (in ng/ml), intercellular adhesion molecule (in ng/ml), sE-selectin (in ng/ml), assymetric dimethylarginine (in ng/ml), heme-oxygenase-1 (in ng/ml)

Before study start the following change in markers will be explored: nitrite (in uM), nitrate (in uM)

Before study start the following change in markers will be explored: endothelin (in pg/ml), prostaglandin E2 (in pg/ml, Interleukin-beta (pg/ml), Interleukin-6 (in pg/ml), Interleukin-8 (in pg/ml), tumor necrosis factor-alpha (in pg/ml), transformin growth factor-beta (in pg/ml) and monocyte chemoattractant protein 1 (in pg/ml).

Difference in cannulation pain in the incident and prevalent group compared with visual analogue scale

Do the patients receiving FIR treatment experience less pain during cannulation compared to the control group evaluated by the VAS (visual analogue scale) score

In a subgroup of patients we want to study the acute changes of the following markers during a FIR treatment Analysing Serum Amyloid A (in Ug/ml)

Acute changes in adhesion molecules, heme-oxygenase and ADMA and selectin as a predictor for AVF survival stenosis after a single FIR treatment

In a subgroup of patients we want to study the acute changes of the following markers during a FIR treatment, analysing: vascular cell adhesion molecule (in ng/ml), intercellular adhesion molecule (in ng/ml), sE-selectin (in ng/ml), assymetric dimethylarginine (in ng/ml), heme-oxygenase-1 (in ng/ml)

In a subgroup of patients we want to study the acute changes of the following markers during a FIR treatment Analysing: von WillebrandFactor (in ml-1)

In a subgroup of patients we want to study the acute changes of the following markers during a FIR treatment Analysing: nitrite (in uM), nitrate (in uM)

In a subgroup of patients we want to study the acute changes of the following markers during a FIR treatment Analysing: endothelin (in pg/ml), prostaglandin E2 (in pg/ml), Interleukin-beta (pg/ml), Interleukin-6 (in pg/ml), Interleukin-8 (in pg/ml), tumor necrosis factor-alpha (in pg/ml), transformin growth factor-beta (in pg/ml) and monocyte chemoattractant protein 1 (in pg/ml).

Inclusion Criteria: For incident AVF: Patients of 18 years of age or above Patients on chronic hemodialysis with a central venous catheter, who is having an AVF placed An AVF, that are maximum 3 weeks old For prevalent AVF: Patients in chronic hemodialysis with a functioning AVF Patients of 18 yeas of age or above Exclusion Criteria: Not obtainable informed consent Non compliant patients Patients who use both a CVC and an AVF as their vascular access Patient on both hemodialysis and peritoneal dialysis Planned living donor kidney transplantation Short life expectancy, less than a 1 year Patients on hemodialysis less than 3 times per week

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