Gracz fistula is a feasible option after two failed percutaneous arteriovenous fistulae

Arteriovenous Fistulae ◽

Feasible Option ◽

Brachial Vein ◽

End Stage ◽

Perforating Vein

Two devices for the creation of an endovascular percutaneous (pAVF) endovascular (endoAVF) arteriovenous fistulae (AVF) are available: the Ellipsys and the WavelinQ-4F systems. The main difference is the location of the anastomosis, making it feasible to use both pAVFs and surgical Gracz-type AVF in an algorithm sequence. A 66-year-old male patient with end-stage kidney disease and HIV was referred for a creation of a dialysis access after failed peritoneal dialysis. A radial-radial WavelinQ-pAVF with simultaneous coil embolization of a brachial vein was created but failed within 4 weeks. Therefore, an Ellipsys-pAVF was successfully created between the proximal radial artery and perforating vein on the same arm. After 2 days, however, the Ellipsys-pAVF anastomosis occluded. The ipsilateral Gracz-AVF was created, anastomosing perforating vein with the antecubital brachial artery. Cannulations were started 28 days later. During the follow up of 807 days, the AVF remained patent with last known volume flow of 1500 ml/min and no need for secondary interventions. We report a successful creation of a Gracz-AVF after primary failed pAVFs created with both pAVF-systems in a single patient and in the same arm. Thus, based on that case we recommend creation of pAVF prior to Gracz-AVF as integral part of Vascular Access creation algorithm, based on each patient’s life plan.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

Transplantology ◽

10.3390/transplantology2020010 ◽

2021 ◽

Vol 2 (2) ◽

pp. 92-108

Author(s):

Maurizio Salvadori ◽

Aris Tsalouchos

Keyword(s):

Renal Transplantation ◽

Time Lapse ◽

Sexual Life ◽

Correct Evaluation ◽

Functional Aspects ◽

Long Term Follow Up ◽

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Dietary Factors and Prevention: Risk of End-Stage Kidney Disease by Fruit and Vegetable Consumption

American Journal of Nephrology ◽

10.1159/000514754 ◽

2021 ◽

pp. 1-12

Author(s):

Tanushree Banerjee ◽

Juan Jesus Carrero ◽

Charles McCulloch ◽

Nilka Rios Burrows ◽

Karen R. Siegel ◽

...

Keyword(s):

Kidney Disease ◽

Risk Model ◽

Vegetable Consumption ◽

Dietary Factors ◽

Inverse Association ◽

Fruit And Vegetable ◽

Strong Inverse Association ◽

Background: The association between fruit and vegetable (FV) intake and the risk of end-stage kidney disease (ESKD) has not been examined in the general population and fully explored in chronic kidney disease (CKD). We prospectively evaluated this relationship in US representative sample of adults and evaluated consistency by the presence or absence, and severity, of CKD. Methods: We used data from the Third National Health and Nutrition Examination Survey (1988–1994) linked with the US Renal Data System, including 14,725 adults aged ≥20 years and with follow-up for ESKD through 2008. Daily FV intake was ascertained using a food frequency questionnaire. We examined the association between selected categories of FV intake and ESKD using a Fine Gray competing risk model adjusting for sociodemographics, lifestyle, clinical and nutritional factors, estimated glomerular filtration rate, and albuminuria. We evaluated whether risk varied in individuals with severe versus any CKD. Results: 230 participants (1.5%) developed ESKD during follow-up. In the adjusted model, compared to highest intake, those in lowest categories of FV intake had a higher risk of ESKD, for <2 times/day (1.45 [1.24–1.68], 2 to <3 times/day (1.40 [1.18–1.61]), 3 to <4 times/day (1.25 [1.04–1.46]), and 4 to <6 times/day (1.14 [0.97–1.31]). There was suggestion of heterogeneity (p for interaction = 0.03) with possible stronger inverse association in patients with CKD than those without CKD. After stratification, we obtained similar strong inverse association when we examined ESKD incidence across intake of FVs in participants with CKD stages 1–4 (n = 5,346) and specifically in those with CKD stages 3–4 (n = 1,084). Conclusions: Low intake of FVs was associated with higher risk of ESKD in US adults with and without CKD, supporting an emerging body of literature on the potential benefits of plant-rich diets for prevention of ESKD.

