Nocturnal dialysis: Comparing six night/week with alternate night therapy

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  • Hemodialysis Abstracts from the AnnualDialysis Conference

    25th Annual Conference on Peritoneal Dialysis,11th International Symposium on Hemodialysis, and

    16th Annual Symposium on Pediatric Dialysis

    Tampa, FloridaFebruary 28March 2, 2005

    70 2005 International Society for Hemodialysis

    Hemodialysis International 2005; 9: 70103

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    High output heart failure in patients with upper armA-V fistulae: Diagnosis and treatment

    Amerling R., Malostovker I., Dubrow A., Rosero H., Haveson S.

    Division of Nephrology and Hypertension, Division of Cardiology,

    Division of Vascular Surgery, Beth Israel Medical Center, New

    York, NY.

    Purpose: Arteriovenous fistula (AVF) is the preferred blood

    access for hemodialysis due to its longevity and resistance

    to infection. Little attention is given to the long-term

    hemodynamic consequences of large left-to-right shunts,

    particularly in patients with brachial artery fistulae.

    Materials and Methods: We describe 9 patients (8 on

    dialysis, 1 post-transplant), aged 2573, who developed

    clinical heart failure, primarily due to large, upper arm

    AVFs. Results: 4/9 had access flows in excess of 2 liters/

    min, assessed by blood temperature monitoring. 6/9 had

    cardiac output measured by right heart catheterization,

    before and after shunt compression. One also underwent

    left heart catheterization with ventriculography. 3/9 had

    surgical reduction of the fistula, either by banding or by

    serial interposition of small caliber GoreTex graft. In 2/9

    the shunt was ligated. One patient had heart failure in

    association with 2 large, upper arm AVFs, one of which

    was ligated. After years of improved cardiac symptoms,

    heart failure recurred in association with marked hypertro-

    phy of his remaining AVF. Resting cardiac output in this

    patient was in excess of 11 liters/min. 2/9 experienced acute

    onset of heart failure within 13 days of angioplasty of a

    venous stenosis. One of these, with very poor baseline cardiac

    function, expired. Surgical revision or ligation was accompanied

    by clinical improvement in the 5 patients so treated. One of

    these expired of a stroke after two months of cardiac

    improvement. Conclusion: High output heart failure is

    under-diagnosed in dialysis patients. Patients with large

    upper arm shunts are particularly at risk. Access flow

    should be assessed regularly and those with outputs >1.5liters/min should be monitored closely for development of

    heart failure. Surgical correction is beneficial and indicated

    in symptomatic patients.






    ChangeCO (liters/min) Rx Outcome

    1 37/M AVF 8 >2 1.7 Reduction Improved2 26/M AVF 5 >2 2.4 Band Improved3 73/M AVF 3 >2 1.5 Reduction Improved4 45/M AVF 10 n/a 3.2 Reduction Improved5 65/M AVF 4 >2 2.8 Band Improved6 57/F AVG 4 1.2 1.87 39/F AVF 2 n/a n/a Ligate Improved8 66/M AVG 0.3 0.7 n/a Ligate Improved9 69/F AVF 0.25 n/a n/a Expired

    Cutting balloon angioplasty for resistant venousstenoses in hemodialysis patients

    Jung H.W., Kim Y.O., Song H.H.*, Park J.A., Kim Y.S., Kim S.Y.,

    Choi E.J., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,

    College of Medicine, The Catholic University of Korea, Seoul,


    Purpose: To report our initial experience of using cutting bal-

    loons angioplasty in the treatment of resistant venous stenoses of

    Brescia-Cimino fistulas. Materials and Methods: Forty-eight

    patients with Brescia-Cimino fistulas underwent percutaneous

    transluminal angioplasty (PTA) of 62 venous stenoses. Of these

    48 patients, we encountered 8 venous stenoses (8/62, 12.9%) in 7

    patients that were not successfully dilated with 68 mm high-

    pressure balloons inflated up to 24 atm. In each of 8 stenoses,

    peripheral cutting balloons with diameters of 58 mm were

    employed to dilate resistant stenoses. Results: The locations of

    stenoses were 3 at the surgical vein mobilization site (swing

    point), 4 at the cephalic vein downstream from the anastomosis,

    and 1 at the cephalic arch. The grade of stenosis after high-

    pressure balloon angioplasty ranged from 57% to 87% (mean,

    76%). Cutting balloons expanded completely in all stenoses

    and the residual stenosis after cutting balloon PTA ranged from

    0% to 24% (mean, 7%). Residual stenosis was virtually non-

    exisistent at the 3 stenoses of swing point. A focal rupture

    with a large hematoma occurred at the cephalic arch stenosis,

    which was treated by a stent placement. One minimal rupture

    that did not require any treatment occurred at the stenosis of

    downstream cephalic vein. No repeat angioplasty has been

    needed during follow-up period (range, 74249 days).

