To study the effect of handgrip exercise on the outcome of arteriovenous fistula surgery. A randomized controlled trial.

INTRODUCTION

 The prevalence of CKDin India is 17.2% with end stage renal disease (ESRD) being 0.8%1. Hemodialysis(HD) is an important modality in the treatment of chronic renal failure.Patients undergoing chronic HD require a placement of permanent vascular accesswhich is superficial and has little resistance with optimum flow.2-6Native arteriovenous fistula ,arteriovenous shunts – AV grafts and tunneled double lumen catheters arevarious access which can be used for hemodialysis.2-6 As centralvenous catheters and grafts have high infection and thrombosis rates ,AV fistulais the preferred access.7

Alexis Carrel first introduced the three-point end-to-end- and a side-to-side-anastomosis in 1912, amilestone and still used today . Brescia and Cimino introduced nativearteriovenous fistula for hemodialysis in 1966 8. Hemodialysis access survival rates are longer with native A-V fistulathan A-V grafts. 9 Native A-V fistulas are associated with lowerinfection rate than A-V grafts and percutaneous catheters. 10

There are differenttypes of native arteriovenous fistula – Radial-cephalic, Brachial-cephalic orbrachial-basilic. They can be differentiated on the basis of type of anastomosis– side to side, end to side and end to end. The most commonly used isradial-cephalic end to side.  Before wecan use the A-V fistula it requires some time for structural modification ofvein .It results in arterialization of vein as a result of turbulent flow afterwhich it can be used for cannulation for hemodialysis.11

Patients onhemodialysis have reduced physical exercise. Exercise maintains blood pressureand oxidative stress and also improves arterial compliance, cardio-vascularprofile ,  cardiac and left ventricularfunction.12 The NationalKidney Foundation Disease outcome quality initiative 2006 guidelines recommendregular forearm exercise post-operatively to aid in maturation of A-V fistula.13Although a definitive conclusion regarding post-operative exercise isstill awaited from studies , but some studies show that regular fore-armexercise improve vein diameter and thus help in maturation of A-V fistula . 9

Ithas been shown that local physical exercise in patients with end-stage renaldisease may have a beneficial effect on forearm arteries and veins 14,and that intermittent compression of the upper arm veins alone improved thediameter of forearm veins 15.An intensive exercise program mayimprove fistula maturation via increasing the luminal diameter of vein and maypermit early use of arteriovenous fistula.9 Along with that regular handgrip training increases thediameters of forearm vessels. It also improves endothelium-dependent vasodilatation.17,18

A simple, incremental resistance, exercise-trainingprogram has been found to cause a significant increase in the size of thecephalic vein commonly used in the creation of an arteriovenousfistula. The increase in size and resultant probable increase in bloodflow may theoretically accelerate the maturation of native arteriovenous fistulae,thereby lessening the morbidity associated with vascular access.18

There have been onlya few studies for evaluation of influence of exercise on functioning,maturation and success of A-V fistula surgery. So we are going to conduct astudy in which we will evaluate both pre-operative and post – operative effectof exercise on overall outcome of A-V fistula surgery.

PURPOSE OF STUDY**-**

1. The arteriovenousfistula is considered to be the gold standard form of access for haemodialysispatients. 2-6 Better strategies are needed to promote AVF creationand maturation. Therefore, interventions aimed at enhancing fistula maturationare warranted.

2. However, there is no evidence for handgrip exerciseresulting in improvement in AV fistula surgery outcome. Therefore, the purposeof this study is to find whether handgrip exercise performed before and afterthe surgery results in the improvement of the outcome of Arteriovenous fistulasurgery in CKD patients (pre-dialysis patients). 16

PROCEDURE

**PRE-OPERATIVEWORKUP:**Patients attending vascular access clinic for creationof arteriovenous fistula for the purpose of haemodialysis will be recruitedunder the study protocol.

History of risk factors will be taken – Diabetesmellitus , Hypertension , peripheral vascular disease , Congestive cardiacfailure , previous surgery in neck or chest , PICC(Peripherally insertedcentral catheter) , Central line insertion(temporary or perm catheter) ,previous failed attempt at AV fistula and site and complications of previousAVF/ catheters .

Examination of artery and vein – Brachial artery,radial artery and ulnar artery pulses palpability, arterial wall hardening/plaques,compressibility of vein, patency of palmar arch, dilated collateral veins over chest/breastand upper arm, Scars of previous central line insertions in the neck, Scars ofPICC line in arm or forearm, Multiple sites of vein prick scars / localizedthickening or phlebitis and sites available for creation of vascular access isassessed.

Investigations that will be performed – Investigationslike kidney function test will be done. USG Doppler will be preformed 8 weeksbefore the surgery, on the day of surgery and 8 weeks after creation of AVfistula.

Patients will be allocated to one of the three groups-Patients in group A will be given routine pre-operative teaching and care of AVfistula. Patients in group B will be asked to do handgrip exercise (withouttourniquet at arm) for 8 weeks after AV fistula surgery.

**OPERATIVEPROCEDURE –**Depending on the site most suitable for creation of AVfistula – Radio cephalic, Brachiocephalic or Brachiobasilic fistula will becreated.

