MIHÁLY TAPOLYAI, MD, FASN, FACP Associate Professor, Louisiana State University; Shreveport, Louisiana, USA Associate Professor; University of Hawai

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1 MIHÁLY TAPOLYAI, MD, FASN, FACP Associate Professor, Louisiana State University; Shreveport, Louisiana, USA Associate Professor; University of Hawai i Postgraduate Training Program at Chubu Hospital, Okinawa, Uruma shi Japan Fresenius Dialysis Center, Semmelweis University, Budapest, Hungary

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3 Adjusted Relative Risk (RR) of Mortality and Percent of Patients Outside Guideline Target by Practice Pattern

4 Late referral 1 Surgeon s preference and training 2 Patients preference: cosmetic Lack of education 3 High degree of obesity in the population Patient s noncompliance 1 Gibson KD et al Kidney Int June; 59 (6): pp Allon M et al Kidney Int 60 (2001): pp USRDS Wave Annual Data Report:60

5 Infections Vascular stenoses Delay of fistula creation

6 All catheters can get infected Location of temporary catheters do not matter: Subclavian catheters <femoral catheters <jugular catheters Femoral catheters are not more prone to infection

7 In the largest prospective randomized study: the risk of infection was evaluated jugular vs. femoral venous catheterization 750 patients were randomly assigned to jugular or femoral vein catheters The rate of catheter related sepsis was the same with both groups (2.3 versus 1.5 per 1000 catheter days for jugular and femoral venous catheterization, respectively). The risk of catheter colonization at removal did not differ between the femoral and jugular groups (incidence: 40.8 vs 35.7per 1000 catheter days; hazard ratio [HR], 0.85 Among obese patients (BMI >28.4), the incidence of catheter colonization was significantly lower with jugular catheterization, but there was no difference in rates of clinical infection! In addition, hematomas were significantly more common with jugular catheterization (3.6% versus 1.1 %). Parienti JJ; Thirion M; Megarbane B; et al. JAMA May 28;299(20):

8 Parienti JJ; Thirion M; Megarbane B; et al. JAMA May 28;299(20):

9 A prospective study of 105 hemodialysis catheters (79 subclavian, 26 jugular) inserted in 52 patients. 1 Catheter related bacteremia (CRB) was diagnosed in 17 catheters (16%), giving a bacteremia rate of 6.5 episodes per 1000 catheter days. Subgroup analysis revealed a higher risk of CRB with the use of the internal jugular compared with the subclavian site (hazard ratio 3.97, P=0.02). Femoral lines do not have a higher rate of infection. 2 Rate of infection: SUBCLAVIAN < FEMORAL < JUGULAR 1 Kairaitis LK; Gottlieb T Nephrol Dial Transplant 1999 Jul;14(7): Murai DT Chest 2002; 121:

10 Catheters can be salvaged by antibiotics use upto 30% of the time Prospective, observational study 102 patients Marr KA; Sexton DJ; Conlon PJ et al. Ann Intern Med 1997 Aug 15;127(4): Salvage was successful in 66.1% of incident bacteremias with a very low complication risk (0.9%) prospective cohort study 252,986 catheter days, 208 episodes were of bacteremias involving 133 patients Ashby DR; Power A; Singh S et al Clin J Am Soc Nephrol Oct;4(10): Epub 2009 Aug 13. Tunneled Dialysis catheters can be exchanged over a wire; no need for a separate stick The infection free catheter survival is the same (p = 0.72) Retrospective study of 69 patients Kidney Int 2000 May;57(5):

11 Catheters can only be salvaged if: Afebrile after 48 hours of antibiotic therapy Clinically stable No evidence of tunnel tract involvement

12 With subclavian vein catheters (not just dialysis catheters), the incidence of subsequent venous stenosis is approximately 30 to 50 percent Subclavian stenosis occurs 24 to 48 h after catheter removal and 1 mo later Hernandez D; Diaz F; Rufino M et al J Am Soc Nephrol 1998 Aug;9(8): Cimochowski GE; Worley E; Rutherford WE et al Nephron 1990;54(2): Schillinger F; Schillinger D; Montagnac R et al Nephrol Dial Transplant 1991;6(10): Left sided Internal Jugular (IJ) catheters have a high rate of central venous occlusion and twice as high rate of infection as the right IJ Salgado OJ; Urdaneta B; Colmenares B et al Artif Organs Aug;28(8):

