Dialysis access venous stenosis: Treatment with balloon angioplasty 30‐second vs. 1‐minute inflation times

Percutaneous balloon angioplasty is the standard of care in the endovascular treatment of dialysis access venous stenosis. The significance of balloon inflation times in the treatment of these stenoses is not well defined. Our objective was to examine the outcomes of 30‐second vs. 1‐minute balloon inflation times on primary‐assisted patency of arteriovenous fistulae and grafts. Using a prospectively collected vascular access database, we identified a total of 75 patients referred for access dysfunction during a 5‐year period. These patients received 223 interventions (178 with 30‐second inflations and 45 with 1‐minute inflations). We compared primary‐assisted patency during the subsequent 9 months across groups defined by inflation times. Demographics and baseline characteristics were similar across groups. Immediate technical success and patency in the first 3 months were similar across groups (hazard ratio [HR] = 0.86; 95% confidence interval [CI]: 0.34–2.20). After 3 months, however, a 1‐minute inflation time was associated with greater incidence of access failure (adjusted HR [aHR] = 1.74; 95% CI: 1.09–2.79). Other predictors of access failure included age over 60 (aHR = 1.02; 95% CI: 1.01–1.04), central location of the lesion (aHR = 2.49; CI: 1.27–4.89), and three or more prior procedures (aHR 2.48; CI: 1.19–5.16). Our data suggest that shorter balloon inflation times may be associated with improved longer term access patency, although the benefit was not observed until after 3 months. Given the increasing demands of maintaining access patency in the era of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and Fistula First, the role of angioplasty times requires further study.     

Hypoproteinemia as a prognostic risk factor for arteriovenous fistula failure

Introduction: Any vascular access is of limited duration with many factors which influence survival in patients on chronic hemodialysis (HD). Hypoproteinemia as a marker of chronic illness is common among chronic HD patients. Our aim was to analyze the survival of the primary arteriovenous fistula (AVFs) and the risk factors which influence their patency and to test the hypothesis that patients with normal values of serum proteins have lower risk of AVF failure compared to patients with hypoproteinemia. Methods: Seven hundred thirty‐four consecutive patients were included who underwent creation of an AVF. The patients were prospectively followed‐up for 2 years. Only patients with AVF function after a month from its creation were analyzed. The patients were divided into two subgroups, with normal and low serum protein levels (<65 g/L). Findings: At follow‐up 497 (67.7%) AVFs were still functional while 237 (32.3%) AVFs failed due to thrombosis or stenosis. Serum proteins and AVFs created on the forearm were positive predictors while diabetes was a negative predictor of longer AVF survival (P < 0.001; P = 0.003; P = 0.043). When comparing patients with normal and low serum protein levels (<65 g/L), mean survival time was significantly longer in patients with normal serum levels (P < 0.001). Discussion: In this study, hypoproteinemia was an independent prognostic marker for AVF failure at 2 years. Hypoproteinemia, based on our results, is an independent, more sensitive and prognostic marker of possible vascular access failure than the presence of other common factors which influence shorter AVF survival.     

Hemodialysis access-related survival and morbidity in an elderly population in South West Thames, UK

Elderly patients form the most rapidly expanding group of hemodialysis (HD) patients in Europe and the United States. There are initiatives to promote an increase in arteriovenous fistula (AVF) formation. There are concerns that elderly patients may have lower rates of surgical vascular access compared with younger patients due to risks of higher co-morbidities, surgical complications, and higher AVF nonuse rates. The aim of this study was to compare access-related survival and morbidity for dialysis catheters and AVFs and to evaluate the AVF nonuse rate in an elderly population. We have performed a retrospective analysis of access survival and morbidity in patients > or = 70 years of age, either on maintenance HD or predialysis with preemptive formation of surgical access. One hundred and forty-six patients had permanent HD access created during the 18-month study period, from 1 January 2006 to June 2007. There were 89 male and 57 female patients in whom 78 AVFs and 137 tunneled venous catheters were inserted. There was a significantly greater loss of vascular access due to infection in the catheter group compared with the AVF group (P<0.016). Access survival was also significantly prolonged in the AVF group (446 days, 95% confidence interval 405-487) compared with the catheter group (276 days, 95% confidence interval 240-313), P=0.001. The rate of nonuse of AVFs was low (16%). We conclude that an AVF is the preferred form of vascular access in elderly HD patients.     

