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

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<ul><li><p>Hemodialysis Abstracts from the AnnualDialysis Conference</p><p>25th Annual Conference on Peritoneal Dialysis,11th International Symposium on Hemodialysis, and</p><p>16th Annual Symposium on Pediatric Dialysis</p><p>Tampa, FloridaFebruary 28March 2, 2005</p><p>70 2005 International Society for Hemodialysis</p><p>Hemodialysis International 2005; 9: 70103</p></li><li><p>Access</p><p>High output heart failure in patients with upper armA-V fistulae: Diagnosis and treatment</p><p>Amerling R., Malostovker I., Dubrow A., Rosero H., Haveson S.</p><p>Division of Nephrology and Hypertension, Division of Cardiology,</p><p>Division of Vascular Surgery, Beth Israel Medical Center, New</p><p>York, NY.</p><p>Purpose: Arteriovenous fistula (AVF) is the preferred blood</p><p>access for hemodialysis due to its longevity and resistance</p><p>to infection. Little attention is given to the long-term</p><p>hemodynamic consequences of large left-to-right shunts,</p><p>particularly in patients with brachial artery fistulae.</p><p>Materials and Methods: We describe 9 patients (8 on</p><p>dialysis, 1 post-transplant), aged 2573, who developed</p><p>clinical heart failure, primarily due to large, upper arm</p><p>AVFs. Results: 4/9 had access flows in excess of 2 liters/</p><p>min, assessed by blood temperature monitoring. 6/9 had</p><p>cardiac output measured by right heart catheterization,</p><p>before and after shunt compression. One also underwent</p><p>left heart catheterization with ventriculography. 3/9 had</p><p>surgical reduction of the fistula, either by banding or by</p><p>serial interposition of small caliber GoreTex graft. In 2/9</p><p>the shunt was ligated. One patient had heart failure in</p><p>association with 2 large, upper arm AVFs, one of which</p><p>was ligated. After years of improved cardiac symptoms,</p><p>heart failure recurred in association with marked hypertro-</p><p>phy of his remaining AVF. Resting cardiac output in this</p><p>patient was in excess of 11 liters/min. 2/9 experienced acute</p><p>onset of heart failure within 13 days of angioplasty of a</p><p>venous stenosis. One of these, with very poor baseline cardiac</p><p>function, expired. Surgical revision or ligation was accompanied</p><p>by clinical improvement in the 5 patients so treated. One of</p><p>these expired of a stroke after two months of cardiac</p><p>improvement. Conclusion: High output heart failure is</p><p>under-diagnosed in dialysis patients. Patients with large</p><p>upper arm shunts are particularly at risk. Access flow</p><p>should be assessed regularly and those with outputs &gt;1.5liters/min should be monitored closely for development of</p><p>heart failure. Surgical correction is beneficial and indicated</p><p>in symptomatic patients.</p><p>Patientnumber</p><p>Age/Sex</p><p>Accesstype</p><p>Yearswithaccess</p><p>Flow(liters/min)</p><p>ChangeCO (liters/min) Rx Outcome</p><p>1 37/M AVF 8 &gt;2 1.7 Reduction Improved2 26/M AVF 5 &gt;2 2.4 Band Improved3 73/M AVF 3 &gt;2 1.5 Reduction Improved4 45/M AVF 10 n/a 3.2 Reduction Improved5 65/M AVF 4 &gt;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</p><p>Cutting balloon angioplasty for resistant venousstenoses in hemodialysis patients</p><p>Jung H.W., Kim Y.O., Song H.H.*, Park J.A., Kim Y.S., Kim S.Y.,</p><p>Choi E.J., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,</p><p>College of Medicine, The Catholic University of Korea, Seoul,</p><p>Korea.