Dialysis Outcomes Quality Initiative Guidelines Research Articles

Self-reported Financial Conflict of Interest in Nephrology Clinical Practice Guidelines

IntroductionThere is ongoing controversy concerning the potential influence of industry and financial conflict of interest (FCOI) in the development of clinical practice guidelines (CPG). The influence of industry in renal guideline development has been discussed in the past with emphasis on the National Kidney foundation (NKF) and Kidney and Dialysis Outcomes Quality Initiative guidelines. In this study we evaluate the self-reported FCOI among guideline panel members in Kidney Disease: Improving Global Outcomes (KDIGO) CPGs.MethodsWe examined 10 of the most recent KDIGO CPGs developed between 2009 and 2018. Using disclosure lists, we catalogued FCOIs for panelists for each individual CPG. The categories were Advisor/Consultant, Honoraria, Travel Stipend, Grant/Research Support, Speaker, Equity Interest, Employee, Board of Trustees, Royalties, Advisory Board, Employment, Ownership, Data Monitoring Committee, Expert Testimony, and Development of Education Materials. We also reviewed FCOIs for members of evidence review team (ERT). We also catalogued the company involved in each disclosure. One conflict describes 1 instance of participation of an individual in 1 category in each guideline. “Company” describes a commercial, industry, or institute affiliation reported in each episode.ResultsOne hundred two (66.4%) of the total 151 panelists reported FCOI. A total of 662 conflicts were disclosed. Being a consultant or advisor was the most common category. One hundred fifty-one companies were associated with FCOI disclosure. One company was most frequently reported, involving 60 (9%) of 662 conflicts. Of the 52 members in the ERT, there was 1 instance of FCOI.ConclusionFCOI is prevalent in KDIGO guidelines with almost two thirds of the panelists self-reporting FCOI. The evidence review team had only 1 instance of FCOI.

Serum Calcium and Phosphorus Levels in Hemodialysis Patients: A Large Population-Based Multicenter Study

Background: Mineral bone disorder is one of the major factors affecting mortality and morbidity in dialysis patients, which is called chronic kidney disease-mineral and bone disorder (CKD-MBD). Objectives: This study aimed to evaluate the laboratory parameters of mineral bone disorder in hemodialysis patients in Iran and their relationship with malnutrition and inflammation. Methods: This multicenter observational study was conducted in 2016 in 58 dialysis centers in Iran. Data of a total number of 7191 chronic hemodialysis patients aged older than 18 years with a dialysis duration of > 3 months were collected. Idiopathic hypercalcemia and history of parathyroidectomy were considered as the exclusion criteria. The serum levels of calcium (Ca), phosphorus (P), and intact parathyroid hormone (iPTH) were measured over a period of three months, and the findings were compared with the K/DOQI (National Kidney Foundation Dialysis Outcomes Quality Initiative) guidelines. Moreover, the serum level of C-reactive protein (CRP) and nutritional status based on geriatric nutritional risk index (GNRI) were assessed. Results: The percentage of the patients who had a serum iPTH level of 300 pg/mL was 29.3%. Hypercalcemia and hyperphosphatemia were observed in 20.6% and 34.2% of the patients, respectively. Moreover, 51.7%, 61.3%, 24.7%, and 84.7% of the patients, respectively, reached the K/DOQI target range of Ca, P, iPTH, and Ca × P product. The percentages of mild-to-severe malnutrition based on GNRI in patients whose iPTH level was within, below, and above the recommended range of K/DOQI guidelines were 30.7%, 34.1%, and 25.9%, respectively (P < 0.001). Furthermore, the serum level of CRP was significantly higher in low-serum PTH patients than in the other two groups. In total, only could 8.3% of the patients reach the four KDOQI target levels of CKD-MBD. Conclusions: The findings showed a significant percentage of patients had a low serum PTH level, which might be attributed to inflammatory and nutritional factors. Only had a small percentage of patients reached all the K/DOQI targets. Therefore, the effects of inflammatory and nutritional factors should also be considered, particularly in developing countries.

