High-flow Hemodialysis Research Articles

Elimination of Medium/High Molecular Weight Solutes. Comparison of High Flow Hemodialysis with Extended Hemodialysis

Introduction: Post-dilution online hemodiafiltration is the most efficient extracorporeal depurative treatment of CKD. Recently a new type of membrane has been developed, with a higher cut-off point also called a medium cut-off point, which has the capacity to eliminate higher molecular weight molecules in hemodialysis. The hemodialysis performed with these membranes has been called “Expanded Hemodialysis”. Objective: Compare the purifying efficacy of medium and high molecular weight molecules in patients dialyzed with high-flux hemodialysis, VitaPES 210HF, and with patients treated with expanded hemodialysis with the medium cut-off dialyzer, Elisio-HX. We also assessed the effect that the increased removal of inflammatory mediators by MCO hemodialysis had on fecal Calprotectin levels. Patients and methods: This is a prospective observational cross-over study in which 8 prevalent hemodialysis patients were followed for two months. Blood levels of IL-6, C-reactive protein (CRP), β2-microglobulin, Kappa and Lambda immunoglobulin light chains, and serum albumin were determined before and after each hemodialysis session. Results: The percentage of reduction of medium and higher molecular weight molecules: β2microglobulin, IL-6, Kappa and Lambda chains and CRP were higher with the Elisio-21HX dialyzer compared to the VitaPES 210HF dialyzer. There was no difference in albumin clearance between the two dialyzers. Fecal calprotectin levels were lower in patients dialyzed with Elisio-21HX. Conclusion: The medium cutoff dialyzer, Elisio-HX, is more efficient in the elimination of medium/high molecular weight molecules than the VitaPES HF high-flux dialyzer, with the same albumin elimination. Improving inflammation at the local intestinal level with lower levels of fecal Calprotectin.

Is hemodiafiltration superior to high-flow hemodialysis in reducing all-cause and cardiovascular mortality in kidney failure patients? A meta-analysis of randomized controlled trials.

Hemodiafiltration (HDF) and high-flux hemodialysis (hf-HD) are different methods of kidney replacement therapy (KRT) used for the treatment of kidney failure patients. A debate has raged over the last decade about the survival benefit of patients with the use of HDF compared with hf-HD, but with divergent results from randomized controlled trials. Therefore, this study aimed to perform a meta-analysis to compare HDF and hf-HD regarding all-cause and cardiovascular mortality. PubMed and Cochrane databases were searched until July 19, 2023, for randomized clinical trials comparing HDF and hf-HD in patients on maintenance dialysis. A meta-analysis was performed using Stata 16.1, applying fixed or random effect models according to the heterogeneity between studies. Of the 496 studies found, five met the inclusion criteria. Compared with the hf-HD group, the risk ratio (RR) for all-cause mortality with HDF use was 0.76 (95% CI: 0.67-0.88, I2 = 0%). HDF was associated with lower cardiovascular mortality, although the sensitivity analysis showed that the result differed between scenarios. Subgroup analysis showed lower all-cause mortality among patients without diabetes in the HDF group compared with hf-HD (RR 0.66, 95% CI: 0.51-0.81, I2 = 0%), but not in diabetic patients (RR = 0.89, 95% CI: 0.65-1.12, I2 = 0.0%). A subgroup analysis considering convection volumes was not performed, but the studies with the highest weight in the meta-analysis described convection volume as more than 20 L/session. More clinical studies considering critical risk factors, such as advanced age and preexisting cardiovascular disease, are needed to confirm the supremacy of HDF over hf-HD on the survival of patients treated by these two forms of kidney replacement therapy.

