Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres

OBJECTIVE:

It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed.

METHODS:

All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined – the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05.

RESULTS:

There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity.

CONCLUSIONS:

In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.     

Influence of intravenous drug abuse on native arteriovenous fistula thrombosis in chronic hemodialysis patients

The influence of intravenous drug abuse (IVDA) on native arteriovenous fistula thrombosis (NAT) in chronic hemodialysis patients is unknown. We conducted a retrospective study of 123 chronic hemodialysis patients incarcerated in a male prison in Mid-Taiwan. All patients were dialyzed three times per week, 4 h per session. The development of NAT was compared in patients with a history of IVDA (42, 34.1%) and those without (81, 65.9%). A total of 36 patients experienced one or more NAT episodes in 6 years and 29 (80.6%) of them had a history of IVDA. In these 29 patients, 22 (75.9%) relied on repeated thrombectomy or thrombolysis therapy to maintain patent vascular access. In Kaplan-Meier survival analysis, patients with a history of IVDA were prone to develop NAT (log-rank, P < 0.001). The result of Cox regression suggested that a history of IVDA, independent of diabetes, was associated with the development of NAT. Patients with a history of IVDA, even after IVDA has stopped, were still prone to develop NAT and vascular access infection.     

立体定向放射外科治疗硬脑膜动静脉瘘

目的评估立体定向放射外科治疗硬脑膜动静脉瘘的安全性和有效性。方法采用伽玛刀治疗硬脑膜动静脉瘘16例，其中单纯伽玛刀治疗7例，经动脉途径栓塞或手术治疗后再行伽玛刀治疗9例。根据Congard分型，硬脑膜动静脉瘘Ⅰ型4例，Ⅱa型5例，Ⅱa b型3例，Ⅲ型3例，Ⅳ型1例。靶点边缘剂量16～20Gy，平均18Gy，靶点边缘被50％～70％等剂量曲线所包含。所有患者均获得随访，随访时间为5～108个月。结果14例患者术后症状消失，2例部分改善。12例MRI或造影证实瘘口完全或近全闭塞，4例部分闭塞。无放射治疗导致的并发症。结论立体定向放射外科是一种治疗硬脑膜动静脉瘘安全、有效的方法。对侵袭型硬脑膜动静脉瘘且伴有广泛皮质静脉引流的患者，血管内治疗或手术治疗结合放射外科是一种有效的治疗模式。     

Regular exercise as a part of treatment for patients with end-stage renal disease

Physical inactivity and its negative influence on health and the quality of life is a common problem generally, especially in patients with chronic illness and also in patients with end-stage renal disease. Motivation for regular physical exercise could be a problem. A supervised outpatient program in a rehabilitation center, a home exercise rehabilitation program and an exercise rehabilitation program during the first hours of the hemodialysis treatment with a bed bicycle ergometer in the renal unit could be carried out. Low intensity aerobic activity has a favorable effect on cardiovascular risk factor, and gymnastics to increase strength, flexibility and coordination, as well as relaxation techniques are very effective exercises in a rehabilitation program. The positive influence of individual regular exercise on health, quality of life, physical exercise capacity, endurance, muscle strength, social, professional and emotional status is also very high in patients. Side effects of exercise are very rare.     

Vascular access in children on chronic hemodialysis: a Slovenian experience

The aim of our study was to report our experience with arteriovenous fistulas (AVFs) and non-cuffed central venous catheters (CVCs) in children and adolescents with end-stage renal disease (ESRD) on hemodialysis (HD). The children with ESRD (18 years or younger) who were hemodialyzed at the Center of Dialysis and Transplantation, Children's Hospital, Ljubljana, in the period between December 1998 and December 2010 were included in our retrospective study. We recorded the data considering the CVCs and AVFs used for HD. Thirty-one children (13 females, 18 males) with ESRD received HD treatment. The mean patient age when HD was started was 13.3 ± 3.4 years. Altogether, 35 AVFs were created, and the primary failure rate was 25.7% (9/35). The time to maturation was 4.0 ± 2.5 months. The mean patency of the AVF was 42.5 ± 51.9 months. Seventy-seven CVCs (non-cuffed) were inserted in the observation period; 89.6% of the CVCs were inserted in the jugular vein, and citrate locking was used in the interdialysis period. The CVCs were removed after 0.1-17.4 months (3.6 ± 3.7 months). The incidence of bacteremia was 0.9 episodes per 1000 catheter days. The preferred vascular accesses for pediatric hemodialysis are native AVFs; however, a single lumen, non-cuffed, citrate-locked CVC placed in a jugular vein can be acceptable as a long-term vascular access when AVF cannot be constructed or used.     