Choice of endpoint in kidney outcome trials: considerations from the EMPA-REG OUTCOME® trial

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz179 ◽

2019 ◽

Vol 35 (12) ◽

pp. 2103-2111 ◽

Cited By ~ 5

Author(s):

Vlado Perkovic ◽

Audrey Koitka-Weber ◽

Mark E Cooper ◽

Guntram Schernthaner ◽

Egon Pfarr ◽

...

Keyword(s):

Estimated Glomerular Filtration Rate ◽

Standard Of Care ◽

High Cardiovascular Risk ◽

End Stage ◽

Post Hoc ◽

Event Rates ◽

Egfr Decline

Abstract Background Doubling of serum creatinine [equivalent to 57% reduction in estimated glomerular filtration rate (eGFR)] is an established surrogate for end-stage kidney disease (ESKD); however, this endpoint necessitates lengthy follow-up and large sample sizes in clinical trials. We explored whether alternative eGFR decline thresholds provide more feasible surrogate kidney endpoints. Methods The study involved post hoc analysis of the EMPA-REG OUTCOME® trial. Adults with type 2 diabetes, high cardiovascular risk and eGFR ≥30 mL/min/1.73 m2 were assigned empagliflozin 10 mg or 25 mg (n = 4687) or placebo (n = 2333), on top of standard of care. We assessed composite endpoints incorporating different eGFR decline thresholds (≥30, ≥40, ≥50 or ≥57%) combined with initiation of renal replacement therapy (RRT) or renal death. This trial is registered with ClinicalTrials.gov (NCT01131676). Results Empagliflozin versus placebo significantly lowered the risk of decline in eGFR for each threshold listed above, combined with initiation of RRT or renal death, ranging from a hazard ratio (HR) of 0.81 [95% confidence interval (CI) 0.72–0.91] for endpoints based on 30% eGFR decline to an HR of 0.37 (0.23–0.61) for endpoints based on 57% eGFR decline. Lower thresholds (e.g. 30%) were associated with higher event rates but weaker treatment effects. The time to the 95% CI of the HR falling to <1.0 decreased with increasing eGFR threshold. Conclusions The composite of 40% decline in eGFR, ESKD or renal death appears to provide reliable results similar to the traditional 57% decline in eGFR.

Increased Inflammatory Response in Association with the Initiation of Hemodialysis Compared with Peritoneal Dialysis in a Prospective Study of End-Stage Kidney Disease Patients

Peritoneal Dialysis International ◽

10.3747/pdi.2017.00060 ◽

2018 ◽

Vol 38 (1) ◽

pp. 18-23 ◽

Cited By ~ 6

Author(s):

Kenneth Yong ◽

Gursharan Dogra ◽

Neil Boudville ◽

Wai Lim

Keyword(s):

Blood Pressure ◽

Peritoneal Dialysis ◽

Kidney Disease ◽

Inflammatory Response ◽

Prospective Study ◽

Cvd Risk ◽

Ckd Stage ◽

Background Large epidemiological studies have demonstrated an early survival advantage with the initiation of peritoneal dialysis (PD) compared to haemodialysis (HD). Chronic inflammation may contribute to atherosclerosis and cardiovascular (CVD) mortality in end-stage kidney disease (ESKD). We hypothesize that the initiation of HD in ESKD patients is associated with a greater inflammatory response compared with PD. Aims To examine the effects of initiating HD and PD upon inflammation and CVD risk markers in ESKD patients. Methods We per formed a pilot prospective study on 75 predialysis CKD stage-5 subjects comparing the effects of HD and PD upon high sensitivity C-reactive protein (hsCRP), interleukin(IL)-12, IL-18 and pulse wave velocity (PWV). Study visits were conducted 3 – 6 months before (baseline) and after (follow-up) initiation of dialysis Results Thirty-nine and 36 patients were initiated on HD and PD respectively. HD patients were older than PD patients (65.1 ± 2.1 vs 57.7 ± 2.7 years; p = 0.03) but had similar baseline systolic blood pressure (SBP), pulse pressure (PP), hsCRP, IL-12, IL-18, and PWV. At follow-up, HD patients had significantly increased hsCRP levels [5.2(3.7, 7.3) vs 1.7(1.0, 2.8)g/L; p < 0.001] compared to PD. Follow-up blood pressure, IL-12, IL-18, and PWV were similar between groups. A significant association remained between hsCRP and HD after adjustment for age, previous CVD, and residual urine output. Conclusion The initiation of HD was associated with significantly increased hsCRP compared to PD. Further study is required to determine the plausibility of inflammation as a potential underlying contributor to the observed early mortality difference between dialysis modalities.