Factors predicting failure of AV “fistula first” policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre‐dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥67 years old who had an AVF as their initial vascular access placed pre‐dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty‐eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre‐HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00–1.02), female gender (OR 1.69; 95% CI 1.55–1.83), black race (OR 1.41; 95% CI 1.26–1.58), history of diabetes (OR 1.22; 95% CI 1.06–1.39), cardiac failure (OR 1.26; 95% CI 1.15–1.37), and shorter duration of pre–end‐stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre‐ESRD nephrology follow up of more than 12 months; 95% CI 1.07–1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre‐ESRD nephrology care with predialysis AVF failure.     

Does the presence of an arteriovenous fistula alter changes in body water following hemodialysis as determined by multifrequency bioelectrical impedance assessment?

Multifrequency bioelectrical impedance assessments (MFBIAs) aid clinical assessment of hydration status for hemodialysis (HD) patients. Many MFBIA devices are restricted to whole body measurements and as many patients dialyze using arteriovenous fistulas (AVFs), we wished to determine whether AVFs affected body water measurements. We reviewed pre‐ and post‐HD segmental MFBIA measurements in 229 patients attending for midweek HD sessions. Up to 144 were dialyzed with a left arm AVF (L‐AVF), 42 with a right arm AVF (R‐AVF), and 43 by central venous access catheter (CVC). Water content and lean tissue were greater in the left compared to right arm in those patients with L‐AVFs both pre and post dialysis (pre 2.1 ± 0.7 vs. 2.0 ± 0.7 L, and post 1.9 ± 0.6 vs. 1.8 ± 0.6 L and pre 2.65 ± 0.9 vs. 2.56 ± 0.8 kg, and post 2.34 ± 0.8 vs. 2.48 ± 0.8 vs. 2.34 ± 0.8 kg, respectively) and were also greater in the right compared to left arm for those patients dialyzing with R‐AVFs (pre‐HD 1.92 ± 0.5 vs. 1.86 ± 0.6 L and post‐HD 1.79 ± 0.5 vs. 1.7 ± 0.5 L, and pre‐HD 2.47 ± 0.6 vs. 2.38 ± 0.7 kg and post‐HD 2.3 ± 0.74 vs. 1.28 ± 0.7 kg, respectively), all Ps < 0.05. There were no significant differences in arm volumes or composition pre or post dialysis in those dialyzing with CVCs. Segmental MFBIA detects differences in arm water and lean mass in patients with AVFs. The presence on an AVF increases the water content in the ipsilateral arm both pre and post HD. This increased water content of the fistula arm will not be detected by whole body bioimpedance devices.     

Does the extracorporeal blood flow affect survival of the arteriovenous vascular access?

Hemodiafiltration with high‐convective volumes is associated with improved patient survival, whereby practical realization is contingent on high extracorporeal blood flow (Qb) and dialysis treatment time. However, Qb is restricted by vascular access (VA) quality and/or concerns that high Qb could damage the VA. Taking VA quality into consideration, one can investigate the relationship between Qb and VA survival. We analyzed data from 1039 patients treated by hemodiafiltration over a 21‐month period where access blood flow (Qa) measurements were also available at baseline. VA failure was defined as a surgical intervention resulting in the generation of a new VA. Qa was included as a stratification variable within a Cox regression model. A second Cox proportional hazard model with a penalized spline was used to describe the association between Qb and VA survival. Compared with Qb in the 350–357 mL/min range, a significantly higher hazard ratio (HR) for VA failure was detected for fistula only, and then only for Qb < 312 mL/min (HR: 2.361, 95% confidence interval [CI]: 1.251–4.453), Qb = 387–397 mL/min (HR: 1.920, 95% CI: 1.007–3.660) and Qb >414 mL/min (HR: 2.207, 95% CI: 1.101–4.424). Age, gender, diabetes, VA vintage, position of the VA, and arterial pressure were not significantly associated with outcome. The form of the penalized spline confirmed higher risk for VA failure for the lowest and the highest values of Qb. Taking Qa into consideration, no association was found between VA failure and Qb up to flows as high as approximately 390 mL/min.     

