Need For Vascular Access Research Articles

#1465 Enhancing vascular access planning in CKD: validating the 40% KFRE threshold in a French retrospective cohort study

Abstract Background and Aims The optimal timing for dialysis vascular access creation remains a complex clinical decision, balancing the risk of early intervention against the prospect of starting dialysis with a central venous catheter. This study sought to compare the predictive capabilities of the Kidney Failure Risk Equation (KFRE) and estimated Glomerular Filtration Rate (eGFR) in determining the appropriate timing for arteriovenous fistula (AVF) creation in patients with advanced chronic kidney disease (CKD). Method A retrospective cohort of 238 patients referred for ultrasound vascular mapping from April 2013 to June 2023 was analyzed. Data on patient characteristics, laboratory results, and clinical outcomes were collected. The 4-variable and 8-variable KFRE and eGFR were assessed for their ability to predict end-stage kidney disease (ESKD) within a 2-year period. Discrimination was evaluated using receiver operating characteristic (ROC) curves, and calibration was assessed graphically. Net benefit decision curves were utilized to compare the net benefit of the KFRE models at various threshold probabilities. Results The cohort comprised 238 patients with an average age of 65.2 years and a mean eGFR of 13.3 mL/min/m²73. During the median 10.7-month follow-up, 178 patients (74.8%) progressed to ESKD, and 21 (9.2%) died prior to reaching ESKD. At the 1-year mark, the probability of progressing to ESKD was 77.6% (95% CI, 69.9-85.3%) when a 40% threshold for the 4-variable KFRE was applied, compared to 65.8% (95% CI, 58.3-73.3%) with an eGFR threshold of 15 mL/min/m²73. Discrimination analysis demonstrated a superior predictive performance for the 8-variable KFRE at 6 months, with a C-statistic of 0.82 (95% CI: 0.76-0.88). At 1 year, both KFRE models showed strong predictive abilities, with C-statistics of 0.835 (95% CI: 0.78-0.89) for the 4-variable KFRE and 0.82 (95% CI: 0.76-0.875) for the 8-variable KFRE. Sensitivity and specificity analyses underscored the benefits of utilizing the 40% KFRE threshold for predicting ESKD over the eGFR threshold. Conclusion The study demonstrates that both the 4-variable and 8-variable KFRE are valuable tools for predicting the need for vascular access in pre-dialysis patients, outperforming eGFR alone. The 8-variable KFRE, in particular, provides a significant improvement in 6-months ESKD prediction, with potential implications for clinical decision-making and patient management in advanced CKD. These findings advocate for the incorporation of KFRE in the clinical evaluation process for timely and appropriate vascular access planning.

Suture-Based Vascular Closure Versus Surgical Closure of Large Bore Arteriotomies: A Real-World Experience.

