Arteriovenous Fistula Construction Research Articles

Arteriovenous Fistula Has Better Cardiac Outcome Than Permanent Catheter in Hemodialysis Patients with Heart Failure

Abstract Background and Aims End stage renal disease patients with heart failure (HF) are at high-risk to develop clinical worsening after arteriovenous fistula (AVF) construction. This study evaluates effects of AVF versus permanent catheter on cardiac parameters in prevalent hemodialysis patients with heart failure and its relation to short term dialysis outcome. Methods A prospective study included 60 hemodialysis patients with HF ejection fraction (EF) 35- 50%. Patients were divided into: 30 patients with distal AVF, 30 patients with permanent hemodialysis catheter. Echocardiography was done for all patients at the beginning of the study and after 6 months with follow up of short term dialysis outcome. Result Patients with AVF after 6 months had significant improvement in TSAT, KT/v, URR, with increase in left atrial diameter (LAD) (p < 0.001, <0.001, <0.001,0.013) respectively while no significance in pulmonary hypertension, RAD, LVEDD (p value 1.000, 0.226,0.100) respectively. Patients with permanent catheter after 6 months had deterioration in TAST, serum albumin, URR, kt/v, hemoglobin, EF, LAD, RAD, LVEDD (p value <0.001, <0.001, 0.014, 0.010, 0.012, <0.001, 0.002, 0.001, <0.001) respectively. In comparing both groups: permanent catheter had significant deterioration in {hemoglobin, WBC, ferritin, TAST, albumin, EF} compared to AVF (p value <0.001, <0.001, <0.001, <0.001,0.001, <0.001) respectively, while no significance in LAD, RAD, LVEDD, pulmonary hypertension (p value 0.137, 0.435,0.052,0.315) respectively. Patients with Permanent catheter had a risk 10 times to have lower EF than AVF (odds ratio10.000). The EF after 6 months was positively correlated with URR, p value (0.028) and negatively correlated with dialysis duration p value (0.022) in AVF, while in permanent catheter was negatively correlated with-phosphorus, and potassium, p value (0.01, 0.048) respectively. Conclusion AVF is the preferred vascular access in heart failure for hemodialysis with better cardiac and dialysis outcome compared to permanent hemodialysis catheter. Adequatedialysis linked to positive effect on EF.

Construction and key technical points of arteriovenous graft fistula

Hemodialysis remains the main kidney replacement therapy for end-stage renal disease patients worldwide. When superficial veins are exhausted or arteriovenous fistula cannot be established, arteriovenous graft fistula should be selected as the permanent dialysis access. The article elaborates on the process of arteriovenous graft fistula construction, including many technical aspects, such as preoperative evaluation, surgical plan, graft selection, preoperative preparation, and surgical procedure, which are related to surgical outcomes, complications, and long-term patency rate.

Application of a supporting catheter in surgery for forearm arteriovenous fistula construction.

This study explored the feasibility of a supporting catheter combined with modified end-to-side anastomosis in the operation of radio-cephalic arteriovenous fistula (RC-AVF) and evaluated the clinical application value of this technique. Sixty patients underwent RC-AVF operations in our hospital from January 2022 to June 2022. All the patients were treated with modified end-to-side AVF anastomosis and divided into the control group or the test group depending on whether a supporting catheter was applied. The clinical data of 60 cases were analysed retrospectively. Intraoperative related indices, the first time the fistula was used, the success rate of first puncture, the blood flow of first dialysis, the maturity condition of fistula, the size of anastomosis, the diameter of radial artery and drainage vein, the blood flow of brachial artery 8 weeks after operation and the incidence of complications within 6 months after operation were compared between the two groups. Compared with that in the control group, the time spent on the vascular anastomosis in the test group was significantly shortened (p<0.05). The blood flow of the first dialysis, the size of the anastomosis, the diameter of the drainage vein, the blood flow of the brachial artery 8 weeks after the operation and the incidence of complications within 6 months after operation were significantly different between the two groups (p<0.05). In the RC-AVF operation, using a supporting catheter can not only increase operation efficiency by reducing surgical injury and difficulty of vascular anastomosis, but also improve postoperative prognosis. RC-AVF is worth promoting in clinical practice.

Use of Basilic vein in arteriovenous fistulas construction for hemodialysis access. Is it a good option alternative to prosthetic arteriovenous grafts?