#3062 ROLE OF ONLINE HEMODIAFILTRATION (OL-HDF) IN THE CONTINUOUS MEASUREMENT OF THE DIALYSIS DOSE

Abstract Background and Aims OL-HDF provides multiple advantages and benefits to patients compared to conventional high-flow hemodialysis (HFHD). Current monitors have a wide variety of biosensors and devices that provide continuous information on the patient's biological parameter and the efficiency of the dialysis session. Monofrequency bioimpedance (BIVA) provides information regarding the state of hydration (HE) and nutrition (EN) of our patients. Method Observational study in 493 patients, distributed in 8 dialysis centers and with a three different model of dialysis monitor. Demographic data, dialysis techniques and regimens, mean values for one month of ultrafiltration rate readings and KT are analyzed. The continuous measurement of DD is estimated by the ion dialysance biosensor. The OL-HDF technique is post-dilutional. The BIVA measurement is performed between 10 and 30 minutes after the end of the session. The Kt/V is estimated from the total TBW (V) by BIVA, using the Watson and Hume-Wiers formulas. Statistical analysis: descriptive, t-Student for statistics of groups and independent samples, Chi square for the association in cross tables. Results See Table 1. Conclusion Obtaining lower dialysis dose values in OL-HDF than in HFHD in some monitor models, despite longer dialysis times and greater dialyzer surface area, is probably due to dilution due to post- re-infusion and/or to the positioning of the dialysance sensors within the hydraulic circuit. This makes us think about the advisability of maintaining urea Kt/V measurements, by laboratory, to ensure adequate dialysis quality.

Medtronic Mahurkar Acute Dual Lumen High Flow Hemodialysis Catheters

Biomedical Safety & Standards 53(7):p 51, April 15, 2023. | DOI: 10.1097/01.BMSAS.0000924576.57821.13

Interventional Management of High Flow Hemodialysis Access (MILLER Technique): What Size of Balloon is Appropriate for the Procedure?

Interventional Management of High Flow Hemodialysis Access (MILLER Technique): What Size of Balloon is Appropriate for the Procedure?

Contemporary outcomes of precision banding for high flow hemodialysis access.

High-flow hemodialysis accesses are a well-recognized source of patient morbidity. Among available management strategies inflow constriction based on real-time physiologic flow monitoring offers a technically straightforward data-driven approach with potentially low morbidity. Despite the benefits offered by this approach, large contemporary series are lacking. A retrospective review of a prospectively maintained clinical database was undertaken to capture patients undergoing precision banding within a signal tertiary care institution between 2010 and 2019. Multivariable logistic regression modeling of thrombosis within 30 days and re-banding within 1 year were performed. In total, 297 patients underwent banding during the study period for a total number of 398 encounters. Median [IQR] follow-up was 157 [52-373] days. Most accesses were upper arm with brachial artery inflow (84%) and half of the banding procedures were performed for flow imbalance based on exam, duplex, or fistulogram. Median flow rate reduction was 58%. The 30-day thrombosis rate after banding was 15 of 397 (3.8%) with a median time to event of 5.5 days (2-102). The re-banding rate within a year was 54 of 398 (14%) with a median time to re-banding of 134 days [56-224]. Multivariate logistic regression analysis using a univariate screen did not identify any predictors of 30-day thrombosis. Having a forearm radial-cephalic AVF compared to all other access types was protective against need for rebanding at 1 year (OR 0.12 95% CI 0.02-0.92, p = 0.04), as was flow imbalance as the indication for banding (OR 0.43 95% 0.23-0.79, p = 0.006). Precision banding offers an effective, low-morbidity approach for high-flow hemodialysis accesses. Early thrombosis is a rare event after precision banding, although in the long term, one in four patients will require re-banding to maintain control of flow volumes.

Contemporary Outcomes of Precision Banding for High-Flow Hemodialysis Access

High-flow hemodialysis accesses are increasingly recognized as the source of complications (cardiopulmonary, hand ischemia, access aneurysmal degeneration). Among management strategies (access elongation, revision-using-distal-inflow), precision banding (inflow constriction based on real-time physiologic flow monitoring) offers a technically straightforward approach with potentially low morbidity. However, large contemporary series on banding outcomes (and their predictors) are lacking.