Clinical outcome of percutaneous thrombectomy of dialysis access thrombosis by an interventional nephrologist

BackgroundTraditionally, the treatment of a thrombosed dialysis access in hemodialysis patients in Korea has been primarily performed by vascular surgeons and interventional radiologists. The objective of this study was to evaluate the outcome of percutaneous thrombectomy procedures performed by an interventional nephrologist. MethodsFrom October 2010 to May 2014, 75 consecutive percutaneous thrombectomies were performed on 42 patients treated with maintenance hemodialysis. All percutaneous thrombectomy procedures were performed by an interventional nephrologist in a single hospital in Jeju, Korea. The thrombosed arteriovenous graft and arteriovenous fistula were declotted by thromboaspiration mechanical thrombectomy or pharmacomechanical thrombolysis. Kaplan–Meier survival analysis was performed to analyze the primary and secondary patency after the initial successful thrombectomy. Success and complication rates were identified and compared with the recommendations of the Kidney Disease Dialysis Outcomes Quality Initiative (KDOQI) guideline. ResultsThe overall clinical success rate was 89.3% (67/75). In the successful cases, the postintervention primary (unassisted) patency rates at 30 days, 90 days, and 180 days were 79.9%, 56.6%, and 25.6%, respectively. The secondary patency rates at 30 days, 90 days, and 180 days were 92.2%, 85.7%, and 83.7%, respectively. There were no major complications, and all complications were treated successfully during the procedure. ConclusionThe clinical success rate and primary patency rate at 3 months exceeded the recommendations of the KDOQI guideline, and were comparable to that of other reports. Percutaneous thrombectomy by an interventional nephrologist was safe and effective.

A Study of Vitamin-C Level as Oxidative Stress Marker In chronic Renal Failure Patients

Aim: The aim of this studywas to measure the Vitamin-C levels in chronic kidney disease patients. Chronic renal failure is a clinical syndrome resulting in the progressive loss of renal function. The symptoms of chronic renal failure result not only from simple excretory failure but also from the onset of regulating failure, the kidney’s failure to regulate certain substances, such as sodium & water. According to National Kidney Foundation- Kidney Dialysis Outcomes Quality Initiative (NKF-KDOQI) guidelines CRF is classified into 5 stages. An increased oxidative stress and inflammation are both common features of end stage renal disease. Methods: Here, we determined the vitamin-C levels in patients with chronic kidney disease and the antioxidant status of vitamin-C in these patients. Results: The mean plasma Vitamin – C concentration has found to be decreased in CKD patients when compared with the controls. Conclusion: Vitamin C improves endothelial function in the resistance vasculature of patients with chronic renal failure, and this effect was abolished by an inhibitor of nitric oxide (NO) synthesis.There is insufficient evidence to recommend the use of vitamin C (ascorbate) in the management of patients with CKD.

Effectiveness of Dietetic Intervention on Nutritional Status and Hydration Status in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients

In Hong Kong, more than 3,000 patients with end-stage renal failure (ESRF) on CAPD in 20091. Protein-energy malnutrition and volume overload are common problems in CAPD patients and associated with high morbidity and mortality2-6. Hyperphosphatemia is also a frequent complication in Chinese CAPD patients and is associated with development of renal bone disease or osteodystrophy7. The Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines suggested a combination of valid, complementary measures should be used to assess nutritional status in CAPD patients and anthropometric measurements are valid and clinically useful indicators of protein-energy nutritional status in maintenance dialysis patients8. Bioelectrical Impedance Analysis (BIA), which is a simple, inexpensive and non-invasive method, provides another powerful tool for monitoring of nutrition and hydration in CAPD patients9—10. The objective of this study is to evaluate the effectiveness of dietetic intervention in a local acute hospital on nutritional status and hydration status of patients on CAPD in outpatient setting. This is a retrospective study of 22 ESRF patients receiving dietetic intervention during CAPD training from February 2010 to January 2011. Patients with cognitive impairment or contraindicated with bioimepdence analysis (BIA) were excluded. Baseline demographic and clinical data were retrieved from the dietetic consultation record and the electronic records in Clinical Management System (CMS). The parameters related to the nutrition and hydration status in the first and follow-up dietetic consultation were also collected from the record. They included the dietary protein and energy intakes estimated from the dietary history, anthropometric measurements such as weight, height, body mass index (BMI), skeletal muscle mass (SMM), body fat mass (BFM), body fat percentage (BF%), intracellular water (ICW), extracellular water (ECW) measured by body composition analyzer (InBody720, Biospace Inc., UK), and the biochemical parameters such as albumin, haemoglobin, sodium, potassium, urea, creatinine and phosphate.