For patients with a failed forearm autogenous fistula (AF) and an exhausted cephalic vein, there is controversy about whether a brachial basilic AF with transposition or an arteriovenous prosthetic bridging graft (BG) must be the second vascular access option. This work measured and compared these two modalities according to patency rates, complications, and revisions. A retrospective study of 104 cases that had either a brachial basilic AF (72) or an Arteriovenous BG (32). Technical success, operative complications, procedurerelated mortality, maturation time, functional primary, secondary, and overall patency rates were all assessed. Technical success was obtained in all participants. No procedure-linked mortality. Maturation time for BGs was significantly shorter than AFs. The complication rate was significantly higher in BGs than in AFs. The most prevalent complication was access thrombosis. The functional primary patency rate was significantly higher in AF than in BG at 12-month followup: 77.7% vs 53.1% (p < 0.012). secondary patency rate was higher in AF than in BG at 1-year follow-up 62.5% vs 42.8% (p = 0.063), respectively. In addition, BGs required more interventions to preserve patency. AF had higher primary, secondary and overall functional patency rates and needed fewer procedures to keep patency than BGs. Cases that need early vascular access as a result of central venous catheter complications or who have a reduced life expectancy may benefit from BGs.

Painless ulceration due to digital hypoperfusion ischaemic syndrome: case report and literature review

Digital hypoperfusion ischaemic syndrome (DHIS), also known as steal syndrome, is a well recognised serious complication of haemodialysis (HD) access creation. The clinical presentation varies from cyanosis to tissue loss due to necrosis or gangrene. In this article, we present a case of painless digital ulceration due to DHIS and provide a review of the literature. A 40-year-old-female presented with multiple painless digital ulcerations of the left hand. Her medical profile included atherosclerotic disease, hypertension, hyperparathyroidism and type I diabetes causing retinopathy, peripheral neuropathy, gastroparesis and end-stage renal disease (ESRD). Her ESRD required HD with the construction of a left-arm basilic vein transposition arteriovenous fistula (AVF). A year later, she developed intermittent, painless ulcerations of the left hand. A Doppler ultrasound confirmed the diagnosis of DHIS. The patient was treated with AVF ligation surgery. At six months postoperatively, she had near complete re-epithelialisation of her ulcers. This case is unique in that the patient did not have preceding pain, likely due to her underlying diabetic neuropathy. While DHIS in haemodialysis patients with AVF is well documented in literature, digital ulceration in this context is an advanced form of this condition. Early recognition of digital ulceration as a complication of DHIS may enable early intervention and prevent permanent damage.

#4923 ARTERIOVENOUS FISTULAS AS HEMODIALYSIS ACCESS IN A PEDIATRIC POPULATION – IS YOUNGER AGE A REASON TO MAINTAIN CENTRAL VENOUS CATHETER?

Abstract Background and Aims In the pediatric population, transplantation remains the first-line therapy in patients with end-stage renal disease (ESRD). However, it is not always possible, increasing the need for other kidney replacement therapy (KRT) modalities, and hemodialysis (HD) has been growing as a modality choice in recent years. To provide quality HD treatment, efficient vascular access is mandatory, and the arteriovenous fistula (AVF) is advocated as the best long-term access option. However, its creation is technically challenging, and its development and maintenance are some of the most difficult elements in the pediatric population. In this study, we describe our experience in the utilization of AVFs in children and adolescents on HD. Method We conducted a retrospective study including all the AVFs performed in our center on underage patients between January 2006 and December 2022. We reviewed the medical records, collected data on demographic variables, AVF characteristics, blood test results, and clinical outcomes. Statistical analysis was performed using SPSS software. Results Forty-three AVFs were performed in 32 pediatric patients. The median age at first AVF construction was 13.5 years (min 4.8; max 17.9). The most frequent etiology of ESRD was congenital anomalies of kidney and urinary tract (n = 20, 62.5%) and most patients (n = 24, 75.0%) were already receiving KRT. Median follow-up time was 16.4 months (min 1; max 98.4) and, at the end of the follow-up period, most patients (n = 22, 68.8%) were transplanted. The mortality rate was 6.3% (n = 2). In what concerns to the location of the AVF, radiocephalic was the first choice in 46.9% of the cases (n = 15), accounting for 34.9% of the total AVFs. Brachiocephalic location was used in 34.4% (n = 11) of first fistulas and 6 subsequent accesses, accounting for 39.5% of the total AVFs. The brachiobasilic location was chosen in 18.8% (n = 6) of the first AVFs and 25.6% of the total AVFs. Primary AVF failure occurred in 26.6% (n = 11) cases and, in 4 of these (36.4%), it was possible to successfully use the same location for a second AVF. We observed no statistical association between primary AVF failure dysfunction and gender, age at the construction of the first fistula, AVF location, or dialysis vintage. Platelet-lymphocyte (PLR) and neutrophil-lymphocyte (NLR) ratios also did not differ between groups. Primary and secondary patency rates at one year were, respectively, 62.5% and 93.8%. With respect to total AVF complications, we observed: thrombosis (27.9%), stenosis (18.6%), distal ischemia induced by vascular access (4.7%), and high flow/aneurismatic dilations (18.6%). The presence of complications was statistically related to age (p = 0.046), with more events in older patients at the time of AVF construction. There was no statistical difference between complications’ occurrence and AVF type, sex, gender, PLR, and NLR. Conclusion The utilization of AVF for HD has been growingly recognized as a safe and efficient alternative for the performance of KRT in pediatric patients. Although larger studies are needed, we demonstrate positive results in its usage in a pediatric population, with high primary and secondary patency rates. These outcomes were independent of the AVF location. We also advocate AVF usage in younger patients, as complications were associated with older age. PLR and NLR, which are emerging biomarkers for systemic inflammation, were not associated with AVF dysfunction, aligning with the results of other studies in pediatrics.