Surgical salvage of thrombosed arteriovenous fistulas and grafts

Our clinical experience with surgical salvage of thrombosed arteriovenous (AV) fistula and grafts, performed by a skilled interventional nephrologist is presented. A total of 286 surgical interventions were performed in 246 chronic hemodialysis patients aged 12-87 years (55 +/- 16 years), 268/286 (93.7%) in AV fistulas, 18/286 (6.3%) in grafts, and analyzed retrospectively. A subgroup of 61 procedures was analyzed prospectively. The type of procedure, immediate success and patency after surgery were evaluated. Thrombectomy with reanastomosis was performed in 197/286 (68.9%) and simple thrombectomy in 89/286 (31.1%) of the procedures. The time from thrombosis to surgery was 1-60 days (3.7 +/- 1.8). Immediate success was achieved in 258/286 (90.2%) of surgical procedures, 95.5% (189/198) in thrombectomies with reanastomosis, and 77.5% (69/89) in simple thrombectomies. Primary and secondary patency rates for AV fistulas after surgical salvage at 3, 6, 9, and 12 months were 93.1, 84.0, 78.3, 75.0% and 96.6, 88.0, 78.3, 77.3%, respectively. In order to maintain secondary patency, 1.15 surgical procedures per AV fistula were needed. The time to thrombosis in grafts was on average 10.2 months, primary and secondary functioning time from thrombectomy (until the end of observation period) was from 1 to 19 months (average 6.9 +/- 6.3 months) and from 5.5 to 19 months (average 9.1 +/- 5.6 months), respectively. In 7/16 (43.8%) surgical procedures, transluminal angioplasty and in 3/16 endovascular stent was placed after angioplasty. To maintain secondary patency, 2.3 surgical procedures per graft were needed. The surgical salvage of thrombosed AV fistulas and grafts, performed by a skilled interventional nephrologist, is successful in the short and long-term.     

动静脉内瘘对血液透析患者心脏功能的影响

目的探讨动静脉内瘘对血液透析患者心脏功能的影响。方法对中国医科大学附属第二医院肾内科2004—2005年收治的55例尿毒症血液透析患者于动静脉内瘘术(AVF)前后进行心脏彩色超声心动图检测,对比分析左心房内径(LAD)、左心室内径(LVD)、左室舒张末容积(LVEDV)、左心室每搏输出量(SV)、左心室射血分数(EF)及右心室内径(RVD)指标的变化。结果AVF术后LAD、RVD、LVD、LV-EDV均有不同程度的增大,而EF水平下降,P<0·05有统计学意义;SV有所增加,P>0·05无统计学意义。结论AVF可以造成血液透析患者左心房、心室腔的扩大,左心室的收缩功能下降。     

硬脑膜动静脉瘘的血管构筑及治疗方法分析

目的探讨硬脑膜动静脉瘘（DAVF）的血管构筑特点及相应的治疗策略.方法回顾性分析159例DAVF患者的临床表现、血管构筑模式及相应的治疗方法,在此基础上运用卡方检验分析影响疗效的因素.所有DAVF的血管构筑均按照部位与引流静脉相结合的方法进行分类.结果海绵窦区DAVF 69例,Ⅰ型58例,Ⅱ型11例;侧窦区41例,Ⅰ型26例,Ⅱ型14例,Ⅲ型1例;上矢状窦区13例,Ⅰ型1例,Ⅱ型2例,Ⅲ型10例;天幕区20例,颅底区7例,均为Ⅲ型.多发性DAVF 9例.治疗方法主要采用血管内治疗,术后影像学治愈79例,好转71例,无效9例.术后出现并发症9例,8例痊愈或好转,1例死亡.结论DAVF的临床表现、预后、治疗方式取决于其血管构筑模式,特别是病灶部位和静脉引流方式,血管内治疗是首选和主要的治疗方法.     