**POST-OPERATIVELY-**Post operatively patient will be started on antibioticsand analgesics depending on cases to case basis as per the requirement of thepatient. They will be followed in the post operative period according topre-determined parameters provided in the Performa.

Success of fistula in terms of its use successfullyfor dialysis at the end of two months will be assessed and successfulmaturation of fistula will be assessed via USG Doppler at the end of 8 weeks.

REVIEWOF LITERATURE –

The basis for management of chronicrenal failure patients is hemodialysis initially.19 Hemodialysisrequires placement of a permanent vascular access which should provide safe andeffective withdrawal of blood and return of blood via extracorporeal circuit. 20The fundamental forms of chronic vascular access available are nativearteriovenous fistula, arteriovenous grafts and double lumen catheters. Ofthese, the native AVF is preferred for long-term hemodialysis vascular accesssince it has low morbidity, superior primary patency rates, lowest rates of thrombosis,longer duration of action, lower infection rates, lower need of secondaryinterventions and low cost .2-6

The National KidneyFoundation Kidney Disease Quality Outcomes Initiative (NKF-KDOQI) clinicalpractice guidelines suggest a goal prevalence rate for successful native AVF of65 percent 7. NKF-K/DOQI2006 defines vascular access functional when – flow is >600ml / min, veindiameter is >0.6 cm ,  it has depth< 0.6 cm and it has clearly defined margins. According toNKF-KDOQI Practice Guidelines, the order of preference for the creation of AVFis radial-cephalic, brachial-cephalic, and then brachial-basilic transposition .23

Thereare still difficulties in both pre-operative and post-operative periods regardingA-V fistula surgeries. Overly aggressive attempts to increase AVF prevalence inpatients with suboptimal anatomy leads to reduced maturation rates, and alonger duration of dialysis catheter use 8. Post-operatively primarycauses for fistula abandonment are –failure to mature (27%), thrombosis (17%),post operative steal syndrome (1%) etc . Primary endpoint for every fistulasurgery is maturation / fistula functional maturation. The maturation can beassessed on physical examination as well as on post-operative USG Doppler ifneeded. On USG Doppler maturation is defined by adequate vein dilation (Depth< 6mm, diameter >6mm). 21

Fistula maturation depends on several changes involving thevein such as increased rate of blood flow, increased vein diameter, andincreased visibility of the vein. Successful fistula creation results in easycannulation within 90 days of placement and adequate blood flow to supportdialysis.22

 Vessel diameter is an important predictorof functional maturity of a fistula . 23 The artery and vein intraluminaldiameter are very important before construction of an A-V fistula 24, because it is known thatatherosclerotic and/or smaller arteries and small-sized cephalic veins aremostly responsible for the primary failure of arteriovenous fistula construction25. In previousstudies vein diameter was found to have major predictor of fistula maturation. 26In Lauvao et al (2009) showed that vein diameter of size four or more aresignificant predictor for maturation of fistula. (p<0.0002). 26 Dueto lack of adequate size vein in the forearm or arm, AV fistula surgery isoften associated with higher failure rate

 Adequate blood flow volume is also anessential requirement for proper hemodialysis. For functional maturation a flowrate of 350-400 ml/min may be needed for atleast 4 hours.

 So thematuration of an A-V fistula is an important part in a fistula surgery .26Lack of maturation of AV fistula (i.e. inadequate flow rate and/or lack ofadequate luminal diameter) may result in failure of AVF surgery or latedialysis suitability.

 Aerobic exercise has been reported toimprove vascular flow and venous compliance.  Various types of handgrip and softballexercises have been described for local physical training in end stage renaldisease patients. 28Oder et al (2003) showed significantincrease in diameter of vein ranging from 3.8% to 25% in his study(p<0.0001). 27SimilarlySangwon kong et al (2014) compared both handgrip as well as soft ball exercisesand found that both handgrip as well as soft ball exercises were increasing thevein diameter significantly(7.0+/- 1.3mm and 7.4+/- 1.2mm respectively) .30

The only randomizedcontrol trial assessing the effect of progressive handgrip training on arteriovenousfistula showed small effect on change of venous diameter. 30Similarly other studies also show that hand grip exercises increases vein sizeand diameter.

Sangwon kong et al(2014)  showed that both hand grip andsoft ball exercises were increasing blood flow volume through the fistula(861.5ml and 575. 8 ml respectively).28

It has been shown thatlocal physical exercise in patients with end-stage renal disease may have abeneficial effect on forearm arteries and veins 13, and thatintermittent compression of the upper arm veins alone improved the diameter offorearm veins. 14 An intensive exercise program may improve fistulamaturation via increasing the diameter of vein and may permit early use ofarteriovenous fistula. 31

A controlled exerciseprogram in post operative period increases maturation rate of arteriovenousfistula. 16

Studies have shown thathand squeezing exercise programalso result in acute dilatation of arteriovenous fistula and they do recommendthat exercise should be continued in post operative period. 31

However there is lack of evidence aboutthe benefit of preoperative hand exercise in improving the outcome ofarteriovenous fistula surgery. It is known that regular handgrip trainingincreases the diameters of forearm vessels. It also improvesendothelium-dependent vasodilatation.27 , 30. A simple, incremental resistance, exercise-trainingprogram has been found to cause a significant increase in the size of thecephalic vein commonly used in the creation of an arteriovenousfistula. The increase in size and resultant probable increase in bloodflow may theoretically accelerate the maturation of native arteriovenous fistulae,thereby lessening the morbidity associated with vascular access.36

These changes point to the possiblebeneficial effects of daily handgrip training in chronic renal failure patientsbefore arteriovenous fistula construction.