#5078 “FISTULA FIRST, CATHETER LAST” IN THE VERY ELDERLY: ONE SIZE FITS ALL?

Abstract Background and Aims The demographic characteristics of incident and prevalent hemodialysis (HD) patients have been undergoing significant changes over the last decades, in what has been called an “epidemic of aging in renal replacement therapy” [1]. The higher proportion of very elderly patients has brought significant challenges to the nephrologists, namely regarding the choice and timing of vascular access (VA) creation. Despite the arteriovenous fistula (AVF) undeniable status has the preferred VA, the applicability of the “Fistula First” initiative in very elderly patients has been questioned. Method This single-center observational retrospective cohort study took place at the Coimbra Hospital and University Centre, a Portuguese tertiary referral hospital. Patients were selected from the Nephrology department's database of HD referrals. Inclusion criteria were HD referral between January 2017 and December 2021 and age equal or over 80-years old at time of referral. We collected data regarding demographic characteristics, comorbid conditions, first VA, pre-HD nephrology care and functional status at referral, as well as the time and cause of death during the follow-up period. Functional status was assessed through the Katz index of independence in activities of daily living and the comorbid conditions were assessed through the Charlson comorbidity index. Primary outcome was mortality, and follow-up ended on the 31st of May 2022. Variables associated independently with mortality were included in Cox proportional-hazards regression models. Results Our study sample included 288 patients, predominantly male (63.9%), with a median age of 83 and a diabetes prevalence of 42.8%. The VA at first dialysis was a central venous catheter (CVC) in 77.8% and 68.1% had an unplanned HD start. Eighty-four percent had at least 3 months of pre-HD nephrology care. The mean Charlson Index at HD referral was 9.1 and 50.6% presented a Katz index under 5. The mortality incidence rate during follow-up was 32.8/100 patient-year, with 90-days, one-year, and two-year survival rates of 88.2%, 69.1% and 51.4%, respectively. The main known causes of death were infections not related with the VA (29%) and cardiovascular disease (14%). Starting HD through a CVC was associated with worse survival in univariate analysis (Log-rank 15.4, p&amp;lt;0.001). Other mortality-related variables in survival analysis were age at HD referral [hazard ratio (HR) 1.082, p&amp;lt;0.001], absence of pre-HD nephrology care (Log-rank 14.6, p&amp;lt;0.001), urgent-start HD (Log-rank 24.3, p&amp;lt;0.001), Katz index (HR 0.67, p&amp;lt;0.001) and Charlson index (HR 1.28, p&amp;lt;0.001). In a Cox Proportional Hazards model, when adjusting for the other mortality predictors, CVC use at first HD and unplanned HD start did not present a statistically significant association with mortality (HR 1.587, p = 0.074; HR 1.508, p = 0.098, respectively). Conclusion In our study sample, most patients started HD through a CVC, despite the majority having at least 3 months of pre-HD nephrology care. When adjusting for other covariates in a multivariate model, the first VA did not present a strong association with survival outcomes. The appropriate VA in the very elderly patient is an ongoing debate, and doubts remain regarding the applicability of the “Fistula First, Catheter Last” policy in octogenarian and nonagenarian patients. Our results are in line with recent reports which suggest that initial CVC use with later placement of an AVF, shortly after HD initiation, does not confer worse prognosis than initial AVF use in very elderly patients [2]. One of the limitations of our study was not having collected data regarding timings of AVF construction and use, which might have been informative regarding the impact of catheter-dependence time in survival.

A Modified Technique for Arteriovenous Fistula Construction in Rabbits.