With the introduction of transcatheter aortic valve implantation (TAVI), endovascular abdominal aortic aneurysm repair (EVAR), thoracic endovascular aortic aneurysm repair (TEVAR), and frequent use ofleft ventricular assist devices in complicated percutaneous coronary interventions, the use of large bore arterial access has become a necessity. In the index study, we compared the percutaneous closure of large arteriotomies with open surgical (OS) closure. It was a prospective study in which we compared the technical success and vascular complication rate associated with the use of a suture-based vascular closure device (VCD): Perclose ProGlide(PP) with that of OS closure. The study was carried out at Command Hospital Air Force,Bengaluru, India, from January 1, 2016, toDecember 31, 2020. The inclusion criteria were any percutaneous intervention involving large bore arterial access (≥12 French (F) sheath). The exclusion criteria were any condition where a persistent need for vascular access at the end of the procedure was required. We noted the baseline characteristicsand type of anesthesia for all patients. The primary outcome was technical success and major vascular complications, which included major local site bleeding: Bleeding Academic Research Consortium (BARC) 3 or more, failed hemostasis requiring a second intervention, and acute vessel occlusion. Total time taken for the procedure (TTP), time to ambulation (TTA), and time to discharge post-procedure (TTD) were noted for each patient. The secondary outcomes were any bleeding other than major, local hematoma sized >5 cm at 24 hours, pseudo aneurysm formation at 30 days, and acute limb ischemia at 30 days. A total of 120 patients (PP: 60 (males: 54, females: 6), OS: 60 (males: 50, females: 10)) were included in this study.The mean age of patients was comparable in both groups (PP: 71.8 ± 9.62 years and OS: 71.0 ± 7.76 years, p-value: 0.63). Total large arteriotomies (mean size: 18.03F ± 3.34) closed were 184 (PP: 90, OS: 94). The procedures performed were EVAR: 64 (PP: 30, OS: 34), TAVI: 38 (PP: 21, OS: 17), and TEVAR: 18 (PP: 9, OS: 9). All patients in PP group received dual ProGlide with preclose technique. All TEVAR procedures (total arteriotomies: 18) required a vascular sheath of ≥ 24F.There was no statistical difference between the mean size of sheaths used in the two groups. The technical success (PP: 95.55%, OS: 97.87%, 95% CI: -5.78%-10.98%, p-value: 0.48) and rate of major complications were similar in both groups. Three patients in the PP group who had failed hemostasis with two ProGlides were successfully managed with one additional Angioseal (6F) each.The occurrence of hematoma sized larger than 5 cm was significantly more in the PP group compared to the OS group (PP: 7 (7.78%), OS: 0 (0%), p-value: 0.006). While GA was used for all patients who underwent vascular closure with OS, only eight patients (13.33%) in the PP group required GA. The TTP, TTA, and TTD were significantly lower in the PP group as compared to the OS group. The percutaneous closure of large bore arteriotomies with suture-based VCDs is equally effective and is not associated with increased major vascular complications. In fact, the TTP, TTA, and TTD are significantly lower in the PP group which can translate to better patient comfort and lower costs.

Surgical aspects of peritoneal dialysis

Modern replacement kidney therapy belongs to a life-saving type of medical aid and includes dialysis and kidney transplantation. In the worlds nephrological practice integrated approach is preferable: the treatment starts with peritoneal dialysis as the most physiological method and later kidney transplantation or hemodialysis. Well-functioning peritoneal access is a key factor of successful peritoneal dialysis. Studies have shown that peritoneal dialysis, compared with hemodialysis, especially when performed in a dialysis center (not at home), has some clinical advantages. In particular, this treatment better preserves residual kidney function, better corrects anemia, avoids the need for vascular access, which in turn reduces the risk of access-related infectious complications, which in turn are the main cause of hospitalization and mortality among patients with end-stage renal disease. This review is focused on catheters for peritoneal dialysis access and methods of their placement. Malpractice of implantation technique can lead to unwanted consequences ranging from cuff extrusion and catheter migration to total loss of the latter. Following implantation technique by surgeons helps to avoid malpractice and improve the results. Implantation of a peritoneal catheter is an important component of peritoneal dialysis, which determines the quality of treatment, the development of non-infectious and infectious complications of peritoneal dialysis, and the duration of peritoneal dialysis therapy. A number of methods for implanting peritoneal catheters have been proposed in the world. All of them have the right to exist, each has its own advantages and disadvantages. When choosing a method, the surgeon is guided by the objective data of the patient, the patients ability to endure more invasive interventions (duration, anesthesia, volume of surgery), the capabilities of the surgical department, experience and qualifications. Expansion of indications for the use of the peritoneal dialysis technique, its complications, as well as concomitant diseases should determine the optimal method for implanting a peritoneal dialysis catheter for a given patient. It should be noted that to date, sufficient data have not been obtained on the effect of the method of peritoneal catheter implantation on the expansion of indications for peritoneal dialysis, the incidence of complications, and the need for additional surgical interventions.

S-ICD Implantation "Tips and Tricks".

