Buttonhole Cannulation of Arteriovenous Fistulas in the United States.

The cannulation technique of a hemodialysis vascular access has remained controversial with differing viewpoints. The quality of dialysis, overall patient safety, and individual dialysis experience often dictate the type of cannulation technique used in clinical practice. The three commonly used techniques to access a hemodialysis vascular access are the rope ladder, area, and buttonhole. Although the buttonhole technique has been around since the mid-1970s, the dialysis community remains divided on its suitability for routine use to provide maintenance hemodialysis therapy. The proponents of this technique value the ease of cannulation with less pain and discomfort whereas the opponents highlight the increased risk of infection. The actual clinical evidence from the United States is limited and remains inconclusive. The current review provides an overview of the available experience from the United States, highlighting the correct technique of creating a buttonhole, summarizing the current evidence, and recommending a need for larger randomized controlled studies in both in-center and home hemodialysis populations.

Graftula: a composite access consisting of a graft used to repair a dysfunctional hemodialysis fistula.

Nonmaturing or dysfunctional hemodialysis fistulas are often repaired with interposition grafts placed either within the fistula (fistula-to-fistula configuration), or connected to another vein (fistula-to-vein configuration). The goal of this study was to compare the survival and usefulness of the composite accesses thus created, which we call "graftulas," with upperarm grafts. This was a retrospective study wherein we determined the survival and thrombosis rates of graftulas (n=24) and upper arm grafts (n=31) placed 1/1/07 through 12/31/09 and followed through 11/30/10. Graftulas resembled grafts as most (96%) were successfully cannulated in 65 ± 43 days. Survival of graftulas was also similar to grafts (58%, 47%, and 32% vs. 56%, 47%, and 39% at 1, 2, and 3 years respectively, p=0.60). However, graftulas had a lower thrombosis rate than grafts (0.5 vs. 1.2 per patient year, p=0.04), and in the fistula-to-fistula configuration, a 2-year thrombosis-free survival of 78%. Total survival of the access site (fistula+graftula) was 92%, 73%, and 42% at 1, 3, and 5 years, respectively. Graftulas possess certain beneficial properties of fistulas and grafts that allows for continued use of the original access site.

Dialysis vascular access management by interventional nephrology programs at University Medical Centers in the United States.

The development of interventional nephrology has undoubtedly led to an improvement in patient care at many facilities across the United States. However, these services have traditionally been offered by interventional nephrologists in the private practice arena. While interventional nephrology was born in the private practice setting, several academic medical centers across the United States have now developed interventional nephrology programs. University Medical Centers (UMCs) that offer interventional nephrology face challenges, such as smaller dialysis populations, limited financial resources, and real or perceived political "turf" issues." Despite these hurdles, several UMCs have successfully established interventional nephrology as an intricate part of a larger nephrology program. This has largely been accomplished by consolidating available resources and collaborating with other specialties irrespective of the size of the dialysis population. The collaboration with other specialties also offers an opportunity to perform advanced procedures, such as application of excimer laser and endovascular ultrasound. As more UMCs establish interventional nephrology programs, opportunities for developing standardized training centers will improve, resulting in better quality and availability of nephrology-related procedures, and providing an impetus for research activities.

Successful models of interventional nephrology at academic medical centers.

The foundation of endovascular procedures by nephrologists was laid in the private practice arena. Because of political issues such as training, credentialing, space and equipment expenses, and co-management concerns surrounding the performance of dialysis-access procedures, the majority of these programs provided care in an outpatient vascular access center. On the basis of the improvement of patient care demonstrated by these centers, several nephrology programs at academic medical centers have also embraced this approach. In addition to providing interventional care on an outpatient basis, academic medical centers have taken a step further to expand collaboration with other specialties with similar expertise (such as with interventional radiologists and cardiologists) to enhance patient care and research. The enthusiastic initiative, cooperative, and mutually collaborative efforts used by academic medical centers have resulted in the successful establishment of interventional nephrology programs. This article describes various models of interventional nephrology programs at academic medical centers across the United States.

Thigh grafts contribute significantly to patients' time on dialysis.

BACKGROUND AND OBJECTIVES: Thigh grafts are placed in hemodialysis patients who have exhausted all arm access sites. The goal of this study was to compare the survival, complication rates, and overall contribution of thigh grafts with arm grafts and fistulas in patients with at least one functional thigh graft during their dialysis history. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This longitudinal review of a prospectively acquired clinical database included 85 thigh graft recipients. The rates of survival, thrombosis, infection, and other complications were determined for a total of 268 fistulas, arm grafts, and thigh grafts placed in these patients. RESULTS: In this patient subset, thigh graft primary failure rate was lower than arm grafts and fistulas (3 versus 13 and 61%, respectively). Excluding primary failures, thigh grafts survived longer than both arm grafts and mature fistulas (53 versus 14 and 32%, at 3 years; 47 versus 3 and 11% at 5 years). Thigh grafts had a lower thrombosis rate than arm grafts (0.543 versus 1.457/patient-year) but similar rates of loss as a result of infection and surgical revision. In patients with previous arm accesses, thigh grafts contributed 51% of total dialysis time compared with 38 and 11% for arm grafts and fistulas. CONCLUSIONS: Thigh grafts provide long-term, thrombosis- and infection-free dialysis access for patients with exhausted arm access sites. The decision for thigh graft placement should, therefore, be made as soon as there is evidence for unavailability of arm access sites so that catheter use can be minimized.

Thigh grafts: a preferable alternative to catheters when upper extremity access sites are exhausted.

