Vascular Access Problems Research Articles

Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists

The purpose of this report was to analyze the results obtained from a group of interventional nephrologists working in multiple centers performing basic procedures that are used routinely in the management of vascular access problems, with an effort toward establishing standards for evaluating success, complication rates, and acceptable times for procedure duration and fluoroscopy. Data on six basic procedures were analyzed-angioplasty of arteriovenous fistulas (AVF-PTA), angioplasty of synthetic grafts (graft-PTA), thrombectomy of arteriovenous fistulas (AVF declot), thrombectomy of synthetic grafts (graft declot), placement of tunneled dialysis catheters (TDC placement), and tunneled dialysis catheter exchange (TDC exchange). These data were examined both as a group and by individual physician operator. RESULTS. A total of 14,067 cases were performed under the six categories of procedure that were the subject of this report; 13,503 cases (96.18%) were successful. The overall complication rate for the combined group of procedures was 3.54%, with 3.26% falling within the minor category and 0.28% within the major. The number of cases performed in each individual category with success rates for each were as follows: TDC placement-1765 cases, 98.24% successful; TDC exchange-2262 cases, 98.36% successful, AVF-PTA-1561 cases, 96.58% successful; graft-PTA-3560 cases, 98.06% successful; AVF declot-228 cases, 78.10% successful; graft declot-4671 cases, 93.08% successful. This study demonstrates that appropriately trained interventional nephrologists can perform these basic procedures in both a safe and effective manner.

Effect of tapered grafts on hemodynamics and flow rate in dialysis access grafts.

Aside from the high incidence of venous stenosis, high-output failure and peripheral steal syndromes remain serious problems of vascular access. Meanwhile commercial tapered grafts are available to address this topic, but little is known about its effect neither on graft flow nor on hemodynamics. Anastomotic models were constructed using a clear silicon elastomer. The arterial anastomosis was shaped in two ways: 1) like a direct connection of artery and 7-mm graft and 2) with a 4-mm diameter segment between artery and graft. Hemodynamic measurements were performed in a pulsatile flow circuit to simulate blood flow at physiological conditions. Flow patterns were obtained by direct dye injection. Additionally, the correlation between the length of narrow segment and mean arterial pressure was investigated. In all models using a 4-mm segment, the oscillating anastomotic vortex was disappeared. This vortex was shifted to the area behind the well-rounded expansions of the graft demonstrating a new separation region, but the flow direction was constant during the whole simulated cycle. At identical pressure rates and waveforms the length of narrow segment determined the graft flow rate directly (e.g., at mean pressure 100 mmHg, flow reduction up to 28% in 4-mm segments, and up to 55% in 3-mm segments). These findings indicate that taper is an important consideration in the design of vascular access grafts.

Dialysis in the Old: A Centenarian Nursing Home Resident With End-Stage Renal Disease

Aging trends in the U.S. have resulted in the over 65 years age group with End Stage Renal Disease (ESRD) becoming the fastest growing segment of the population presenting for dialysis. Their profile differs from younger adults in that they present with significant comorbidity and vascular access problems, and require earlier preparation for dialysis. ESRD in the geriatric population most commonly results from diabetes, hypertension, glomerular and tubulointerstitial nephritis. Described are experiences with initiating a centenarian nursing home resident with uremia on hemodialysis; resulting in improved quality of life and illustrating that age alone should never be a barrier to receiving dialysis. Renal replacement therapy can enhance quality of life and function even in the old. A review of select literature pertinent to ESRD in the geriatric population follows. Aging trends in the U.S. have resulted in the over 65 years age group with End Stage Renal Disease (ESRD) becoming the fastest growing segment of the population presenting for dialysis. Their profile differs from younger adults in that they present with significant comorbidity and vascular access problems, and require earlier preparation for dialysis. ESRD in the geriatric population most commonly results from diabetes, hypertension, glomerular and tubulointerstitial nephritis. Described are experiences with initiating a centenarian nursing home resident with uremia on hemodialysis; resulting in improved quality of life and illustrating that age alone should never be a barrier to receiving dialysis. Renal replacement therapy can enhance quality of life and function even in the old. A review of select literature pertinent to ESRD in the geriatric population follows.

