Frailty at the beginning of dialysis; is it a prognostic factor?

Introduction: Frailty (F) refers to the cumulative organic damage caused by aging, as a consequence of a diminished physiological reserve. Frailty’s prevalence is 73% in dialysis. Objectives: Our aim was to identify the prevalence of F in patients starting hemodialysis (HD) or hemodiafiltration online (HDF) treatment. To asses change in frailty during a six-month period of dialysis Patients and Methods: This prospective cohort study evaluated 67 incident patient starting-HD or HDF at one year, with a follow-up period of at least six months. The frailty was assessed by the Fried frailty method. According to this test, we divided the population in two groups: Pre-frail (0-2) and frail (3-5). Results: Mean age was 64 years, 64% were male and 92% were treated with HD. A total of 35.8% of the patients were admitted to dialysis with a prosthetic or native fistula. The prevalence of F at the beginning of dialysis was 65.7%. The mean value of Charlson index (CHI) was 5.2 ± 2. There was a significant correlation between CHI and frailty test (P<0.0001). Basal F score (n=67) improved after 6 month (n=52): 3 (2-4) versus1 (1-2) (P<0.0001). Hematocrit (28 versus 32% P=0.05) and calcium levels (8.6 and 8.9 mg/dL, P<0.002) also increased after sixth-month. Global mortality was 7.5%. In the multivariate analysis CHI (P<0.001) and albumin (P=0.003) were frailty predictors. Conclusion: The prevalence of F in patients who start dialysis therapy is high. There was an improvement in F score after six-month of dialysis treatment. Patients with higher F score had higher mortality with higher CHI

Repeated venipuncture as a reason of aneurysm and pseudoaneurysm of vascular access

The most complications of the vascular access are: thrombosis, aneurysm, infection. Aneurysms can be either true, containing all layers of a venous wall, or false (pseudoaneurysm), lined by fibrous tissue and thrombosis. Aneurysm dilatation is one of the major complications of vascular access. The incidence increased with the duration of the usage, repeated puncture at the same or nearby site, and increased intraluminal pressure of the graft. We present an uncommon case in which aneurysm and pseudoaneurysm of the native fistula is caused by puncture, in both sides. Repeated punctures at the same site, may progressively weaken the venous wall resulting in dilation of the outflow vein. A 68- year-old Albanian women had been in a hemodialysis program for 4 years, using a left brachiocephalic fistula. The inflow artery, outflow vein, and the deep veins were examined in detail. During the study period the patient have had three surgeries, for aneurysm of hemodialysis access on one hand, and for pseudoanurysm of hemodialysis access on the other hand. But, even that the patient survived and everything went well. The idea of our paper was that in patients we have predisposition for the formation of aneurysm and pseudoaneursym, the medical staff have more frequent meetings, so that such cases are treated more specifically, with more frequent visits to vascular surgeon, with more frequent measurements of draining vein diameter and flow of vascular access. The K/DOQI guidelines recommend a regular program of monitoring and surveillance of the vascular access. Color Doppler ultrasound s considered a valuable tool in the preoperative evaluation and in the follow-up.

Stima della portata della fistola artero-venosa mediante termodiluizione nei pazienti in emodialisi cronica: esperienza monocentrica.

Purpose: Vascular access surveillance in hemodialysis is today an important challenge for nephrologist. Low blood flow is a risk factor for development of thrombosis of native fistula or graft. The aim of the study is to evaluate the correspondence between flow measurement by thermodilution and Color Doppler, and to identify flow rate values using the Blood temperature monitor (BTM) method in the case of stenosis. Methods: We evaluated 29 patients on chronic hemodialysis. The evaluation of blood flow with BTM were performed during the first hour of the hemodialysis session. All patients underwent a color doppler of vascular access within 10 days from the BTM measurements. Results: The mean vascular access flow calculated with BTM resulted 1142 ± 700 ml/min and there was a correlation with color doppler data 1199 ± 644 ml/min (p=0,0001 r=0,829). The flow of patients with hemodynamically significant stenosis was 332 ± 92 ml/min with a minimum value of 270 ml/min and a maximum value of 440 ml/min. Conclusion: the correspondence between thermodilution and color doppler support the implementation of intradialitic evaluation of the vascular access blood flow with the BTM method. Thermodilution allows to identify earlier patients with high risk of vascular access failure and the need for further diagnostic and therapeutic investigations.