Relationship between Vessel Diameter and Time to Maturation of Arteriovenous Fistula for Hemodialysis Access

Introduction. Native arteriovenous fistula (AVF) is the recommended vascular access for HD patients by the Dialysis Outcomes Quality Initiative (DOQI) guidelines. The aim of our study was to determine the correlation between diameter and maturation of vessels in radiocephalic AVF. Methods. A prospective cross-sectional study carried out during 2006-2007 on 96 hemodialysis patients from Hasheminejad Kidney Center with non probability selection, all of them with end to side native AVF. Results. In this population 62.5% had wrist (distal radial artery) AVF and 37.5% had antecubital (proximal radial artery) AVF. The mean diameter of artery was 2.57 mm (SD = 1.09) and the mean diameter of vein was 2.40 mm (SD = 0.79). The mean of maturation period was 38.60 days (SD = 42.13). There were no relationship between duration of maturation period and diabetes mellitus, sex, age, diameter of vein and artery (P > 0.05). Period of maturation showed some correlation with the diameter of vein (P = 0.04) in patients with distal radiocephalic fistulae. Conclusions. The maturation of fistula shows correlation with vein diameter, but no correlation was seen with diameter of the arteries. There is much discrepancy between times to maturation in various reports. The average time for fistula maturation was 38/6 days in our study.

A comparison of laboratory values in pediatric hemodialysis patients: does day of the week matter?

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-K/DOQI) guidelines recommend the delivered dose of hemodialysis (HD) be measured no less than monthly by checking Kt/V (K is effective urea clearance, t is minute and V is urea distribution). To date, no studies have explored whether the day of the week for checking maintenance HD laboratory studies impacts dialysis dosing. Data were collected at two HD facilities on 19 patients, ages ≤ 21 years receiving maintenance HD thrice weekly over a consecutive 6-month period. Data obtained from the Monday and Wednesday of each full third week of the month included dialysis vintage, ultrafiltration volume, serum electrolytes, hemoglobin and clearances. Kt/V and K+ were significantly different between Monday and Wednesday (P = 0.013 and P = 0.047, respectively). Due to variability in values based on the day of laboratory evaluations, the dialysis provider must consider the impact of this on the quality of patient care when prescribing dialysis. Research on a larger scale needs to be conducted to allow for better decision-making capabilities in the chronic HD population.

Vascular access for hemodialysis: Thrills and thrombosis

Hemodialysis is a life saving treatment for Americans with end stage renal disease. In the last decade, liberal selection of patients treated by hemodialysis has resulted in patients who are substantially older, diabetics, who have higher co-morbidities including extensive atherosclerotic vascular disease. Many of these patients start hemodialysis treatments with a synthetic graft access rather than with their own native vessels. Grafts are appropriate for patients with inadequate vessels for construction of an arterio-venous (A-V) fistulas. The National Kidney Foundation published the Dialysis Outcome Quality Initiative (DOQI) guidelines in 1997, a set of evidenced based guidelines regarding the optimal management of vascular access. One important guideline had been to increase the number of patient dialyzing with Arterio-Venous (A-V) fistulas rather than A-V grafts which are prone to frequent stenosis, thrombosis, and thus are more costly and labor intensive. The prevalence of patient dialyzing with fistulas depends on several factors; timing of the referral, anatomy and adequacy of the patients vessels, type of fistula placed, fistula maturation, minimal accepted dialysis blood flow and patency of the fistula. The management of a vascular access for hemodialysis is a challenging area of practice for those who care for the hemodialysis patient population. The multidisciplinary approach to management of patients with hemodialysis access includes support, education, collaboration and ongoing communication with the multidisciplinary team, patients, and their family members.

