The quality of evidence is downgraded by inconsistency (unexplained variability in results) and by indirectness (differences between the outcomes of interest and those reported: only short-term outcomes reported).
A Cochrane review [Abstract] 1 included 13 studies with a total of 2 080 subjects to assess the effects of adjuvant drug treatment in end-stage renal disease (ESRD) patients on haemodialysis via autologous arteriovenous (AV) fistulae or prosthetic interposition AV shunts. Treatments compared to placebo in the studies were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone, and glyseryl trinatrete. All studies reported on graft patency by measuring graft thrombosis.
Results are shown in table T1. Treatment with ticlopidine was favoured over placebo. All studies used a dose of 250 mg twice daily, although the follow-up time was only one month. Other comparisons did not reach statistical significance. There was statistical heterogeneity in the meta-analyses comparing aspirin (I2 = 79%), fish oil (I2 =76%), and clopidogrel (I2 =54%) to placebo. The single trial that examined the effect of low-intensity warfarin treatment versus placebo was terminated prematurely due to a significant increase in bleeding seen in the treatment group. No trials with follow-up longer than 36 months demonstrated a beneficial effect of anti-thrombotic or anti-platelet treatment to increase patency of arteriovenous fistulae and grafts, thus their long-term effect remains unclear.
| Comparison | Participants (studies) | Relative effect (95% CI) |
|---|---|---|
| Aspirin versus placebo | 175 (3 studies) | OR 0.40 (0.07 to 2.25) |
| Ticlopidine versus placebo* | 339 (3 studies) | OR 0.45 (0.25 to 0.82) |
| Dipyridamole versus placebo | 42 (1 studdy) | OR 0.46 (0.11 to 1.94) |
| Dipyridamole + aspirin versus placebo | 41 (1 study) | OR 0.64 (0.16 to 2.56) |
| Warfarin versus placebo | 107 (1 study) | OR 1.76 (0.78 to 3.99) |
| Fish oil versus placebo | 220 (2 studies) | OR 0.24 (0.03 to 1.95) |
| Clopidogrel versus placebo | 959 (2 studies) | OR 0.40 (0.13 to 1.19) |
| Sulphinpyrazone versus placebo | 16 (1 study) | OR 0.43 (0.03 to 5.98) |
| Glyceryl trinitrate patch | 167 (1) | OR 1.26(0.63 to 2.54) |
| *Fistulae thromboses at one month | ||
| References | ||
| Mohamed I, Kamarizan MFA, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2021;(7):CD002786. [PubMed]
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