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dialysis shunt [keywords]
- Renal dysfunction in patients with cirrhosis: Where do we stand? [Journal Article, Review]
- World J Gastrointest Pharmacol Ther 2014 Aug 6; 5(3):156-68.
Patients with cirrhosis and renal failure are high-risk patients who can hardly be grouped to form precise instructions for diagnosis and treatment. When it comes to evaluate renal function in patients with cirrhosis, determination of acute kidney injury (AKI), chronic kidney disease (CKD) or AKI on CKD should be made. First it should be excluded the prerenal causes of AKI. All cirrhotic patients should undergo renal ultrasound for measurement of renal resistive index in every stage of liver dysfunction and urine microscopy for differentiation of all causes of AKI. If there is history of dehydration on the ground of normal renal ultrasound and urine microscopy the diuretics should be withdrawn and plasma volume expansion should be tried with albumin. If the patient does not respond, the correct diagnosis is HRS. In case there is recent use of nephrotoxic agents or contrast media and examination shows shock, granular cast in urinary sediment and proteinuria above 0.5 g daily, acute tubular necrosis is the prominent diagnosis. Renal biopsy should be performed when glomerular filtration rate is between 30-60 mL/min and there are signs of parenchymal renal disease. The acute renal function is preferable to be assessed with modified AKIN. Patients with AKIN stage 1 and serum creatinine ≥ 1.5 mg/dL should be at close surveillance. Management options include hemodynamic monitoring and management of fluid balance and infections, potentially driving to HRS. Terlipressin is the treatment of choice in case of established HRS, administered until there are signs of improvement, but not more than two weeks. Midodrine is the alternative for therapy continuation or when terlipressin is unavailable. Norepinephrine has shown similar effect with terlipressin in patients being in Intensive Care Unit, but with much lower cost than that of terlipressin. If the patient meets the requirements for transplantation, dialysis and transjugular intrahepatic portosystemic shunt are the bridging therapies to keep the transplant candidate in the best clinical status. The present review clarifies the latest therapeutic modalities and the proposed recommendations and algorithms in order to be applied in clinical practice.
- Radiological diagnosis of dialysis-associated complications. [JOURNAL ARTICLE]
- Insights Imaging 2014 Aug 6.
In daily clinical practice, the radiologist in the context of diagnosis often faces dialysis-associated complications. The complications are numerous and range from infections, catheter dysfunctions, haematomas, cardiovascular diseases, digital ischaemia, and pseudoaneurysms to shunt stenosis. In this pictorial essay, we take a close look at the imaging diagnostics of the most common complications in dialysis patients. Teaching Points • The occurrence of venous stenosis in haemodialysis patients is up to 41 %. • Catheters usually have a fibrin sheath that can be rinsed but not aspirated. • The steal phenomenon occurs in 75-90 % of patients with a shunt system. • Arterial pseudoaneurysms can cause a number of complications.
- Endovascular management of thrombosed axillary artery to right atrium hemodialysis graft. [JOURNAL ARTICLE]
- Clin Imaging 2014 Jun 19.
To describe the salvage of a left axillary artery to right atrium hemodialysis graft using endovascular techniques.A 54-year-old man with multiple arteriovenous graft failures presented with a thrombosed left axillary artery to right atrium Gore-tex hemodialysis graft. The graft was salvaged using rheolytic catheter thrombectomy, mechanical thrombectomy, balloon angioplasty, and stenting.This single case report suggests that when axillary to right atrium grafts fail, various endovascular techniques can be employed to salvage the graft and maintain dialysis access.
- Abdominal pseudocyst development in a peritoneal dialysis patient with a ventriculoperitoneal shunt: an indication for switch to hemodialysis? [Letter]
- Perit Dial Int 2014 Jun; 34(4):470-1.
- Bilateral central vein stenosis in a dialysis patient with a pacemaker. [JOURNAL ARTICLE]
- Asian Cardiovasc Thorac Ann 2013 Oct 16.
Central vein stenosis is not uncommon in hemodialysis-dependent patients as a result of mechanical damage to the vessel walls from prior cannulation. It can cause ipsilateral upper limb swelling and pain, resulting in suboptimal hemodialysis. It is unfortunate for bilateral central vein stenosis to develop concomitantly, and rare in the setting of an in-situ pacemaker. This case illustrates the successful ligation of a nondependent left arteriovenous fistula and stenting of the right subclavian vein with functioning ipsilateral arteriovenous fistula, to overcome the problem of symptomatic bilateral upper limb swelling.
- Vascular access management: ongoing challenges and strategies for success. [Journal Article]
- Nephrol News Issues 2014 Mar; 28(3):26, 28, 30-3.
- Tube banding to correct steal syndrome after arteriovenous fistula construction for hemodialysis. [Journal Article]
- Am Surg 2014 Mar; 80(3):E71-3.
- Distal revascularization and interval ligation (DRIL) procedure requires a long bypass for optimal inflow. [Journal Article]
- Can J Surg 2014 Apr; 57(2):112-5.