Evaluation of the efficacy of the forearm basilic vein transposition arteriovenous fistula

Since the publication of Dialysis Outcomes Quality Initiative (DOQI) guidelines, the use of native veins for the construction of arteriovenous fistulas (AVF) for hemodialysis has been highly recommended rather than prosthetic arteriovenous grafts (AVG). Upper arm basilic vein transposition (BVT) has been accepted widely, with superior patency compared with AVG, but only a few studies have reported outcomes of forearm BVT (FBVT). This study evaluated the efficacy of FBVT compared with direct AVF (DAVF) and AVG in a tertiary referral center. From January 2005 to December 2007, 461 patients underwent AV access for hemodialysis in Seoul National University Hospital. We retrospectively reviewed the medical records and dialysis sheets and evaluated the current AVF function in the outpatient clinic or by telephone interviews. Patients were grouped by the operation type: DAVF, FBVT, and AVG. The outcomes compared were primary, assisted-primary and secondary patency rates, maturation failure, and complications. The mean age was 59 years (range, 14-92 years), and 280 patients (60.7%) were male. By operation type, the 461 accesses were 389 DAVF (84.4%), 34 FBVT (7.4%), and 38 AVG (8.2%). Mean follow-up duration was 21 months (range, 1-51 months). The primary patency rates for DAVF, FBVT, and AVG were 67.6%, 41.5%, 35% at 12 months and 53.9%, 30.2%, 10.3% at 24 months, respectively. The secondary patency rates were 89.2%, 79.1%, 78.3% at 12 months and 83.8%, 74.4%, 64.9% at 24 months, respectively. Maturation failure occurred in five DAVF patients and in one FBVT patient. The infection rate was 0.3% in DAVF and 12.5% in AVG, but no infection occurred in patients with FBVT. Multivariate analysis revealed that age and history of previous access were associated with lower primary patency. Forearm BVT showed an acceptable, high 2-year patency rate and fewer thromboses and infectious complications than AVG. Forearm BVT could be considered before forming an upper arm AVF or forearm AVG, if the basilic vein is available.

Quality of care assessment and adherence to the international guidelines considering dialysis, water treatment, and protection against transmission of infections in university hospital‐based dialysis units in Cairo, Egypt

End-stage renal disease has emerged as a major public health problem around the world. In recent decades, several important advances have been made in the therapy of hemodialysis (HD) with the introduction of international guidelines to ensure the delivery of optimum care to HD patients. An increased mortality risk in HD patients unable to meet six targets in different areas of HD practice has been reported by the Dialysis Outcomes and Practice Patterns Study investigators. In this retrospective study, we assessed the current practice patterns of care for HD patients in the Kaser El-Aini Nephrology and Dialysis Center in comparison with Dialysis Outcomes Quality Initiative Guidelines, European Best Practice Guidelines, Centers for Disease Control and Prevention guidelines for prevention of transmission of infections among HD patients, and American Association for Medical Instrumentation (AAMI) standards for dialysis water quality. The mean percent of urea reduction was 63 +/- 8.8% in prevalent HD patients. An arteriovenous fistula was the vascular access in 91% of prevalent HD patients, whereas a temporary catheter was used in 9% of cases mostly as a bridge till arteriovenous fistula creation/maturation. Bicarbonate was the base used in 80% of the cases. Ninty-seven percent patients had thrice-weekly sessions and 3% had two dialysis sessions/wk. The mean serum albumin was 4.19 +/- 0.39 g/dL; 66.66% of prevalent patients had serum albumin level >4 g/dL. The mean serum calcium was 8.66 +/- 1.4 mg/dL, phosphorus was 6.26 +/- 2.54 mg/dL, and approximately 60% of patients had a serum phosphorus level >5.5 mg/dL. The CaxPi product was higher than 55 in around 40% of the cases, and the parathyroid hormone level was in the range of 150 to 300 pg/mL in around 10% of prevalent patients. The mean hemoglobin was 9.23 +/- 7.18 g/dL in prevalent cases; around 70% of cases had a hemoglobin level <11 g/dL. Iron deficiency was prevalent as 18% of patients, with serum ferritin <200 ng/L, and 34% had total serum test <20%. Seventy percent of the patients were hepatitis C virus positive and 4% were hepatitis B surface antigen positive, and all were negative for the human immunodeficiency virus serological test. Dialysis water was monitored regularly for chemical and bacterial contamination as recommended by the American Association for Medical Instrumentation, but an endotoxin assay is currently not included in the monitoring checklist. The annual mortality rate was 8% in 2007. The current audit revealed a reasonable quality of care for HD patients in the fields of vascular access care, dialysis adequacy, and nutrition areas. It also reveals the need for improving anemia management and control of hyperphosphatemia with dietary counseling and more frequent dialysis. To fully meet the guideline targets, each patient should be treated in an individualized way with more counseling, nutritional education, and individualized dialysis prescription. Besides, the unit needs to adopt primary and secondary intervention strategies to prevent and promptly correct any deviation from the desired targets.