    Conclusion: Our early experience demonstrated that when

    high-pressure balloons fail to dilate stenoses of Brescia-Cimino

    fistulas, peripheral cutting balloons with diameters of 58 mm

    can be effectively used to overcome the resistance of stenoses.

    Efficacy of percutaneous angioplasty in non-maturingBrescia-Cimino fistulas

    Kim Y.S., Kim Y.O., Song H.H.*, Jung H.W., Park J.A., Yoon S.A.,

    Lee S.H., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,

    College of Medicine, The Catholic University of Korea, Seoul, Korea.

    Purpose: To evaluate efficacy of percutaneous transluminal

    angioplasty (PTA) in non-maturing Brescia-Cimino fistulas.

    Methods: Between January 1997 and December 2003, we treated

    22 patients with non-maturing Brescia-Cimino fistulas by PTA.

    Retrospective analysis was performed on the findings of fistulo-

    gram, techniques and success rate of PTA, and patency

    rate. Results: Seventeen segmental stenoses and 5 segmental

    occlusions of cephalic veins were identified. Sixteen stenoses

    and 2 occlusions were located at the cephalic vein adjacent to

    the anastomosis site, and 3 occlusions and 1 stenosis were seen

    Hemodialysis International, Vol. 9, No. 1, 2005 25th Annual Dialysis Conference: Abstracts

    2005 International Society for Hemodialysis 71

  • at the proximal vein near the elbow joint. In addition to venous

    stenosis, a focal arterial stenosis at the anastomosis site and two

    accompanying accessory veins that might hamper maturation of

    main cephalic vein was seen in each of two patients, respec-

    tively. Simultaneous occlusion of left innominate vein as well as

    occlusion of cephalic vein were noted in one patient. Initial

    success rate of PTA was 95.5% (21/22). Overall success rate

    including 11 additional PTAs performed during follow-up was

    96.9% (32/33). No major complication occurred. Primary and

    secondary patency rates were 72% and 95% at 3 months, and

    50% and 77% at 6 months, respectively. Conclusion: PTA is an

    effective and safe method in salvaging non-maturing Brescia-

    Cimino fistulas.

    Intima-media thickness of radial artery isassociated with early access failure in hemodialysis


    Kim Y.O., Choi Y.J.*, Kim J.I.**, Shin M.J., Kim B.S., Song H.C.,

    Yoon S.A., Kim Y.S., Kim S.Y., Choi E.J., Chang Y.S., Bang B.K.

    Dept. of Int. Med., Clinical Pathology*, Surgery**, The Catholic

    University of Korea, Seoul, Korea.

    Objective: We have reported that intimal hyperplasia, which

    is the pathologic change of the radial artery, is associated

    with early failure of arteriovenous fistula (AVF) in hemodialysis

    (HD) patients (Am J Kidney Dis, 41:422428, 2003). Intima-

    media thickness (IMT), which represents the whole thickness

    of arterial wall, can be easily measured by ultrasonography,

    unlike intima thickness. This study was performed to investigate

    the impact of IMT of radial artery on early failure of AVF in HD

    patients. Methods: Ninety HD patients undergoing radiocepha-

    lic AVF operation were included in this study. The AVF was

    constructed in an end veintoside artery fashion at the wrist by

    one vascular surgeon. During the operation, 10-mm long partial

    arterial walls were removed with elliptical form for microscopic

    analysis. Specimens were stained with trichrome and examined

    by a pathologist blinded to the clinical data. AVF patency was

    prospectively followed up for 1 year after the operation.

    Results: Mean age of the patients was 56 13 years and thenumber of females was 44 (48.9%). Mean IMT was 430132 mm (133760 mm). Of the total 90 patients, 31 patients(34.4%) had AVF failure within 1 year after the operation. Mean

    IMT was higher in the failed group (n 31) than in patentgroup (n 59) (486 130 mm vs. 330 178 mm, p 0.004).Using a threshold of 500 mm of IMT, AVF patency rate wascompared between these two groups using Kaplan-Meier

    method with log rank test. The AVF patency rate within 1 year

    after the operation was higher in patients with IMT 500 mm(n 26) than in patients with IMT< 500 mm (n 64)(p< 0.001). The patients with IMT 500 mm were older andhad higher incidence of diabetes mellitus, compared to the

    patients with IMT< 500 mm. There was no difference in sex,smoking, hypertension, total cholesterol and albumin levels

    between the two groups. Conclusion: Our data suggest that

    increased intima-media thickness of radial artery is associated

    with early failure of radiocephalic arteriovenous fistula in hemo-

    dialysis patients.

    Central venous stenosis in chronic hemodialysispatients: The effect of percutaneous angioplasty