An implantable cardioverter-defibrillator (ICD) was developed to provide protection against sudden cardiac death. Despite being effective in terminating ventricular arrhythmias, traditional transvenous ICDs appeared over time to have certain limitations related to the need for vascular access and the presence of foreign material inside the circulatory system (namely lead failure and infections). A subcutaneous implantable cardioverter-defibrillator (S-ICD) was developed to overcome those limitations and to provide prevention against sudden cardiac death from outside the cardiovascular system. Utilization of that modern method of treatment is constantly increasing worldwide, and new centers incorporate implantation of that system in their portfolio. This review aims to present the most relevant issues related to S-ICD implantation procedure, based on experience of the authors and an extensive literature search.

Epidemiology of peritoneal dialysis outcomes.

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

Inpatient consultations with the vascular and endovascular surgery team at an academic tertiary hospital.

ABSTRACTBackgroundInpatient consultations are a fundamental component of practice in tertiary care centers. However, such consultations demand resources, generating a significant workload.ObjectivesTo investigate the profile of inpatient consultations requested by other specialties and provided by the Vascular and Endovascular Surgery team at an academic tertiary hospital.MethodsProspective observational study.ResultsFrom May 2017 to May 2018, 223 consultations were provided, representing 2.2% of the workload. Most consultations were requested by Oncology (16.6%), Hematology (9.9%), Nephrology (9.0%), and Cardiology (6.3%). The leading reasons for inpatient consultation were: need for vascular access (51.1%) and requests to evaluate a vascular disease (48.9%). Acute venous diseases accounted for 19.3% of consultations, chronic arterial diseases for 14.8%, acute arterial diseases for 7.2%, diabetic feet for 5.4%, and chronic venous diseases accounted for 2.2%. Surgical treatment was performed in 57.0%, either conventional (43.9%) or endovascular (13.0%). Almost all (98.2%) patients’ issues were resolved.ConclusionsInpatient consultations with the Vascular and Endovascular Surgery team in a tertiary academic hospital accounted for 2.2% of the team’s entire workload. Most patients were elective and underwent low-complexity elective surgical procedures. There may be an opportunity to improve healthcare, redirecting these patients to the outpatient flow.

A Prospective Randomized Study Comparing the use of Plain PTA Balloon Catheters for Primary Balloon Angioplasty (PBA) Versus Hydrostatic Dilatation to Prepare the Cephalic Vein Prior to Creation of Radio-Cephalic Arteriovenous for Dialysis

Introduction: Most of patients in Egypt with end stage renal disease (ESRD) are on hemodialysis because of the low rate of kidney transplantation due to legal, religious, and financial issues. While in the United States, it is estimated that 65% of ESRD patients were on hemodialysis, 30% underwent transplantation, and 5% on peritoneal dialysis. That is why maintenance of the hemodialysis access is of utmost importance because most of hospital admissions or ESRD patients is due to access site complications. Therefore, creating a natural functioning arteriovenous fistula is a top priority in our practice. Native arteriovenous fistulas are recommended but on the other hand these types of fistula fail to mature at higher rates than do arteriovenous grafts. For native arteriovenous fistula, the KDOQI guidelines identified a fully mature arteriovenous fistula suitable for cannulation by the rule of 6s, which include a 6 mm diameter vein, 6mm access depth from skin, with an access flow rate of 600ml/min. Methods: Fifty-seven (57) patients with ESRD in need for vascular access for whom a radio-cephalic arteriovenous fistula was of choice, with a cephalic vein ≤ 3 mm. They presented to us from the period of November 2014 till January 2017, were randomized into two groups. The cephalic vein was prepared in group (A) using hydrostatic dilatation prior to creation of the fistula, while in group (B) the vein was prepared using a PTA balloon catheter for primary balloon angioplasty prior to the creation of the fistula. Results: The technical success rate was 96.5%, 100% in both groups respectively. The reintervention rate was 35.7%, 7.1% in both groups respectively. The mean maturation time was 43days , 32.1 days in both groups respectively. Conclusion: Using primary balloon dilatation during creation of a radiocephalic arteriovenous fistula leads to a decreased maturation time and less reintervention rate, but still these results are statistically insignificant may be due to small number of study sample. Disclosure: Nothing to disclose