Vascular imaging for hemodialysis vascular access planning

Introduction: Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established. Methods: Retrospective cohort of patients initiating HD with CVC in 2010–2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time‐dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors. Findings: Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83‐0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02–1.16, P = 0.008). Discussion: Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.     

Improving arteriovenous fistula rate: Effect on hemodialysis quality

Vascular access (VA) is the lifeline for patients with end‐stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the “Fistula First Initiative,” avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient's outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first.     

Coronal mode ultrasound guided hemodialysis cannulation: A pilot randomized comparison with standard cannulation technique

Background: Infiltrations from cannulation result in significant morbidity including loss of hemodialysis (HD) vascular access (VA). Cannulation is dependent on personnel skill and VA characteristics. Surface marking of VA lacks real‐time information and traditional ultrasound (US) devices are large, expensive, requiring skilled operators. Sonic Window© (Analogic Ultrasound, Peabody, MA, USA) is a coronal mode ultrasound device (CMUD) approved for VA cannulation. Methods: Single center randomized, prospective pilot study comparing handheld US‐guided cannulation of new arteriovenous fistula (AVF) to standard cannulation practices. Patients with end stage renal disease (ESRD) on in‐center HD who had a new AVF cleared for cannulation and dialysis were enrolled. Patients with new AVF received either standard cannulation (control group) or image guidance using CMUD (study group) for 3 weeks. Ultrasound characteristics of VA, cannulation practices and complications end points were obtained. Results: An infiltration rate of 9.7% was noted during the study. Slightly lower odds ratio (OR) of infiltration was observed in the study group (OR 0.94, 95% CI: 0.26–3.41, P value = 0.93). Study group yielded longer time for assessment (101.8 ± 80.2 vs. 22.3 ± 22.5 seconds, P = < 0.001), increased cannulation time (41.1 ± 70.6 vs. 25.0 ± 27.9 seconds, P = 0.04), and increased patient satisfaction (94.6% vs. 82%, P = 0.04) compared to control group. Number of cannulation attempts, needle size, arterial or venous needle insertion, and tourniquet usage between groups were not statistically different. Conclusion: Handheld ultrasound is a safe and useful aid in cannulation of dialysis access.     

The effect of statin therapy on the formation of arteriovenous fistula stenoses and the rate of reoccurrence of previously treated stenoses

Statins reduce inflammation in end‐stage renal disease patients and improve endothelial function beyond cholesterol lowering. Despite this, statins do not improve the maturation rate, primary patency rate, and the cumulative survival of arteriovenous fistulas (AVFs). It is unknown if statins decrease the number of stenoses developing in AVFs or prolong the intervals between angioplasties needed to treat recurring stenoses. We conducted a retrospective chart review of our 265 active dialysis patients. The statin group was significantly more likely to be diabetic (64% vs. 43.6%) and treated with aspirin (64% vs. 40%) when compared to those not treated with statins (P = 0.04 and 0.01). The mean time to first intervention (primary patency) was 16.5 months in statin users and 15.8 months in the nonstatin group (P = 0.49) with standard deviations of ±18.5 and 16.6 months, respectively. Statin use was not associated with a significant decrease in the number of stenoses diagnosed (P = 0.28). The mean time between recurrent stenoses’ angioplasties was 8.9 months in statin users and 7.3 months in the nonstatin patients (P = 0.25). Aspirin users were more likely to have a decreased primary patency (rate ratio = 1.65, P = 0.03) compared with nonaspirin users. Patients who were prescribed aspirin developed 1.6 (P 0.01) times more stenoses than those not treated with aspirin. We report for the first time that statin therapy does not decrease the number of stenotic lesions developing in the AVF or prolong the interval between procedures required to treat recurrent stenoses.     

