Explorations fonctionnelles des abords vasculaires pour hémodialyse
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1 Explorations fonctionnelles des abords vasculaires pour hémodialyse Frank Le Roy Nephrology Department Actualités Néphrologiques Jean Hamburger Necker, 27 avril 2015
2 1966 Brescia, Cimino, Appel, Hurwich. N Engl J Med 1966;275:
3 Low flow fistula High flow fistula KDOQI 2006 Updates. Am J Kidney Dis 2006;48:suppl 1
4 Guidelines K/DOQI Thrombotic events year-patient AV fistulae Grafts Patients Exposition Thrombosis event/year/patient (n) time(y-p) event Facility A Facility B
5 Guidelines KDOQI/EBPG AVF Prefered methods 1. Vascular access blood flow (A) 2. Clinical abnormalities (B) 3. Doppler-US (A) Alternative methods 1. Recirculation (B) 2. Static venous pressure (B) Grafts Prefered methods 1. Vascular access blood flow (A) 2. Static venous pressure(a) 3. Doppler US (A) Alternative methods 1. Clinical abnormalities (B) Guideline 5 : before cannulation, clinical exam (niveau IV) KDOQI 2006 Updates. Am J Kidney Dis 2006;48:suppl 1 EBPG on haemodialysis. Nephrol Dial Transplant 2007;22:suppl2
6 Delayed fistula maturation (week 6)
7 Raymonde 66 years-old. Cephalic AVF
8 Clinical exam vs Angiography Stenosis detection n=177 Experienced and skilled nephrologist between needles outflow PNV specificity sensitivity inflow 0 0,2 0,4 0,6 0,8 1 Coentrao and coll. Nephrol Dial Transplant 2012; 27:
9 Extracorporeal pressure analysis P = 8µLQ b / R4 AP- 210 mm Hg VP mm Hg
10 1995 Transonic
11 VAF measurement (ultrasonic dilution) Transonic system Krivitski. Kidney Int 1995;48:
12 For an easier measurement!!! Twister system
13 Intervention threshold Graft : 600 ml/min Distal AVF: 300mL/min ou 20%/mois Proximal AVF: no guideline EBPG on haemodialysis. Nephrol Dial Transplant 2007;22:suppl2
14 On-line tools for vascular access flow measurement Diascan device (Hospal-Gambro) OCM device BTM device (Fresenius)
15 Kdc (ml/mn) Ionic dialysance and urea effective clearance Total Dialysate collection (ml/min) R 2 = Keff (ml/mn) Ionic dialysance (ml/min) Petitclerc and coll. Nephrol Dial Transplant 1995 ;10:
16 Qa measurement (ionic dialysance) Diascan / OCM devices Dn=200 Inversion lignes Qa =(Dn-UF).Dr Dn-Dr Dinv=150 Mercadal and coll. Kidney Int ; 56 :
17
18 Qa measurement (ionic dialysance) OCM device (4008 monitor) Lacson and coll. Am J Kidney Dis 2008; 51 :
19 Qa measurement (Thermodilution) «double recirculation technique» BTM device R x =35% R n =10% Reversed lines Normal lines Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
20
21 Qa measurement (Thermodilution) «double recirculation technique» 50VA(42 AVF, 8 grafts) Fontsere and coll. Blood Purif AVF Personal datas. Rouen Qa Transonic Patients (n) Q a Transonic Q a BTM r 2 Schneditz Fontsere Rouen
22 Qa measurement prevents thrombosis Right for AVF, Wrong for grafts Monthly Qa Sensitivity 53 % False positive 21% Qa variation Sensitivity 58 % False positive25 % Rara and coll. Am J KidneyDis 2008: 52; Tonelli and coll. Am J Kidney Dis 2008; 51:
23 On-line monitoring Evaluate your VA at each dialysis session! Diascan device (Hospal-Gambro) OCM device BTM device (Fresenius)
24
25 ?