Precision Banding for High-Flow Hemodialysis Access—Contemporary Outcomes and Failure Predictors

High-flow hemodialysis accesses are increasingly recognized as the source of complications (cardiopulmonary, hand ischemia, access malfunction). Among management strategies (access elongation, revision using distal inflow), precision banding (inflow constriction based on real-time physiologic flow monitoring) offers a technically straightforward approach with potentially low morbidity. However, large contemporary series on banding outcomes (and their predictors) are lacking. Banding was performed with 2-0 doubly looped Prolene over an internal balloon or 3- to 4-mm external mandrel with Transonic thermodilution flow volume monitoring (Transonic Systems, Ithaca, NY). Demographics and clinical characteristics were captured during a 10-year period through prospective databases and some retrospective record review. Multivariable logistic predictive regression models (stepwise selection of clinically relevant variables, P < .10 as entry criterion) were completed for thrombosis within 30 days and rebanding within 1 year as well as during the entire period. In total, 397 patients underwent banding during the study period. One patient had early wound bleeding requiring return to the operating room, and none had discovered complications of band erosion. The infection rate was 0.5% (2/397). Median (interquartile range) follow-up was 157 (52-373) days. Most accesses were upper arm with brachial artery inflow (Table I); half were performed prophylactically on the basis of experienced clinical judgment (mean duplex ultrasound flow 2 L/min), and a third were for steal. Median flow rate reduction was 41%. Among 134 steal patients, only 2 required subsequent ligation to control symptoms. The 30-day thrombosis rate after banding was 13 of 397 (3.3%). Including all thrombotic events (25/397 [6.3%]), median time was 9.5 days (2.0-101.5 days). The rebanding rate within a year was 51 of 397 (13%), and median time from banding to rebanding within 1 year was 133 days; 8 of 397 (2.0%) had to be rebanded within 30 days. During the entire period, 103 of 397 (26%) patients needed rebanding. Multivariate logistic regression analysis showed prosthetic graft as the sole predictor of early thrombosis. After adjustment, only smaller banding diameter was independently associated with any thrombotic event (including those beyond 30 days) and prebanding vein diameter with any need for rebanding (Table II). Precision banding offers an effective, low-morbidity approach for high-flow hemodialysis accesses. Early thrombosis is a rare event after precision banding, although in the long term, one in four patients will require rebanding to control flow.Table IPatient cohort characteristicsVariableTotal cohort (n = 397)Demographic characteristics Median age, years [IQR]59 [48, 73] SexFemale (%)152 (38)Male (%)245 (62) RaceWhite (%)183 (46)Latino (%)132 (33)African-American (%)63 (16)Asian (%)8 (2)Other/unknown (%)13 (3)Comorbidities Hypertension (%)368 (93) Diabetes (%)160 (40) Coronary artery disease (%)129 (32) Dialysis (%)296 (75)Access details SiteForearm (%)50 (13)Upper arm (%)347 (87) TypeAutogenous (%)360 (91)Graft (%)37 (9)Inflow arteryBrachial (%)342 (86)Radial (%)51 (13)Ulnar (%)2 (1) Outflow veinCephalic (%)300 (76)Basilic (%)66 (17)Axillary (%)13 (3)Other (%)16 (4)Access in use at time of banding (%)269 (68) Median preoperative flow rate by Duplex, ml/min [IQR]1975 [1510, 2532]Indication for banding Prophylactic (%)203 (51) Enlarging aneurysm/pseudoaneurysm (%)18 (4) Ischemic steal (%)134 (34) High output heart failure (%)42 (11)Procedural details Time from access creation to banding1234 [534, 2283] Median intraoperative pre-banding flow rate by flow meter, ml/min [IQR]1545 [1210, 2080] Median number of bands [IQR]1 [1, 1] Banding diameter3 [3, 4] Technique of precision bandingIntravascular balloon (%)100 (25)External mandrel (%)297 (75) Median intraoperative post-banding flow rate by flowmeter, ml/min [IQR]640 [445, 865] Median percent flow reduction [IQR]58 [39, 73] Open table in a new tab Table IIUnadjusted univariate and adjusted multivariate logistic regression analysis for association of demographic, access, and procedural characteristics with thrombosis and banding failureVariableThrombosis at 30 daysBanding failure at 1 yearUnadjusted analysisAdjusted analysisUnadjusted analysisAdjusted analysisOdds ratio (95% CI)P valueOdds ratio (95% CI)P valueOdds ratio (95% CI)P valueOdds ratio (95% CI)P valueAge0.97 (0.94-1.0).080.97 (0.94-1.01)0.090.99 (0.97-1.00).080.98 (0.97-1.0).09Male1.4 (0.43-4.66).570.79 (0.44-1.44).45Dialysis at time of banding3.76 (0.48-29.32).210.96 (0.48-1.92).90Access in use at time of banding5.32 (0.68-41.4).111.11 (0.5-2.16).75Indication for banding ProphylacticRefRef Enlarging aneurysm/pseudoaneurysm0.001 (<0.001->999).962.19 (0.58-8.32).72 Ischemic steal0.56 (0.14-2.14).972.39 (1.23-4.64).32 High output heart failure1.22 (0.25-5.95).952.19 (0.84-5.67).63Prosthetic graft5.03 (1.47-17.28).014.96 (1.43-17.25).011.45 (0.57-3.68).44Lower arm access1.30 (0.28-6.05).740.26 (0.06-1.10).070.24 (0.06-1.03).05Inflow artery BrachialRefRef Radial1.23 (0.26-5.71).980.24 (0.06-1.04).98 Ulnar0.001 (<0.001->999).980.001 (<0.001->999).97Outflow vein CephalicRefRef Basilic0.001 (<0.001->999).940.14 (0.66-2.86).20 Axillary2.42 (0.29-20.4).940.57 (0.07-4.54).72 Other4.14 (0.83-20.7).930.46 (0.06-3.58).52Number of bands1.08 (0.32-3.65).911.00 (0.53-1.91).99Pre-banding vein diameter1.00 (0.92-1.09).981.02 (0.98-1.06).31Banding diameter0.47 (0.15-1.51).210.98 (0.56-1.69).93% Flow reduction0.99 (0.97-1.02).631.00 (0.99-1.01).81Intraoperative post-banding flow rate (flowmeter)0.99 (0.99-1.00).571.00 (0.99-1.00).77 Open table in a new tab