Dipyridamole stress echocardiography in diagnosis and prognosis of hemodialysis patients with asymptomatic coronary disease

The prevalence of coronary artery disease (CAD) is high in hemodialysis (HD) patients. The aim of the study was to assess the diagnostic and prognostic value of dipyridamole stress echocardiography (DSE) in nondiabetic HD patients without signs or symptoms of CAD. In 51 out of 158 evaluated HD patients (21 females, age 67 [33–85] years, HD duration 38 [9–271] months), resting echocardiography and DSE were performed. Exclusion criteria were known CAD, diabetes mellitus, and pulmonary and oncologic pathologies. Logistic regression analysis was carried out to identify predictors of abnormal DSE response, while Cox regression analysis was performed to determine variables associated with total and cardiovascular mortality, after 43.3 (11–60) months of follow‐up. Seven patients (14%) showed a positive response to DSE (DSE+). In 5/7, CAD was documented by angiography: All of them underwent coronary revascularization. DSE+ patients had significantly smaller body mass index than patients with a negative response (DSE‐): 21.7 ± 1.9 vs. 25.1 ± 3.4 kg/m² (p = 0.018). During follow‐up, 16 (31%) patients died. Older age hazard ratio [HR = 1.07; confidence interval (CI) = 1.01–1.12; p = 0.02] and higher plasma phosphate levels (HR = 10.41; CI = 2.30–47.17; p < 0.01) were predictors of total mortality. Male gender (HR = 22.7; CI = 1.45–354.4; p = 0.03), older age (HR = 1.24; CI = 1.03–1.50; p = 0.02), longer HD duration (HR = 1.13; CI = 1.01–1.26; p = 0.04), and positive response to DSE (HR = 5.82; CI = 1.04–32.65; p = 0.04) were associated with cardiovascular mortality. Ten percent of asymptomatic HD patients had significant CAD, but timely diagnosis did not seem to improve their prognosis. Total survival was associated with age and higher levels of plasma phosphate, while male gender, older age, longer HD duration, and DSE+ were predictors of cardiovascular mortality.     

Refractory orthostatic hypotension after creation of a brachio‐basilic arteriovenous fistula

Arteriovenous fistulas (AVFs) are preferred vascular access in patients with end‐stage renal disease (ESRD) undergoing hemodialysis (HD). However, AVFs, can occasionally lead to clinically significant complications. Of these, cardiovascular complications have been well described in the literature. In this report, we describe a case of a 78‐year‐old Caucasian male with ESRD who presented with severe debilitating dizziness and orthostatic hypotension that started soon after the creation of left brachiobasilic AVF. The patient had no significant cardiovascular history apart from essential hypertension. His symptoms persisted despite extensive evaluation and interventions, and abated only after banding of the AVF. This report describes the timeline of the patient's clinical course beginning from the day of creation of his AVF, through the course of his hospitalization leading to AVF banding and ending with postoperative recovery phase with resolution of symptoms. We will also review the pathophysiologic effects of AVF on cardiovascular system, as well as the potential causes of our patient's clinical presentation.     