Juxta-anastomotic stenosis is a challenging problem that often causes non-maturation and decreases the patency of an arteriovenous fistula (AVF). Injury to the veins and arteries during the operation and hemodynamic changes can lead to intimal hyperplasia, leading to juxta-anastomotic stenosis. To reduce injury to the veins and arteries during the operation, this study proposes a new modified no-touch technique (MNTT) for AVF construction that can decrease the rate of juxta-anastomotic stenosis and improve the AVF patency. To unravel the hemodynamic changes and mechanisms of the MNTT, this study presented an AVF procedure using this technique. Although this procedure is technically challenging, 94.4% procedural success was achieved after adequate training. Ultimately, 13 out of 34 rabbits had a functional AVF 4 weeks after the surgery, leading to a 38.2% AVF patency rate. However, at 4 weeks, the survival rate was 86.1%. Ultrasonography showed active blood flow through AVF anastomosis. Furthermore, the spiral laminar flow was observed in the vein and artery near the anastomosis, suggesting that this technique may improve the hemodynamics of the AVF. On histological observation, significant venous intimal hyperplasia was observed at the AVF anastomosis, whereas no significant intimal hyperplasia was observed at the proximal external jugular vein (EJV) of the anastomosis. This technique will improve the understanding of the mechanisms underlying the use of MNTT for AVF construction and provide technical support for the further optimization of the surgical approach in AVF construction.

High bifurcation of the brachial artery and its implications for arteriovenous fistula construction

High bifurcation of the brachial artery and its implications for arteriovenous fistula construction

The effect of the location of arteriovenous fistula on the right ventricle in end stage renal disease patients indicated for hemodialysis

Abstract Background End-stage renal disease (ESRD) has significantly increased in developing countries such as Egypt [1]. There are many sites for arteriovenous fistula (AVF) creation. The most common sites for AVF are radio-cephalic AVF (RC-AVF) followed by brachio-cephalic AVF (BC-AVF) [2]. To date, there are no significant studies discussing the possible correlation between the AVF location and abnormalities in the right ventricle (RV) in hemodialysis (HD) patients. Objective To determine the best location for AVF in order to ensure the least possible hazardous side effects of the AVF on the RV. Methods Our study, designed as an interventional study, included 50 ESRD patients referred for primary AVF construction to start HD for the first time. Patients were divided into two groups, 25 patients each. one group underwent a RC-AVF construction and the other had a BC-AVF. We assessed the RV by two dimensional transthoracic echocardiography (2D TTE) twice for each patient, firstly just before the AVF surgery and secondly three months after AVF construction. Results There was a statistically significant difference in between study groups regarding change in RV Tei index (p=0.001) with a decrease in the radial group (Mean ± SD = −0.19±0.2) and an increase in the brachial group (Mean ± SD = 0.02±0.12), and regarding the right ventricular outflow tract proximal diameter (p&amp;lt;0.001) with a decrease in the radial group (Mean ± SD = −2.32±5.49) and a larger increase in the brachial group (Mean ± SD = 2.94±3.14). Changes in the other RV dimensions and functional parameters did not show statistically significant difference. Conclusion After three months follow up, despite the fact that all the RV parameters remained within the normal range, the RV indices with the RC-AVF were associated with either improvement or less decline than with the BC-AVF. Funding Acknowledgement Type of funding sources: None.

Outcome of Radiocephalic Arteriovenous Fistula Constructed Under Brachial Plexus Block Versus Local Anesthesia: A Randomized Controlled Trial

Backgrounds: Hemodialysis (HD) is the commonest modality of renal replacement therapy (RRT) which needs vascular access. Ideal vascular access should be well functional, durable, stable, and have fewer complications. An arteriovenous fistula (AVF) is the preferred form of vascular access and is recommended by Kidney Disease Improving Global Outcome (KDIGO) guidelines. Most of the AVFs are constructed under local anesthetic infiltration which has a high failure rate which is about 30-40% for radiocephalic arteriovenous fistula (RCAVF). This study aimed to change the anesthetic technique to brachial plexus block (BPB) for RCAVF creation to improve the primary patency rate and reduce early thrombotic complications. Objectives: The objective was to see the effect of brachial plexus block (BPB) on the outcome of AVF creation by primary patency rate, maturation time, primary functional patency rate, and complications. Materials and Method: This was a randomized controlled trial conducted in the Department of Urology, Bangabandhu Sheikh Mujib Medical University, Dhaka from December 2018 to December 2019. A total of 80 patients were selected from the study population according to inclusion and exclusion criteria. Then divided into two groups by simple random sampling. In the group, A RCAVF constructed under BPB, and group B RCAVF was constructed under LA. The standard operation technique of AVF construction was followed. Evaluation of AVFs was done at 3rd POD, 2nd week, 6th week, and 12th weeks to see the functional status and any complications. Doppler US was done at the 6th week routinely. Results: Among these 80 patients 3 patients were lost from the follow-up, two from group A and one from group B. There was no significant difference in age, sex, comorbidities, and HD status between the groups. There was higher primary patency in group A at 3rd POD and 2nd weeks but was not statistically significant. In the 6th week primary patency in group A was 33/38 (86.8%) and in group B 25/39(64.1%), p=0.033. In the 12th week, primary patency and functional primary patency rate were in group A was 33/38 (86.8%) and in group B 25/39(64.1%), p=0.033 and statistically significant. No significant difference in maturation time between the groups. Thrombosis was the most common complication, 14 in group B and 5 in group A. One BPB was failed but there was no significant complication related to BPB. Conclusion: Radiocephalic arteriovenous fistula constructed under brachial plexus block has better primary patency and functional primary patency than local anesthesia at 6th and 12th week. Early thrombotic complications were higher in AVF creation under local anesthetic infiltration. Anaesthesia with BPB can be used for primary radiocephalic AVF construction surgery to improve the outcome of RCAVF fistula and early complications. Bangladesh J. Urol. 2021; 24(2): 129-134

