Explorations fonctionnelles des abords vasculaires pour hémodialyse Frank Le Roy Nephrology Department Actualités Néphrologiques Jean Hamburger Necker, 27 avril 2015
1966 Brescia, Cimino, Appel, Hurwich. N Engl J Med 1966;275:1089-1092
Low flow fistula High flow fistula KDOQI 2006 Updates. Am J Kidney Dis 2006;48:suppl 1
Guidelines K/DOQI Thrombotic events year-patient AV fistulae Grafts 0.25 0.5 Patients Exposition Thrombosis event/year/patient (n) time(y-p) event Facility A 50 35 10 0.28 Facility B 100 50 4 0.08
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
Delayed fistula maturation (week 6)
Raymonde 66 years-old. Cephalic AVF
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: 1993-1996
Extracorporeal pressure analysis P = 8µLQ b / R4 AP- 210 mm Hg VP + 255 mm Hg
1995 Transonic
VAF measurement (ultrasonic dilution) Transonic system Krivitski. Kidney Int 1995;48:244-250
For an easier measurement!!! Twister system
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
On-line tools for vascular access flow measurement Diascan device (Hospal-Gambro) OCM device BTM device (Fresenius)
Kdc (ml/mn) Ionic dialysance and urea effective clearance Total Dialysate collection (ml/min) 210 200 190 180 170 160 150 140 130 120 R 2 =0.94 110 110 120 130 140 150 160 170 180 190 200 210 Keff (ml/mn) Ionic dialysance (ml/min) Petitclerc and coll. Nephrol Dial Transplant 1995 ;10:212-216
Qa measurement (ionic dialysance) Diascan / OCM devices Dn=200 Inversion lignes Qa =(Dn-UF).Dr Dn-Dr Dinv=150 Mercadal and coll. Kidney Int. 1999 ; 56 : 1560-1565
Qa measurement (ionic dialysance) OCM device (4008 monitor) Lacson and coll. Am J Kidney Dis 2008; 51 : 99-106
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 : 376-383
Qa measurement (Thermodilution) «double recirculation technique» 50VA(42 AVF, 8 grafts) Fontsere and coll. Blood Purif 2011 3500 54 AVF Personal datas. Rouen 3000 2500 2000 1500 1000 500 0 0 500 1000 1500 2000 2500 3000 3500 4000 Qa Transonic Patients (n) Q a Transonic Q a BTM r 2 Schneditz 1999 17 1390 1328 0.84 Fontsere 2011 50 1021 1094 0.82 Rouen 2008 54 1116 1083 0.82
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;930-938 Tonelli and coll. Am J Kidney Dis 2008; 51: 630-640
On-line monitoring Evaluate your VA at each dialysis session! Diascan device (Hospal-Gambro) OCM device BTM device (Fresenius)
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Reference table (membrane surface 2m 2, needles 15 Gauge) The «alarm clearance» HD (ml/min) HDF (ml/min) Q b 300 165 220 Q b 350 175 240 Q b 400 185 260
Stenosis detection ionic dialysance Post-anastomotic stenosis clearance = 140 ml/min Post angioplasty Clearance = 262 ml/min
Dialysis dose monitoring Kt Fontsere and coll. Hemodialysis International 2011;21:2225-2231
Dialysis dose monitoring «alarm Kt» : mean Kt minus 10% 55 Angioplasty 50 45 Kt 40 (liters) 35 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 sessions
Dialysis dose monitoring «alarm Kt» : mean Kt minus 10% 55 Angioplasty 50 45 Kt 40 (liters) 35 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 sessions
Spanish monitoring At each session monthly 74 AVF VAF «alarm Historic» Kt group: 0.148 + thrombosis/y-p measurement Study group: 0.027 thrombosis /y-p Intervention Intervention Qa < 500 ml/min 20% mean Kt or 20% Fontsere and coll. Blood purif 2014 : 37;67-72
Recirculation measurement Transonic system Krivitski. Kidney Int 1995;48:244-250
BTM device (Fresenius Medical Care) dialysis monitor 4008/5008 10%
VA recirculation and cardiopulmonary recirculation CO 4 liters/min CPR = Q a / Q c Q a 1 liter/min Q syst 3 liters/min
Total recirculation measurement Thermodilution (BTM) BTM rec = VA rec 15 % + CPR Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 : 376-383
Total recirculation measurement Thermodilution (BTM) BTM rec 15 = VA rec 0 15 % + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 : 376-383
Total recirculation measurement Thermodilution (BTM) BTM rec 20 20 % = VA rec 5 + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 : 376-383
Total recirculation measurement Thermodilution (BTM) BTM rec 25 25 % = VA rec 10 + CPR 15 Schneditz and coll. Nephrol Dial Transplant 1999 ; 14 : 376-383
On-line Recirculation Thermodilution (BTM device) 40 35 30 25 20 % 15 10 5 0 1 3 5 7 9 11 Angioplasty 15 jours 13 15 17 19
With catheter, No cardio-pulmonary recirculation! CO 4 liters/min Q syst 4 liters/min
On line Recirculation Cathéters R (%) 20 16,5 18 16 13,5 13,5 14,6 Reversed 14 11,4 lines 12 10 Normal lines 8 6 5,7 5,5 6,8 6,7 8,1 4 200 250 300 350 400 Qs (ml/min)
On-line dialysance Clearance (ml/min) 260 Catheters 240 Normal lines 220 200-7,6% Reversed lines - 9,2% 180-6,9% - 5,4% 160 140-3,1% 200 250 300 350 400 Qs (ml/min)
Brachiocephalic AVF (Transonic system) Recirculation : 0% Q a : 2240 ml/min
High flow fistula guideline 20.3 VA blood flow rate> 1000-1500 ml/min (Q a ) and VA blood flow rate /cardiac output> 20% (Q a /C0)
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;23:288-293
High flow fistula predictive factors VA blood flow (L/min) Q a /C0 (%) 1.94 2.0 2.2 Sensitivity 97 89 55 Specificity 99 100 100 20 27 30 Sensitivity 100 55 22 Specificity 75 93 99 Basile and coll. Nephrol Dial Transplant 2008;23:288-293
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
How to identify «dangerous» fistulae? Q a /CO = 2240/5520 = 40.5%
Results Transonic system (n=38) VA recirculation (%) Q a (ml/min) CO (liters/min) Q a /C0 (%) 0 1068 ± 648 (420-3430) 4.85 ± 1.2 (2.86-8.17) 21.5 ± 8.3 (8.2-41.9)
How to identify «dangerous» fistulae? Relative high flow rate 45 40 35 Q a /CO (%) 30 25 20 15 10 Absolute high flow rate 5 0 500 1000 1500 2000 2500 3000 3500 Q a (ml/min)
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 : 376-383
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 : 376-383
Thermodilution vs dilution ultrasonic results Thermodilution Transonic BTM-Transonic p Q a (ml/min) 1125 ± 595 1068 ± 648-57 0.23 CO (L/min) 4.16 ± 1.20 4.85 ± 1.27-0.69 0.0001 Q a /C0 (%) 27.5 ± 11.1 21.5 ± 8.3 + 6 <0.0001
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