Factors influencing first vascular access placement in patients starting hemodialysis.

BACKGROUND: The aim of the study was to assess whether age, gender and the primary renal disease are associated with differences in the type of first vascular access placement. METHODS: We reviewed the records of 145 patients on hemodialysis (HD) 44 females and 101 males with a mean age of 64±14.5 years, on HD for 46.9±41.2 months (range 1-252). RESULTS: The primary renal diseases were diabetes (23.4%), hypertension (17.2%), glomerulonephritis (25.7%), cardiac failure (6.9%) and others (26.8%). Double lumen catheter and arteriovenous fistula was the first vascular access in 109 (75%) and 35 patients (24%) patients, respectively. Graft was the first vascular access in 1 patient (0.5%). Arteriovenous fistula was the first choice for 29.7% of the male patients and 9% of the female. Double lumen catheter was the first choice for 70.3% of the male (subclavian 50.5%, femoral 4.95%, and jugular 14.85%) and 86.4% of the female (subclavian 75%, femoral 2.3%, and jugular 9.1%) (P=0.04). Double lumen catheter was the first choice for 79.7% of the patients older than 65 years and 70.4% for the patients younger than 65 years (P=0.19). Double lumen catheter was the first choice for all the patients with cardiac failure as the primary cause of renal disease. CONCLUSION: Double lumen catheter was the first vascular access for the majority of our patients, probably due to late Nephrologist's referral. Cardiac failure being the primary cause of renal disease and female gender influence also this choice, but not the age of the patients.

Multiple histopathological skin alterations in a hemodialysis patient with severe pruritus.

Pruritus is an alarming symptom in patients with end-stage renal disease (ESRD) accompanied by sleep disturbances and physical and mental disorders. Although its prevalence is very high among hemodialysis patients (90%), its etiology and its successful treatment have been unconfirmed (Melo N, Elias R, Castro M, Romao G, Abensur H. Pruritus in hemodialysis patients: The problem still remains. Hemodial Int. 2009;13:38-42.). Common pruritus etiologies, such as high parathyroid hormone levels, dialysis inadequacy, and iron deficiency are matters of conflict. The case of a hemodialysis patient with consistent itching and a variety of cutaneous eruptions, which after performing skin biopsy were explored and cured, is described. This article addresses the possibility of other causes of pruritus in ESRD and encourages watchful waiting with simple medical interventions, which would relieve patients' symptoms.

Hepatitis C virus and kidney: a strong association with different clinical aspects.

The most frequent kidney disease associated with chronic hepatitis C virus (HCV) infection is membranoproliferative glomerulonephritis in patients with type II mixed cryoglobulinaemia. The principal clinical manifestations of glomerular disease in HCV-infected patients are the presence of proteinuria and haematuria with or without impaired kidney function. Pharmaceutical regimens vary because the main pathogenesis of renal dysfunction often mediated by cryoglobulins has not been fully elucidated. HCV infection remains common in patients on renal replacement therapy and has an adverse impact on their survival. Safe and effective pharmaceutical regimens have not been yet established and nosocomial spread within dialysis units continues to occur. Monotherapy with interferon for HCV infection is probably more effective in dialysis than in non-uraemic patients, while experience with ribavirin is limited because of its adverse haemolytic effect. Based on shortage of cadaver kidneys and the fact that HCV renal transplant recipients have better survival than stay on maintenance haemodialysis or at list for transplantation, health organization proposed the use of cadaver kidneys from anti-HCV-positive donors, bringing up concerns and conflicting views. This present review describes the main renal manifestations of HCV infection, the epidemiological and clinical characteristics of chronic kidney disease population and comments on the limitations and shortcomings of current therapeutical regiments.

Pregnancy in dialysis-dependent women--the importance of frequent dialysis and collaborative care: a case report.

An increasing number of successful pregnancies have been reported among women on chronic hemodialysis. Even with reduced fertility and high risk of complications, women of childbearing age receiving hemodialysis, should not be discouraged from pregnancy. Practitioners should be familiar with the effects of renal disease on pregnancy, consult patients about the possibility of pregnancy and its hazards and provide, if necessary, prompt surveillance and treatment. This paper describes the case of an unplanned but successful pregnancy of a woman receiving hemodialysis, emphasizing pregnancy management, mother's response evaluation, and infant growth.

Two cases of silent superior vena cava syndrome associated with vascular access and end-stage renal disease.