A Meta-analysis of Preoperative Duplex Ultrasound Vessel Diameters for Successful Radiocephalic Fistula Placement

Background The Kidney Dialysis Outcomes Quality Initiative (K/DOQI) guidelines for vascular access recommend the use of radiocephalic wrist arteriovenous fistulas (RCAVFs) as the initial option for dialysis access. The survival rate of a successfully placed fistula is excellent. However, 10–24% of RCAVFs fail to reach functional status as the result of early thrombosis or maturation failure. Many authors have investigated the utility of preoperative vascular mapping by Duplex ultrasound to predict adequate vessel size for successful fistula placement. This meta-analysis is the first in which preoperative radial arterial (RAD) and cephalic venous diameters (CVD) required for favorable fistula outcomes are reviewed. Methods A literature search was performed by use of the MEDLINE electronic base for “arteriovenous, fistula, ultrasound, and hemodialysis.” The analysis yielded 166 studies, of which 20 studies included preoperative duplex data. Meta-analysis was performed by applying the statistical test of comparing two proportions, assuming equal variances. Results A total of 433 patients were duplexed for preoperative evaluation of the RAD and 386 for CVD. The total number of subjects ranged from 21 to 91, mean age 58.7 years. The subjects were 55.5% male, 39.0% with diabetes mellitus. Meta-analysis yielded 2.0 mm for RAD and 2.0 mm for CVD as designated cutoff vessel diameters. Our study showed the mean fistula success rate was significantly different between RAD &gt;2.0 mm (59%) and RAD &gt;2.0 mm (40%). The mean fistula success rate was also significantly different between CVD &gt; 2.0 mm (71%) and &gt;2.0 mm (29%). Successful fistula placement was defined as a functional fistula at least 4–6 weeks after creation. Conclusion On the basis of our study, the use of Duplex ultrasound is important in determining preoperative vessel diameter size, and subsequent functional success rate of fistula placement.

Associations of anemia persistency with medical expenditures in Medicare ESRD patients on dialysis

Most end-stage renal disease (ESRD) patients begin renal replacement therapy with hemoglobin levels below the recommended US National Kidney Foundation Dialysis Outcomes Quality Initiative Guidelines lower level of 110 g/L. Although most patients eventually reach this target, the time required varies substantially. This study aimed to determine whether length of time with below-target hemoglobin levels after dialysis initiation is associated with medical costs, and if so, whether intermediate factors underlie the associations. US patients initiating dialysis in 2002 were studied using the Centers for Medicare and Medicaid Services ESRD database. Anemia persistence (time in months with hemoglobin below 110 g/L) was determined in a six-month entry period, and outcomes were assessed in the subsequent six-month follow-up period. The structural equation modeling technique was used to evaluate associations between persistent anemia and medical costs and to determine intermediate factors for these associations. The study included 28,985 patients. Mean per-patient-per-month medical cost was $6267 (standard deviation $5713) in the six-month follow-up period. Each additional month with hemoglobin below 110 g/L was associated with an 8.9% increment in medical cost. The increased cost was associated with increased erythropoietin use and blood transfusions, and increased rates of hospitalization and vascular access procedures in the follow-up period.