Cardiovascular calcification in patients with end-stage renal disease

Vascular calcifications are very frequent extraosseous calcifications in patients with chronic renal disease. They occur in the intima and in the media. They are associated with decreased arterial elasticity and increased mortality. The risk factors are: advanced age, duration of dialysis treatment, diabetes, increased phosphate concentration, the dose of Ca-containing phosphate binders and inflammation. It is now well established that vascular smooth muscle cells actively take up phosphate to form bioapatite. This process is associated with a phenotypic transformation of vascular smooth muscle cells during which they express osteoblast markers. Lipids and inflammatory cytokines also increase bioapatite formation. Calcification inhibitors are matrix Gla protein and fetuin-A. Decreased serum fetuin-A concentration is associated with a higher mortality rate in dialysis patients. An important preventive measure for vascular calcification is the substitution of Ca-containing by non-Ca-containing phosphate binders.     

Vascular access for hemodialysis: arteriovenous fistula

The long-term survival and quality of life of patients on hemodialysis (HD) is dependant on the adequacy of dialysis via an appropriately placed vascular access. The optimal vascular access is unquestionably the autologous arteriovenous fistula (AVF), with the most common method being the conventional radio-cephalic fistula at the wrist. Recent clinical practice guidelines recommend the creation of native fistula or synthetic graft before the start of chronic HD therapy to prevent the need for complication-prone dialysis catheters. This could also have a beneficial effect on the rapidity of worsening kidney failure. A multidisciplinary approach (nephrologists, surgeons, radiologists and nurses) should improve the HD outcome by promoting the use of AVF. An important additional component of this program is the Doppler ultrasound for preoperative vascular mapping. Such an approach may be realized without unsuccessful surgical explorations, with a minimal early failure rate and a high maturation, even in patients with diabetes mellitus.     

Outcomes of salvage procedures for occluded autogenous radiocephalic arteriovenous fistula

The outcomes of surgical and endovascular treatments for thrombosed access fistulas are variable and provide no definitive indications for treatment choice. We purposed to review our experience in treating thrombosed radiocephalic arteriovenous fistulas (AVFs) and to evaluate the outcome of procedures, including proximal neo‐anastomosis (NEO), replacement of the stenosed segment with a polytetrafluoroethylene graft (GI), patch angioplasty (PA), and endovascular procedures (such as percutaneous transluminal angioplasty [PTA]). A total of 117 occluded radiocephalic AVFs were treated by surgery or an endovascular procedure from January 2002 to December 2007. We evaluated the rates of initial success, re‐thrombosis, the post‐interventional five‐year patency rate, and temporary catheter requirement. Forty‐five patients (38.5%) underwent NEO, 32 patients (27.4%) GI, 10 patients (8.5%) PA, and 30 patients (25.6%) PTA. The overall initial procedural success rate was 98.3% (surgery 98.9% and PTA 96.7%), and the post‐interventional patency rates at five years were 92.2% (97.1% for NEO, 82.7% for GI, 90.0% for PA, and 96.7% for PTA). Twenty‐four patients (20.5%) required a temporary catheter during healing of the functioning segment after treatment: four patients for NEO, 18 patients for GI, two patients for PA, and no patients for PTA (P < 0.001). Both surgery and endovascular treatment gave high rates of initial success and low re‐thrombosis rates as salvage treatments for occlusion of radiocephalic AVFs, if treatments were selected according to the length, and location of the stenosis to be corrected. When stenosis of a long segment is suspected, endovascular treatment should be attempted first in order to maintain the functional segment and thereby avoid use of a temporary catheter.     