Long‐term effects of daily hemodialysis on vascular access outcomes: A prospective controlled study

Daily hemodialysis has been associated with surrogate markers of improved survival among hemodialysis patients. A potential disadvantage of daily hemodialysis is that frequent vascular access cannulations may affect long‐term vascular access patency. The study design was a 4‐year, nonrandomized, contemporary control, prospective study of 77 subjects in either 3‐h daily hemodialysis (six 3‐h dialysis treatments weekly; n = 26) or conventional dialysis (three 4‐h dialysis treatments weekly; n = 51). Outcomes of interest were vascular access procedures (fistulagram, thrombectomy and access revision). Total access procedures (fistulagram, thrombectomy and access revision) were 543.2 (95% confidence interval [CI]: 432.9, 673.0) per 1000 person‐years in the conventional dialysis group vs. 400.8 (95% CI: 270.2, 572.4) per 1000 person‐years in the daily hemodialysis dialysis group (incidence rate ratio = 0.74 with 95% CI: from 0.40 to 1.36, P = 0.33), after adjusting for age, gender, diabetes status, serum phosphorus, hemoglobin level and erythropoietin dose, there was no significant differences in incidence rate of total access procedures (P‐value > 0.05). There was no difference in time to first access revision between the daily dialysis and the conventional dialysis groups after adjustment for covariates (hazard ratio = 0.99 95% CI: 0.42, 2.36, P = 0.96). Daily hemodialysis is not associated with increased vascular access complications, or increased vascular access failure rates.     

Clinical effects of buttonhole cannulation method on hemodialysis patients

Although the buttonhole cannulation method is now widely used as an alternative to the rope‐ladder method in most countries, only the latter method is used in Korea. This study was performed to investigate clinical benefit of the buttonhole technique for arteriovenous fistula (AVF) cannulation in maintenance hemodialysis (HD) patients. Thirty‐two patients receiving HD via mature AVF were included and AVF cannulation was performed by 20 experienced nurses. During the 8 weeks, AVFs were cannulated by the rope‐ladder method with 15‐gauge sharp needles. After creating of 2 pairs of tunnel tracks by sharp needles for 7 weeks, AVFs were cannulated by the buttonhole method using 15‐gauge blunt needles during the 16 weeks. Vascular access blood flow rate (BFR), dialysis venous pressure (DVP), and dialysis adequacy (Kt/V) were measured within the first week of the two cannulation methods. Cannulation pain, hemostasis time, and nurse's stress were evaluated at the end of the two methods. There were no statistical differences in vascular access BFR (P = 0.139), DVP (P = 0.152), and dialysis adequacy (P = 0.343) between the two methods. However, the buttonhole method shortened hemostasis time (P = 0.001) and decreased cannulation pain (P = 0.001) as well as nurse's stress (P = 0.001) compared with the rope‐ladder method. In conclusion, the buttonhole cannulation method improves hemostasis time, cannulation pain, and nurse's stress without a change in vascular access BFR and dialysis adequacy in HD patients.     

Outcomes of patients with end‐stage renal disease (ESRD) under chronic hemodialysis requiring continuous renal replacement therapy (CRRT) and patients without ESRD in acute kidney injury requiring CRRT: A single‐center study

In most continuous renal replacement therapy (CRRT) studies, end‐stage renal disease (ESRD) patients were excluded and the outcomes of patients with ESRD treated with chronic hemodialysis (HD) were unknown. The purposes of this study were to (1) evaluate short‐term patient survival and (2) compare the survival of conventional HD patients needing CRRT with the survival of non‐ ESRD patients in acute kidney injury (AKI) requiring CRRT. We evaluated adults (>18 years) requiring CRRT who were treated in the intensive care unit (ICU) at Kosin University Gospel Hospital from January 1, 2009 to December 31, 2010. A total of 100 (24 ESRD, 76 non‐ESRD) patients underwent CRRT during the study period. Patients were divided into two major groups: patients with ESRD requiring chronic dialysis and patients without ESRD (non‐ESRD) with AKI. We compared the survival of conventional HD patients requiring CRRT with the survival of non‐ ESRD patients in AKI requiring CRRT. For non‐ESRD patients, the 90‐day survival rate was 41.6%. For ESRD patients, the 90‐day survival rate was 55.3%. Multivariate Cox proportional hazards analyses demonstrated that conventional HD was not a significant predictor of mortality (hazard ratio [HR]: 0.334, 95% confidence interval [CI]: 0.063–1.763, P = 0.196), after adjustment for age, gender, presence of sepsis, APACHE score, use of vasoactive drugs, number of organ failures, ultrafiltration rate, and arterial pH. The survival rates of non‐ESRD and ESRD patients requiring CRRT did not differ; ESRD with conventional HD patients may be not a significant predictor of mortality.     

