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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2006  |  Volume : 17  |  Issue : 4  |  Page : 516-520
Analysis of Vascular Access in Hemodialysis Patients: A Report From a Dialysis Unit in Casablanca


Nephrology and Dialysis Department, UHC Ibn Rochd, Casablanca, Morocco

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   Abstract 

Vascular access (VA) for patients needing maintenance hemodialysis (HD) remains a major obstacle in the management of patients with end-stage renal disease (ESRD). We retrospectively analyzed 190 patients, (92 males and 98 females) who had been on HD for a period ranging from 12 to 240 months. Their mean age was 42.8 years (range: 13 to 83 years). The study was carried out to analyze the VA, including the management of its complications. The cause of renal failure was chronic glomerulonephritis in 34.2% and unknown in 30.5% of the study cases. In 164 patients (86.3%), HD was initiated through a temporary catheter inserted in the internal jugular vein. Each patient had, on an average, two catheters inserted that lasted for a mean duration of 29 days. All patients had a native arteriovenous fistula (AVF) as the permanent VA. A primary radial-cephalic AVF was created in 96.3% of the patients. The median period before cannulation was 15 days. Failure of AVF function occurred in 18.4% of cases while the median survival of the primary AVF was 54.8 months. Thrombosis, seen in 26.4% of the patients, was the predominant complication, and this event seemed to be causally related to prior insertion of temporary catheters. Ten patients had arterio-venous grafts (AVG) placed due to recurrent thrombosis of the AVF. The AVG was brachial-cephalic in five patients. A tunneled cuffed catheter was placed in four patients who had no other possible access sites available. These catheters were placed in the right internal jugular vein in all of these patients. The success of VA in patients on HD requires a multi-disciplinary approach and early referral to a vascular surgeon.

Keywords: Hemodialysis, Vascular access, Catheter, Arteriovenous fistula.

How to cite this article:
Medkouri G, Aghai R, Anabi A, Yazidi A, Benghanem MG, Hachim K, Ramdani B, Zaid D. Analysis of Vascular Access in Hemodialysis Patients: A Report From a Dialysis Unit in Casablanca. Saudi J Kidney Dis Transpl 2006;17:516-20

How to cite this URL:
Medkouri G, Aghai R, Anabi A, Yazidi A, Benghanem MG, Hachim K, Ramdani B, Zaid D. Analysis of Vascular Access in Hemodialysis Patients: A Report From a Dialysis Unit in Casablanca. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2019 Nov 13];17:516-20. Available from: http://www.sjkdt.org/text.asp?2006/17/4/516/32489

   Introduction Top


The management of vascular access (VA) in patients on hemodialysis (HD) remains a major issue in the care of patients with end­stage renal disease (ESRD). Despite the technological advances made in the field of HD, VA continues to be a significant economic, surgical, and logistic problem for both patients and their medical care providers. [1]

The aim of this study was to describe the VA profile and its complications in patients on HD in the dialysis unit of UHC Ibn Rochd in Casablanca, Morocco.


   Patients and Methods Top


This is a retrospective study that involved 190 patients on HD in our unit. For each patient, the demographic characteristics, HD parameters and type and evolution of tem­porary and permanent VA were noted. Data were collected and analyzed using the software "Epi-Info" (version 6.04 fr).


   Results Top


Of the 190 patients studied, there were 98 females (51.6%) and 92 males (48.4%); their mean age was 42.8 years (range: 13 to 83 years). The study patients were on HD for a mean duration of 98.4 months (12 to 240 months). The cause of renal disease was chronic glomerulonephritis in 34.2% and unknown in 30.5% of the cases. The other etiologies included nephrosclerosis (13.2%), diabetes (9%), chronic pyelonephritis (7.9%), polycystic kidney disease (2.1%), and miscellaneous causes in 3.1% of the patients. Forty-seven (24.7%) received two HD sessions, while 143 patients (75.3%) received three HD sessions per week. A temporary venous catheter was placed for initiation of HD in 164 patients (86.3%). It was inserted in the internal jugular vein in 86.9% of cases and in the femoral and subclavian veins in 7.5 and 5.6% of cases, respectively.

A total of 81 patients had at least two catheters inserted because of failure or thrombosis of their arteriovenous fistulae (AVF). The mean number of temporary catheters used per patient was two, and the mean duration of their use was 29 days per catheter.

