A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis

Purpose

Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible.

Methods

To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37–78 yrs (60 ± 13.6 yrs).

Results

In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was performed in 2 patients 24hr and in 1 patient 48hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively.

Conclusion

In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.

Pathogenic role of antibodies against monomeric C-reactive protein in tubulointerstitial nephritis and uveitis syndrome

Antibodies against monomeric C-reactive protein, which is a target antigen expressed both in kidney tubules and uveal cells, have been recently detected in patients with active tubulointerstitial nephritis and uveitis syndrome. We report the case of an 65-year-old woman with acute renal failure caused by biopsy-proven tubulointerstitial nephritis and the onset of uveitis 21 months later. The expression of monomeric C-reactive protein in kidney oligobiopsy was confirmed by immunohistochemical staining using mouse monoclonal antibody against human monomeric C-reactive protein. The levels of antibodies against monomeric C-reactive protein were 117% of the reference during the flare and 22% during the remission of the disease. The difference in the levels of antibodies against monomeric C-reactive protein during flare and remission, and above all positive biopsy staining, supports their pathogenic role in this disease.

Risk factors for glucose metabolism disorders after kidney transplantation with uneventful course

A wide range of glucose metabolic disorders (GMDs) often arise after renal transplantation that predispose to graft dysfunction, infections, and cardiovascular disease. This study evaluated the risk factors for GMDs among 50 patients including 30 males and overall mean age 44.9 +/- 12.1 years. All 50 subjects displayed normal glucose tolerance tests pretransplantation and no family history of diabetes. They were selected from the 99 consecutive patients transplanted from April 2005 to January 2006 based upon uneventful posttransplantation course, without rejection episodes or hepatitis C virus (HCV) infections. The study concentrated on risk factors originating during the dialysis period. Even in this selected group, the risk of posttransplant GMD development was high (28%). Patients with GMDs showed significantly worse renal function at 1 month after transplantation (serum creatinine concentration: 1.70 +/- 1.67 mg/dL in the GMD group vs. 1.44 +/- 0.96 mg/dL in the group without GMDs [P = .027] and eGFR, 56.68 +/- 22.70 mL/min/1.73 m(2) versus 71.29 +/- 27.37 mL/min/1.73 m(2), respectively, [(P = .099)]. In a logistic regression model, a statistically significant difference between the groups was shown only for cold ischemia time (P = .037). In the logistic regression model with two independent variables, statistical significance was observed (P = .038) for body mass index at the time of transplantation. In this model, a lower pretransplant serum insulin concentration showed an influence that bordered on significance (P = .074). This study confirmed that the etiology of GMD after kidney transplantation is multifactorial, and at least in part connected with the pre-transplantation period.

Influence of autologous arteriovenous fistula on the blood supply to the hand in very elderly hemodialyzed patients

INTRODUCTION

Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia.

PURPOSE AND METHODS

To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously.

RESULTS

Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR).

CONCLUSIONS

Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.

Outcome of Autogenous Fistula Construction in Hemodialyzed Patients Over 75 Years of Age

BACKGROUND

There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age.

METHODS

The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 +/- 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed.

RESULTS

The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 +/- 4.3% (+/- SE) at 1 month; 70 +/- 4.7% at 6 months; 59 +/- 4.9% at 1 year; 59 +/- 4.9% at 2 years; 59+/- 4.9% at 3 years; 59 +/- 4.9% at 4 years, and 58 +/- 4.9% at 5 years. The secondary patency rates were: 95 +/- 2.0; 92 +/- 2.2; 84 +/- 3.3; 79 +/- 4.0; 72 +/- 4.3; 71 +/- 4.4, and 69 +/- 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques.

CONCLUSIONS

By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.

Vascular abnormalities in patients with autosomal dominant polycystic kidney disease – the influence on arteriovenous fistula creation

AIM

Patients with autosomal dominant polycystic kidney (ADPKD) present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of aorta and abdominal aortic aneurysms. The aim of our study was to investigate whether vascular abnormalities that occur in wrist vessels, make native arteriovenous fistula creation difficult in this group of patients.