High rate of fistula placement in a cohort of dialysis patients in a single payer system

Arteriovenous fistulas (AVFs) are considered superior to arteriovenous grafts and catheters. Nevertheless, AVF prevalence in the United States remains under the established target. The complication rates and financial cost of vascular access continue to rise and disproportionately contribute to the burgeoning health care costs. The relationship between financial incentives for a type of vascular access and rate of access placement is unclear. All chronic hemodialysis patients (n=99) receiving care at Philadelphia Veterans Affairs Medical Center as of August 1, 2008 were participants. Demographic characteristics, vascular access type, and nonrelative value unit compensation were assessed as predictors, and the vascular access prevalence rate, operative times, and frequency of access interventions were analyzed. A 73.7% AVF rate was achieved in this cohort of patients with 51.5% diabetes mellitus. The number of access procedures per patient per year remained constant over time. The Philadelphia Veterans Affairs Medical Center, a single payer system, achieved superior AVF prevalence and exceeded the national AVF target. Financial incentives for arteriovenous graft placement currently exist in the United States, as there is similar Medicare reimbursement for arteriovenous graft and basilic vein transposition, despite longer operative times for basilic vein transpositions. The high AVF prevalence at the Philadelphia Veterans Affairs Medical Center may be due to the VA nonrelative value unit‐driven system that allows for interdisciplinary care, priority of AVFs, and frequent use of basilic vein transposition surgery, when appropriate. We have identified an important, hypothesis‐generating example of a nonrelative value unit‐based approach to vascular access yielding superior results with respect to patient care and cost.     

Native arteriovenous fistula placement in three patients after implantation of a left ventricular assist device with non‐pulsatile blood flow

Patients with left ventricular assist device have an increased risk for postoperative acute kidney injury and long‐term requirement of dialysis. As a chronic access for dialysis, native arteriovenous fistulae are uncommon options due to suspected maturation failure. We present three patients who received successful arteriovenous fistulae placement after left ventricular assist device implantation with assisted long term patency.     

Short and long alteplase dwells in dysfunctional hemodialysis catheters

Background: Hemodialysis catheter dysfunction (CD) is the inability to attain adequate blood pump speeds (BPS) and is attributed to thrombus or catheter malposition; alteplase (TPA) is often given in a variety of dwell times to treat CD. The purpose of this study was to determine if TPA dwell time affects short‐ or long‐term catheter patency rates. Methods: Sixty hemodialysis (HD) patients with CD, as defined by BPS of < 250 mL/min, were randomized to receive either 1‐ or > 48‐hr (to subsequent HD run) TPA dwell. The primary outcomes were catheter patency (BPS of > 250 mL/min) at the subsequent HD run and catheter patency at 2 weeks. The secondary outcome was the time from study entry to the next catheter intervention (including subsequent TPA installation). Results: After TPA installation, a 78% overall catheter patency rate was observed at the subsequent HD run, falling to 48% patency at 2 weeks. There is no statistically significant difference between the short and long TPA dwell groups for catheter patency at the subsequent HD run (76.9% vs. 79.4%) or at 2 weeks (42.3% vs. 52.9%). Multivariate analysis demonstrates that the use of TPA on two or more previous occasions is a predictor of TPA failure both at the subsequent HD run and at 2 weeks. TPA installation achieves a median catheter function time of only 14 days, after which CD reoccurs. Conclusion: This study demonstrates that although patency for the next HD run can be achieved with either short or long TPA dwell, neither is reliable in terms of long‐term patency. Strategies that employ TPA for CD are temporary and allow a 2‐week window during which more definitive therapies for HD access should be sought.     