Dialysis Dose Parameters. How Much We Can Improve Them in Our Clinical Practice? Role of Online Conductivity Monitor

The mortality and morbidity of hemodialysis patients is, to a large extent, determined by demographics and by existing comorbidities, but it is obvious that variations in dialysis dose have substantial effects. Using eKt/V, 1.2 monthly comparisons are recommended by European guidelines, but they assume that dose is maintained during all monthly sessions. Because of dialysis‐related problems like hypotension, reduction of blood flow, dialysis time, microclotting of the dialyzer, and vascular access problems, the delivered dose may vary from session to session. New developed devices based on online conductivity clearance reflect the electrolyte clearance and, thus, clearance of urea. The aim of this prospective study was to show the variability of dialysis dose. 24 anuric patients were studied during 3 months: 20.8% were diabetics, mean age 64.7 ± 18.2 years; 16% females. Access blood were AVFi and the effective dialyzed blood flow was set at 350 mL/min, with recirculation <5%. BMI was 25.4 ± 3.8 kg/m2 and body weight was 69.7 ± 12 kg. All patients were dialyzed thrice weekly (245 ± 21 min) with dialysis machine 4008H (Fresenius Medical Care) equipped with online conductivity monitor (OCM) and the hollow fiber high‐flux polysulfone membrane (HF‐80 1.8 m2) and helixone (Fx‐60, 1.6 m2). OCM was validated for our population and reported in other abstracts (r2 = 0.96, p < 0.001). Dialysate flow was maintained at 500 mL/min, with standard dialysate liquid. Each patient was subjected to OCM on regular sessions during 3 months, and blood Kt/V samples were taken on midweek day, once a month. Data were processed and statistically analyzed with SPSS 11.0 software package. Kt/V OCM relation with other baseline characteristics was assessed by using contingency tables, t‐tests, analysis of variance, and linear regression, as appropriate. All the tests were performed for a 0.05 significance level. The conductivity‐based OCM provides an accurate tool to monitor the dose and control of each hemodialysis session and adds to the efficiency of current dialysis adequacy monitoring. OCM device requires little maintenance, and no extra effort is needed. Monthly Kt/V does not reflect the variability of each session. Further studies are necessary to evaluate its influence on morbidity and mortality. Descriptives Variables Minimum Maximum Mean SD Age (year) 31 86 64.75 18.243 Membrane surface 1.6 1.8 1.675 0.0989 Interdialysis weight gain 500 4200 2266.67 1016.673 BMI 18.22 31.03 25.4155 3.83630 Time on dialysis (min) 210 320 245.21 21.340 OCM 0.990 1.880 1.29921 0.201072 dPVV/Kt/V (Daugirdas) 1.00 2.09 1.4067 0.21924 Watson volume (L) 25.8 49.3 36.833 6.3095

Long-term study of high-comorbidity ESRD patients converted from conventional to short daily hemodialysis

Background: Conventional hemodialysis (CHD) is associated with suboptimal clinical outcomes and high mortality rates. Daily hemodialysis (DHD) has been reported to improve outcomes and quality of life (QOL), predominantly in self-care or home dialysis populations. The effect of short DHD (sDHD) on patients with end-stage renal disease (ESRD) with high comorbidities has not been established. Methods: This prospective study compared clinical outcomes and QOL in high-comorbidity patients with ESRD converted from CHD to sDHD while maintaining the same total weekly dialysis time. Study patients had 4.0 ± 1.7 major comorbid conditions in addition to ESRD. Standard dialysis parameters, antihypertensive and erythropoietin (EPO) requirements, Kidney Disease Quality of Life (KDQOL) measurements, vascular access problems, and hospitalization rates were compared while on sDHD therapy versus the previous 12 months on CHD therapy. Results: Forty-two patients were studied on sDHD therapy for 793 patient-months during a 72-month period. During sDHD, standard Kt/V increased 31%, hospitalization days decreased significantly by 34%, and vascular access problems did not increase. Cumulative survival was 33% at 6 years. In the 20 patients who remained on sDHD therapy for 12 months, after 1 year, we found significant improvements in KDQOL scores, a 69% reduction in antihypertensive medications with stable blood pressure, and a 45% reduction in EPO requirements with stable hematocrits. We hypothesize that these improvements are the result of the less extreme solute and fluid fluctuations and greater dialysis dose provided by sDHD, even when weekly dialysis time is unchanged. Conclusion: High-comorbidity patients with ESRD converted to sDHD therapy had significantly improved clinical outcomes and QOL and decreased hospitalizations, with no increase in vascular access problems.

European guidelines for vascular access: clinical algorithms on vascular access for haemodialysis.

