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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 3  |  Page : 486-487
Predicting hemodialysis access failure with the measurement of dialysis access recirculation

Renal Transplant Unit, St George’s Hospital, London, United Kingdom

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How to cite this article:
Jahromi AH, Morsy M, Chemla E. Predicting hemodialysis access failure with the measurement of dialysis access recirculation. Saudi J Kidney Dis Transpl 2009;20:486-7

How to cite this URL:
Jahromi AH, Morsy M, Chemla E. Predicting hemodialysis access failure with the measurement of dialysis access recirculation. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 May 16];20:486-7. Available from: https://www.sjkdt.org/text.asp?2009/20/3/486/50789
To the Editor,

We read with great interest the published re­port by Salimi et al about predicting hemodia­lysis access failure with the measurement of dialysis access recirculation. [1] However; we have few queries for which clarification is required from the authors.

With an increasing number of elderly pa­tients, with multiple co-morbidities requiring more complex vascular access surgery in the hemodialysis population, creation and survei­llance of a well functioning vascular access remains a challenge. Vascular access failure is still a major cause of morbidity and mortality for hemodialysis patients.

Rescue of a failing vascular access prior to thrombosis using either endovascular or surgi­cal intervention, can significantly prolong the life of access. [2] The high cost and associated morbidity of multiple vascular access surgeries justifies calls for strategies to predict and pre­vent access thrombosis.

Fistulae surveillance protocols state that "fre­quent monitoring of arterio-venous fistulas (AVF) and grafts could result in rescue of fai­ling or failed access, and help avoid or mini­mize the risk of under-dialysis". [3]

As the authors have also mentioned, among the variety of techniques in assessing access recirculation, the most accurate method is by a non-urea-based dilutional method. [3] The purpose of their study was to evaluate recirculation for early detection of access stenosis and urea-based method was used only.

We agree with the conclusions of the paper that in situations with equivocal results on the indirect methods to assess access adequacy, non-invasive method such as Doppler ultrasound should precede more expensive and invasive methods such as angiography or fistulography. Other methods such as frequent periodic sur­veillance transonic flow measure can provide similar information. [4],[5]

It is correctly mentioned in the article that there are other explanations for a high mea­sured recirculation such as inadequate arterial blood flow and improper needle placement, etc. We would appreciate clarifications of what measures have been taken to prevent these factors affecting the recirculation readings in this study.

There should be at least one follow up eva­luation in the study to show the comparison in the outcomes of the vascular access based on the recirculation values. The accuracy of the recirculation measures in detection of access stenosis should also be compared with some more definitive methods such as Doppler ultra­sound, transonic and finally with fistulography or angiography.

The types of hemodialysis vascular access in the studied patients included 82.4% native AVF and 17.6% synthetic arterio-venous grafts. According to the study, "age of the VA in the AVF group varied between 1 to 240 months and 3 to 30 months for patients with synthetic arterio-venous grafts". It is not clear whether the age of the VA was calculated from the time the vascular access was created or from the time it was first used. It is also not clear if any of the patients received dialysis through a line any time during the study.

   References Top

1.Salimi J, Razeghi E, Karjalian H, et al. Predicting haemodialysis access failure with the measure­ment of dialysis access recirculation. Saudi J Kidney Dis Transpl 2008;19(5):781-4.  Back to cited text no. 1    
2.May RE, Himmelfarb J, Yenicesu M, et al. Predictive measures of vascular access throm­bosis: a prospective study. Kidney Int 1997;52 (6):1656-62.  Back to cited text no. 2    
3.The National Kidney Foundation. Kidney Disease Outcomes Quality Initiative (NKF KDOQI), clinical practice guidelines for vascular access, update 2006.  Back to cited text no. 3    
4.Branger B, Granolleras C, Dauzat M, et al. Frequency of thrombosis in haemodialysis arterio-venous fistulas. Contribution of 2 sur­veillance methods: Doppler and dilution ultra­sound techniques Nephrologie 2004;25(1):17­22.(French)  Back to cited text no. 4    
5.MacDonald JT, Sosa MA, Krivitski NM, Glidden D, Sands JJ. Identifying a new reality: zero vascular access recirculation using ultra­sound dilution. ANNA J 1996;23(6):603-8, 635.  Back to cited text no. 5    

Correspondence Address:
Alireza Hamidian Jahromi
Renal Transplant Unit, St George’s Hospital, London
United Kingdom
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PMID: 19414961

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