Vascular Access in Hemodialysis: Peculiarities in a Low-Income Setting, Pattern, Prevalence and Relationship with Intradialysis Events and Dialysis Dose.

OBJECTIVES: Dialysis vascular access has remained a major determinant of intra and inter-dialytic events and the dialysis dose, and this impacts the quality of life, morbidity and mortality of dialysis patients. Assessing the different access types would help minimize peri-dialytic events and improve outcome. METHODS: This was a retrospective, age and sex-matched, comparative study that assessed dialysis sessions with tunneled dialysis catheters (TDCs) with arteriovenous fistula (AVF). RESULTS: Two hundred and four participants with 1062 sessions were involved. The male participants had 66.7% of all sessions, 60.6% of sessions with TDCs and 87.3% of sessions with AVF, P=0.001. The elderly constituted 23.5% of all participants but 37.7% of sessions with AVF, P=0.04. The percentage of the health-insured was more in sessions with AVF compared to the study population, P<0.001. Diabetics were more likely to use the TDCs, P=0.06. Participants using AVF were more likely to receive full dialysis and erythropoietin treatment, P<0.001. Intradialytic hypotension and dialysis termination were commoner with AVF than TDCs, P=0.03 and P=0.04 respectively. The dialysis dose was higher with AVF than TDCs, P=0.02. Predictors of AVF as dialysis access were male gender, advancing age, health insurance and full treatment compliance. CONCLUSION: There is predominance of venous catheters in our dialysis population. The AVF gave better BP control, fluid and solute clearance, and dialysis dose, and was commoner with males, the health insured and older participants. Intradialytic hypotension was commoner with AVF as IDHT was commoner with TDCs.

OBJECTIFS: L'accès vasculaire à la dialyse reste un déterminant majeur des événements intra et inter-dialytiques et de la dose de dialyse, ce qui a un impact sur la qualité de vie, la morbidité et lamortalité des dialysés. L'évaluation des différents types d'accès permettrait de minimiser les événements péridialytiques et d'améliorer les résultats. MÉTHODES: Il s'agit d'une étude comparative rétrospective, appariée selon l'âge et le sexe, qui a évalué les séances de dialyse avec des cathéters de dialyse tunnellisés (CDT) et des fistules artérioveineuses (FAV). RÉSULTATS: Deux cent quatre participants ont participé à 1 062 séances. Les hommes représentaient 66,7 % de toutes les séances, 60,6 % des séances avec CDT et 87,3 % des séances avec FAV, P=0,001. Les personnes âgées représentaient 23,5 % de l'ensemble des participants, mais 37,7 % des séances avec FVA, P=0,04. Le pourcentage d'assurés sociaux était plus élevé dans les sessions avec AVF que dans la population étudiée, P<0.001. Les diabétiques étaient plus susceptibles d'utiliser les CDT, P=0,06. Les participants utilisant la FVA étaient plus susceptibles de recevoir une dialyse complète et un traitement à l'érythropoïétine, P<0,001. L'hypotension intradialytique et l'arrêt de la dialyse étaient plus fréquents avec l'AVF qu'avec les CDT, P=0,03 et P=0,04. La dose de dialyse était plus élevée en cas de FVA qu'en cas de CDT, P=0,02. Les facteurs prédictifs de l'utilisation de la FVA comme accès à la dialyse étaient le sexe masculin, l'âge avancé, l'assurance maladie et l'observance totale du traitement. CONCLUSION: Il y a une prédominance des cathéters veineux dans notre population de dialysés. Le FVA permet un meilleur contrôle de la PA, de la clairance des fluides et des solutés et de la dose de dialyse, et il est plus fréquent chez les hommes, les assurés sociaux et les participants plus âgés. L'hypotension intradialytique était plus fréquente avec le FVA que l'IDHT était plus fréquente avec les CDT. Mots-clés: Cathéters veineux centraux, fistule artério-veineuse, veine jugulaire interne tunnellisée.

Iron status and benefit of the use of parenteral iron therapy in pre-dialysis Chronic Kidney disease patients.

AIMS AND OBJECTIVES: Anaemia is a major cardiovascular risk factor in chronic kidney disease (CKD). Treatment and correction of anaemia leads to improvement of cardiovascular status and quality of life of patients with CKD. This interventional open labeled randomised controlled study comparing the effect of intravenous and oral iron therapy in improving red cell indices and iron status in anaemic pre-dialysis Chronic Kidney Disease was carried out to determine iron status in anaemic pre-dialysis CKD patients to assess the benefit of parenteral iron supplementation as against empirical oral iron in CKD patients with iron deficiency. PATIENTS AND METHODS: Sixty consecutive pre-dialysis chronic kidney disease patients attending the renal clinic over a six month period were screened. Forty- one subjects (68.3%) were found to be anaemic and were subsequently studied. RESULTS: The ages of the patients ranged between 19 and 71 years with a mean age of 39 years. The mean serum creatinine and mean creatinine clearance were 201.80 (70.25)?mol/L and 37.90 (± 12.17)ml/minute respectively. The haematocrit concentration was found to correlate inversely with the level of serum creatinine and 56.1% of the anaemic patients had iron deficiency. The mean PCV rise in the intravenous iron group was 2.42 (± 1.98)% and this was statistically significant (p=0.002) while the mean PCV difference was 0.909 (± 0.94)% in the oral iron group. Intravenously administered iron alone permitted anaemia correction in about one-third of these patients without any life threatening adverse drug event. CONCLUSION: Anaemia is very common in the pre-dialysis CKD population and the prevalence of iron deficiency is high. Intravenous iron supplementation is an effective and safe treatment for the anaemia in the pre-dialysis CKD patients. Response to oral iron was poor.

Acute renal failure (ARF) in developing countries: which factors actually influence survival.

Acute renal failure, a relatively common clinical condition, is still associated with a high mortality rate in both developed and developing countries despite the differences in the epidemiology, clinical characteristics and therapeutic modalities offered to affected patients. The various modalities of renal replacement therapy are still largely inaccessible, unaffordable and unavailable in most parts of sub-Saharan Africa, hence the need to judiciously utilise available resources. Consequently we studied patients with acute renal failure to critically appraise the factors that influence survival and determine the usefulness or otherwise of available renal replacement therapies (Acute HD and Acute PD). A total of 46 (34 (73.9%) males and 12 (26.1%) females) patients satisfied the inclusion criteria. Their ages ranged between 15 and 76 years (mean +/- SD; 38.2 +/-16.3 years). The commonest causes were gastro-enteritis (cholera) and septicaemia in 36.9% and 30.5% respectively. Twenty six (56.5%) of all the patients survived while the remaining 20 (43.5%) died. Twenty four (52.2%) patients had different complications of which pulmonary oedema was singularly found to significantly influence survival. Other factors that were found to significantly influence survival included availability of renal replacement therapy, the aetiology of ARF; gender; age of the patients and the duration of oliguria. We further compared the patients managed with haemodialysis with those managed with peritoneal dialysis and found no difference(s) in the age; duration of oliguria or hospitalisation; survival figures; effect of pulmonary oedema and the aetiology of ARF. However, the number of sessions for HD and the duration of PD significantly influenced survival. We conclude that ARF is still associated with a high mortality rate and prompt institution of available renal replacement therapy and aggressive management of complications would assist in reducing the trend.