</p><p>Purpose: To report our initial experience of using cutting bal-</p><p>loons angioplasty in the treatment of resistant venous stenoses of</p><p>Brescia-Cimino fistulas. Materials and Methods: Forty-eight</p><p>patients with Brescia-Cimino fistulas underwent percutaneous</p><p>transluminal angioplasty (PTA) of 62 venous stenoses. Of these</p><p>48 patients, we encountered 8 venous stenoses (8/62, 12.9%) in 7</p><p>patients that were not successfully dilated with 68 mm high-</p><p>pressure balloons inflated up to 24 atm. In each of 8 stenoses,</p><p>peripheral cutting balloons with diameters of 58 mm were</p><p>employed to dilate resistant stenoses. Results: The locations of</p><p>stenoses were 3 at the surgical vein mobilization site (swing</p><p>point), 4 at the cephalic vein downstream from the anastomosis,</p><p>and 1 at the cephalic arch. The grade of stenosis after high-</p><p>pressure balloon angioplasty ranged from 57% to 87% (mean,</p><p>76%). Cutting balloons expanded completely in all stenoses</p><p>and the residual stenosis after cutting balloon PTA ranged from</p><p>0% to 24% (mean, 7%). Residual stenosis was virtually non-</p><p>exisistent at the 3 stenoses of swing point. A focal rupture</p><p>with a large hematoma occurred at the cephalic arch stenosis,</p><p>which was treated by a stent placement. One minimal rupture</p><p>that did not require any treatment occurred at the stenosis of</p><p>downstream cephalic vein. No repeat angioplasty has been</p><p>needed during follow-up period (range, 74249 days).</p><p>Conclusion: Our early experience demonstrated that when</p><p>high-pressure balloons fail to dilate stenoses of Brescia-Cimino</p><p>fistulas, peripheral cutting balloons with diameters of 58 mm</p><p>can be effectively used to overcome the resistance of stenoses.</p><p>Efficacy of percutaneous angioplasty in non-maturingBrescia-Cimino fistulas</p><p>Kim Y.S., Kim Y.O., Song H.H.*, Jung H.W., Park J.A., Yoon S.A.,</p><p>Lee S.H., Chang Y.S., Bang B.K. Dept. of Int. Med., Radiology*,</p><p>College of Medicine, The Catholic University of Korea, Seoul, Korea.</p><p>Purpose: To evaluate efficacy of percutaneous transluminal</p><p>angioplasty (PTA) in non-maturing Brescia-Cimino fistulas.</p><p>Methods: Between January 1997 and December 2003, we treated</p><p>22 patients with non-maturing Brescia-Cimino fistulas by PTA.</p><p>Retrospective analysis was performed on the findings of fistulo-</p><p>gram, techniques and success rate of PTA, and patency</p><p>rate. Results: Seventeen segmental stenoses and 5 segmental</p><p>occlusions of cephalic veins were identified. Sixteen stenoses</p><p>and 2 occlusions were located at the cephalic vein adjacent to</p><p>the anastomosis site, and 3 occlusions and 1 stenosis were seen</p><p>Hemodialysis International, Vol. 9, No. 1, 2005 25th Annual Dialysis Conference: Abstracts</p><p> 2005 International Society for Hemodialysis 71</p></li><li><p>at the proximal vein near the elbow joint. In addition to venous</p><p>stenosis, a focal arterial stenosis at the anastomosis site and two</p><p>accompanying accessory veins that might hamper maturation of</p><p>main cephalic vein was seen in each of two patients, respec-</p><p>tively. Simultaneous occlusion of left innominate vein as well as</p><p>occlusion of cephalic vein were noted in one patient. Initial</p><p>success rate of PTA was 95.5% (21/22). Overall success rate</p><p>including 11 additional PTAs performed during follow-up was</p><p>96.9% (32/33). No major complication occurred. Primary and</p><p>secondary patency rates were 72% and 95% at 3 months, and</p><p>50% and 77% at 6 months, respectively. Conclusion: PTA is an</p><p>effective and safe method in salvaging non-maturing Brescia-</p><p>Cimino fistulas.</p><p>Intima-media thickness of radial artery isassociated with early access failure in hemodialysis</p><p>patients</p><p>Kim Y.O., Choi Y.J.*, Kim J.I.**, Shin M.J., Kim B.S., Song H.C.,</p><p>Yoon S.A., Kim Y.S., Kim S.Y., Choi E.J., Chang Y.S., Bang B.K.</p><p>Dept. of Int. Med., Clinical Pathology*, Surgery**, The Catholic</p><p>University of Korea, Seoul, Korea.