Distal revascularization and interval ligation (DRIL) is commonly used to treat ischemic steal syndrome caused by arteriovenous hemodialysis access and has been associated with good outcomes. However, the literature lacks technical details of a successful intervention. We tested the hypothesis that a brachial-level arteriovenous fistula (AVF) generates a zone of low arterial blood pressure in the brachial artery near the AVF origin.We identified patients with ischemic steal syndrome caused by an AVF originating from the brachial artery level who were eligible for the DRIL procedure. All patients were studied with invasive pressure monitoring in the brachial artery at the time of digital subtraction angiography. We measured systolic, diastolic and mean arterial blood pressure at 5 cm intervals from a point in the arterial circulation 5 cm distal to the origin of the AVF and continuing proximally into the subclavian artery.Our series involved 10 patients with a mean age of 66.5 (range 53-81) years. Four patients were women and 8 had diabetes. All patients had grade 3 ischemic steal syndrome with ischemic rest pain and/or ischemic tissue loss. Mean systolic, diastolic and arterial pressures increased from the level of the AVF until central pressures were reached. Systolic blood pressure was significantly lower than central blood pressure until a level 20-25 cm proximal to the AVF.The benefits of the DRIL procedure in alleviating ischemic steal syndrome associated with hemodialysis access are best achieved with a DRIL bypass for which inflow originates at least 20-25 cm proximal to the origin of the AVF.
- Outcomes with arteriovenous fistulas in a pediatric population. [JOURNAL ARTICLE]
- J Vasc Surg 2014 Mar 7.
Kidney Disease Outcome Quality Initiative guidelines recommend permanent access in dialysis patients aged 0 to 19 years who weigh >20 kg and are unlikely to receive a transplant within 1 year. Unfortunately, >80% of these patients currently receive dialysis through a permanent catheter and are exposed to the associated risks and shortcomings. With a clear imperative to increase the incident use of permanent access in pediatric patients, our objective was to examine the long-term outcomes of pediatric arteriovenous fistulas (AVFs).A retrospective review was performed of all AVFs created in a hemodialysis (HD) population aged 0 to 19 years at a single institution from 1999 to 2012. Data abstracted included age, weight, etiology of renal failure, time on dialysis, central venous catheter history, and transplantation history. Data were analyzed to determine the influence of these variables on primary and secondary patency.During the study period, 101 AVFs were performed in 93 patients, of whom 65 patients (70%) were male. Mean patient age was 14 years (range, 3-19 years), and mean weight was 51 kg (range, 12-131 kg). At the time of AVF creation, 66 patients (82%) were already receiving HD, with a mean length of HD dependence of 18 months. At the time of surgery, 78% of patients had a previous central venous catheter, and 24% had two or more catheters. Procedures performed included 43 radiocephalic fistulas, 29 brachiocephalic fistulas, 20 basilic vein transpositions, and 9 femoral vein transpositions. Mean follow-up was 2.5 years. The 2-year and 4-year primary and secondary patency rates were 83% and 92%, and 65% and 83%, respectively. Increasing age was correlated with improved primary patency (P = .02) but had no effect on secondary patency. Weight, etiology, catheter location, and catheter history were not significantly associated with primary or secondary patency. During the postoperative period, 68 patients (75%) received a renal transplant, with a mean time to transplant of 556 days.AVFs demonstrate excellent long-term patency with minimal complications in pediatric HD patients, regardless of weight. Concerted efforts should be made to improve the incident use of AVFs in all pediatric patients with end-stage renal disease.
- Risk factors of sensitization to human leukocyte antigen in end-stage renal disease patients. [JOURNAL ARTICLE]
- Hum Immunol 2014 Mar 6.
Pre-sensitization to human leukocyte antigen (HLA) is closely related to the prognosis of renal transplantation. Concerning the risk factors for HLA sensitization, most studies focused only on selected transplant candidates.All patients with end-stage renal disease (ESRD) in a single teaching hospital and a group of healthy subjects were enrolled for the tests of panel-reactive antibodies (PRA).A total of 1177 subjects were recruited, including 289 ESRD patients (140 hemodialysis, 98 peritoneal dialysis, and 51 pre-dialysis) and 888 healthy volunteers. The prevalence of PRA positivity (for either type I or II HLA) for ESRD patients was higher than for healthy subjects (23.2% vs. 12.8%, p=0.000). Only pregnancy and transfusion showed independent correlations with PRA positivity, and not ESRD itself. The PRA-positive ESRD patients were prone to be female, have histories of pregnancy, transfusion, no hepatitis B, and use of graft shunt for dialysis. Multivariate analyses showed that pregnancy and time interval of the latest transfusion had independent correlations with PRA positivity. The time interval of less than 1year had the highest odds ratio 10.06 (p=0.000).Pregnancy and recent transfusion, not ESRD itself or dialysis modality, remain the independent risk factors for HLA sensitization.