Doppler Ultrasonography in Planning Arteriovenous Fistula for Haemodialysis with Follow-up for Maturity and Complications- A Cohort Study

Introduction: Patients having End Stage Renal Disease (ESRD) require kidney replacement therapy for survival. As kidney transplantation is expensive, haemodialysis using an Arteriovenous Fistula (AVF) is the preferred mode of management. Preoperative assessment of blood vessels using Doppler Ultrasonography (DUS) in the creation of an efficient AVF. Aim: To use DUS for the evaluation and mapping of blood vessels, selection for AVF construction, the time taken for fistula maturation, the primary patency rate, the vascular changes in major co-morbidities and the complications on follow-up. Materials and Methods: An observational and cohort study of 100 patients requiring AVF for haemodialysis was undertaken between January 2015 to November 2016 at Department of Radiodiagnosis and Imaging, PES Institute of Medical sciences and Research, Kuppam, Andhra Pradesh, India. Pre-operative vascular evaluation using duplex DUS was performed to know the diameter, caliber, distensibility of veins and flow velocity of arteries. Postoperative follow-up was done in fourth and sixth week for early detection and management of complications. Results: The study included total of 100 patients (64 men and 36 women, mean age of 40±15.4 years) requiring AVF aged between 16 to 65 years. Following vascular mapping, Brachio- Cephalic Fistula (BCF) was constructed in 48 and Radio- Cephalic Fistula (RCF) in 52 patients. A mean diameter of 2.1 mm for cephalic vein in forearm and 2.6 mm in arm was adequate for AVF construction. Overall maturity rate was 75% and time taken for maturation was 4 weeks for BCF, 6 weeks for RCF and one year primary patency rate was 80%. Complications were noted in 30%, included thrombosis, haematoma, stenosis, pseudoaneurysm and so on. Conclusion: Preoperative DUS is an economical investigation with exceptional ability to visualise vascular features and aids in planning reliable AVF. Systematic postoperative surveillance of AVF reduces the risk of failure due to early detection and management of complications.

A Comparative Study between Radiocephalic and Brachiocephalic Arteriovenous Fistula in End Stage Renal Disease

Background: Chronic Kidney Disease (CKD) is a major health issue all over the world. Patients with deteriorating renal function and end-stage renal disease require vascular access for hemodialysis. Studies suggest that Arterio-Venous fistula (AVF) constructed judiciously using autologous conduit give the best outcome in this regard. Objective of the study was to compare the outcomes of Radiocephalic and Brachiocephalic AVF in end stage renal disease (ESRD). Methods: It was a quasi-experimental study carried out at the Department of Vascular Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. The study was conducted from June 2019 to May 2020. Patients suffering from ESRD underwent AVF creation surgery for hemodialysis access. A total of 60 (Sixty) patients were included in this study. The patients were divided into two groups; Group I included 30 patients who underwent Radiocephalic AVF operation and Group II included 30 patients who had Brachiocephalic AVF operation. Results: In Group I, (Radiocephalic AVF) 60% were male and 40% were female. On the other hand, in Group II (Brachiocephalic AVF) 73.3% were male and 26.7% were female. Calculated volume flow (Q max) was significantly higher in Group II compared with Group I (769.11±101.54 ml/min vs 626.37±55.81) ml/min) with the difference being statistically significant (P=0.001). Maturation time was significantly less in Group II compared with Group I )37.78±1.93 vs 43.33±2.12 days) with the difference between the two group being statistically significant (P=0.001). Complication was more in Group I than Group II (16.7% vs 3.3%). Conclusion: The present study shows that Brachiocephalic AVF gives significantly better outcome in terms of shorter maturation time and less complications compared with Radio-Cephalic AVF. Color Doppler study is an essential tool for preoperative vessel evaluation which guides the selection of suitable AVF construction site. Cardiovasc j 2021; 14(1): 44-49

Utility of 'back-up' arterio-venous fistulae in patients on peritoneal dialysis and use of haemodialysis catheters.