</p><p>Objective: We have reported that intimal hyperplasia, which</p><p>is the pathologic change of the radial artery, is associated</p><p>with early failure of arteriovenous fistula (AVF) in hemodialysis</p><p>(HD) patients (Am J Kidney Dis, 41:422428, 2003). Intima-</p><p>media thickness (IMT), which represents the whole thickness</p><p>of arterial wall, can be easily measured by ultrasonography,</p><p>unlike intima thickness. This study was performed to investigate</p><p>the impact of IMT of radial artery on early failure of AVF in HD</p><p>patients. Methods: Ninety HD patients undergoing radiocepha-</p><p>lic AVF operation were included in this study. The AVF was</p><p>constructed in an end veintoside artery fashion at the wrist by</p><p>one vascular surgeon. During the operation, 10-mm long partial</p><p>arterial walls were removed with elliptical form for microscopic</p><p>analysis. Specimens were stained with trichrome and examined</p><p>by a pathologist blinded to the clinical data. AVF patency was</p><p>prospectively followed up for 1 year after the operation.</p><p>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</p><p>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</p><p>method with log rank test. The AVF patency rate within 1 year</p><p>after the operation was higher in patients with IMT 500 mm(n 26) than in patients with IMT&lt; 500 mm (n 64)(p&lt; 0.001). The patients with IMT 500 mm were older andhad higher incidence of diabetes mellitus, compared to the</p><p>patients with IMT&lt; 500 mm. There was no difference in sex,smoking, hypertension, total cholesterol and albumin levels</p><p>between the two groups. Conclusion: Our data suggest that</p><p>increased intima-media thickness of radial artery is associated</p><p>with early failure of radiocephalic arteriovenous fistula in hemo-</p><p>dialysis patients.</p><p>Central venous stenosis in chronic hemodialysispatients: The effect of percutaneous angioplasty and</p><p>stenting</p><p>Yoon J.M., Park J.A., Jung H.A., Kim Y.O., Kim Y.S., Yoon S.A.,</p><p>Kim S.Y., Chang Y.S., Bang B.K. Department of Internal Medicine,</p><p>College of Medicine, The Catholic University of Korea, Seoul,</p><p>Korea.</p><p>Background: Central venous stenosis in chronic hemodialysis</p><p>patients occurs in about 17% of all venous stenosis and it is</p><p>associated with central vein catheterization. We evaluated the</p><p>effect of percutaneous angioplasty and stenting in the treatment</p><p>of central venous stenosis in hemodialysis patients. Methods: We</p><p>retrospectively investigated the medical records of a total of 31</p><p>dialysis patients who had central venous stenosis. We reviewed</p><p>the causes of central venous stenosis, clinical manifestations, veno-</p><p>graphic findings, and patency rate of radiological intervention.</p><p>Results: Of the total 31 patients, 28 patients had past history of</p><p>central vein catheterization ipsilateral to vascular access. Mean</p><p>duration of the catheterization was 32 14 days. Venographyshowed complete obstruction of central vein (n 14) and stenosis(n 17). The site of venous lesion was right subclavian vein(n 11), innominate vein (n 9), left subclavian vein (n 7),and superior vena cava (n 14). A total of 30 procedures ofangioplasty with or without stenting were performed in 26 of 31</p><p>patients. Initial success rate was 96.1% and there was no severe</p><p>complication such as rupture or bleeding. The primary patency rate</p><p>at 6, 12, 24, and 48 months after the procedure was 87.3%, 75.6%,</p><p>67.9%, and 65.4%, respectively. The cumulative patency rate at</p><p>the same time point was 96.0%, 90.6%, 74.0%, and 72.8%,</p><p>respectively. Conclusion: Our data suggest that angioplasty with</p><p>or without stenting is safe and effective in the treatment of central</p><p>venous stenosis in hemodialysis patients.