自体动静脉内瘘在血液透析中的应用

目的分析慢性肾功能不全尿毒症期患者自体动静脉内瘘在血液透析中的应用,并探讨其使用时间、初期成熟影响因素、并发症及透析充分性.方法回顾分析182人188例次自体内瘘手术的慢性肾功能不全尿毒症期患者的临床资料,探讨性别、年龄、原发病、术前血白蛋白、血色素、血肌酐、尿素氮、血脂、术后抗凝剂用量与内瘘初期成熟相关性以及1年内并发症和透析充分性.结果 182例慢性透析患者中男性93例,女性89例, 平均年龄52.4岁±8.52岁(18～89)岁,原发病为糖尿病肾病31例(17%).172例内瘘成熟,10例患者16例次失败;Logistic回归分析显示血压低于100/60mmHg患者与内瘘初期成熟成负相关(P<0.001),术后应用抗凝治疗与内瘘初期成熟成正相关(P<0.02);内瘘成熟后1年,通畅率为97.6%(168/172例次),栓塞率为2.3%(4/172例次),感染率为0.每例内瘘平均透析次数为(140.2±10.6)次,平均透析时间为(560.8±42.4)小时, 透析血流量200～250ml/min,KT/V为1.2～1.5, 再循环率R为3.2～3.4%.结论自体内瘘为1种永久性血液透析通路,其并发症主要为栓塞;血压低于100/60mmHg的患者内瘘初期成熟机率较低,术后应用抗凝治疗可减少内瘘阻塞的发生机率;自体内瘘作为血液透析通路,透析充分性好.     

Vitamin D as a Novel Nontraditional Risk Factor for Mortality in Hemodialysis Patients

We examined the prevalence of vitamin D deficiency in hemodialysis patients and tested the hypothesis that decreased levels of 25‐hydroxyvitamin D (25D) are associated with an increased risk for early all‐cause mortality. One hundred and two patients, 57 (56%) men and 45 (44%) women, mean age 60.5 ± 13.1 years, were included in our study. Serum calcium and phosphorus levels were measured by routine laboratory methods. Parathyroid hormone (PTH) was measured by immunoassay and 25D by enzyme immunoassay. Patients were divided into two groups depending on the serum concentration of 25D: below or above 50 nmol/L. Survival rates were analyzed using the Kaplan–Meier survival curves. The Cox regression model was used to define potential variables effecting all‐cause mortality. The mean level of 25D in all patients was 58 ± 35.6 nmol/L, 52% of patients had 25D levels >50 nmol/L and 48% had levels of 10.5–50 nmol/L. Compared with men, women were more likely to be 25D deficient (67% vs. 37%; P = 0.005). Patients were observed from the date of laboratory measurement until their death or to a maximum of 730 days. Kaplan–Meier survival analysis showed that mortality in patients was significantly higher in the group with 25D levels ≤50 nmol/L (P < 0.033). With Cox multivariable regression modeling, the PTH level (P < 0.029) turned out to be the only predictor of mortality in our patients. Using the definitions recommended in the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines, we found that our hemodialysis patients on average have vitamin D insufficiency. Our results indicate that patients with 25D levels ≤50 nmol/L are associated with higher all‐cause early mortality.     

Comparison of sexual function in females receiving haemodialysis and after renal transplantation

The aim of this study is to compare the sexual function of kidney transplant recipients and end-stage renal disease (ESRD) patients receiving haemodialysis (HD) in female patients. In the sample population of this study, there were 72 women in the transplant group and 40 women in the HD group. To test the differences in the quantitative variables between these two groups, an independent sample Student's t-test was performed. Sexual relationship, sexual function, sexual frequency and sexual fear in the renal transplant patients are significantly better than HD patients. Sexual intercourse satisfaction was apparently higher in the kidney recipients than in the HD patients. Twenty-one patients in transplanted group described number was 6 (15%) (p = 0.03). This study indicated that female kidney transplant recipients experienced a significantly better sexual relationship compared with the ESRD patients receiving HD.     