Potenciales indicaciones de dalbavancina en la práctica clínica

Dalbavancin is a semisynthetic lipoglycopeptide with two properties that distinguish it from other members of the antibiotic family from which it is derived: a greater intrinsic activity and a very prolonged mean half-life that allows weekly or twice-weekly dosing with a single 1000mg or 1500mg dose, respectively. Because of this half-life, dalbavancin is a unique antibiotic. This drug allows the design of new treatment strategies that facilitate early hospital discharge without the need for vascular access and with guaranteed treatment adherence. Dalbavancin could be used to resolve some of the problems that commonly occur in the management of infections in daily clinical practice, particularly in consolidation therapy in acute processes, infections requiring prolonged treatment and in the prophylaxis of some recurrent processes caused by Gram-positive cocci.

Wearable Cardioverter-Defibrillator Therapy for the Prevention of Sudden Cardiac Death: A Science Advisory From the American Heart Association.

Sudden cardiac death (SCD) accounts for >300 000 deaths in the United States annually.1 Although the majority of these deaths occur in low-risk populations2 in which aggressive interventions are not practical, some higher-risk populations have been established in whom intervention with an implantable cardioverter-defibrillator (ICD) has been shown in randomized trials to reduce mortality.3–7 Additionally, there is a population of patients who may benefit from automatic emergency cardioversion-defibrillation but are not deemed appropriate candidates for ICD implantation at the time of presentation. This group is defined by 2 populations. The first subgroup comprises those who are at perceived risk but for whom there may be optimism for clinical improvement (eg, patients soon after revascularization or those with a recent diagnosis of myocardial infarction [MI] or cardiomyopathy). Alternatively stated, the optimal management of these patients at risk (or perceived risk) during the waiting period before an ICD is indicated remains unknown. The second subgroup includes those who have a clear indication for ICD but also have a contraindication to immediate ICD placement (eg, active infection or unknown prognosis). The wearable cardioverter-defibrillator (WCD) is a device designed for patients at risk of SCD who are not immediate candidates for ICD therapy. By providing automatic therapy, the WCD does not depend on a second person to defibrillate, as required with a manual or automated external defibrillator (AED). Unlike the ICD (including both transvenous and subcutaneous devices), the WCD requires no surgical operation, can be provided for a short period of time, is temporary, and is easily removed. These characteristics of the WCD, along with safety and efficacy data presented to the US Food and Drug Administration (FDA), resulted in approval in the United States in 2002.8 Because of the increasing use of the WCD and uncertainty of indications …

Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence.

The number of elderly patients on maintenance dialysis has rapidly increased in the past few decades, particularly in developed countries, imposing a growing burden on dialysis centres. Hence, many nephrologists and healthcare authorities feel that greater emphasis should be placed on the promotion of home dialysis therapies such as peritoneal dialysis (PD) and home haemodialysis (HD). There is currently no general consensus as to the best dialysis modality for elderly patients with end-stage renal disease. In-centre HD is predominant in most countries, although it is widely recognized that PD has several advantages over HD, including the lack of need for vascular access, continuous slow ultrafiltration, less interference with patients' lifestyle and lower costs. Comparisons of outcomes between elderly patients on PD and HD rely on observational studies, as randomized controlled trials are lacking. The results of these studies are variable. However, most of them suggest that survival rates are largely similar between the two modalities, except for elderly patients with diabetes and/or beyond 1-3 years from dialysis initiation, in which cases HD appears to be superior. An equally important aspect to consider when choosing dialysis modality, particularly in this age group, is the quality of life, and in this regard most studies found no significant differences between PD and HD. In these circumstances, we believe that dialysis modality selection should be guided by patient's preference, based on comprehensive and unbiased information. A multidisciplinary team should review elderly patients starting on dialysis, aiming to identify possible barriers to PD and home HD, including physical, visual, cognitive, psychological and social problems, and to overcome such barriers by adequate care, education, psychological counselling and dialysis assistance.