Metabolic Syndrome Severity Score, Comparable to Serum Creatinine, Could Predict the Occurrence of End-Stage Kidney Disease in Patients with Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Journal of Clinical Medicine ◽

10.3390/jcm10245744 ◽

2021 ◽

Vol 10 (24) ◽

pp. 5744

Author(s):

Pil Gyu Park ◽

Jung Yoon Pyo ◽

Sung Soo Ahn ◽

Jason Jungsik Song ◽

Yong-Beom Park ◽

...

Keyword(s):

Metabolic Syndrome ◽

Kidney Disease ◽

Serum Creatinine ◽

Characteristic Curve ◽

Antineutrophil Cytoplasmic Antibody ◽

The Metabolic Syndrome ◽

Poor Outcomes ◽

This study investigated whether the metabolic syndrome (MetS) severity (MSSS) at diagnosis could predict poor outcomes during follow-up in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients with MetS. The equation for the MSSS at diagnosis used in this study was developed and validated in Korean adults aged 20–59 years. The medical records of 261 patients with AAV were retrospectively reviewed, and finally, 36 AAV patients with MetS aged 20–59 years fulfilling the inclusion criteria were included in this study. All-cause mortality, relapse, end-stage kidney disease (ESKD), cerebrovascular accident, and cardiovascular disease were assessed as the poor outcomes of AAV. Their median age was 51.2 years and 36.1% were male. The MSSS was significantly correlated with age and serum albumin but not AAV-specific indices. Among the five poor outcomes, only ESKD showed a relatively significant area under the curve (area 0.696) in receiver operating characteristic curve analysis. In the multivariable Cox hazards model analysis, both serum creatinine (HR 3.033) and MSSS (HR = 2.221) were significantly associated with ESKD occurrence. When the cut-off of the MSSS for ESKD was set at 1.72, ESKD occurred more frequently in patients with MSSS ≥ 1.72 than in those with MSSS < 1.72 (75.0% versus 14.3%, p = 0.002). Furthermore, patients with MSSS ≥ 1.72 exhibited a significantly lower cumulative ESKD-free survival rate than those with MSSS < 1.72 (p = 0.001). MSSS at the time of AAV diagnosis independently predicted the occurrence of ESKD during follow-up in patients with AAV and MetS.

Changes in measures of cognitive function in patients with end-stage kidney disease on dialysis and the effect of dialysis vintage: A longitudinal cohort study

PLoS ONE ◽

10.1371/journal.pone.0252237 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0252237

Author(s):

Karumathil M. Murali ◽

Judy Mullan ◽

Steven Roodenrys ◽

Hicham I. Cheikh Hassan ◽

Maureen Lonergan

Keyword(s):