Patients undergoing peritoneal dialysis may require unanticipated transfer to haemodialysis. Back up fistula are often created in selected patients. These may help reduce the infective burden of haemodialysis (HD) catheter. To study the utility of back-up arterio-venous fistulae (AVF) in patients initiated on peritoneal dialysis (PD) and to determine the rates of HD catheter use in patients requiring conversion to HD. Data on HD transfer and HD catheter usage were retrospectively analysed in all patients initiating PD between January 2010 and December 2014 at Royal Adelaide Hospital (RAH; universal back-up AVF creation at PD commencement) and Princess Alexandra Hospital (PAH; selective back-up AVF creation in 'high risk' patients). A total of 374 patients initiated PD during the study period: 142 in RAH group and 232 in PAH group. The groups were reasonably comparable, except that RAH patients were more likely to be older, Caucasian and diabetic. Transfer to HD occurred in 33 (23%) patients in RAH group and 99 (43%) in the PAH group with respective median times to HD transfer of 289 and 295 days. HD catheter usage was required at the time of HD transfer in 11 (33%) patients at RAH and 64 (65%) in patients at PAH (P < 0.001). AVF complications occurred in 13 (9%) patients in RAH group (fistuloplasty n = 8, transposition n = 2, ligation due to ischaemia n = 2 and construction of new AVF n = 1). Patients undergoing PD frequently require urgent unanticipated transfer to HD and back-up AVF can be successfully utilised in this setting in the majority of cases, which in turn can reduce the infective burden of HD catheter exposure.

MO778ASSOCIATION OF ADVANCED GLYCATION END PRODUCTS (AGE) AND INDOXYL SULPHATE WITH ARTERIO-VENOUS FISTULA NON-MATURATION

Abstract Background and Aims The main hindrance in adequate utilization of Arteriovenous fistula (AVF) is its high rates of primary failure. Its etiology is multi factorial and several uremic toxins are under investigation. Here we explore the potential influence of Advanced Glycation End Products (AGE) and Human Indoxyl Sulphate (HIS) on AVF non maturation. Method This one year prospective observational study included single stage AVF in consecutive CKD 4 and 5 patients. At baseline, demographic, biochemical (including AGE and HIS levels) and doppler ultrasound of upper limb were done followed by AVF construction. At 12 weeks, AVF was assessed for clinical maturation (usage of fistula with 2 needles for 75% of dialysis sessions during 15 day period); accordingly divided in to matured or non-matured groups. Demographic and biochemical parameters between both groups were compared; ROC and correlation of AGE and HIS were analyzed. Results Of 129 AVF, 67.4% were matured and 32.5% non-matured. Overall mean age was 40.9 year, male predominance (77.5%) and more non-matured AVF among diabetes. The mean value of AGE and IS was 0.18 µg/ml and 0.18µg/ml respectively; but difference was non significant between two group. AGE levels were further showing positive correlation with CRP (p 0.01, r 0.21) and venous diameter (p 0.02, r -0.22). There were significant positive correlation between AGE and HIS (p&amp;lt;0.00, r 0.5) but not with other parameters. AUC of AGE and HIS were 0.48 and 0.5 respectively and association could not be demonstrated between all studied parameters and AVF outcome. Conclusion Study cohort showed high incidence of primary failure without any association of AGE and HIS with clinical AVF non maturation.

Abnormal preoperative digital brachial index is associated with lower 2-year arteriovenous fistula access patency