Revision using distal inflow for high flow hemodialysis access alters arterial flow characteristics in the dialysis arm

ObjectiveRevision using distal inflow (RUDI) is currently proposed in patients on hemodialysis having a high flow access (HFA; >2 L/min) or hemodialysis access-induced distal ischemia (HAIDI). However, a recurrence of high flow or hand ischemia is not unusual in the years after RUDI. The aim of the present study was to describe changes in flow characteristics and arterial diameters in the dialysis arm after RUDI for HFA. MethodsVolume flow, diameter, peak systolic velocity and end diastolic velocity of the brachial artery (BA) were studied 2 and 12 months after RUDI using duplex imaging. In a portion of patients, these characteristics were also assessed at proximal and distal portions of radial and ulnar arteries (proximal forearm radial artery, distal radial artery, ulnar artery, and distal ulnar artery), and in the greater saphenous venous interponate. HFA patients were grouped according to presence of concomitant hand ischemia (HFA-HAIDI) or absence (HFA). ResultsFifteen patients (54 ± 16 year old; 10 males; HFA-HAIDI, n = 6; HFA, n = 9) with a BA HFA (flow volume, 2740 ± 322 mL/min) undergoing RUDI were studied between March 2011 and October 2016 in two Dutch hospitals. After 2 months, flow volume had decreased (1180 ± 189 mL/min), but again increased at 12 months (1520 ± 217 mL/min; P < .001). BA diameters did not change (7.4 ± 0.5 mm), but proximal forearm radial diameters doubled (overall 2.6 ± 0.2 mm to 5.4 ±1.0 mm; P < .001), albeit less prominent in HFA-HAIDI (+80%) than in HFA (+130%; P = .019). During follow-up, the distal ulnar artery peak systolic velocity in HFA-HAIDI (83 ± 10 cm/s) was higher compared with the HFA group (54 ± 5 cm/s; P < .01). Dilatation was not present in the greater saphenous venous interponate. ConclusionsRUDI for HFA reduction does not reverse BA dilatation, suggesting irreversible structural arterial wall damage possibly contributing to recurrent high flow. Radial artery remodeling is attenuated in HFA patients previously reporting concurrent hand ischemia diminishing the likelihood of high flow recurrence in this subgroup.