Vascular access remains the Achilles heel of end-stage renal disease patients, receiving haemodialysis. The increase in the number of elderly dialysis patients with additional cardiovascular co-morbidities and diabetes mellitus makes the creation and maintenance of functioning vascular access, more difficult and cumbersome. Therefore, the development of guidelines for vascular access management seems logical. A team of multidisciplinary vascular access experts created a set of algorithms covering the whole spectrum from pre-operative vessel assessment, peri-operative access management and post-operative follow up and surveillance. Additionally, a range of various access complications with their diagnosis and treatment options were included in these algorithms. The new European guidelines for vascular access augment the knowledge of vascular access problems and their management. Additionally, the use of algorithms facilitates the decision-making when treating complications by all physicians dedicated to this field of healthcare.

Vascular access: anatomy, examination, management.

A systematic approach to managing vascular access problems is the key to reducing current high rates of access thrombosis and failure. This approach begins with a thorough knowledge of vascular access anatomy that, when combined with the physical examination, can help optimize access planning and maintenance. Because of the high complication rate of synthetic grafts, there has been increased emphasis on creating autogenous arteriovenous (AV) fistulae, which, once established, are more trouble-free. The benefit of increased fistula creation will not be realized, however, until the high rate of early fistula failure is reduced. It is widely recommended that graft surveillance programs be implemented and that stenosis be corrected when accompanied by graft dysfunction. Graft blood flow (Q(a)) is the preferred surveillance method, but has a poor accuracy in predicting thrombosis. Most studies that have evaluated the benefit of Q(a) surveillance have used historical control groups, or have been retrospective or nonrandomized. Consequently, we believe it is not currently possible to make definitive, evidence-based recommendations concerning Q(a) surveillance. The most important factor in access survival may be a team approach with an organized commitment to access planning followed by recognition and treatment of access problems.

Adverse events and problems in therapeutic hemapheresis. A report from the Swedish registry

Background: Since 1996 adverse events (AE) in therapeutic apheresis (TA) have been more extensively registered in Sweden. This report analyzes the extent and relation of AEs to procedures and diagnoses. Materials and methods: Reporting of TA performed in Sweden was centralized. A separate system for the registration of AE in TA was established and the data received were entered into a central database for registration and analyses. Fifteen of all 35 apheresis units reported both TA and AE during 1996–1999. These centers performed 75% of all TA procedures. Adverse events included medical symptoms, vascular access problems, technical and other problems. Results: More than 14,000 procedures were registered during the observation period. No fatalities occurred. AEs occurred in 3.7% (1996), 4.6% (1997), 4.2% (1998) and 4.4% (1999) of procedures. Interventions during the adverse event were performed in about 65% of the events. Apheresis procedures were interrupted due to an adverse event in about 1%. Adverse events occurred in 5.6% of plasma exchanges, 1.9% of plasma modulations and 6.8% of cytapheresis procedures. Paresthesia was registered in 22% and hypotensive events in 20.5%. Other more frequent symptoms were urticaria (14.4%), shivering (7.4%) and nausea (7.4%). AEs were most frequent in patients with Goodpasture's syndrome (12.5%), TTP/HUS (10.5%) and GuillainBarré syndrome (11.0%). Conclusion: AEs are few, often mild and less common in plasma modulation than plasma exchange. AEs are more frequent during TA of patients with certain diagnoses such as TTP/HUS.

Vascular access problems in dialysis patients: pathogenesis and strategies for management.

Repetitive hemodialysis was made possible through the development of a chronic means of accessing the circulation. This was accomplished through the use of arteriovenous fistulae or grafts, using autologous veins or synthetic materials. Although the arteriovenous fistula remains the access of choice, synthetic arteriovenous grafts are used in most patients because of problems with late referral to a nephrologist and poor vasculature. This article describes the means of accessing the circulation for hemodialysis, the pathogenesis of access failure through progressive stenosis followed by thrombosis, methods of detecting access dysfunction before thrombosis, and therapeutic options. Although angiographic or surgical intervention remain the mainstays of management, medical treatments to decrease stenosis and delay thrombosis are currently under investigation.

