ABSTRACT
The arteriovenous fistula is currently the best permanent access for the hemodialysis patient. Unfortunately, stenosis impairs maturation, long-term survival, and function of the arteriovenous fistula. Angioplasty currently is the best procedure for the treatment of immature and dysfunctional arteriovenous fistulas. In this review, the authors discuss the optimum time to evaluate arteriovenous fistulas for maturity, methods of evaluation for maturity, and the role of angioplasty in salvaging immature arteriovenous fistulas. The review also discusses the effect of stenosis on dysfunction in mature arteriovenous fistulas and the role of angioplasty to treat this complication. Finally, the impact of cutting balloons and drug-eluting balloons in the treatment of resistant and recurrent stenosis, respectively, is also discussed.
Subject(s)
Arteriovenous Shunt, Surgical/adverse effects , Graft Occlusion, Vascular/therapy , Renal Dialysis , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/instrumentation , Cardiovascular Agents/administration & dosage , Coated Materials, Biocompatible , Equipment Design , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Humans , Risk Factors , Salvage Therapy , Time Factors , Treatment Outcome , Vascular Access Devices , Vascular PatencyABSTRACT
Hyponatremia is the most frequently occurring electrolyte abnormality and can lead to life-threatening complications. This disorder may be present on admission to the intensive care setting or develop during hospitalization as a result of treatment or multiple comorbidities. Patients with acute hyponatremia or symptomatic chronic hyponatremia will likely require treatment in the intensive care unit (ICU). Immediate treatment with hypertonic saline is needed to reduce the risk of permanent neurologic injury. Chronic hyponatremia should be corrected at a rate sufficient to reduce symptoms but not at an excessive rate that would create a risk of osmotic injury. Determination of the etiology of chronic hyponatremia requires analysis of serum osmolality, volume status, and urine osmolality and sodium level. Correct diagnosis points to the appropriate treatment and helps identify risk factors for accelerated correction of the serum sodium level. Management in the ICU facilitates frequent laboratory draws and allows close monitoring of the patient's mentation as well as quantification of urine output. Overly aggressive correction of serum sodium levels can result in neurological injury caused by osmotic demyelination. Therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly.
Subject(s)
Hyponatremia/therapy , Fluid Therapy/methods , Humans , Hyponatremia/diagnosis , Hyponatremia/etiology , Intensive Care Units , Risk Factors , Saline Solution, Hypertonic/therapeutic use , Sodium/bloodABSTRACT
During hemodialysis, the development of hypotension or symptoms suggestive of ischemia is used as a surrogate marker for the establishment of dry weight. These symptoms manifest commonly as muscle cramps, chest pain or abdominal pain. Hemodialysis patients are also prone to vascular calcification which may be medial or intimal. We report the case of a 68-year-old male who developed testicular pain while attempting to establish dry weight. Computerized tomography scan of his abdomen showed extensive vascular calcification. The end result in this case was bilateral orchiectomy. Histopathology revealed hyperplastic arteriolosclerosis with intimal calcification contributing to ischemia.
