ABSTRACT
Introduction: Although AVFs are preferred vascular access for hemodialysis, tunneled cuffed catheters(TCC) are increasingly being used as dialysis access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant. Aim and objective of this study was to study the characteristics of the population having benefited from tunneled cuffed catheters, to identify the different indications as well as the complications secondary to tunneled cuffed catheters in hemodialysis patients and to determine the catheter and patient survival rate and the factors associated with complications and survival. Method(s): This was an retrospective Observational study done after institutional ethics committee approval. All data was captured using standard proforma. The data was tabulated using MS excel and all results projected in form of bar graphs, pie charts, histograms or tables. Kaplan- meier analysis was used for survival. All patients included in the study consented for the procedure as well as collection of data. 527 TCC placement were done in 498 patients by nephrologists without fluoroscopy in a percutaneous fashion between jan 2021 to march 2022. Minimum follow up was 12 months. 37 patients lost to follow up. Result(s): 316 (68.5%) were males and mean age was 48.3+/-12.6 years. Staggered tip MAHURKAR MaxidTM Covidien, was used in every patient. Most common native kidney disease was cresentic GN 176(38.1%). Most common Site of TCC was right internal jugular 88.9%(441/496), followed by left internal jugular 10.48%(52/496), femoral TCC done in 0.6%. Mean blood flow achieved was 311+/- 32ml/min. Most common indication of TCC placement was starting of HD after 1/2 temporary access- 162(32.66%), followed by awaiting Maturation of autogenous AVF 66 (13.3%) and awaiting living-related transplantation 54(10.88%). Total catheter related infective episodes (CRBSI) were 229 (1.07 episodes/1000catheter days),Exit site infection was in 57 cases (0.26 /1000 catheter days), Tunnel infection was in 51(0.19/1000 catheter days), Infective endocarditis was seen in 3 cases. Catheter loss due to CRBSI was 23 (12.16%). Most common organism was Enterococci (29.7%), followed by s.aureus (24.32%). Most common immediate complication was tunnel bleeding (5.9% ), followed by improper tip position 4.68%. Late complications due to TCC thrombosis/ fibrin sheath was 74(15.07%). Recanalisation with urokinase was successful in 36.84%. Central venous stenosis was in 26 cases. successful recanalisation after central venoplasty was 16/19 (84.21%). Mean catheter survival was 201.9 +/- 114.9 days (3day to 12 months). Catheter survival at the end of 3 months was 75.76%, at 6 months 63.4%, at 12months 32.17%. Patient survival at 6 months was 86.7%, at 12 months- 77.5%. Most common cause of death was unrelated to TCC - cardiovascular cause (77.6%). Direct TCC related death was in 5 cases. Most common cause of catheter drop out was patient death (33.03%), followed by maturation of AVF (22.82%), catheter thrombosis/fibrin sheath (22.2%). [Formula presented] Conclusion(s): Though AVF is the best access, for late unplanned HD initiation in many CKD patients, TCC insertion becomes next best option. In access crisis patients, TCC may remain one feasible option for bridge to available live donor transplant. With strict asepsis protocol and technical aptitude TCC placement is safe with few side effects. No conflict of interestCopyright © 2023
ABSTRACT
BACKGROUND: Anti-glomerular basement membrane (GBM) antibody GN is a rare glomerular disease (0.5-1 per million population) with poor outcome in terms of renal survival. It is caused by auto-antibodies against the non-collagenous domain of the a3 chain of type IV collagen and usually present as a rapidly progressive crescentic GN. Anti-GBM GN may present either as an isolated kidney disease or as a pulmonary-renal syndrome (Goodpasture's syndrome) in 40%-60% of patients. Linear staining of the GBMs for immunoglobulin ( Predominantly IgG & rarely IgA ) in renal biopsy with anti-GBM antibodies in serum is pathognomonic of Anti-GBM disease. Initiating immunosuppression with steroids and cyclophosphamide plus plasmapheresis are the cornerstone of treatment whereas no treatment is recommended if dialysis dependent at presentation 100% crescents or >50% global glomerulosclerosis in an adequate biopsy sample or not having pulmonary hemorrhage. AIM OF THE STUDY: To study demographic and clinical profile treatment administered and outcome (in terms of renal survival) in the patients with biopsy-proven anti-GBM disease. METHOD(S): Single-center prospective observational study (January 2021 to June 2022 ) and study population being the admitted patients in Nephrology Department of I.P.G.M.E.R and SSKM hospital Kolkata. RESULT(S): Total 7 patients were diagnosed as having Anti- GBM disease in this time period with median age of 42 yrs ( range from 11 yrs to 68 yrs), and Female : Male ratio was 5:2. Rapidly Progressive Renal Failure with Oliguria (71.4% ) was the most common presentation and 85.7% required Hemodialysis on presentation. 57.1% patients had 100% crescent in renal biopsy. 1 out of 7 patients had overlap with MPO and did not required RRT at presentation. 1 out of 7 patients had associated pulmonary hemorrhage. 28.5% patients received PLEX while others were treated supportively as per protocol. 28.5% patients previously had COVID 19 infection which was diagnosed retrospectively by detecting COVID 19 IgG antibody in serum. 71.4% patients end up in HD requiring renal failure while 1 patient succumbed to death. CONCLUSION(S): Most of the patients aged between 20 yrs to 60 yrs and were female (both 71.4%). Most of the patients (71.4%) received supportive treatment as per protocol. Only 1 patient (with MPO overlap) is dialysis free with discharge creatinine of 3.3 and receiving EUVAS protocol. Most of the patients who presented late with HD requiring renal failure end up in ESRD.