Drug eluting balloon angioplasty for assisted maturation of failing fistulae

Objective: To present our experience of balloon-assisted maturation with drug-eluting balloon dilation in patients with recurrent failing arteriovenous fistulae. Case series: Three patients (all males, mean age 71 years) with a complex history of failed attempts at native fistula creation underwent surgical creation of arteriovenous fistulae. Two patients had a two-stage brachio-brachial fistula and 1 had a brachio-cephalic fistula that also required subsequent elevation. After a few weeks of preserved patency with a thrill detected clinically, all patients had a gradual deterioration of flow manifested with loss of thrill and multiple severely stenotic lesions of neo-intimal hyperplasia seen on duplex ultrasound. All 3 non-maturing native arteriovenous fistulae had 1 or more angioplasties with regular balloons that were initially successful; however, they rapidly deteriorated with a loss of thrill and a recurrence of multiple stenosis. Drug-eluting balloon dilation was used subsequently as a last resort to save these failing fistulae. All procedures were successful with the preservation of patency and adequate fistula flow (>600 mL/min) during the follow-up period (4-8 months, mean 6 months), and all patients received successful dialysis with 2-needle cannulation of their fistulae. There were no adverse events during the study period. Conclusions: Drug-eluting balloon angioplasty was to salvage nonmaturing fistulae with durable results in complex patients where conventional treatment had previously failed. Drug-eluting balloons may provide a useful treatment option for patients prone to multiple access failures due accelerated neo-intimal hyperplasia.

Use of bovine carotid artery for buttonhole technique hemodialysis

Purpose: Assess the feasibility of using a bovine carotid artery graft for buttonhole technique hemodialysis in patients who are not candidates for a native fistula. Methods: Case reports used to demonstrate selection criteria and results for this approach. Criteria include: knowledgeable patient with prior dialysis experience, stable graft in place for 3 months minimum, not a candidate for a native fistula, and able to maintain close follow-up. Results: Both grafts were based on axillary vessels and have been in place for a total of 64 months. They have been used for dialysis via buttonhole for a total of 40 months. There have been three procedures on these patients, post-buttonhole use (.87/year). There have been no infections. Conclusions: These patients were carefully selected based on desire, support, knowledge/experience and ability. Their success suggests that buttonhole technique for hemodialysis on a synthetic semi-biologic graft can be accomplished with morbidity and longevity similar to any graft using non-buttonhole needle access.

Graft for Immediate use as First Stage of a Native Fistula

The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2–3 week period. This approach minimizes or circumvents catheter use altogether.

Strategy for the Maximal Use of Native Arteriovenous Fistulae for Hemodialysis

The long-term survival and quality of life of patients on hemodialysis is dependant on the adequacy of dialysis via an appropriately placed vascular access. The native arteriovenous fistula (AV fistula) at the wrist is generally accepted as the vascular access of choice in hemodialysis patients due to its low complication and high patency rates. It has been shown beyond doubt that an optimally functioning AV fistula is a good prognostic factor of patient morbidity and mortality in the dialysis phase. Recent clinical practice guidelines recommend the creation of a vascular access (native fistula or synthetic graft) before the start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. A multidisciplinary approach, including nephrologists, surgeons, interventional radiologists, and nurses should improve the hemodialysis outcome by promoting the use of native AV fistulae. An important additional component of this program is the Doppler ultrasound for preoperative vascular mapping. This approach may be realized without unsuccessful surgical explorations, with a minimal early failure rate, and a high maturation, even in risk groups such as elderly and diabetic patients. Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results also support clinical practice guidelines that recommend the preferential placement of a native fistula.