26 Reference table (membrane surface 2m 2, needles 15 Gauge) The «alarm clearance» HD (ml/min) HDF (ml/min) Q b Q b Q b
27 Stenosis detection ionic dialysance Post-anastomotic stenosis clearance = 140 ml/min Post angioplasty Clearance = 262 ml/min
28 Dialysis dose monitoring Kt Fontsere and coll. Hemodialysis International 2011;21:
29 Dialysis dose monitoring «alarm Kt» : mean Kt minus 10% 55 Angioplasty Kt 40 (liters) sessions
30
31 Dialysis dose monitoring «alarm Kt» : mean Kt minus 10% 55 Angioplasty Kt 40 (liters) sessions
32 Spanish monitoring At each session monthly 74 AVF VAF «alarm Historic» Kt group: thrombosis/y-p measurement Study group: thrombosis /y-p Intervention Intervention Qa < 500 ml/min 20% mean Kt or 20% Fontsere and coll. Blood purif 2014 : 37;67-72
33 Recirculation measurement Transonic system Krivitski. Kidney Int 1995;48:
34 BTM device (Fresenius Medical Care) dialysis monitor 4008/ %
35 VA recirculation and cardiopulmonary recirculation CO 4 liters/min CPR = Q a / Q c Q a 1 liter/min Q syst 3 liters/min
36 Total recirculation measurement Thermodilution (BTM) BTM rec = VA rec 15 % + CPR Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
37 Total recirculation measurement Thermodilution (BTM) BTM rec 15 = VA rec 0 15 % + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
38 Total recirculation measurement Thermodilution (BTM) BTM rec % = VA rec 5 + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
39 Total recirculation measurement Thermodilution (BTM) BTM rec % = VA rec 10 + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
40 On-line Recirculation Thermodilution (BTM device) % Angioplasty 15 jours
41 With catheter, No cardio-pulmonary recirculation! CO 4 liters/min Q syst 4 liters/min
42 On line Recirculation Cathéters R (%) 20 16, ,5 13,5 14,6 Reversed 14 11,4 lines Normal lines 8 6 5,7 5,5 6,8 6,7 8, Qs (ml/min)
43 On-line dialysance Clearance (ml/min) 260 Catheters 240 Normal lines ,6% Reversed lines - 9,2% 180-6,9% - 5,4% ,1% Qs (ml/min)
44 Brachiocephalic AVF (Transonic system) Recirculation : 0% Q a : 2240 ml/min
45 High flow fistula guideline 20.3 VA blood flow rate> ml/min (Q a ) and VA blood flow rate /cardiac output> 20% (Q a /C0)
46 Hifh flow fistula cardiac output and fistula flow 96 patients 65 distal AVF- 31 proximal AVF High-output cardiac failure Qa 2.3 l/mn CO 8.4 l/mn IC > 3l/mn/m² Basile and coll. Nephrol Dial Transplant 2008;23:
47 High flow fistula predictive factors VA blood flow (L/min) Q a /C0 (%) Sensitivity Specificity Sensitivity Specificity Basile and coll. Nephrol Dial Transplant 2008;23:
48 AVF Toxicity Absolute high flow rate Q a >2.0 L/min Relative high flow rate Q a 1 L/min C0 5 L/min Q a /C0 40 % CO 2.5 L/min Q a /C0 40 % High-output cardiac failure Cardiac failure
49 How to identify «dangerous» fistulae? Q a /CO = 2240/5520 = 40.5%
50 Results Transonic system (n=38) VA recirculation (%) Q a (ml/min) CO (liters/min) Q a /C0 (%) ± 648 ( ) 4.85 ± 1.2 ( ) 21.5 ± 8.3 ( )
51 How to identify «dangerous» fistulae? Relative high flow rate Q a /CO (%) Absolute high flow rate Q a (ml/min)
52 Q a and CO measurement by Thermodilution «double recirculation technique» BTM device 35% 10% Reversed lines Normal lines Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
53 Thermodilution vs dilution ultrasonic 23±10 vs 22±11 % 5.6±1.4 vs 6.7±1.6 l/mn Q a /C0 CO R 2 =0.66 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 :
54 Thermodilution vs dilution ultrasonic results Thermodilution Transonic BTM-Transonic p Q a (ml/min) 1125 ± ± CO (L/min) 4.16 ± ± Q a /C0 (%) 27.5 ± ± <0.0001
55 Dialysance In case of unexplained decrease, take a look at AVF Recirculation In case of unexplained increase, take a look at AVF Dialysis dose In case of unexplained decrease, take a look at AVF
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