13 50% of patients who had a temporary subclavian catheter will have subclavian vein stenosis: That extremity cannot be used for a dialysis access anymore Nephrol Dial Transplant (1988) 3:

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16 High venous pressure Inadequate Kt/V Prolonged bleeding Difficult cannulation Inadequate blood flow Abnormal exam

17 Prospective study of 142 dialysis patients were examined prior to a fistulogram. Then, comparisons were made between physical exam findings and angiography. Sensitivity and specificity for OUTFLOW STENOSIS: 92% and 86% Sensitivity and specificity for INFLOW STENOSIS: 85% and 71% Asif A; Leon C; Orozco Vargas LC et al. Clin J Am Soc Nephrol Nov;2(6): Epub 2007 Oct 10.

18 Controversial subject: Lack of evidence Data are negative when grafts are monitored: Prospective study of 101 patients Clinical criteria for angiography, Qa criteria (<600 ml/min) or stenosis group (all had angiography) Qa monitoring led to higher rate of angiography All three groups had the same 2 year graft survival (60 64% p=0,89) Ram SJ, Work J, Caldito GC, et al. Kidney Int Jul;64(1):

19 5 of 6 randomized clinical trials failed to show a reduction of graft thrombosis in patients undergoing graft surveillance Routine surveillance for graft stenosis, with pre emptive angioplasty, cannot be recommended for reduction of graft thrombosis Data on AVF are even more lacking Allon M, Robbin ML. Hemodial Int Apr;13(2):

20 GUIDELINE 11 Monitoring Primary AV Fistulae for Stenosis Primary AV fistulae should be monitored as outlined for dialysis AV grafts (see Guideline 10: Monitoring Dialysis AV Grafts for Stenosis). (Opinion) Direct flow measurements, if available, are preferable compared to more indirect measures. (Evidence) Methods appropriate for monitoring stenosis in grafts (eg, static and dynamic venous pressures) are not as accurate for monitoring in primary AV fistulae. (Evidence) Recirculation and Doppler analysis are of potential benefit. (Opinion)

21 Inflow problems: pulse augmentation? Outflow problem: venous collapse?

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23 There should be a continuous, systolic thrill The thrill should be continuous Not only during the systole The thrill should be felt throughout the fistula Normally, the pulse is soft and easily compressible.

24 Inflow The fistula should be soft, compressible and not pulstile When the fistula is compressed in the middle, there pulse should bea pulse on the arterial side: this means there is a good inflow. This is pulse augmentation. If there is no pulse augmentation, the inflow is insufficient. The strength of the pulse is directly proportional to the arterial inflow pressure. This is an arterial problem, it can be angioplastied. This occurs in about 10% of fistula problems.

25 This lesion can be easily diagnosed by palpation of the anastomosis and distal vein Normally, a very prominent thrill is present at the anastomosis. Normally, the pulse is soft and easily compressible. With juxta-anastomotic stenosis, the thrill, which is normally continuous; is present only in systole only. As one moves up the vein from the anastomosis with the palpating finger, the pulse goes away rather abruptly as the site of stenosis is encountered. Above this level, the pulse is very weak and the vein is poorly developed. The stenosis itself can frequently be felt as an abrupt diminution in the size of the vein, almost like a shelf. Juxta-anastomotic stenosis. A radial artery, B stenotic lesion, C cephalic vein.

26 When the extremity is elevated above the head the entire fistula should collapse, at least partially. With a proximal stenosis, the AVF becomes more forcibly pulsatile and firm. It also enlarges rapidly When the extremity is elevated, that portion of the fistula distal to point of stenosis remains distended, while the proximal portion collapses in the normal fashion

27 The type of dialysis access is a major determinnat of outcome on dialysis. Dialysis catheter confer an unacceptible risk. Dialysis fistulas should be maintained and familiarity with the fistula improves its care and maintenance.