Hemodialysis patients with failed upper extremity (arm) access sites comprise 5-10% of the dialysis population. In these patients, arm vessels are either unsuitable for access placement due to trauma or peripheral vascular disease, or have been exhausted following dialysis usage. Synthetic grafts in the lower extremity (thigh) would benefit these patients, but surgeons are often reluctant to place them, due to concerns of infection and vascular complications. As a result, these patients receive tunneled central venous catheters as their permanent dialysis access. Recent studies have shown, however, that survival and complication rates of thigh grafts are similar to arm grafts and fistulas. Moreover, thigh grafts have lower infection and mortality rates than catheters and provide higher blood flows and dialysis adequacy. In this editorial we argue that thigh grafts are the better option in patients who have lost all arm access sites; they should be placed in preference to tunneled central venous catheters.

Timing of secondary arteriovenous fistula creation avoids tunneled catheter placement.

The concept of secondary arteriovenous fistula, though not novel, is seldom practiced for lack of initiative or hesitancy in deciding the appropriate timing to abandon the existing access. We report a case illustrating the benefits of implementing the strategy in an elderly diabetic dialysis patient, successfully avoiding a tunneled cuffed catheter placement.

Retrieval of a fractured piece of Tessio catheter with a snare using a transcutaneous transvenous approach.

Approximately 20% of end-stage renal disease patients requiring hemodialysis have central dialysis catheters as their vascular access. The major cause of central dialysis catheters removal or revision is infection or occlusion. Catheter occlusions may occur as a result of thrombosis or fibrin sheath formation. However, the presence of a fractured dialysis catheter tip requiring immediate extraction to prevent serious complications is rare. Herein we present the case of a central dialysis catheter referred to us for malfunction. An incidental finding was a piece of catheter that had broken off the venous port and was seen in the right atrium. The retrieval and subsequent placement of a new central dialysis catheter are outlined.

Pretransplant bilateral hand-assisted laparoscopic nephrectomy in adult patients with polycystic kidney disease.

Laparoscopic procedures continue to gain popularity over traditional open procedures for a number of abdominal and pelvic surgeries. With increasing experience, the application of this technique is rising because it provides an alternative, less invasive, approach to various surgical procedures. Herein, we report our experience with adult patients with polycystic kidney disease, requiring bilateral laparoscopic nephrectomy before renal transplantation.

Fluoroscopy-assisted placement of peritoneal dialysis catheters by nephrologists.

In the early 1950s and 1960s, peritoneal dialysis (PD) was used primarily to treat patients with acute renal failure. Continuous ambulatory peritoneal dialysis (CAPD) was introduced in 1976 and continues to gain popularity as an effective method of renal replacement therapy for patients with end-stage renal disease (ESRD). The PD catheter is inserted into the abdominal cavity either by a surgeon, interventional radiologist, or nephrologist. We have adopted a percutaneous approach with fluoroscopic guidance for PD catheter insertion that is easy, safe, and provides good patency and infection rate results. In this article we describe the technique and our results. From August 2000 to May 2003, 34 PD catheters out of 36 were successfully inserted using the percutaneous fluoroscopic technique in selected patients referred from the nephrology clinic. All the PD catheters were placed in our Interventional Nephrology Vascular Suite by nephrologists.

Pancreatic transplantation: evaluation and management.

More than 2 million people in the United States have type 1 diabetes mellitus. Pancreatic transplantation has emerged as the single most effective means of achieving normal glucose homeostasis in this patient population. Newer immunosuppressive agents and surgical techniques continue to evolve, resulting in improved long-term graft and patient survival. Herein, an understanding of the evaluation, technical aspects, and perioperative management of pancreas transplantation is outlined.

Successful orthotopic liver transplantation after trimethoprim-sulfamethoxazole associated fulminant liver failure.

Trimethoprim-sulfamethoxazole (TMP-SMZ) is one of the most commonly used antibiotics. Although many of its adverse effects are well recognized, TMP-SMZ related hepatotoxicity is considered rare and is usually characterized by cholestasis or mixed hepatocellular-holestatic reactions. In this study, we describe the case of a previously healthy young man with acute fulminant liver failure caused by TMP-SMZ. The patient presented with complaints of 'flu-like' symptoms with myalgia and fever after taking TMP-SMZ for 7 d for otitis externa. The patient subsequently developed fever, worsening jaundice, and a rash on his neck and chest. Liver enzymes peaked on day 3 with alanine aminotransferase (ALT) 11,549, aspartate aminotransferase (AST) 23,289, alkaline phosphatase 245, and total bilirubin 10.3 mg/dL, with a conjugated bilirubin of 8.3 mg/dL, prothrombin time (PT) 60.5 s, partial normalized ratio (PTT) 49 s, and international normalized ratio (INR) 7.5. Of note, acetaminophen level on admission was undetectable. Serology for hepatitis A, B, C, cytomegalovirus, HIV, toxoplasmosis, and blood cultures were all negative. The patient developed hepatic encephalopathy with hallucination on day 4. Laboratory tests revealed a serum ammonia level of 190 U, serum creatinine kinase (CK) 10,466 (42 on admission), serum creatinine 8.2 mg/dL (1.2 on admission), and significant metabolic acidosis. Renal ultrasound was unremarkable. The patient was started on hemodialysis for acute renal failure. Meanwhile, liver transplantation assessment was also initiated. On day 8 post-admission (15 d after taking TMP-SMZ), the patient received a successful orthotopic liver transplant.