Adaptive remodeling of hypoplastic hemodialysis fistulas salvaged with angioplasty

Objectives : The aim of this study was to determine whether immature hemodialysis fistulas undergo flow‐induced adaptive remodeling after successful percutaneous angioplasty. Background : Approximately 50% of radiocephalic fistulas remain immature after surgery and cannot be used for hemodialysis. Small fistulas with anastomotic inflow stenoses may undergo salvage angioplasty, but the time course of outward remodeling after successful treatment has not been defined. Methods : Thirty‐two of 39 patients (82%) with inaccessible, hypoplastic radiocephalic fistulas underwent attempted salvage angioplasty of inflow stenoses involving the arteriovenous anastomoses. Twenty patients experienced salvage of their fistulas and successfully underwent hemodialysis (51%). Results : Eleven patients had serial angiographic procedures, which allowed paired sequential quantitative angiographic measurements of the fistulas to be made during a median follow‐up of 200 days (range 5–2,298 days). Fistula diameters increased from 4.5 ± 1.3 mm to 8.0 ± 2.5 mm (mean ± S.D.). The mean growth of the fistulas was 1.0 ± 0.9 mm per year. Conclusions : The mechanism of adaptive remodeling transforms nonmaturing hypoplastic autogenous fistulas into functioning accessible dialysis accesses after successful percutaneous transluminal angioplasty of inflow anastomotic stenoses. © 2009 Wiley‐Liss, Inc.     

Evaluation of pulmonary artery pressure and resistance by pulsed Doppler echocardiography in patients with end-stage renal disease on dialysis therapy

Background

Pulmonary hypertension (PH) is one of the most important comorbidities in patients undergoing hemodialysis (HD). The goal of the present work is to determine the possible etiologic factors for its occurrence.

Methods

The prevalence of PH was estimated by Doppler echocardiography in a cohort of 100 patients aged 49.3 ± 13.9 years on regular HD. Mean pulmonary artery pressure was estimated from pulmonary acceleration time by Mahan’s regression equation. Pulmonary vascular resistance and pulmonary capillary wedge pressure were calculated. We focused on the effect of HD on left and right ventricle diastolic and systolic function. Right ventricle systolic function was assessed by tricuspid annular systolic excursion and pulsed Doppler myocardial performance index. Since impaired endothelial function was postulated as an underlying cause of PH, we studied the effects of HD on brachial artery endothelial function.

Results

The current study found that pulmonary hypertension was prevalent in 70% of patients on dialysis. Left atrium diameter, left ventricle mass indexed to body surface area, and mitral E/E′ were increased in the dialysis group (4.4 ± 0.2 cm, 126.5 ± 24.6 g/m², and 16.9 ± 4.4, respectively, p < 0.001 for all). Pulmonary artery systolic pressure was positively correlated to duration of dialysis and negatively correlated to glomerular filtration rate (p < 0.001 and r = −0.991). Pulmonary vascular resistance was significantly increased in dialysis patients (1.9 ± 0.2 Wood units vs. 1.2 Wood units in controls, p < 0.001). Endothelial dysfunction, defined as brachial artery flow mediated dilatation <6%, was found in 46% of dialysis group.

Conclusion

Increased pulmonary artery systolic pressure in the HD population could be attributed to left atrium dilatation and left ventricle diastolic dysfunction. Pulmonary vascular resistance was significantly increased in dialysis group. This might be explained by impaired endothelial nitric oxide synthesis that not only caused systemic vasoconstriction but also affected the pulmonary vasculature.     

Renal replacement therapy in Slovenia: 2003 annual report

The total number of end-stage renal disease patients treated by renal replacement therapy increased from 1584 on 31 December 2002 to 1661 on 31 December 2003 (4.9% increase). Of these patients, 70.5% were treated by hemodialysis, 7.0% by peritoneal dialysis and 22.5% had a functioning renal graft. The patients were treated at 18 dialysis centers and one transplant center. The number of prevalent patients treated by renal replacement therapy per million of the population (p.m.p.) was 846 at the end of 2003. The number of incident (new) patients in 2003 was 131 p.m.p. The gross mortality rate of dialysis patients was stable through the years of the study and reached 11.8% in 2003. 57.6% of new patients starting hemodialysis were > or = 65 years old and 23.2% were diabetics. Epoetin therapy was prescribed to 89.8% of dialysis patients. The number of patients positive for hepatitis B or hepatitis C viruses is stable and low (3.1% of all dialysis patients).     

Remaining lifetime risk for developing end stage renal disease among Australian Aboriginal people with diabetes

The remaining lifetime risks for end stage renal disease among Aboriginal people with and without diabetes were estimated. The value for young adults with diabetes was high, about 1 in 2 at the age of 30 years, while it decreased with age to 1 in 7 at 60 years.