ObjectiveThe aim of the present study was to assess whether a single measurement of the digital brachial index (DBI; systolic finger pressure/systemic pressure ratio), reflecting the arm's circulation, was associated with access patency in patients with severe chronic kidney disease scheduled for arteriovenous fistula (AVF) creation. MethodsA bilateral DBI was obtained using digital plethysmography just before construction of the patient's first AVF from January 2009 to December 2017 at one center. A DBI of 80% to 99% was considered normal, and a DBI of <80% (low) or DBI of ≥100% (high) were considered abnormal. DBI values ipsilateral to the AVF were used for analysis. The primary and secondary access patency rates were calculated using reported standards and compared using standard statistical techniques. ResultsData sets of 163 patients were obtained (69 women; age, 71 ± 12 years). The median follow-up was 40 weeks (range, 0-104 weeks; follow-up index, 99% ± 1%). Patients with abnormal preoperative DBI values had lower 2-year primary patency rates (low DBI, 25% ± 11%; high DBI, 28% ± 6%; normal DBI, 49% ± 8%; P = .018). After correction for age, sex, hypertension, diabetes mellitus, cardiovascular disease, smoking status, and a history of ipsilateral central venous catheter use, an adjusted model demonstrated that abnormal DBI values conferred an increased risk of primary patency failure (low DBI [<80%]: hazard ratio [HR], 2.25; 95% confidence interval [CI], 1.13-4.48; high DBI [≥100%]: HR, 1.74; 95% CI, 1.06-2.85; P < .030 for both). Patients with a low preoperative DBI had also had diminished secondary patency (HR, 2.86; 95% CI, 1.08-7.59; P = .035). In contrast, the diameters of the outflow veins did not determine access patency. ConclusionsPatients with abnormal DBI values before AVF construction for hemodialysis had lower 2-year access patency rates compared with patients with a normal DBI. Plethysmographic finger measurements might have a role in the preoperative counseling of patients with severe chronic kidney disease requiring an AVF.

P1219SLEEP AND PERITONEAL DIALYSIS

Abstract Background and Aims Sleep is considered a basic human need according to Maslow. It helps in the individual‘s physical and psychological recovery. Nowadays, sleep disturbances are an increasingly frequent reality and they interfere negatively with quality of life. Poor sleep quality has a negative impact on the individual’s health (attention, memory, Diabetes, Hypertension, immune system depression, mortality). Peritoneal dialysis (PD) may be an additional insult that is disturbing to its quality. The aim of the study was to assess the quality and health of sleep in PD patients. Method We carried out a single-center study in 35 prevalent PD patients. We used the Pittsburgh Sleep Quality Scale (PSQI), which evaluates seven components (subjective quality, latency, duration, usual efficiency of sleep and sleep changes, medication use and daytime dysfunction) and which considers a good sleep quality when PSQI ≤5. We used a sleep health scale assessed by SATED PT (validated for the Portuguese population) and which considers 0 poor sleep health and 30 good sleep health. Each patient answered both PSQI and SATED-PT questionnaires. Demographic and clinical variables were analyzed. Continuous variables are presented as means (standard deviation) or medians (interquartile range), depending on normality; categorical as frequencies. Univariate analysis was performed. STATA software was used and p &amp;lt;0.05 was considered significant. Results Our cohort has 18 (51%) women, 34 (97%) Caucasians, mean age 49 ± 15 years, median dialysis time of 20.5 (8-33) months; 4 (11%) had a history of attempted construction of arteriovenous fistula and 7 underwent a short period of hemodialysis before starting PD (median 60 months). Charlson's median score was 4 (2-5). 21 patients (60%) were on automated PD, 14 on manual, 18 on Baxter system and 17 on Fresenius system. Regarding sleep quality, the average obtained on the PSQI scale was 7 ± 3.4 and 60% had values&amp;gt; 5. We found no correlations between these parameters and the demographic and clinical variables studied. We found that 36.4% of patients wake up earlier than expected, 43.8% get up to go to the bathroom, 30% have nightmares, 20% have pain while sleeping, 23.5% depend on sleeping medication, 34.3% have restless legs, all these parameters in a frequency greater than 3x week. Regarding sleep health, the mean of the SATED scale was 22 ± 5.8 and only 2 patients (5.7%) had values &amp;lt;10. We found a negative correlation between the SATED value and time on dialysis (p = 0.03) and a positive correlation with BMI (p = 0.04). Only 1 patient with normal values lived alone (p = 0.03). None of these scales (and respective sub-scales) correlated with the PD modality. Conclusion In conclusion, the majority of our patients have poor sleep quality but the small sample size limits further conclusions from this study.

Effect of Early Cannulation with Plastic Cannula on Arteriovenous Fistula Patency in Hemodialysis Patients

Introduction: Plastic cannulas have been used to cannulate arteriovenous fistulas (AVFs) for hemodialysis (HD) in Japan for many years. However, the effect of early cannulation with plastic cannulas on AVF patency is not known. Objective: We analyzed the relationship between first cannulation time (FCT) and patency rates for AVFs cannulated with plastic cannulas and investigated whether early cannulation with plastic cannulas affects AVF patency. Methods: In total, 122 patients who underwent primary AVF construction were divided into an early cannulation group (FCT <10 days) and a late cannulation group (FCT ≥10 days). The Kaplan-Meier method and multivariable Cox regression models were used to investigate AVF patency. Results: Median FCT was 6 days. There was no statistically significant between-group difference in primary (p = 0.643) or secondary (p = 0.453) patency rates. Early or late cannulation was not significantly associated with primary patency (hazard ratio [HR] 1.21; 95% CI 0.71–2.05) or secondary patency (HR 0.46; 95% CI 0.08–2.77) after adjustment for age, sex, presence of diabetes mellitus or hypertension, and HD at baseline. Conclusions: Early AVF cannulation (<10 days from creation) with plastic cannulas does not affect access patency, and it may be possible to cannulate AVFs earlier than 10 days to decrease the need for use of a central venous catheter.