Monocyte/lymphocyte ratio as a better predictor of cardiovascular and all‐cause mortality in hemodialysis patients: A prospective cohort study

Introduction: Patients with chronic kidney disease, especially those with end‐stage renal disease, have an increased risk of death. Previous studies have suggested neutrophil/lymphocyte ratio (NLR) was related to worse outcome in patients undergoing hemodialysis (HD). However, monocyte/lymphocyte ratio (MLR) has not been evaluated in HD patients. In this study, we prospectively studied the predictive value of MLR for all‐cause and cardiovascular mortality in HD patients and compared it with NLR. Methods: Patients who had been on a HD treatment for at least 6 months were enrolled. MLR was calculated by dividing the monocyte count by the lymphocyte count. Survival outcomes were estimated using the Kaplan‐Meier method and compared by the log‐rank test. Univariate and multivariate analyses were performed to evaluate the prognostic impact of MLR and other clinical factors on all‐cause and cardiovascular mortality. Results: Mortality rates for the lowest, middle, and highest MLR tertile group were 3.65, 7.02, and 11.15, respectively per 100 patient‐years. The Kaplan‐Meier analysis revealed that survival rates were significantly different among three MLR groups (P < 0.001). In multivariate Cox regression analyses, MLR was independently associated with all‐cause mortality (HR 4.842; 95% CI, 2.091–11.214; P < 0.001) and cardiovascular mortality (HR 6.985, 95% CI 1.943–25.115, P = 0.003) as continuous variables. NLR was not an independent predictor of all‐cause nor cardiovascular mortality after adjusted with MLR. Conclusions: The main finding of the study suggest that higher MLR was a strong and independent predictor of all‐cause and cardiovascular mortality and overwhelmed NLR among HD patients.     

Relation between Access-Related Infection and Preinfection Serum Albumin Concentration in Patients on Chronic Hemodialysis

Background: Hemodialysis (HD) access‐related infection is a major cause of morbidity and mortality in HD patients. We tested whether hypoalbuminemia is a risk factor for HD access infection and whether mortality of HD catheter infection is affected by removal of the infected catheter. Methods: We analyzed the records of 87 patients on chronic HD who were hospitalized for HD access‐related infection. We obtained data on age, sex, preinfection serum albumin level, comorbidities, complications, infecting organism, type of infection, mode of management, and mortality. We compared preinfection serum albumin levels in 79 patients with HD access infection with the serum albumin levels of 198 control patients on chronic HD without HD access infection admitted to the hospital during the same time for other reasons. In the HD catheter infection subgroup, we compared mortalities between patients treated with catheter removal plus antibiotics as the primary mode of management and those treated initially with antibiotics alone. Results: Preadmission serum albumin level was lower in the HD access infection group (2.4 ± 0.6 g/dL) than in the control group (3.2 ± 0.6 g/dL, P < 0.0001). Logistic regression identified preadmission serum albumin level as a strong independent predictor of HD access infection. In a logistic regression model, with age, sex, HIV status, diabetes, and type of HD vascular access (excluding arterovenous fistula) as the covariates, the odds ratio of HD access infection was 9.8 (95% confidence interval [CI] 4.9–19.7) for a serum albumin level ≤ 3.0 g/dL (P < 0.0001), 10.4 (95% CI 4.97–21.6) for a serum albumin level ≤ 2.5 g/dL (P < 0.0001), and 28.0 (95% CI 5.8–135.9) for a serum albumin level ≤ 2.0 g/dL (P < 0.0001). Case mortality was 25.0% (4/16) in patients with tunneled HD catheter infection initially treated with antibiotics alone and 2.8% (2/71) in those treated with catheter removal plus antibiotics at the time of presentation (P = 0.0096). Conclusion: Hypoalbuminemia is associated with increased risk of HD access infection. Treatment of HD access infection with antibiotics alone is associated with increased risk of death.