PATIENTS AND METHODS

The problem was analyzed retrospectively in 783 patients with chronic kidney failure who had had arteriovenous fistula created in our centre in the period between 1991 and 2001. ADPKD was the cause of terminal renal failure in 57 patients (7.3%). These were 31 men and 26 women aged 28 - 69 years (52 +/- 16 years on average).

RESULTS

A difference between left and right radial artery diameters and a narrow radial artery (below 2 mm), unsuitable for fistula creation, occurred in 12% of patients with ADPKD and in 0.38% of other patients. Instead of a cephalic vein in the typical place, a few small vessels were present in 14% of patients with ADPKD and in 2.17% of patients with other causes of renal failure.

CONCLUSION

Our experience shows a higher incidence of wrist vascular abnormalities in patients with ADPKD. This decreases the possibility of wrist native arteriovenous fistula creation in this group of patients.

[Prolonged use of the femoral catheter as a temporary access for hemodialysis]

Cannulation of the femoral vein is the safest method of acute vascular access. It is recommended the removal of the femoral catheter after 72 h. The trial was undertaken, if it is possible a safe prolonged use of the femoral cannulation. The observations were performed in 70 patients (31 F, 39 M, age 3-70 years) with acute and chronic renal failure (RF). The femoral catheter was left in place for the period from 7 to 104 days, mean 21 days. None complications occurred in the group of 16 patients in whose the cannula was left up to 14 days. Bt duration of the cannulation above 15 days (54 patients) exist site infections appeared in 10 patients, catheter thrombosis in 12 patients and fiber in 6 patients (all with the catheter in place above 21 days). Noteworthly chronic RF patients were dialysed mostly on the ambulatory basis. Femoral catheter can be left safely in place for 14 days.

The variety of clinical and histopathologic presentations of glomerulonephritis associated with latent syphilis

Glomerulonephritis is a well established but rather uncommon complication of latent secondary syphilis. We present three cases of glomerulopathies associated with luetic infection, observed and managed in our institutions in the past three years. They illustrate a variety of clinicopathologic presentations of this nephropathy, from acute nephrotic syndrome through membranous glomerulopathy up to rapidly progressive glomerulonephritis. Regardless of the clinical course and histologic type, they were all characterized by strongly positive results of serologic tests for syphilis. Our observations suggest the necessity of eliminating luetic infection in aetiologic considerations of each newly diagnosed case of nephrotic syndrome.

[Changes in rubidium and cesium levels in the blood of patients on long-term dialysis and decreased velocity of neural conduction]

In 19 patients aged 19 to 45 years on long-term dialysis treatment during 12.6 +/- 18.2 months the concentrations of Rb and Cs were determined by atomic spectrometry in whole blood before and behind the dialyser at the beginning and end of dialysis. At the same time the concentrations of these elements were determined in the dialysing fluid. In all patients the velocity of conduction in the motor fibres in the upper and lower extremities was determined before and after dialysis. Damage to the peripheral neurons was demonstrated in the lower extremities mainly in 79% of cases. Increased velocity of motor conduction in at least one nerve related directly proportionally to the Cs concentration of the serum was demonstrated in 56-70% of the patients after one dialysis.

Clinical trial of hemodialysis in chronic schizophrenia

The hemodialysis program was carried out in four male chronic schizophrenic patients hospitalized 3--12 months in the Psychiatric Clinic, Medical University, Wroclaw. The diagnosis was made independently by three psychiatrists. The disease lasted 5 to 26 years. The clinical assessment of mental and physical state followed each dialysis. The BPRS, CGI and Wing's Ward Behavior Scale were filled. Eleven to 20 dialyses were conducted once a week (two patients) or twice weekly (two patients). Neuroleptics were withdrawn. A short period of slight, unspecific improvement was followed by a deterioration in all cases, which made it necessary to put the patients back on neuroleptics. At the end of the dialysis program none of the patients improved. Further research on the efficacy of dialysis in chronic schizophrenia should be made before the final assessment of its value.