</p><p>Effective interventions with chlorhexidine gluconate(CHG) to decrease hemodialysis (HD) tunneled</p><p>catheter-related infections</p><p>Redman N.1, Schweon S.1, Tokars J.2, Jahre J.1. St. Lukes Hospital,</p><p>Bethlehem, PA1; CDC, Atlanta, GA.2</p><p>Purpose: Identify practices to reduce HD catheter access related</p><p>bacteremias (ARB). Methods: Data was collected per the CDC</p><p>Dialysis Surveillance Network protocol. ARB was defined as a</p><p>patient with a positive blood culture with no apparent source</p><p>other than the vascular access catheter. ARBs were calculated in</p><p>events per 100 patient months with 3 cohorts. Cohort 1 was</p><p>observed for 12 months, Cohort 2 for the subsequent 10 months,</p><p>and Cohort 3 for the final 10 months. Cohort 1 had weekly</p><p>25th Annual Dialysis Conference: Abstracts Hemodialysis International, Vol. 9, No. 1, 2005</p><p>72 2005 International Society for Hemodialysis</p></li><li><p>transparent dressing changes, cleansing of the skin and 5 min-</p><p>ute soaking of the connection lines with 10% povidone-iodine</p><p>(PI) solution, and HCW use of clean gloves and face shield</p><p>without a mask. Cohort 2 changes consisted of thrice weekly</p><p>gauze dressing changes, skin cleansing with ChloraPrep, a 2%</p><p>CHG/70% isopropyl alcohol applicator, masks on the patients,</p><p>adding a face mask to the shield, and application of 10% PI</p><p>ointment to the exit site. Cohort 3 changes included weekly</p><p>application of BioPatch (BioP), an antimicrobial dressing with</p><p>CHG, sterile glove use, and replacing the PI line soaks with 4%</p><p>CHG. Results: The catheter-associated ARB rate per 100 patient</p><p>months was 7.9 (17ARB/216 patient months) in Cohort 1, 8.6</p><p>(13/151) in Cohort 2, and 4.7 (5/107) in Cohort 3 (p 0.31compared with Cohorts 1 and 2 combined). During the last 2</p><p>months, in Cohort 3, 9 catheter lumen cracks occurred, with one</p><p>of the patients having a bacteremia. Conclusions: Addition of</p><p>CHG line soaks and BioP reduced tunneled catheter infections,</p><p>although this is not statistically significant. The increased</p><p>number of catheter lumen cracks raises concern with the use</p><p>of CHG line soaks. Further investigation with use of CHG line</p><p>soaks and the BioP for decreasing ARB is needed.</p><p>Obesity promotes forearm primary arteriovenousfistula creation in chronic haemodialyzed</p><p>patients</p><p>Weyde W., Porazko T., Kusztal M., Banasik M., Bartosik H.,</p><p>Trafidlo E., Letachowicz W., Krajewska M., Klinger M. Dept. of</p><p>Nephrology and Transplantation Medicine, Wroclaw Medical</p><p>University, Wroclaw, Poland.</p><p>The increase in number of obese people seen in the general</p><p>population, is also what is seen in the hemodialyzed population.</p><p>It is generally believed that the location of deep forearm vessels</p><p>in the subcutaneous fat tissue makes primary arteriovenous</p><p>fistula (AVF) a disadvantage because of difficulties in vessel</p><p>puncturing. For obese patients, it is suggested that a fistula</p><p>with PTFE is created or a central catheter inserted, but these</p><p>solutions increase already high morbidity rate and significantly</p><p>increase mortality rate. Methods: The deep location of veins</p><p>situated on the anterior part of the forearm involved 57 patients</p><p>(45 female and 12 male) aged 1387 years (mean 67 15.2years). Patients body mass index (BMI) ranged from 29.1 to</p><p>53.73 (mean 34.6 7.8). The causes of the renal failure werediabetic nephropathy in 30 patients, chronic glomerulonephritis</p><p>in 4, hypertensive nephrosclerosis in 5, lupus nephritis in 2,</p><p>interstitial nephritis in 4, primary amyloidosis in 1, polycystic</p><p>kidney disease in 3, and unknown in 3 patients.Two-step sur-</p><p>gical procedure was performed in all patients. In the first stage,</p><p>the standard distal radiocephalic AVF in the wrist region was</p><p>created. In case of its failure, the next attempt was performed</p><p>above the point of the first intervention. In the second stage,</p><p>superficialization of the venous part of AVF was performed in</p><p>the mode described by us (Kidney 2002;.1:1170). Results: The</p><p>first stage of the procedure was successful in 46 patients. In 6</p><p>cases it was necessary to perform a second attempt, and 2 cases</p><p>required three operations. The second stage was undertaken in</p><p>all of these patients (n 54), and complete success wasachieved in 51. I...</p></li></ul>