Daily Dialysis: Toward a New Standard in Well-Being

Daily hemodialysis (DHD) is a promising option; however, logistic obstacles and clinical perplexities limit its dissemination. Understanding the mechanisms of, and the time until, the onset of improved well-being may help to quantify clinical advantages and to define the minimum length of a “trial” of daily dialysis. By following 30 patients treated in 4 centers, this study aimed to determine how long a period of time is needed until a patient experiences subjective improvement. From November 1998 to November 2000, 30 patients tried at least 2 weeks of short daily dialysis in four Northern Italian centers of Piemonte and Valle d'Aosta. The DHD (2 – 3 hours; blood flow 270 – 350 mL/min; individual HCO3, Na, K) was performed at home or in a center. Motivations to try DHD, fears and concerns regarding DHD, and changes in perceived well-being were assessed by semi-structured interview. The main clinical indications for a trial of DHD were poor tolerance of conventional treatment, cardiovascular disease, and hypertension or hypotension; only 6 patients had no comorbidity at start. The patients' main reasons for choosing DHD were related to job problems and the search for a better treatment. Most of the patients continued DHD because of improved well-being; logistic reasons accounted for the drop-outs (5 patients). The main fears were related to logistic aspects, vascular access problems, and excessive involvement of the partner on home dialysis. Improved well-being was reported by 28 of 30 patients; 2 patients reported no difference. Subjective improvement was perceived within 2 weeks in 22 of 30 patients, and within 1 month in 28 of 30 patients. An offer of a 2 – 4 week trial of DHD may help patients and caregivers to determine whether subjective and objective benefits outweigh logistic problems and whether a permanent transfer to DHD is worthwhile.

Daily Dialysis: Toward a New Standard in Well-Being.

Daily hemodialysis (DHD) is a promising option; however, logistic obstacles and clinical perplexities limit its dissemination. Understanding the mechanisms of, and the time until, the onset of improved well-being may help to quantify clinical advantages and to define the minimum length of a "trial" of daily dialysis. By following 30 patients treated in 4 centers, this study aimed to determine how long a period of time is needed until a patient experiences subjective improvement. From November 1998 to November 2000, 30 patients tried at least 2 weeks of short daily dialysis in four Northern Italian centers of Piemonte and Valle d'Aosta. The DHD (2 - 3 hours; blood flow 270 - 350 mL/min; individual HCO3 , Na, K) was performed at home or in a center. Motivations to try DHD, fears and concerns regarding DHD, and changes in perceived well-being were assessed by semi-structured interview. The main clinical indications for a trial of DHD were poor tolerance of conventional treatment, cardiovascular disease, and hypertension or hypotension; only 6 patients had no comorbidity at start. The patients' main reasons for choosing DHD were related to job problems and the search for a better treatment. Most of the patients continued DHD because of improved well-being; logistic reasons accounted for the drop-outs (5 patients). The main fears were related to logistic aspects, vascular access problems, and excessive involvement of the partner on home dialysis. Improved well-being was reported by 28 of 30 patients; 2 patients reported no difference. Subjective improvement was perceived within 2 weeks in 22 of 30 patients, and within 1 month in 28 of 30 patients. An offer of a 2 - 4 week trial of DHD may help patients and caregivers to determine whether subjective and objective benefits outweigh logistic problems and whether a permanent transfer to DHD is worthwhile.

Initial experience of a nephrologist-operated vascular access center.

A nephrology practice in Alabama did not feel in control of vascular access management. Scheduling delays, as well as variable techniques and outcomes, leading to high morbidity and mortality, caused frustration with the existing care system for vascular access. Our objective was to develop an integrative system of vascular access care, involving nephrologists along with the other caregivers, and to demonstrate an improvement in outcomes. Nephrology Vascular Labs (NVL), a recent RMS-Lifeline acquisition, opened a vascular access center (VAC) as an extension of the nephrology practice. Both pre-ESRD and ESRD patients are evaluated and treated in the VAC. Treatment is rendered in a timely fashion, to the benefit of the patients. Nephrologists serve as the interventionists. More than 90% of vascular access problems detected at dialysis are treated at the VAC. More than 2000 procedures have been performed over 2 years. Procedures carried out include thrombolysis with angioplasty, fluoroscopy alone or with angioplasty, placement of cuffed and noncuffed catheters, removal of cuffed catheters, and minor surgeries. Success rates have been high. Minor and major complications have been relatively low. Referrals to both surgeons and radiologists are shown to emphasize the role of the VAC as part of an integrative system of vascular access care. Results of a patient satisfaction survey were excellent. The VAC has fulfilled the vision of creating a seamless integration of care for vascular access. Hospitalization rate has been reduced and it is suspected that the global cost of access care is markedly lower than prior to the VAC. Multiple nephrologists can rotate as the VAC's interventionist and jointly obtain good outcomes and have little variability among them. Several reasons for using a nephrologists as the interventionist are discussed.

Primary vascular access in diabetic patients: an audit.

