Vascular access for hemodialysis: an indepth review

A multi-disciplinary approach to vascular access planning, early preoperative surgical assessment and increased use of vascular imaging for surveillance, specialist service and pharmacological prevention of intimal hyperplasia will lead to improved patency rates for both autologous AVF and synthetic grafts.

Influence of diabetes mellitus on patient and graft survival in recipients of kidney transplantation

AIMS

To investigate the outcomes in patients who have pre-existing diabetes and those who develop post-transplant diabetes mellitus (PTDM).

METHODS

We retrospectively reviewed the charts of 939 patients who received a first functioning renal transplant in the cyclosporine (CyA) era between 1984 and 1999.

RESULTS

Sixty-six (7%) patients had renal failure due to insulin-dependent diabetes mellitus (IDDM) and 7 (0.8%) patients due to non-insulin-dependent diabetes mellitus (NIDDM). Ten (1.1%) patients had coexistent diabetes and 48 (5.1%) recipients developed PTDM. The mean graft survival for the patients with PTDM was 9.7 yr versus 11.3 yr for the non-diabetic patients, while mean graft survival was 10.1 yr for patients with IDDM and 2.9 yr with NIDDM and 8.3 yr for those with coexistent diabetes (p=ns). However, there was a statistically significant difference in patient survival between patients who developed PTDM and in those who did not develop this complication. The mean survivals of patients with IDDM, NIDDM, coexistent diabetics and PTDM were 8.4, 3.7, 8.6 and 10.3 yr, respectively. The mean survival of the patients without pre-existing diabetes or PTDM was 12.8 yr (p<0.001). The survival of patients older than 55 yr with PTDM was no different to the control group. However, in those younger than 55 yr, PTDM was associated with a higher risk of death (relative risk of 2.54, p<0.001). Fifty percent of patients with IDDM developed acute rejection episodes, whereas rejection rate was 57.1% in NIDDM group, 50.0% in the PTDM group, 20.0% in the coexistent diabetes group and 44.3% in the control group (p=ns).

CONCLUSION

Patient survival, but not graft survival, was adversely affected by both pre-existing diabetes and by PTDM, particularly in those with an age less than 55 yr.

Outcome for arterio-venous fistula at the elbow for haemodialysis

BACKGROUND

Few studies have examined the outcome of arterio-venous fistulas (AVF) at the elbow for haemodialysis.

METHODS

All AVFs at the elbow created between 1994 and 1998 were identified retrospectively from case notes and the computerised database. Patients were followed until fistula failure, death, or for a minimum of 6 months until June 1999. Life table analysis and Kaplan-Meier actuarial curves with the log rank test were used to assess the influence of age, sex, diabetes, hypertension, heart disease, cerebrovascular disease, use of erythropoietin, aspirin or warfarin, previous insertion of subclavian vein catheter and the levels of haemoglobin and serum albumin on long-term AVF survival.

RESULTS

A total of 137 AVFs (primary procedure in 84 and as a secondary procedure in 53 cases) at the elbow were performed in 130 patients; 7 patients had AVFs attempted at both elbows. The mean age was 56.57 yr with a mean follow-up of 48.54 months. Twenty-two patients died with a functioning AVF, while 7 patients also with a functioning AVF received a renal transplant. Overall 74% of AVF were patent at the end of 1 yr, while 22.5% failed or did not mature immediately after the procedure. Two patients had their AVFs tied off due to steal syndrome. Of the various factors known to affect long-term survival of AVF in patients receiving haemodialysis, only plasma albumin > 35 g/L was associated with poorer long-term patency in our study.

CONCLUSION

Our report supports the view that AVF at the elbow may obviate the disadvantages of AVF at the wrist in elderly patients, females and in diabetics. In this group of patients it may be preferable to create a primary AVF at the elbow rather than the wrist. Patients who have a failed attempt at creating an AVF at the wrist should undergo AVF at the elbow before the placement of a synthetic graft. This strategy will result in saving time and avoid multiple operations. There may also be a reduction in the use of synthetic grafts resulting in cost savings and avoiding the complications associated with synthetic grafts.