Pregnancy and hemodialysis access: A case for patient satisfaction in favor of a tunneled dialysis catheter.

While an arteriovenous fistula is the best available access, many patients continue to rely on a tunneled hemodialysis catheter for dialysis therapy. Despite the highest risk of catheter-related bacteremia and associated morbidity and mortality, patients often prefer tunneled hemodialysis catheter to avoid pain associated with cannulation of an arteriovenous access. We report three tunneled hemodialysis catheter-dependent end-stage renal disease patients (age: 38, 35, 33 years), who became pregnant. Pregnancy was discovered at 10, 12 and 10 weeks of gestation. All three patients were switched to daily hemodialysis (six sessions/week) as soon as the pregnancy was discovered. The three patients had refused the placement of an arteriovenous access and expressed their strong preference for tunneled hemodialysis catheter. All had been educated about the risks and benefits of catheter, grafts, and fistulas. Patient preference was acknowledged and dialysis therapy was continued with tunneled hemodialysis catheter. Pregnancy was uneventful in two patients with the delivery of a healthy baby. The third patient had a miscarriage. Patient preference for tunneled hemodialysis catheter and satisfaction is important and can result in a successful outcome in pregnant patients. Nonetheless, in keeping with the National Kidney Foundation guidelines as well as the Fistula First, an arteriovenous fistula should be offered to hemodialysis patients. At the same time, patient's preference and wish should be respected and followed.

Ischemic monomelic neuropathy: a long-term follow-up of two cases.

INTRODUCTION: Ischemic monomelic neuropathy (IMN) is the most dreaded complication of an arteriovenous access creation. While uncommon, it can lead to pain, paresthesia or/and hand weakness. Creation of an arteriovenous connection causing a sudden diversion of blood away from the nerves can lead to ischemic injury to the neural tissue and cause IMN. Immediate surgical ligation has been traditionally recommended to limit ongoing neural tissue injury. CASE DESCRIPTION: We present two diabetic patients who developed IMN after the creation of a left upper extremity brachial-cephalic fistula and refused to undergo surgical ligation. The clinical examination revealed paresthesia localized to the volar aspect of the left forearm with mild weakness of the thumb, index and middle finger. Rehabilitation therapy was initiated in both and revealed a significant improvement in weakness but paresthesia persisted. Fistula maturation was achieved in both patients with an access flow of 1100-1200 cc/min. At 4 months, fistula was used successfully for dialysis in both patients. At a follow-up of 11 months, hand weakness did not progress and paresthesia disappeared. CONCLUSIONS: These cases demonstrate sensory-motor improvement with time and rehabilitation therapy and challenge the traditional approach of fistula ligation. The approach presented in this paper also results in the preservation of the lifeline of a patient. Future investigations should focus on identifying candidates who could benefit from physical therapy and rehabilitation.