The increasing proportion of diabetic patients in the haemodialysis population, mainly elderly patients with diabetes mellitus type 2, is a challenge to nephrologists and vascular surgeons. The aim of this study was to assess different strategies in an effort to improve the commonly disappointing results of arteriovenous (a-v) fistula surgery in this group of patients. Besides the availability of a suitable vein, special attention was paid to the quality of the artery, based on clinical and recently available ultrasonographic parameters. In the case of peripheral arterial narrowing and/or calcification, the elbow region was the preferred location for creation of the first a-v fistula, taking into consideration the reduced life expectancy of the majority of diabetic patients. Furthermore, a clinical surveillance programme was established to treat the failing, not the failed fistula. To this end, elective revisions were performed prior to the onset of thrombosis to correct stenoses, aneurysms, and other signs of fistula dysfunction. Absolute priority was given to the use of native vessels. During the period January 1993 to December 1995, 347 primary Brescia-Cimino fistulae were performed out a total of 799 access procedures. No graft material was used in these first operations. The patients were followed up until 31 July 1998. Of these 347 patients, 269 were non-diabetic and 78 were diabetic. Two hundred and two of all 347 first a-v fistulae were created in the forearm/wrist region, 182 in non-diabetic patients and 20 in diabetic patients, whereas the elbow region was used in 145 patients, 87 in non-diabetic and 58 in diabetic patients. Based on the carefully planned choice of location of the first operation and the strategy of elective revisions, virtually identical results for non-diabetic and diabetic patients could be obtained with regard to revision and patency rates. Some differences were observed with regard to the types of revision. A strategy is presented that helps to reduce the vascular access problems in diabetic and elderly patients.

Vascular access problems.

Vascular access is one of the most commonly used techniques in the care of the patient with cancer. Often treated as a routine matter, venous access can have serious consequences which can be maintained at a very low level providing there is strict adherence to a regimented protocol of surgical technique and of catheter care.

Vascular access problems revisited: the Multinational Association of Supportive Care in Cancer (MASCC) experience.

Despite the increased availability of vascular access devices, there is limited information regarding their pattern of use in the clinical setting or the criteria used for their utilization. To obtain this information, we sent questionnaires to MASCC members. Forty-five percent of the respondents stated that the decision to use vascular access devices depended on the drugs used at the beginning of therapy. Another 30% replied that the decision to use long-term vascular access devices depended on the status of the patient's veins at the beginning of therapy. Only 12% of those surveyed waited until all the veins were exhausted before considering using vascular access devices. Although more than half of the professionals surveyed used long-term vascular access devices in 50% or more of their patients with hematologic malignancies, only 20% used these devices in patients with solid tumors. Features considered most important when selecting long-term vascular access devices were durability of the device and ease of use for medical personnel. Major limitations of long-term vascular access devices were cost, closely followed by patient acceptance. The most common reasons for removal of vascular access devices were infection and thrombosis. We conclude that there is a lack of uniform criteria for the utilization of long-term vascular access devices. Cost is a major limitation to the wider use of this technology. More research is necessary to determine the optimal use of vascular access devices in patients with cancer.

Further Experience With a Percutaneously Inserted Double-Lumen Silastic Catheter for End-Stage Renal Failure Patients With Refractory Vascular Access Problems

Further Experience With a Percutaneously Inserted Double-Lumen Silastic Catheter for End-Stage Renal Failure Patients With Refractory Vascular Access Problems

Further Experience With a Percutaneously Inserted Double- Lumen Silastic Catheter for End-Stage Renal Failure Patients With Refractory Vascular Access Problems

Further Experience With a Percutaneously Inserted Double- Lumen Silastic Catheter for End-Stage Renal Failure Patients With Refractory Vascular Access Problems

Chronic dialysis in patients over age 65.

In the United States, persons over the age of 65 are expected soon to become the majority of those people who will require maintenance dialysis therapy. Many of these individuals have numerous comorbid medical complications, which, together with altered physiologic adaptation related to aging, create a great challenge for the nephrologist. Despite a considerably lower group survival rate and increased hospitalization utilization as compared with younger patients, many elderly dialysis patients tolerate therapy very well and appear quite satisfied with the quality of their lives. Both hemodialysis and peritoneal dialysis are suitable treatment modalities for elderly patients, but recommendations regarding type of dialysis must be individualized, taking both medical and psychosocial issues into consideration. Vascular access problems are particularly important for the elderly and contribute to significant morbidity. Malnutrition and cardiovascular complications also require special attention. Withdrawal from dialysis appears to be increasingly common among elderly ESRD patients and highlights the need for the completion of advance directives. A trial of dialysis may allow elderly patients and their families additional time to decide whether long-term dialysis is deemed appropriate.