Outcomes of Patients Referred for Arteriovenous Fistula Construction: A Systematic Review

Chronic Kidney Disease (CKD) affects 10-16% of the US population and its incidence is rising due to increasing prevalence of associated risk factors. Renal replacement therapy is required to treat late stage CKD and hemodialysis is the preferred modality for many patients. Vascular access is required for hemodialysis and arteriovenous fistulas (AVF) are currently the gold standard. This review intended to collate current knowledge on AVF outcomes regarding both the patient and fistula. Scopus and Medline were utilized to identify relevant literature. Inclusion and exclusion criteria were applied to narrow search results. Among CKD patients, 33.5-77.4% require a central venous catheter (CVC) before dialysis through a fistula. Many patients (33-51%) use a CVC regardless of AVF creation due to fistula immaturity or failure. There are large variations in AVF creation policies internationally; 16% of American hemodialysis patients use a fistula compared to 72% of German patients. Primary patency and primary AVFs' failure ranges from 60-70% and 20-26%, respectively. AVFs reduce morbidity and mortality in CKD. At present, too many patients are receiving hemodialysis through a CVC. Inadequate referral times for AVF creation can lead to fistula immaturity or failure in the intervention. Many countries are lagging behind recommended AVF creation rates published by the Kidney Disease Outcomes Quality Initiative. There is a paucity of literature concerning when a patient should be referred for AVF creation. It is paramount to have better predictive outcome measures and more clarity as to when patients will benefit from an AVF.

Patency and Recurrence Rates of the Revision Using Distal Inflow Technique for High Flow Brachial Artery Based Arteriovenous Fistula

Introduction - High flow access (HFA; >2L/min or >1.5L/min with congestive complaints) is occasionally observed in the presence of a brachial artery based arteriovenous fistula (AVF).1 Several flow reducing techniques are available. Banding suffered from recurrence rates up to 50% within one year.2 Revision using distal inflow (RUDI) demonstrated a substantial flow reduction in the short term.3 Aim of this study was to report on the three-year patency and HFA recurrence rates of RUDI with interposition of the greater saphenous vein (GSV) in dialysis patients with a high flow access. Methods - Patients with a high flow elbow-based AVF scheduled for a RUDI procedure with use of the GSV between March 2011 and March 2017 in three facilities were followed for three years. Patency rates were defined as recommended by Sidawy.4 Recurrent high flow was defined as two consecutive high flow measurements (>2L/min) or signs of venous congestion or cardiac failure in presence of flows exceeding 1.5L/min. Patency and high flow recurrence were analysed using Kaplan-Meier analysis. Results - Twenty-one patients were studied (14 males, 54 ±3 years). RUDI was performed 44 ±12 months after the initial AVF construction. Peripheral arterial occlusive disease (5%) and diabetes mellitus (10%) were rarely observed while hypertension (52%) was more commonly present. Access flows decreased from 3220 ±204 mL/min preoperatively to 1150 ±88 mL/min postoperatively (P<0.001). Primary patency rates were 65% ±10, 54% ±12 and 54% ±12 after one, two and three years, respectively. Assisted patency rates were 79% ±9, 73% ±10 and 62% ±14, respectively. Secondary patency rates were 95% ±5, 95% ±5 and 76% ±14. In order to maintain access patency, twelve percutaneous transluminal angioplasties in eight and seven thrombectomies in four patients were conducted. Furthermore, two GSVs were replaced in a re-RUDI procedure (PTFE n=1; contralateral GSV n=1). HFA free survival was 74% ±10, 61% ±11 and 55% ±12 after one, two and three years. In the recurrence group, immediate postoperative access flow was higher when compared to the non-recurrence group (Flowrecurrence 1410 mL/min ±128, n=8 versus Flowno-recurrence 960mL/min ±87, n=11; P=0.012). The mean age in the recurrence group tended to be lower (Agerecurrence 46 ±4 years versus Ageno-recurrence 58 ±5years; P=0.082). Conclusion - A RUDI procedure with GSV interposition for HFA offers reasonably satisfactory patency rates after three years but requires maintenance. Recurrence free survival is higher when compared to rates described for banding. A relatively high immediate postoperative access flow is associated with recurrent high access flow.