A native AVF was created in all of our patients as the first permanent access. It was radio-cephalic (Cimino-Brescia technique) in 96.3% and brachio-cephalic in 3.7% of the patients. The primary failure rate was 18.4%, and the median time to first cannulation was 15 days (range: 10 to 120 days).

The commonest complication encountered with the primary AVF was thrombosis [Table - 1]. Treatment of these complications consisted of surgical thrombectomy, which was success­fully performed in only five patients; aneurysms were surgically corrected in all of the patients. Stenosis was confirmed by venography in the three afflicted patients, and balloon angio­plasty was performed in two patients, of whom one had successful outcome.

Statistical analysis showed no significant relationship between thrombosis and the cause of renal disease, including diabetes (p = 0.9). Also, there was no correlation between thrombosis and period before first cannulation of AVF (> 21 days versus ≤21 days).

The relationship between a prior temporary catheter (TC) insertion and thrombosis of AVF was studied. Thrombosis occurred in 26% of patients who had a TC inserted as com­pared to 10% of the patients who did not have a TC. The number of TCs used (1 or 2 versus 3 or more catheters) was also related to an increased risk of thrombosis (p < 0.05), and this risk was not increased by duration of use of the catheters (p = 0.92) [Table - 2].

The median survival of the primary AVF was 54.8 months (range: 1 to 216 months). The creation of a second native AVF was nece­ssary in 76 patients and consisted of revision of the initial AVF with a more proximal radial to cephalic vein anastomosis in 10 patients (13.1%), creation of a new elbow level AVF (brachio-cephalic or brachio-basilic) in 17 patients (22.4%), and creation of a new radio­cephalic AVF in the contralateral upper limb in 49 patients (64.5%). During the period of the study, a total of 333 AVF were created. Of these, 114 patients had one AVF, 34 patients two AVF, and 42 other patients had three or more because of recurrent complications [Table - 3].

Arteriovenous graft (AVG) was placed in ten patients who had recurrent thrombosis of the AVF. It was brachio-cephalic in five patients (50%). The median survival of the AVG was 28.7 months (2 to 84 months). Infe­ction of the graft and thrombosis occurred in two and four cases, respectively.

A tunneled cuffed catheter was inserted in four patients for whom all other vascular access sites had been exhausted. Each catheter was placed in the right internal jugular vein.


   Discussion Top


Establishing and maintaining a proper VA is necessary for successfully performing HD. Descriptive analysis of VA for HD in our unit showed many features. The high usage of temporary catheters for initiation of HD in our group of patients (86.3%), when com­pared to other studies where it has varied from 15 to 60%, [2],[3],[4] was due to delayed diagnosis of chronic renal failure (CRF) and late referrals of the patients to a vascular surgeon. The native AVF is the optimal VA in HD. [5],[6] It was created in all patients with the radio­cephalic fistula being the commonest site (used in 96.3% of cases). This was in concordance with international recommendations (K-DOQI guidelines). [6] Before AVF construction, only physical examination was performed in our patients; pre-operative evaluation by sono­graphy is particularly desirable in patients at greater risk for primary failure, such as the elderly and those with diabetes. [7],[8] The immediate failure rate in our group (18.4%) correlates with literature data, which varies from 10 to 30%. [7],[9] The median time to first cannulation of native AVF was 15 days in our study, less than the reported average, which varies between 25 and 98 days respectively in Japan and the US. [10]

The survival of the primary native AVF was, on average, 54.8 months, which is less than the 70 months noted in Ravani's series. [3] Survival was shortened by many complications that were dominated by thrombosis, which occurred in 26.4% of our patients, little more than in other series in which the prevalence varies from 10 to 23%. [11],[12] This high pre­valence of thrombosis seems to be related to prior use of temporary catheters for initiation of HD, [3],[10] which was a risk factor for throm­bosis in our study. Diabetic nephropathy was not associated with a higher risk of AVF thrombosis in our study. Similarly, Sedlacek showed no difference in the percentage of functioning fistulae between patients with and without diabetes. [13] The period before the first cannulation did not increase the risk of thrombosis of AVF in our group, but a study led by Rayner on a larger group of patients showed a higher risk of thrombosis in cases where cannulation was performed within the first 14 days after fistula creation. [10] Further­more, the K-DOQI guidelines recommend that AVF should mature for at least one month before cannulation. [6]

Stenosis of AVF, invariably due to neointimal fibrous hyperplasia, [1] must be looked for in case of thrombosis. Stenosis can be diagnosed by Doppler ultrasound and venography. Balloon angioplasty is the optimal treatment, [14] although it may not be easily available and is so expen­sive that very few patients can afford it.