A Puzzling Accidental Intraoperative Finding

To the Editor: A 15-yr-old ASA physical status II patient with a history of hereditary spherocytosis presented to the operating suite for laparoscopic splenectomy. A preexisting 18-gauge intravenous cannula was noted on the left dorsal forearm area just proximal to the radial styloid process. In view of the possibility of substantial blood loss, a 16-gauge intravenous cannula was sited on the dorsum of the right hand. The preexisting cannula was left in place and flushed with 2-5 mL 0.9% normal saline. Intraoperatively, the ETCO2 increased progressively to approximately 41 mm Hg as the pneumoperitoneum was established. For teaching purposes, a venous gas sample was sent for analysis. The initial sample (A) was taken for convenience from the unused preexisting access line. The results were as follows. Sample A, representing the sample taken from the preexisting line, had a pHa of 7.330, PaO2 of 134 mm Hg, and PaCO2 of 43.3 mm Hg. A repeat sample (B) had a similar result. Sample C from the ipsilateral ulnar artery had the following results: pHa of 7.387, PaO (2) of 119 mm Hg, and PaCO2 of 40.0 mm Hg. All results corresponded with ETCO (2) measurements at times of sampling. The possibilities initially explored were 1) inadvertent arterial cannulation, 2) aberrant radial vessel, 3) arteriovenous fistula, and 4) "arterialized" venous blood. The PaO2 results ruled out "arterialized" venous blood as a possibility. On examination, the cannula was clearly situated at some distance from the radial or ulnar arteries. An invasive arterial monitoring device was set up, but pulsatile waveform was not registered. The flow, while not pulsatile, did not appear typical of venous flow. At this point, a fine guidewire was passed gently through the cannula to approximately 15 cm. No resistance was encountered and no evidence of compromised palmar flow occurred. Waveform was again nonpulsatile. Therefore, it was concluded that this preexisting cannula was situated in an arteriovenous fistula. Venous access is a basic requirement for anesthetics. However, little has been published on the attending problems. Vascular access problems are not uncommon. A recent study of 2000 anesthetic incident reports found 65 associated with vascular access, 33 of which involved peripheral access [1]. Three of the latter cases involved cannulation of aberrant or tortuous radial arteries. Insertion of a cannula into a preformed fistula has not been described. Wolf et al. [2] described the development of an arteriovenous fistula after intravenous cannulation in the antecubital fossa. In one instance, fistula formation appears to have followed simple needle insertion for blood donation. Our patient had no previous history of intravenous cannulation but had frequent blood sampling for coagulation studies. It is possible that this anomaly may have resulted from repeated venous puncture or may be congenital. The complications of arterial injection of anesthetics, including the severe chemical endarteritis associated with thiobarbiturates, are well described [3]. It was fortunate that no drugs were infused through the preexisting line. This case highlights the need for careful inspection of preexisting cannulas prior to induction of anesthesia. It also serves as a reminder of the possible morbidity associated with peripheral vascular access. A. Hayes, FFARCSI D. Lohan-Mannion, FFARCSI Y. Gozal, MD Department of Anesthesiology--UHS2 Oregon Health Sciences University Portland, OR 97201

Dialysis treatment in patients with rheumatoid arthritis

The results of dialysis treatment in 24 rheumatoid arthritis patients, 20 chronic rheumatoid arthritis (RA) and 4 juvenile rheumatoid arthritis (JRA), were analysed. Presence of secondary amyloidosis, renal function, morbidity and survival were examined. Amyloidosis was present in 13 patients. Especially among amyloidosis patients, renal function declined rapidly in the last year before dialysis started. On average, 63 days per patient-year were spent in the hospital, 58% was dialysis-related, mainly due to vascular access problems. Hospitalization was even more widespread in amyloidosis patients (79 days, 72% dialysis-related). Median survival in RA patients with amyloidosis was 11 months; in RA patients without amyloidosis this was 29 months. Two-year survival was only 1 out of 10 for the RA amyloidosis patients; for the RA non-amyloidosis patients this was 5 out of 6 (p < 0.01). Cardiovascular causes of death were most frequent. In conclusion, high morbidity and low survival make RA patients with amyloidosis a high-risk group on renal replacement therapy.