Cognitive Impairment ◽

Cognitive Function ◽

Kidney Disease ◽

Analysis Of Covariance ◽

Change Scores ◽

Dialysis Vintage ◽

One Year ◽

Introduction Prevalence of cognitive impairment increases with worsening severity of chronic kidney disease (CKD) and majority of end-stage kidney disease (ESKD) patients on dialysis have cognitive impairment. Trends of cognitive function (CF) in this population are less well known with published studies reporting conflicting results. Methods We assessed CF in a cohort of non-dialysis CKD and ESKD patients undergoing dialysis using modified mini-mental state examination (3MS), trail-making test (TMT-A & B) scores and Stroop task, and evaluated demographics, comorbidities and depression using Beck depression inventory at baseline. We repeated tests of CF and depression ≥ 1-year after baseline in both groups and compared change scores in CF and depression between ESKD/ CKD sub-groups. Among ESKD patients we compared change scores between patients with dialysis vintage of <1-year and >1-year. Analysis of covariance was used to adjust for the effect of age on these change scores. Results At baseline (N = 211), compared to CKD (N = 108), ESKD (N = 103) patients had significantly worse CF based on 3MS and TMT-A & B scores, and depression scores. On follow-up (N = 160) 3MS scores, especially the memory subscale significantly improved in ESKD, but worsened in CKD, with no significant changes in TMT A /TMT-B, or depression scores after adjusting for age. Among ESKD patients, 3MS, especially memory subscale improved in patients with dialysis vintage <1-year compared to >1-year. The 51 patients who discontinued after baseline assessment had worse baseline CF scores suggesting differential attrition. Conclusion Though baseline cognitive scores were worse in ESKD patients on dialysis, compared to CKD, their 3MS, especially memory subscale improved on follow-up. Among ESKD patients, the improvement was significant only in patients who have been on dialysis for less than one-year which may indicate a beneficial effect of clearance of uraemic toxins. Differential attrition of study subjects may have impacted the observed results.

Relative leucocyte telomere length is associated with incident end-stage kidney disease and rapid decline of kidney function in type 2 diabetes: analysis from the Hong Kong Diabetes Register

Diabetologia ◽

10.1007/s00125-021-05613-1 ◽

2021 ◽

Author(s):

Feifei Cheng ◽

Andrea O. Luk ◽

Hongjiang Wu ◽

Claudia H. T. Tam ◽

Cadmon K. P. Lim ◽

...

Keyword(s):

Type 2 Diabetes ◽

Hong Kong ◽

Kidney Disease ◽

Telomere Length ◽

Rapid Decline ◽

End Stage ◽

Diabetes Register

Abstract Aims/hypothesis Few large-scale prospective studies have investigated associations between relative leucocyte telomere length (rLTL) and kidney dysfunction in individuals with type 2 diabetes. We examined relationships between rLTL and incident end-stage kidney disease (ESKD) and the slope of eGFR decline in Chinese individuals with type 2 diabetes. Methods We studied 4085 Chinese individuals with type 2 diabetes observed between 1995 and 2007 in the Hong Kong Diabetes Register with stored baseline DNA and available follow-up data. rLTL was measured using quantitative PCR. ESKD was diagnosed based on the ICD-9 code and eGFR. Results In this cohort (mean ± SD age 54.3 ± 12.6 years) followed up for 14.1 ± 5.3 years, 564 individuals developed incident ESKD and had shorter rLTL at baseline (4.2 ± 1.2 vs 4.7 ± 1.2, p < 0.001) than the non-progressors (n = 3521). On Cox regression analysis, each ∆∆Ct decrease in rLTL was associated with an increased risk of incident ESKD (HR 1.21 [95% CI 1.13, 1.30], p < 0.001); the association remained significant after adjusting for baseline age, sex, HbA1c, lipids, renal function and other risk factors (HR 1.11 [95% CI 1.03, 1.19], p = 0.007). Shorter rLTL at baseline was associated with rapid decline in eGFR (>4% per year) during follow-up (unadjusted OR 1.22 [95% CI 1.15, 1.30], p < 0.001; adjusted OR 1.09 [95% CI 1.01, 1.17], p = 0.024). Conclusions/interpretation rLTL is independently associated with incident ESKD and rapid eGFR loss in individuals with type 2 diabetes. Telomere length may be a useful biomarker for the progression of kidney function and ESKD in type 2 diabetes. Graphical abstract

Follow-up of aspirin-resistant patients with end-stage kidney disease

International Urology and Nephrology ◽

10.1007/s11255-012-0217-x ◽

2012 ◽

Vol 45 (4) ◽

pp. 1097-1102 ◽

Cited By ~ 7

Author(s):

Kadriye Orta Kilickesmez ◽

Cuneyt Kocas ◽

Okay Abaci ◽

Baris Okcun ◽

Bilal Gorcin ◽

...

