Clinical Utility Of Cavea2t2 Score For Assessing The Survival Of Brachiocephalic Arteriovenous Fistula.

BACKGROUND: There are not many error proof clinical scores to assess the native dialysis access. CAVeA2T2 score is a recent tool in use. Objective of the study is to assess the clinical utility of CAVeA2T2 scoring system in predicting the survival rate of brachiocephalic arteriovenous fistula (BC-AVF). METHODS: All consecutive patients fulfilling the inclusion criteria for BC-AVF from January 2016 to January 2018 were included. According to their CAVeA2T2 score they were divided into two groups (Group A: < 2 and Group B: ≥2). Cumulative primary and secondary patency survival of BC-AVF for both groups were measured. RESULTS: A total of 112 BC-AVFs were analysed. Mean age was 42±SD 14 years (M: F =5:1). Mean CAVeA2T2 score was 1.45±1.8. In terms of primary patency, there was no statistically significant difference between two groups (p=0.074, p = 0.229 and p=0.357 at 6 weeks, 6 months and 12 months respectively). However, the difference was significant in terms of secondary patency (p=0.002, p=0.036 and p=0.032 at 6 weeks, 6 months and 12 months respectively). On comparing the cumulative survival between two groups; a significantly low primary patency rate survival (Log Rank x2 = 12.9, p-value = 0.001) and secondary patency rate survival (Log Rank x2 = 7.6, p-value = 0.001) of BC-AVF was found in Group B. CONCLUSION: We found CAVeA2T2 score an easily applicable and useful tool to assess the patency and survival of BC-AVF. Patients have a poor patency and significantly low survival rate when their CAVeA2T2 score was ≥2.

Type of vascular access and survival among very elderly hemodialysis patients.

The use of central venous catheters (CVC) for hemodialysis (HD) is associated with higher mortality compared to arteriovenous access (AV). However, studies analyzing the influence of the type of vascular access on the survival of very elderly patients (≥75 years) initiating HD are few and involve only a limited number of patients. We studied a cohort of 5,466 incident patients who started HD; of these, 1,841 were aged ≥75. Types of vascular access for HD were classified as either CVC, which included both tunneled and non-tunneled catheters, or AV, which included AV fistula and grafts. The outcome of the study was all-cause mortality during the follow-up period. In the whole cohort, AV use was associated with a survival advantage over CVC use (88 and 63% at 2 and 5 years, respectively, in patients with an AV as compared to 75 and 48% in patients with a CVC) (p < 0.0001). Among patients ≥75, CVC use was associated with a higher number of deaths compared to AV use. Patients ≥75 with an AV showed a greater survival as compared to patients ≥75 with a CVC (80 and 53% at 2 and 5 years, respectively, vs. 68 and 43%; p < 0.0001). Multivariate analysis revealed that CVC use and the presence of arrhythmia were independent risk factors of death in patients ≥75, whereas obesity was associated with greater survival. In conclusion, the type of vascular access has a significant influence on the survival of very elderly patients (≥75) initiating HD. CVC use was associated with poorer survival compared to AV access.

[Evolution of ultrasonic indices of the heart and arteriovenous fistulas in patients on chronic haemodialysis].

The authors assessed the ultrasonic evolution of haemodynamics of arteriovenous fistulas (AVFs), cardiohaemodynamics, and the dimensions of the heart chambers in a total of thirty-five patients presenting with terminal chronic renal insufficiency (TCRI) and being on chronic haemodialysis (CHD). A further thirteen patients without TCRI composed the control group. The TCRI patients were subdivided into two groups: Group One (n=20) with a distal variant of the Cimino-type AVF, 21 vascular accesses, and Group Two (n=15) with a proximal variant of AFV, 16 accesses using a synthetic vascular prosthesis (SVP). The terms of follow up of the TCRI patients were as follows: day 12, months 1, 3, 6 and 12 after creating the AVF. 12 days after creating the AVF there were no differences in the parameters of cardiohaemodynamics and the dimensions of the cardiac chambers between Group I and II. As compared with the control, the both groups of the patients with TCRI at these terms demonstrated increased sizes of the left ventricle (LV). The dynamic follow up during the subsequent periods showed that Group One and Group Two patients had no statistically significant differences in the parameters studied, however, patients of the both study groups were found to have a trend toward increased dimensions of the right chambers of the heart, not exceeding the limits of the norm of these indices. The volumetric velocity of the blood flow (BFVV) through the Cimino-type AVF during 12 months had a tendency towards a graduate growth up to 800 ml/min, whereas the proximal fistulas were characterized by stable indices of the BFVV at a level of 900 ml/min. The revealed alterations in the right chambers of the heart after creating the AVF required no surgical correction of the volumetric blood flow through the AVF during the follow up period up to 12 months.

Copeptin and its relation to arteriovenous fistula (AVF) type and NYHA class in hemodialysis patients.