Due to the unavoidable use of indwelling devices and the magnitude of the operative problems encountered, superior vena cava syndrome (SVCS) has become a serious threat for patients with a history of multiple catheter placements. True diagnosis sometimes is not available due to paucity of symptoms or due to the inadequate considerations of the disease. Particularly in patients with chronic kidney disease, the evidence of central venous occlusion dictates the avoidance of placing peripheral dialysis access in this extremity. In this article, we report two patients (case 1- a patient with end stage renal disease and case 2 - a patient with chronic kidney disease) with silent SVCS related to stenosis resulting from indwelling pacemaker leads. Furthermore, the first patient had an extrinsic factor of compression, a brachial artery pseudoaneurysm - which although it was not causative - it may certainly have contributed to the development of SVCS. The brachial artery pseudoaneurysm restricted even more the flow to cephalic vein and consequently to superior vena cava. Though pacemaker leads have been well identified previously in the literature as a cause of the SVCS, the brachial artery pseudoaneurysm causing extrinsic compression constitutes a novel factor. Through the publication of this paper the awareness of SVCS in these patients shall be definitely enhanced. Moreover, physicians, nurses and patients shall be educated regarding the requirement for peripheral vein presentation in chronic kidney disease.

Cardiovascular risk factors in non-diabetic hemodialysis patients: a comparative study.

Patients on hemodialysis (HD) are prone to atherosclerotic cardiovascular complications. In an attempt to determine the significance of several atherosclerotic and thrombogenic parameters as risk factors for atherothrombotic cardiovascular disease (CVD) in these patients, we compared two groups of non-diabetic HD patients matched for age and sex, selected according to the absence (group 1, n = 30) or presence (group 2, n = 30) of symptomatic atherothrombotic vascular disease affecting the coronary, cerebral, or peripheral arteries. Duration of HD, primary renal disease (PRD), presence of hypertension, EPO treatment, and smoking habits were recorded. Serum total cholesterol (TC), triglycerides (TG), HDL-C, LDL-C, TC/HDL-C ratio, lipoprotein(a) (Lp(a)), fibrinogen (FG), plasminogen (PLG), fibronectin (FN), and hematocrit (HCT) were measured pre-HD in a midweek session. The same blood parameters were also assessed in twenty matched clinically healthy subjects (controls). None of the blood parameters differed between groups 1 and 2, except for serum Lp(a) and FN, which were higher in group 2 (p = 0.005 and p = 0.041, respectively). Both groups were not different regarding PRD, duration of HD, and EPO treatment, but the presence of hypertension and smoking habits were more common in group 2 (p = 0.008 and p = 0.045, respectively). Moreover, multiple stepwise logistic regression analysis with Lp(a), FN, hypertension, and smoking showed that the presence of hypertension (p = 0.016) and the Lp(a) (p = 0.027) and FN (p = 0.024) levels, but not smoking, were independent predictors for the presence of atherothrombotic CVD. Our results suggest that hypertension, abnormal lipid particles, and thrombogenic proteins may contribute to the high prevalence of CVD in HD patients.

Deforming arthropathy in SLE: review in the literature apropos of one case.

Among the clinical manifestations of systemic lupus erythematosus is an arthropathy, which is usually non-erosive. In many cases, the joint involvement is mild. A subset of patients has deforming, non-erosive Jaccoud's arthropathy, and a minority have an arthropathy with clinical findings similar to rheumatoid arthritis that has been called "rhupus". We report a case of a 48-year-old female rhupus patient. The lack of clinical criteria for this rheumatic condition has created confusion in the characterization of this disorder. Thus, more effort is needed to establish a potential and clear definition for rhupus.

The diagnostic importance of photosensitivity dermatoses in chronic alcoholism: report of two cases.

Many of the vitamin deficiency diseases have been almost completely eliminated in developed countries. Niacin deficiency is considered one of them. However, cases of pellagra are recently reported in West Europe, USA, Australia, and Japan in connection with chronic alcoholism, gastrointestinal malabsorption, and some medications. We report two cases of pellagra, manifesting as photosensitivity dermatoses with mental deterioration in chronic alcoholic abusers in the Mediterranean basin, the island of Crete in Greece. The report highlights the fact that all physicians should be alerted to photosensitivity dermatoses in alcoholics; early treatment with multiple vitamin therapy, including nicotinic acid should be initiated in these patients.

Deforming arthropathy in systemic lupus erythematosus.

Systemic lupus erythematosus is an autoimmune and inflammatory disease characterized by a variety of symptoms, including arthropathy. The clinical presentation of joint involvement varies, ranging from arthralgia without erosions or deformity to an erosive arthropathy and severe functional disability. This paper reviews the main forms of deforming arthropathy observed in lupus patients. It includes a) non-erosive arthropathy (it is the most frequent form and characterized as Jaccoud's), b) erosive symmetrical polyarthritis with deformities similar to rheumatoid arthritis, named as rhupus, and c) mild deforming arthropathy. Even though enough such cases of patients have been reported in the international bibliography, no definite criteria for their diagnosis have been published yet. The use of contemporary radiological and immunological methods will facilitate their prevention and treatment.