Bigger is not always better: The consequences of High-flow hemodialysis arterial-venous fistula (Mega fistula)

Bigger is not always better: The consequences of High-flow hemodialysis arterial-venous fistula (Mega fistula)

Effects of high flow hemodialysis on the biomarker of myocardium injury and the cardiac function related records in uremia patients

To investigate the effects of high flow hemodialysis (HFHD) on cardiac function in uremia patients. A prospective randomized controlled study was conducted. Sixty patients who were diagnosed with uremia, taken maintenance hemodialysis (MHD) and 30 healthy controls admitted to the Second People's Hospital of Guiyang from December 2014 to June 2015 were enrolled. They were randomly divided into two groups: HFHD group (HFHD three times a week) and the routine hemodialysis group (HD group, HD three times a week), with 30 in each group. Patients in each group were received hemoperfusion and hemofiltration once a month. Before the treatment and 6 months after the treatment, venous blood from all the patients were collected for testing the brain natriuretic peptide (BNP), cardiac troponin T (cTnT) and the ultrasound cardiograph were done at the same period by a special person, the left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), the left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), left ventricular posterior wall thickness (LVPWT), interventricular septum thickness (IVST), early and late diastolic blood flow to the largest ratio (E/A), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI) were recorded. Compared with the health control group, BNP, cTnT, LVEDD, LVESD, LVESV, LVPWT, IVST were significantly increased, LVEDV were significantly lowered before treatment in the HD group and HFHD group. But no significant differences in the above indexes and E/A, LVEF, LVMI between two groups were found. Compared with the data before treatment, the BNP, LVPWT were significantly lowered after treatment in HD group [BNP (ng/L): 641.50±60.09 vs. 2676.20±454.30, LVPWT (mm): 10.57±1.16 vs. 12.57±1.41, both P < 0.05]. The BNP, LVPWT were significantly lowered in HFHD group as compared with HD group [BNP (ng/L): 253.10±48.77 vs. 641.50±60.09, LVPWT (mm): 9.29±1.08 vs. 10.57±1.16, both P < 0.05]; in addition, the cTnT, IVST, LVMI were significantly lowered after the treatment in HFHD group compared with those before treatment [cTnT (μg/L): 0.014±0.005 vs. 0.028±0.011, IVST (mm): 7.81±1.69 vs. 11.04±2.23, LVMI (g/m2): 149.10±15.77 vs. 158.70±17.25, all P < 0.05], and the LVEF were significantly increased in HFHD group as compared with those before treatment (0.574±0.068 vs. 0.528±0.082, P < 0.05). HFHD has obvious advantages than the routine HD in improving cardiac function of uremia patients.