Keyword(s):

Kidney Disease ◽

Technical note: An alternative method for AV access superficialization

The Journal of Vascular Access ◽

10.1177/1129729820901654 ◽

2020 ◽

Vol 21 (5) ◽

pp. 760-763 ◽

Cited By ~ 1

Author(s):

Danielle Fontenot ◽

Karl A Illig

Keyword(s):

Adipose Tissue ◽

Subcutaneous Tissue ◽

Technical Note ◽

Dialysis Access ◽

Superficial Fascia ◽

Arteriovenous Fistulae ◽

Entire Area ◽

Skin Breakdown ◽

Lost To Follow Up

Introduction: An arteriovenous fistulae for dialysis access is only functional if superficial enough for reliable cannulation. We describe a previously unreported technique to superficialize arteriovenous fistulae too deep for reliable cannulation. Method: The path of the fistula is marked using ultrasound, and three to four transverse incisions are made along this path. The subcutaneous tissue is separated from the dermis over this entire area. The fistula is then accessed through transverse incisions and by dividing the overlying adipose tissue. The mobilized vein is then “trapped” directly under the dermis by closing the superficial fascia and adipose tissue beneath it and using this tissue to elevate the fistula. No anastomotic revisions are necessary, and moderate straightening can be performed. Results: We have performed this procedure on 20 patients with 100% technical success. One fistula had thrombosis within 8–10 weeks of the superficialization procedure and one patient refused access due to pain, but all other fistulas were successfully cannulated. Two patients were lost to follow-up, and one patient developed skin breakdown in the area of the flap which delayed cannulation. Our 3-month patency was 94.4% with a functional patency, defined as a clinically patent fistula successfully being used for hemodialysis, of 87.5%. Conclusion: The technique described allows elevation of the vein to the level of the dermis without division and re-anastomosis or re-tunneling, through several small incisions maintaining virgin skin and normal contour for easier cannulation.

Incomplete Restoration of Homeostatic Shear Stress Within Arteriovenous Fistulae

ASME 2012 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2012-80458 ◽

2012 ◽

Cited By ~ 1

Author(s):

Patrick M. McGah ◽

James J. Riley ◽

Alberto Aliseda ◽

Daniel F. Leotta ◽

Kirk W. Beach

Keyword(s):

Shear Stress ◽

Peripheral Circulation ◽

Shear Stresses ◽

Dialysis Access ◽

Venous Flow ◽

Arteriovenous Fistulae ◽

Flow Rates ◽

Stage Renal Disease ◽

End Stage ◽

Low Shear

Arteriovenous fistulae are created surgically to provide an adequate access for dialysis in patients with End-Stage Renal Disease (ESRD). Producing an autogenous shunt linking an artery and a vein in the peripheral circulation bypasses the high resistance capillary bed in order to provide the necessary flow rates at sites easily accessible for dialysis. In successful fistulae, venous flow rates can easily exceed 1000 mL/min. It has long been recognized that the hemodynamics constitute the primary external influence on the remodeling process [1]; The high flow rate, together with the exposure of the venous tissue to the high arterial pressure, leads to a rapid process of wall remodeling that may end in a mature access or in failure. Recent hemodynamic simulations [2,3] have computed very high viscous wall shear stresses within fistulae; Stresses > 15Pa have been reported which are much greater than what is typically considered normal (i.e. homeostatic, ≈ 1Pa). Both sustained high shear and sustained low shear have been hypothesized to cause pathological venous remodeling (i.e. intimal hyperplasia) which causes stenoses and threatens fistula patency. The role of high vs. low shear stress in effecting patency remains unclear. Given the high failure rate of dialysis access sites (up to 50% require surgical revision within one year [4]), understanding the dynamics of blood flow within the fistula is a necessary step in understanding the remodeling, and ultimately, in improving clinical outcomes.