Arteriovenous fistulas as vascular access for hemodialysis: The preliminary experience at the University Hospital of the West Indies, Jamaica

The demand for vascular hemodialysis access creation is steadily increasing. To satisfy the demand, a vascular access team was established at the University Hospital of the West Indies, Jamaica. The outcomes of this practice are reported. A retrospective study of all patients who had permanent vascular dialysis access established at the University Hospital of the West Indies between January 1, 2002, and December 31, 2006, was performed. Data were analyzed using SPSS version 12.0 (SPSS Inc, USA). A direct anastomosis between an autogenous artery and vein was considered an arteriovenous fistula (AVF). When prosthetic material was used, the access was considered to be an arteriovenous graft. Accesses that were nonfunctional after six weeks of maturation were considered to be primary failures, while those that failed after previous successful dialysis were considered to be secondary failures. Primary patency was defined as the interval between access placement and the first intervention for failure. Secondary patency was the interval between access placement and abandonment. Cumulative patency was defined as the number of accesses that remained patent over a given time period, regardless of the number of interventions performed. Of 41 patients, nine were excluded due to incomplete data. Final analyses were performed on 32 patients with a mean (± SD) age of 42.3±15.3 years (range 18 to 66 years, median 43 years). The access type was an AVF in 100% of cases, which included distal radiocephalic fistulas in 27 patients, brachial-cephalic fistulas in three patients and proximal radiocephalic fistulas in two patients. Operations were performed in four (12.5%) incident and 28 (87.5%) prevalent dialysis patients. The mean delay between initiation of dialysis and AVF creation was 21.2±26.1 months (range one to 94 months, median 10 months). There were eight (25%) primary failures. Of the remaining 24 patients, there were seven (29.2%) secondary failures from thrombosis. There was primary patency for a mean of 723.9±422.1 days (range 199 to 1314 days, median 678 days). Only one (4.2%) patient had thrombectomy to prolong AVF function, resulting in secondary patency for 439 days. Cumulative patency was 62.5%, 33.3%, 25% and 4.2% for one, two, three and four years, respectively. The rate of AVF creation for end-stage renal disease patients in this setting far exceeds the target goals set forward by the National Kidney Foundation published updated Dialysis Outcomes Quality Initiative (NKF/DOQI) Guidelines and the Centers for Medicaid & Medicare Services Fistula First initiative. This is being achieved with acceptable rates of morbidity and patency. There is room for improvement in postoperative surveillance to increase early detection of failing accesses and allow for increased utility of interventions for assisted patency.

Endovascular Interventions of Juxtaanastomotic Stenoses and Thromboses of Hemodialysis Arteriovenous Fistulas

To assess the primary and secondary patency rates for juxtaanastomotic stenoses, with or without superimposed thromboses, of arteriovenous hemodialysis fistulas treated with angioplasty and to compare it with National Kidney Foundation Dialysis Outcomes Quality Initiative treatment guidelines for stenosed and occluded arteriovenous fistulas (50% primary patency rate at 12 months). This study was a retrospective analysis, covering a period of 5(1/2) years. Forty-three hemodialysis patients were referred due to secondary fistula dysfunction, and angiography was diagnostic of a juxtaanastomotic lesion. Interventions consisted of standard angioplasty techniques along with thrombolysis and/or thrombectomy and intravascular stent placement as needed. Follow-up was performed at the attending dialysis center, and repeat angiography was performed as clinically required. Immediate postprocedural angiography demonstrated an angiographic success rate of 98%. Clinical success, with at least one session of normal dialysis, occurred in 95% of interventions. Primary patency rates at 12 months for the stenosed and stenosed/thrombosed fistulas were 56% and 64%, respectively. Secondary patency rates at 12 months were 64% and 63%, respectively. Half of the stenosed fistulas were patent at 1.5 years, 28% were patent at 4 years, and 13% remained patent at 6 years. No major complications were documented. Four minor complications, which did not require therapy, were noted. The results achieved are comparable to those reported for interventions at nonjuxtaanastomotic sites and exceed those quoted by the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Angioplastic interventions in a juxtaanastomatic area of arteriovenous fistulas are safe, promote prolonged patency, and postpone the need for surgical intervention or creation of a new fistula.