The effect analysis of high flow hemodialysis on cardiorenal syndrome maintenance hemodialysis patients

The effect analysis of high flow hemodialysis on cardiorenal syndrome maintenance hemodialysis patients

Hemofiltration and Hemodialysis in the Prevention and Treatment of Acute Renal Failure after Cardiac Surgery under Extracorporeal Circulation

Objective: to analyze the efficiency of hemofiltration (HF) in the stage of extracorporeal circulation (EC) during cardiac surgery in order to prevent acute renal function lowering and the development of acute renal failure (ARF). Materials and methods. The risk of postoperative ARF requiring renal replacement therapy (RRT) was preoperatively assessed by the summed Cleveland risk score and percentage (2005). HF during EC was used in patients at high risk for ARF. The procedure was performed, by combining 2 extracorporeal circuits: EC and a Diapact®CRRT apparatus. With evolving ARF, Stage 3 after Risk, Injury, Failure, Loss of Kidney Function, End-stage Renal Disease (RIFLE), 2004, and Acute Kidney Injury Network (AKIN), 2007, continuous venovenous hemofiltration (CVVHF) and continuous high-flow hemodialysis (CHFHD) were done in the dialysate recirculation mode after surgery under EC. The Mann-Whitney non-parametric test was used to estimate the significance of intergroup differences. The results are presented: median (lower quartile; upper quartile), the differences considered to be significant atpResults. HF during EC; 6 patients were aged 65.5 (range 57—70) years with chronic kidney disease, preoperative glomerular filtration rate (GFR) was 50 (range 41.5—65) ml/min/1.73 m2 using the Cockroft-Gault formula. The maximum GFR decrease by 2.9 (range 0.7—7) ml/min/1.73 m2 was seen after EC. A control group comprised 12 patients aged 73 (range 63—75) years. There was a postoperative GFR reduction by 17 (range 13.7—22) ml/min/1.73 m2. One patient from the control group developed ARF and multiple organ dysfunction, which required CVVHF and CHFHD. Conclusion. The use of intraoperative HF in patients at high risk for renal function lowering is likely to prevent a considerable GFR reduction and ARF after surgery under EC.

High-flow Hemodialysis Arteriovenous Shunt with Concurrent Central Vein Stenosis Masquerading as Sigmoid Sinus Dural Arteriovenous Fistula

High-flow Hemodialysis Arteriovenous Shunt with Concurrent Central Vein Stenosis Masquerading as Sigmoid Sinus Dural Arteriovenous Fistula

Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions

From the Division of Vascular and Interventional Radiology, Jefferson Radiology, Hartford Hospital, 85 Seymour St, Ste 200, Hartford, CT 06106 (P.C.M.); Department of Radiology, Boston Healthcare System, VAMC Boston, Massachusetts (C.J.G.); Department of Medical Imaging, Scarborough General Hospital, Richmond Hill, Ontario, Canada (S.K.); Department of Radiology, GI/GU Division, Massachusetts General Hospital, Boston, Massachusetts (D.A.G.); Department of Radiology and Radiologic Sciences, Uniformed Services University of the Health Sciences and Department of Radiology, National Naval Medical Center, Bethesda, Maryland (D.L.M.); RADIA, Everett, Washington (R.B.O.); Department of Radiology, University of Florida, Gainesville, Florida (D.W.P.); Department of Medical Imaging, Division of Vascular and Interventional Radiology, University of Toronto, University Health Network, Toronto, Ontario, Canada (D.K.R.); Department of Interventional Radiology, The Reading Hospital and Medical Center, West Reading, Pennsylvania (D.S.); Radiology Associates of Central Florida, Mt Dora, Florida (M.S.S.); Mallinckrodt Institute of Radiology, St Louis, Missouri (D.A.Z.); and Geisinger System Radiology, Geisinger Health System, Danville, Pennsylvania (J.F.C.). Received November 18, 2008; accepted November 24, 2008. Address correspondence to P.C.M.; E-mail: pmalloy@ jeffersonradiology.com

Doppler Ultrasonography-Guided Surgery for High-Flow Hemodialysis Vascular Access: Preliminary Results