EFFORTLESS S-ICD registry: another step in the right direction

This editorial refers to ‘Worldwide experience with a totally subcutaneous ICD: early results from the EFFORTLESS S-ICD registry’[†][1], by P.D. Lambiase et al. , on page 1657 While the clinical significance of the implantable cardioverter defibrillator (ICD) in the reduction of sudden cardiac arrest remains unequivocal, the quest for the best implantable system continues. The first successful, yet experimental ICD system involved two electrodes between the pectoralis muscle and the rib cage, two sensing electrodes in the chest wall musculature, with a pulse generator and capacitor implanted intra-abdominally in animals.1 The first ICD implanted in a human in 1980 consisted of epicardial patches and sensing leads.2 Subsequently, the advent of transvenous ICD leads significantly reduced the morbidity of the procedure and complication rates, while improving clinical outcomes. The transvenous leads, however, came with the cost of a spectrum of vascular complications as well as design faults. Therefore, the quest for a better implantable system has continued. The totally subcutaneous ICD (S-ICD), an innovative strategy obviating the need for vascular access, has come on as a contender to fill this void.3 Evidence favouring the clinical use of the S-ICD came from the feasibility studies and European registries that preceded the Food and Drug Administation (FDA) approval of the device.3–5 Most of these studies have comprised smaller numbers with limited follow-up, calling into question the applicability of these results in real-world practice. The study now presented by Lambiase et al. ,6 reporting on early data from the multicentre EFFORTLESS S-ICD registry, provides valuable information on system performance and inappropriate shock rates. This registry is a laudable effort and comprises an observational, non-randomized, standard of care evaluation of S-ICD in countries outside the USA. The term ‘worldwide experience’ in the title, however, may be a misnomer, as … [1]: #fn-2

Porcine model to evaluate local tissue tolerability associated with subcutaneous delivery of protein

IntroductionThe conversion from intravenous (IV) to subcutaneous (SC) delivery of biotherapeutics has increased in recent years. Some of the reasons for this shift in route of delivery are due to patient convenience, reduced adverse systemic effects, lack of a need for vascular access, and reduced cost of patient care, which ultimately lead to improved patient quality of life. One caveat to SC delivery is the limited volumes that can be administered at a single site and the associated local tolerability. To characterize factors that affect subcutaneous delivery of large volumes of therapeutic proteins, a porcine model was developed. Model endpoints included measurement of interstitial pressure, assessment of local skin visco-elasticity, and the qualitative assessment of local infusion sites. MethodsImmunoglobulin G (IgG) was subcutaneously infused into the abdominal region of Yucatan miniature swine. Changes in interstitial pressure were measured, using an in-line pressure transducer, during and after infusions. Additionally, pre- and post-infusion changes in local skin visco-elasticity were measured using a Cutometer®. Lastly, infusion sites were assessed for post-infusion local skin reactions such as erythema and swelling. Similar assessments were made following SC IgG delivery with the permeation enhancer recombinant human hyaluronidase PH20 (rHuPH20). ResultsSubcutaneous infusions of IgG, in the presence of rHuPH20, significantly reduced average interstitial pressures by 55% during the infusion period and by 67% during the post-infusion period, compared to the control. Infusions in the presence of rHuPH20 also maintained better local skin elasticity as seen by a 42% increase in local skin pliability compared to the control. Finally, infusions with rHuPH20 resulted in an 80% reduction in swelling area compared to the control. DiscussionA large animal model was developed that incorporates both quantitative and qualitative assessment methods to aid in understanding SC delivery of proteins.