An AVG was necessary in 5.2 % of our patients, which is a lower percentage than what is reported in the literature, namely 9 to 27 %. [5]


   Conclusion Top


Despite the advances made in HD tech­nology in the last decades, availability of a well-functioning VA remains a major problem. Early diagnosis of CRF allows creation of native AVF before ESRD sets in and, consequently, usage of a temporary catheter can be avoided. Regular monitoring of the VA and a close working relationship between nephrologists, surgeons, interventional radiologists, and nurses can ensure prolonged survival of primary AVF and better treatment of its complications. This will improve the quality of life of the patients and reduce the global cost of health­care in ESRD patients.

 
   References Top

1.Nissenson AR, Fine RN. Dialysis Therapy, 3 rd edition, 2002 Hanley and Belfus.  Back to cited text no. 1    
2.Astor BC, Eustace JA, Powe NR, et al. Timing of nephrologist referral and arteriovenous access use: the CHOICE Study. Am J Kidney Dis 2001;38(3):494-501.  Back to cited text no. 2    
3.Ravani P, Marcelli D, Malberti F. Vascular access surgery managed by renal physi­cians: the choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 2002;40(6):1264-76.  Back to cited text no. 3    
4.Reddan D, Klassen P, Frankenfield DL, et al. National ESRD CPM Work Group. National profile of practice patterns for hemodialysis vascular access in the United States. J Am Soc Nephrol 2002;13(8): 2117-24.  Back to cited text no. 4    
5.Rodriguez Hernandez JA, Lopez Pedret J, Piera L. Vascular access in Spain: analysis of its distribution, morbidity, and monitoring systems. Nefrologia 2001;21(1): 45-51.  Back to cited text no. 5    
6.NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis 2001;37(1 Suppl 1):S137-81.  Back to cited text no. 6    
7.Malovrh M. Native arteriovenous fistula: preoperative evaluation. Am J Kidney Dis 2002;39(6):1218-25.  Back to cited text no. 7    
8.Malovrh M. Approach to patients with end­stage renal disease who need an arterio­venous fistula. Nephrol Dial Transplant 2003;18 Suppl 5:v50-2.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Dixon BS, Novak L, Fangman J. Hemodialysis vascular access survival: upper-arm native arteriovenous fistula. Am J Kidney Dis 2002;39(1):92-101.  Back to cited text no. 9    
10.Rayner HC, Pisoni RL, Gillespie BW, et al. Dialysis Outcomes and Practice Patterns Study. Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study. Kidney Int 2003;63(1):323-30.  Back to cited text no. 10    
11.Yiltok SJ, Orkar KS, Agaba EI, et al. Arteriovenous fistula for patients on long term haemodialysis in jos, Nigeria. Niger Postgrad Med J 2005;12(1):6-9.  Back to cited text no. 11    
12.Bottet P. Fistulae natives or bras. 2nd International VAS Congress London, UK, 2001.  Back to cited text no. 12    
13.Sedlacek M, Teodorescu V, Falk A, Vassalotti JA, Uribarri J. Hemodialysis access placement with preoperative noninvasive vascular mapping: comparison between patients with and without diabetes. Am J Kidney Dis 2001;38(3):560-4.  Back to cited text no. 13    
14.Khazine F, Lefebvre-Vilardebo M, Simons O, Tritz JP, Ban A, Guedj P. Percutaneous transluminal angioplasty for vascular access in hemodialysis. Apropos of 53 operations Nephrologie 1992;13(5):201-5.  Back to cited text no. 14    

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Correspondence Address:
Ghislaine Medkouri
8, Lotissement Ababou, Californie 20150, Casablanca
Morocco
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PMID: 17186686

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    Tables

  [Table - 1], [Table - 2], [Table - 3]

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