Aim We sought to investigate the results of flow reduction with prospective Doppler ultrasonography (USG)-guided surgery. Patients and Methods Thirty patients with end-stage renal failure with high-flow arterio-venous (AV) fistulae (n = 25) or AV grafts (n = 5) were included in the study. The indications for operation were as follows: cardiac failure (n = 18) or steal syndrome (n = 12). AV fistula flow >800 mL/min or AV graft >1200 mL/min was the selection criterion for definition of a high-flow vascular access. The desired postoperative flow was 400 mL/min or 800 mL/min for AV fistula or AV graft, respectively. Before the surgical intervention, a vascular clamp was used to simulate the planned intervention with evaluation by Doppler USG after the anastomosis was narrowed. Results There were 16 men and 14 women with a median age of 48 ± 9 years (range, 39–57 years). Preoperative measurements of median AV fistula, AV graft flow, and anastomosis diameter were as follows: 2663 mL/min (range, 1856–3440 mL/min); 2751 mL/min (range, 2140–3584 mL/min); and 7.3 mm (range, 6.1– 8.5 mm), respectively. The flow was reduced to 615 mL/min (range, 552–810 mL/min) for AV fistulae and 805 mL/min (range, 745–980 mL/min) for AV grafts. The median diameter of the anastomosis was reduced to 4 mm (range, 3.5–4.3 mm). There were no reinterventions. During the median 1-year follow-up, AV fistula and AV graft patency rates were 100% and 80%, respectively and clinical complaints resolved. Cardiac output rate was reduced from 8.5 ± 2.9 L/min to 6.1 ± 1.9 L/min ( P < .01). Conclusion Cardiac failure and steal syndrome resulting from high-flow vascular access can be treated successfully with Doppler USG-guided surgery. The desired anastomotic diameter and flow are limited in cases of excessively dilated efferent veins for vascular access.

Comparison of side hole versus non side hole high flow hemodialysis catheters

Current literature suggests that side holes may be detrimental to dialysis catheter performance. Today, these catheters are primarily available with side holes. The purpose of this study was to compare flow rates, infection rate, and survival of side hole vs. non side hole hemodialysis catheters. Over a 16-month period patients were arbitrarily assigned to either a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter with side holes or a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter without side holes ("non side hole catheters"). We performed a retrospective analysis of catheter flow rates, patency, catheter survival, and catheter-related infections. Information was gathered for the life of the catheter or up to 28 weeks. A total of 54 patients were enrolled in the study. Thirty-seven of 54 (68%) patients received a catheter with side holes for a total of 3,930 catheter days and 17/54 (32%) received a similar catheter without side holes for a total of 2,188 catheter days. Catheter infection necessitating removal of the catheter occurred in 10/37 catheters with side holes and 1/17 without side holes. Infection rates per 1,000 catheter days were 2.545 with side holes and 0.254 without side holes (p<0.001). Slightly improved catheter survival (p<0.05) was recorded with the non side hole catheters. No insertion complication (e.g., air embolization, bleeding, or kinking) occurred with either catheter. One catheter without side holes had to be repositioned 5 days after insertion because of poor flows. No significant difference was recorded in mean blood flow rates between the catheters. Results indicate reduced catheter infection rate in hemodialysis patients with the use of non side hole dual lumen tunneled cuffed catheters.

Insertion of Short Introducer Sheaths into a Polyurethane Vascular Access Graft for Immediate Hemodialysis Access

While native AV fistulae are considered the 'gold standard' for hemodialysis patients in need of long-term access, synthetic grafts are the best option for patients who are not candidates for an AV fistula. While AV fistulae should be allowed to mature for 3 - 4 months prior to cannulation, PTFE grafts may be cannulated 14 days after placement. Despite the benefit of earlier cannulation in PTFE graft recipients compared to AV fistulae patients, one critical limitation is that immediate post-operative cannulation is not possible. The self-sealing nature of the polyurethane Vectra(R) Graft overcomes the time restriction until first cannulation, allowing much earlier vascular access than conventional PTFE grafts. We describe here a procedure for insertion of 5-French DialEasetrade mark Introducer Sheaths into the Vectra Graft for immediate, post-operative hemodialysis access. This procedure eliminates time restrictions until first cannulation of the Vectra Graft; the sheath's large diameter sideport ensures high flow for efficient hemodialysis. Moreover, insertion of the sheath into a new or existing Vectra Graft provides vascular access for inspection of the graft anastomoses, angiography, angioplasty, venography, and declotting procedures. The post-operative introduction of DialEase Sheaths into a Vectra Graft for immediate hemodialysis was successfully performed in 35 patients. All patients then immediately received high-flow hemodialysis (400 - 500 ml) with venous pressures < 125 mmHg and negative arterial pressure ~100 mmHg. To date, there have been no infections, immediate graft thrombosis or other complications associated with this procedure, and all patients have remained free of anastomotic problems. (The Journal of Vascular Access 2003; 4: 62-7).