Placement of Hemodialysis Catheters with a Technical, Functional, and Anatomical Viewpoint

Aims. Vascular access is of prime importance for hemodialysis patients. We aimed to study early complications of hemodialysis catheters placed in different central veins in patients with acute or chronic renal failure with or without ultrasound (US ) guidance. Material and Methods. Patients who were admitted to our unit between March 2008 and December 2010 with need for vascular access have been included. 908 patients were examined for their demographic parameters, primary renal disease, and indication for catheterization, type and location of the catheter, implantation technique, and acute complications. Results. The mean age of the patients was 60.6 ± 16.0 years. 643 (70.8 %) of the catheters were temporary while 265 (29.2%) were permanent. 684 catheters were inserted to internal jugular veins, 213 to femoral, and 11 to subclavian veins. Arterial puncture occurred in 88 (9.7%) among which 13 had resultant subcutaneous hematoma. No patient had lung trauma and there had been no need for removal of the catheter or a surgical intervention for complications. US guidance in jugular vein and experience of operator decreased arterial puncture rate. Conclusion. US-guided replacement of catheter to internal jugular vein would decrease complication rate. Referral to invasive nephrologists may decrease use of subclavian vein. Experience improves complication rates even under US guidance.

Chronic Obstruction of the Brachial Artery in a Patient in Need for Vascular Access: Distal Revascularization and Fistula Creation at the Same Time

Chronic Obstruction of the Brachial Artery in a Patient in Need for Vascular Access: Distal Revascularization and Fistula Creation at the Same Time

How does the training effect the use of intraosseos access with a battery driven device?

Purpose of the study: Intravascular access is a vital component of emergency care and resuscitation. Success rate and time need for vascular access is crucial in the emergency patient under resuscitation. Intraosseous access (IO) has recently been revived in adults as an alternative when conventional intravenous access may be impossible. The aim of our study was to determine use of a battery driven device (EZ-IO system) by doctors, nurses and paramedics on a bone model and have their opinion on IO with a survey. Materials and methods: 60 doctors from several branch, nurses and paramedics were included in this study. All participants were inexperienced on IO access and saw EZ-IO first time. After 30 min lecture and hands-on training, ease of insertion, number of attempts, insertion time and their opinion were recorded. Results: None of the participants used IO access and none of them know powered drill device before. 58 (96%) of the 60 study subjects required only one attempt at placing the EZ-IO. There were 53 (88%) successful placements of the EZ-IO system. The average time taken to place the EZ-IO was 12 s. 55 (91%) of participants stated that it was easy and noninvasive to insert the EZ-IO. There were no differences among doctors, nurses or paramedics. They reported that they did not reluctant for its use from now on. Conclusions: Intraosseous access was currently known as a traumatic procedure due to old models. The EZ-IO system has high success rates of insertion with inexperienced participants and if it is learned, the use of IO access will be increased during resuscitation. Therefore, during CPR training, education and training of the EZ-IO system should not be omitted.

The role of the vascular access nurse specialist

Alison Cornall and Paula Thomas explain why there is a need for vascular access nurse specialists and why more will be needed in the future. They highlight the benefits of employing a dedicated specialist nurse not only for the surgical, radiological and renal teams—but for wellbeing of the patients.

Subcutaneous Transposition of the Superficial Femoral Artery for Arterioarterial Hemodialysis: Technique and Results

We report the use of subcutaneous transposition of the femoral artery (STFA) for placement of both inflow and outflow needles in 14 hemodialysis (HD) adult patients with difficult access. Follow-up time was 318 months during which a total of 3215 arterioarterial HD sessions were done. Kt/V values ranged between 0.71 and 1.59. Elevated access recirculation and dialysis outflow pressures were common findings to all patients. Complications were: (i) two episodes of bleeding secondary to puncture-related arterial wall laceration, repaired by stitching; (ii) three episodes of thrombosis in two patients, all successfully declotted; (iii) three puncture-related complications needing placement of a vein interposition graft, namely, aneurysm, pseudoaneurysm, and arterial stenosis; and (iv) one case of arterial ligation because of suppurative puncture site infection, without subsequent distal ischemia signs or claudication. The use of STFA should only be reserved for patients in urgent need for vascular access with no remaining options.