Copeptin is cosynthesized with vasopressin, also known as anti-diuretic hormone, with similar plasma levels. In the past 2 years, copeptin has been studied as a diagnostic and prognostic marker in infections and other diseases. In patients with decompensated heart failure, copeptin was an accurate prognostic marker for mortality. Cardiovascular disease is a major contributor to the mortality and morbidity in chronic kidney disease. Creation of an arteriovenous fistula (AVF) might contribute to the development or worsening of congestive heart failure (CHF). The aim of the study was to assess associations between copeptin, New York Heart Association (NYHA) class, and the location of the AVF in hemodialysis (HD) patients. The cross-sectional study was performed on a cohort of 93 clinically stable HD patients. Patients with proximal AVF tend to be older, with decreased renal residual function and increased NYHA functional class. These patients were also highly anemic, had more acidosis, and had increased high-sensitivity C-reactive protein along with increased copeptin and NT-proBNP levels. These changes were also associated with significant changes in all intra-cardiac dimensions, including right ventricle, both atria, and intraventricular septum and increase in end-systolic and end-diastolic left ventricular intra-cardiac dimensions. In multiple logistic regression analysis, the only associate of copeptin was NYHA functional class. Copeptin level in HD patients depends on cardiac function and it might be involved in the pathophysiology of cardiovascular disease in these patients. Proximal AVF creation might contribute to the development or worsening of CHF in HD patients.

[Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]. / Accessi vascolari per emodialisi cronica: situazione attuale e nuovi orientamenti in Piemonte.

Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.

Geriatric hemodialysis patients: a comparative study of vascular access.

OBJECTIVES: To compare vascular access in hemodialysis patients > or = 65 years of age with those < 65 years on the following: 1) comorbid disease status, 2) types of vascular access used, and 3) outcome. SAMPLE/SETTING: Hemodialysis patients in a four-state region (Iowa, Kansas, Nebraska, and Missouri) from both free-standing and hospital-affiliated providers were sampled (n = 267). A stratified sampling strategy was used in order to obtain approximately equal-sized age groups (< 65 years and > or = 65 years). DESIGN: A descriptive, longitudinal study with a 1-year follow-up period. METHODS: Following the placement of a permanent vascular access, information was collected by the dialysis nursing staff about the configuration of the access, needle gauge used for cannulation, dialysis prescriptions, diabetic status, and other comorbid disease conditions. Odds ratios (OR) for vascular access thrombosis (VAT) risk were calculated between the two age groups. RESULTS: Comparisons between the two age groups suggest a higher frequency of polytetrafluorethylene (PTFE) grafts in the > or = 65-year-old age group. Peripheral vascular disease (PVD) prevalence was also higher in elders. Oral anticoagulants reduced the risk of VAT in those < 65-year-old group. Patients age > or = 65 years with a PTFE graft experienced a higher risk of VAT (OR 3.38, 95% confidence interval 1.43, 8.11) than those in the same age group with an arteriovenous fistula (AVF). CONCLUSIONS: PTFE grafts are used more frequently among geriatric hemodialysis patients, possibly due to the increased prevalence of peripheral vascular disease (PVD). While use of oral anticoagulants is effective in reducing the risk of VAT among those < 65 years, it did not significantly reduce VAT risk in geriatric hemodialysis patients. This observation may be due to the higher frequencies of PTFE grafts in elderly patients.

Hipertensión venosa asociada a fístulas arteriovenosas para hemodiálisis / Venous hypertension associated to arteriovenous fistulae for hemodialysis

Se han descrito varias complicaciones relacionadas con las fístulas arteriovenosas para hemodiálisis. La hipertensión venosa destaca, más que por su frecuencia, por el grado de incapacidad que produce. El objetivo de este estudio es hacer un análisis descriptivo de los casos observados con esta complicación. Entre abril de 1990 y mayo de 1995 se han construido 1577 accesos vasculares para hemodiálisis en 1340 pacientes, seleccionando para este análisis aquellos pacientes que presentaron evidencia clínica de hipertensión venosa de la extremidad asociada a fístula arteriovenosa con vena autógena. El grupo está constituido por 10 hombres y 5 mujeres, 8 de los cuales eran diabéticos. La edad fluctuó entre 25 y 78 años (promedio de 50 años). 7 pacientes tenían el antecedente de uso prolongado de catéter de hemodiálisis de vena subclavia en 7 casos, a estenosis de vena proximal en 4, oclusión de vena proximal en 2, tromboflebitis superficial en 1 e insuficiencia valvular en 1. Su manejo consistió en el cierre de la fístula asociado a la construcción de un nuevo acceso contralateral en 9 casos, en una reanastomosis proximal en 4 casos, en ligadura de vena tributaria distal en 1 caso y en la confección de un puente venoso en 1 caso, observándose remisión franca de los síntomas en el postoperatorio precoz

Maintenance of permanent hemodialysis vascular access patency.

The morbidity and mortality of maintenance hemodialysis patients are in large part determined by the ability of the nephrologist, dialysis staff, and vascular surgeon to establish and maintain adequate vascular access. Primary arteriovenous fistulae are the preferred form of vascular access because they are the more likely to provide long-term complication-free access. In 1994, however, the majority of patients entering hemodialysis programs have vascular anatomy unsuitable for primary arteriovenous fistula creation. Synthetic fistulae are currently the more common form of vascular access. Unfortunately, this form of vascular access is more prone to thrombosis and infection. Thrombosis is the most common cause of vascular access loss. Venous stenoses account for the majority of thromboses but can be prospectively identified by performing routine measurements of venous dialysis pressure or urea recirculation. Prospective identification of venous stenoses followed by either angioplasty or surgical revision will improve fistula patency and enhance the quality of life of the hemodialysis population.