Randomized comparison of split tip versus step tip high-flow hemodialysis catheters

Our purpose was to compare the function and complications of two high-flow polyurethane hemodialysis catheters. This prospective, randomized trial compared the Ash-Split (MedComp) and Opti-Flow (Bard Access Systems) catheters. All patients referred for tunneled hemodialysis catheter placement were offered entry in the study, provided they met inclusion criteria. Catheters were placed by interventional radiologists using ultrasound and fluoroscopic guidance. Procedure time and initial complications were recorded. Effective (QbEff) catheter flow rates and recirculation were studied at baseline, one month, three and six months using ultrasonic dilution (Transonic) at various pump speeds (Qb). Episodes of catheter malfunction and infection were recorded. Catheter removal or six months was the study endpoint. A total of 132 patients were enrolled in the trial. The groups did not differ as to age, sex distribution, height or weight (P> 0.05). Initial complications included kinking resulting in catheter failure (Optiflow N = 3), and tunnel bleeding (Optiflow N = 1; Ash N = 3). Adjusted mean flow rates (QbEff) at Qb300 were 299 mL/min Ash and 305 mL/min Optiflow (P = 0.06), at Qb400 were 365 mL/min Ash and 382 mL/min Optiflow (P = 0.01), and at QbMax were 414 mL/min Ash and 433 mL/min Optiflow (P = 0.03). Recirculation was significantly higher with the Optiflow catheter at most measurement points. Total late complications were lower in the Ash group (P = 0.04), and catheter survival was significantly higher in the Ash group (P = 0.02). Both catheters can deliver flow rates well beyond those recommended by the Dialysis Outcomes Quality Initiative. While the Optiflow delivered higher flow rates at some measurement points, this was offset by higher recirculation. The Ash catheter showed a long-term survival advantage and fewer late complications.

A Randomized, Prospective Evaluation of the Tesio, Ash Split, and Opti-flow Hemodialysis Catheters

A randomized, prospective evaluation of three high-flow hemodialysis catheters. Ninety-four patients were randomly assigned 113 Tesio, Ash split, and Opti-flow catheters from December 1998 through June 1999. Insertion times, procedural complications, and ease of insertion were recorded. Mean catheter flow rates were recorded at first dialysis, 30 days, and 90 days. Patency, catheter survival, and catheter-related infections were evaluated. Thirty-eight Ash split, 39 Opti-flow, and 36 Tesio catheters were placed. Tesio mean insertion time (41.5 min) was significantly longer than Ash split (29.4 min) or Opti-flow (29.6 min) (P =.004). There were four complications related to Tesio catheters (three cases of pericatheter bleeding, one air embolism), one related to an Opti-flow catheter (pericatheter bleeding), and zero related to Ash split catheters. Opti-flow and Ash split catheters were significantly easier to insert than Tesio catheters (P =.041). Mean flow rates were not significantly different among the catheters initially (P =.112), at 30 days (P =.281), or at 90 days (P =.112). Catheter-related infection rates per 100 catheter days were 0.12 for Ash split, 0.35 for Opti-flow, and 0.14 for TESIO: Median catheter survival was 302 days for Ash split, 176 days for Opti-flow, and 228 days for TESIO: Opti-Flow and Ash split catheters were faster and easier to place than Tesio catheters. There was no difference in hemodialysis flow rates or catheter survival.