Central venous catheters as a vascular access modality for pediatric hemodialysis

The use of hemodialysis catheters is an essential component of dialysis practice. Children are particularly likely to require multiple courses of dialysis over their lifetime, hence the repeated need for vascular access. These catheters remain a significant source of morbidity and mortality. All catheters inserted for hemodialysis at the Center of Pediatric Nephrology and Transplantation, Cairo University over a period of 40 months were studied. Patient data as well as data of catheter insertion, dwell, cause of removal and complications were reported. A total of 195 uncuffed central venous catheters were used for temporary access in 131 patients for a mean duration of 35.7 days. Of attempted insertions, 87.4% achieved successful access, of which 56% remained for the required period, 8.9% were accidentally dislodged, and 35.1% were removed due to complications--mostly infection. The overall rate of possible catheter-related bacteremia was 9.6 episodes/ 1,000 catheter days. Infection increased with longer catheter dwell. Nineteen cuffed tunneled catheters were surgically inserted and used for up to 11 months (mean 117 days). Loss of these catheters was attributed mainly to infection (ten episodes) and catheter thrombosis (six episodes). During the study, 317 femoral catheters were inserted. Uncuffed central venous catheters are both needed and useful for short-term hemodialysis. Vascular access for extended durations may be provided by cuffed tunneled catheters. Infection is the major serious concern with both uncuffed and cuffed catheters.

Complications of apheresis in children

Although the frequency of complications in adults undergoing therapeutic apheresis is low, there are little data in children. A retrospective study of 186 children who had undergone a total of 1632 apheresis procedures between 1994 and 2002 was conducted. Adverse reactions were prospectively documented. The procedures were plasma exchange (67%), hematopoietic progenitor cell collection (18%), red blood cell exchange (6.9%), leukodepletion (0.7%), and plasma exchange with immunoadsorption (6.7%). Adverse reactions, most minor, were reported in 55 percent of procedures in 82 percent of patients. The most frequent complications, per procedure and per patient during an entire course of therapy, were hypotension (14 and 48.4%), hypotension requiring fluid bolus (4.8 and 26.9%), symptomatic hypocalcemia (9.7 and 28.5%), allergic reactions (4.4 and 5.9%), catheter-related thrombosis (1.7 and 12.4%), catheter-related infection (2.1 and 16.1%), and severe anemia (hemoglobin [Hb] level, <7 g/dL; 2.5 and 17.2%). There were two deaths (1% of patients). Risk factors for complications by multivariate analysis were lower body weight, lower preapheresis Hb level, apheresis in a critical care unit, and number of procedures per patient. The 55 percent incidence of complications per procedure in our pediatric cohort is much higher than the 4.3 to 28 percent incidence reported in adults. The excess of adverse reactions in children are mostly related to citrate toxicity, higher relative vascular volume shifts, and the need for vascular access. Pediatric apheresis presents unique challenges and is associated with higher complication rate compared to adults. It is recommended that this procedure be performed in specialized centers.

Arteriovenous fistula after renal transplantation: utility, futility or threat?

Creation of an arteriovenous (AV) fistula for haemodialysis therapy provides convenient access to the circulation in patients with end-stage renal disease. However, the chronic volume overload induced by the AV fistula induces structural and functional cardiac changes, including left ventricular remodelling, which may be deleterious. The balance between the need for vascular access and the deleterious effects of a patent AV fistula on cardiac function and morphology obviously favours the former in patients requiring long-term haemodialysis. After renal transplantation, however, the value of keeping an AV fistula patent is more uncertain and whether it should be closed after successful renal transplantation remains a matter of debate. Since recent studies have provided more insight into the cardiac and haemodynamic changes induced by the procedure, this review aims to summarize the pros and cons of AV fistula closure.