The role of the prosthetic axilloaxillary loop access as a tertiary arteriovenous access procedure

In the last decade, the Dialysis Outcome Quality Initiative (DOQI) Guidelines have enhanced the longevity of patients with end-stage renal disease (ESRD) on hemodialysis. Consequently, surgeons are increasingly challenged to provide vascular access for patients in whom options for access in the upper extremity have been expended. This situation is even more problematic in the morbidly obese patient on hemodialysis. Our group previously reported a high rate of infection and need for secondary interventions in obese patients with prosthetic femorofemoral accesses. We now report a series of patients who underwent placement of a prosthetic axilloaxillary loop access. This study presents our technique and evaluates our results, particularly as they relate to the obese patient. From January 1998 to May 2006, 34 prosthetic axilloaxillary loop accesses were placed in 32 patients with ESRD. Eleven patients (12 accesses) were obese, as defined by a body mass index >/=30 kg/m(2). Median follow-up was 16 months. Kaplan-Meier analysis was used to determine primary and secondary patency as well as patient survival for the entire cohort and for the obese and nonobese patient cohorts. Survival curves were compared using the log-rank test for equality over strata. The secondary patency rate was 59% at 1 year (median, 18 months). The 1-year patient survival was 69%. Infection occurred in 15% patients. Comparison of the obese vs nonobese cohorts demonstrated no statistically significant difference in 1-year primary patency (36% vs 10%, P = .17) or secondary patency (71% vs 65%, P = .34). There were no infections in the obese cohort. These data show that the prosthetic axilloaxillary loop access has acceptable outcomes and should be considered the tertiary vascular access procedure of choice in the obese patient on hemodialysis.

Cephalic Arch Stenosis

The Kidney Dialysis Outcomes Quality Initiative guidelines and the Fistula First Initiative for vascular access have had a measurable impact on the incidence and prevalence of the type of access used to deliver hemodialysis in the United States. There has been a yearly increase in the placement of arteriovenous fistulas and an exponential increase in endovascular treatment of failing and immature fistulas. Undoubtedly, the predominant cause of fistula malfunction is stenosis within the access system. The stenotic lesions can occur anywhere within the access system from the arteries to the outflow and central veins. One of the relatively common sites for stenosis in patients with brachiocephalic fistulas is the cephalic arch region. While access stenoses at many other sites have been successfully treated with percutaneous balloon angioplasty, the results of this approach in the management of cephalic arch stenosis (CAS) have been rather disappointing. This has been in part due to multiple factors including the resistant nature of the stenosis, the development of early restenosis, as well as poor patency and high vein rupture rates. This article discusses the anatomy, postulated etiology and percutaneous interventions for the treatment of CAS. In addition, the report highlights surgical alternatives to the management of stenosis in this segment of the cephalic vein.

Unusual Vascular Access for Hemodialysis: Transposed Venae Comitante of the Brachial Artery

The National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines favor autogenous vein for arteriovenous fistulas. This report describes our technique and results of arteriovenous fistulas between brachial artery and its transposed venae comitantes. The procedure was done in two stages, first anastomosis between brachial artery at the elbow and one of its venae comitantes and, 1 month later, transposition of the vein to a subcutaneous tunnel. The study included 21 patients (15 males, six females), nine of whom were diabetic, with a mean age of 53 years. The cumulative primary patency rate was (75.89%) at 1 year and (55.34%) at 2 years. Complications developed in 11/21 fistulas, including thrombosis, infection, aneurysm formation, and nonmaturation of the vein. Brachial artery to its transposed venae comitante fistula is an alternative access which can be used as a tertiary autogenous access.