BIBLIOGRAPHY–

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8.      Historyof vascular access for haemodialysis.   Klaus Konner

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10.  Cost-effectivenessof Vascular Access for Haemodialysis: Arteriovenous Fistulas VersusArteriovenous Grafts .  J.J.P.M.Leermakers, A.S.Bode, A.Vaidya, S.M.A.A.Evers, J.H.M.Tordoir,

11.   Hemodialysis vascular access survival: upper-arm native arteriovenousfistula.Dixon BS, Novak L, Fangman J SO , Am J Kidney Dis.2002;39(1):92.

12.  The effects of progressive handgrip training onarteriovenous fistula maturation in  chronic kidney disease – a pilot randomised controlled trial . Junglee,N, Law, B, Bigwood, B, William, Jibani, M, Macdonald ,Ysbyty Gwynedd Hospital, BangorGeneral Hospital, Bangor University, North Wales

13.  National Kidney Foundation,Inc . K/DOQIGuidelines – Updates 2006.

14.  Rus RR, Ponikvar R, Kenda R, Buturović-Ponikvar J. Effect oflocal physical training on the forearm arteries and veins in patients withend-stage renal disease. BloodPurif 2003; 21: 389–94.

15.  Rus RR, Ponikvar R, Kenda R, Buturović-Ponikvar J. Effect ofintermittent compression of upper arm veins on forearm vessels in patients withend-stage renal disease. HemodialysisInt .

16.  Effectsof Handgrip Training and Intermittent Compression of Upper Arm Veins on ForearmVessels in Patients With End-stage Renal Failure . Rina Rus, RafaelPonikvar,Rajko B Kenda, Jadranka Buturović-Ponikvar

17.  Effectof Local Physical Training on the Forearm Arteries and Veins in Patients withEnd-Stage Renal Disease . Rus R.R Â· Ponikvar· Kenda R.B. Buturović-Ponikvar J. Departmentsof Pediatric Nephrology and Nephrology, University Medical Centre,Ljubljana, Slovenia

18.  Isometric exercise increases the size of forearm veins inpatients with chronic renal failure.Leaf DA, MacRae HS, Grant E, Kraut J.

19.   The NationalService Framework for Renal Services Part 1: Dialysis and Transplantation,Department of Health, London, UK, January 2004.

20. Atkins D, Best D, Briss PA et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328:1490.

21.   . J Nephrol. 2002 Nov-Dec;15 Suppl6:S28-32.Vascular access in the 21st century. Konner

22.  VascularAccess for Hemodialysis - How to Maintain in Clinical Practice Hossam Elwakeeland Khaled Elalf

23.  Veindiameter is the major predictor of fistula maturation .Lannery S. Lauvao, MD, Daniel M. Ihnat, MD, Kaoru R. Goshima, MD, LeAnnChavez, MD,Angelika C. Gruessner, MS, PhD, and Joseph L. Mills Sr, MD, Tucson,Ariz

24.  Malovrh M. Approachto patients with end-stage renal disease who need an arteriovenous fistula. NephrolDial Transplant 2003;18: v50–52.

25.  Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A. Factorsassociated with early failure of arteriovenous fistulae for haemodialysisaccess. Eur JVasc Endovasc Surg 1996;12: 207–13.

26.   J Nephrol. 2002 Nov-Dec;15 Suppl6:S28-32.Vascular access in the 21st century. Konner

27.  TheEffect of Two Different Hand Exercises on Grip Strength, Forearm Circumference,and Vascular Maturation in Patients Who Underwent Arteriovenous Fistula SurgerySangwon Kong, MD1 , Kyung Soo Lee, MD1 , Junho Kim, MD1 , Seong Ho Jang, MD2

28.  Effect of Exercise on the Diameter ofArteriovenous Fistulae in Hemodialysis Patients.

29.  The effects of progressive handgriptraining on arteriovenous fistula maturation in chronic kidney disease – apilot randomised controlled trial .junglee, n¹, law, b³,bigwood, b², williams, d², jibani, m², macdonald, j² ³

30.  Effectof Local Physical Training on the Forearm Arteries and Veins in Patients withEnd-Stage Renal Disease . Rus R.R.a Â· Ponikvar R.b Â· Kenda R.B.a Â· Buturović-PonikvarJ.b Departmentsof aPediatricNephrology and bNephrology,University Medical Centre, Ljubljana, Slovenia

31.  Effect of Exercise on the Diameter of ArteriovenousFistula in Hemodialysis         Patients. Terrence f. oder,victoria teodorescu, and jaime uribarri.