An Interventional Controlled Trial Comparing 2 Management Models for the Treatment of Tunneled Cuffed Catheter Bacteremia: A Collaborative Team Model Versus Usual Physician-Managed Care

The management of tunneled cuffed catheter (TCC)-associated bacteremias varies among nephrologists. To determine whether patient outcomes after TCC-associated bacteremia can be improved by modifying the management model, we performed an interventional controlled trial comparing a collaborative team model, intervention (INT), with the usual physician-managed model, usual care (UC). INT consisted of an infection manager who worked closely with nephrologists and dialysis staff and made treatment recommendations using the available published guidelines at the time of the study's conception (Dialysis Outcomes Quality Initiative guideline no. 26, 1997) and additional literature-based recommendations. Nephrologists made the final treatment decisions. TCC-associated bacteremia was physician managed in the UC group. Two hundred twenty-three episodes of TCC-associated bacteremia occurred in 7 outpatient hemodialysis units during the 2-year study period. The INT was associated with a significantly lower incidence of recurrent bacteremia with the same organism (INT, 6% versus UC, 18%; odds ratio, 0.28; 95% confidence interval, 0.09 to 0.8; P = 0.015) and death from sepsis (INT, 0% versus UC, 6%; P < 0.02). In INT units, there was a 45% decrease in the practice of TCC salvage (TCC not removed; P = 0.05). Antibiotic prescribing practices (final antibiotic selection, dose, and duration of therapy) were improved in INT units compared with UC units. By using multivariate analysis, the INT was associated with a 73% decrease in the combined outcome of recurrent bacteremia or septic death (P < 0.02). Implementation of a collaborative team model for the management of TCC-associated bacteremic episodes is associated with improvement in the quality of heath care delivery and patient outcomes.

Impact of pre-operative venography on the planning and outcome of vascular access for hemodialysis patients

Pre-operative venous mapping has increased dramatically in most dialysis units since the Dialysis Outcome Quality Initiative (DOQI) guidelines recommended a native arteriovenous venous fistula (AVF) rather than a graft for hemodialysis (HD) access procedures. However, there are conflicting consequences as a result of this policy. Some studies have showed that routine mapping has resulted in a marked increase in maturation rate while others have observed the reverse. This study aimed to evaluate the impact of pre-operative venography on the planning and outcome of AVF for our HD patients. A prospective study was performed on all patients with end-stage renal disease (ESRD) who had HD access procedures and pre-operative venography between October 2003 and November 2005. Upper limb venography was done for all patients except those that required primary access and had visible veins. All patients had HD immediately after the venography. Access procedure selection was based on the result of the venography. The complications of venography, the surgical procedure and the outcome were recorded. One hundred and twenty-nine patients with ESRD who had pre-operative venography were included in this study. They were mostly middle age (mean age +/- SD = 41 +/- 15.5 yrs) with a high rate of diabetes mellitus (53%). No single complication was reported. A graft was placed in six patients (5%) only. Unsuccessful surgical exploration was 0%. Early failure was in 10 patients (8%). Pre-operative venography resulted in an increase in the number of AVFs. It can improve the results of HD access procedures by selecting the most suitable veins.

Iliac cuffed tunnelled catheters for chronic haemodialysis vascular access

Obtaining and maintaining vascular access is of pivotal importance in the care of chronic haemodialysis patients. According to the Dialysis Outcomes Quality Initiative (DOQI) guidelines, peripheral arteriovenous (AV) fistulas or grafts are the preferred type of access [1]. The use of central venous catheters for chronic haemodialysis is discouraged [1]. Compared with AV fistulas, central catheters carry a substantially increased risk of infection and bacteraemia [2]. However, in approximately a quarter of the patients, peripheral venous access has been exhausted or is not feasible in the first place [3,4]. In these cases, cuffed tunnelled right atrial catheters inserted into the jugular or subclavian veins permit adequate blood flow for dialysis. The femoral veins may be used in situations where the jugular or subclavian veins are not available. Femoral catheters are prone to exit-site infections and bacteraemia, and have an unacceptable risk of thrombosis and life-threatening embolism in ambulatory patients. In the current case report, we describe an alternative approach to haemodialysis vascular access. We successfully placed cuffed tunnelled catheters in the iliac veins of six patients, A–F, from our own chronic haemodialysis programme and an affiliated dialysis centre (Table 1). Each of the patients had a history of repeated creation and loss of peripheral vascular access except for one, in whom vascular surgeons ruled out peripheral access in the first place. All six patients had documented thrombosis of the jugular and/or subclavian veins (Table 1). Patient D had a history of chronic anticoagulation due to repeated catheter-related thrombosis (Figure 1). Description of procedure and clinical outcome