Protected: The new frontier in endovascular treatment of arteriovenous fistula stenosis: the role of ultrasound-guided percutaneous transluminal angioplasty

Abstract

Native arteriovenous fistula is the preferred vascular access because of it does not usually cause infections and seems to be closely related with prolonged patient survival, compared to prosthetic grafts and central venous catheters; it also is cost effective. Venous stenosis is one of the main causes of AVF failure. It is caused by a number of upstream and downstream events. The former group comprises hemodynamic and surgical stressors, inflammatory stimuli and uraemia, while downstream events involve the proliferation of smooth muscle cells and myofibroblasts and the development of neo-intimal hyperplasia. Percutaneous transluminal angioplasty is the gold standard for arteriovenous fistula stenosis. It allows the visualization of the whole vascular circuit and the immediate use of the vascular access for the next dialysis session. Ultrasound-guided percutaneous endovascular angioplasty is a feasible and safe alternative to conventional fluoroscopic technique: it is equally effective in treating arteriovenous fistula stenosis, but it presents the advantage of not using contrast media or ionizing radiation. The aim of this review is to report the latest evidence on cellular and molecular mechanisms that contribute to the development of neo-intimal hyperplasia, as well as the current and future therapeutic perspectives, especially concerning the use of anti-proliferative drugs, and the efficacy of the ultrasound-guided angioplasty in restoring and maintaining the vascular access patency over time.

Key words: Percutaneous angioplasty, ultrasound, arteriovenous fistula, hemodialysis, stenosis.

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Retroperitoneal renal hemorrhage: experience of our dialysis center

Abstract

The aging of the uremic population, the increasingly common use of anticoagulants, antiplatelet agents e heparin, during hemodialysis, can expose our patients to a greatest risk of bleeding. Spontaneous retroperitoneal hematomas are a fairly rare and potentially fatal condition.
We describe 5 clinical cases of retroperitoneal hemorrhage that we observed during 10 years in our department, focusing on modalities of symptom onset, clinical-laboratory picture and treatment modalities

Keywords: Retroperitoneal hemorrhage, hemodialysis

Sorry, this entry is only available in Italian.

Microbiological quality of hemodialysis water: what are the risk factors?

Abstract

Background A dialyzed patient weekly gets in touch with a large amount of water (on average 350 liters) through the dialysis bath. It is therefore essential that this solution would have a high quality and purity. The aim of our study was to monitor the microbiological quality of the hemodialysis water in order to identify possible factors that could affect it.

Methods We conducted a cross-sectional study from January 2015 to October 2017 collecting the dialysis water in AOU Careggi. Samples were aseptically collected by specialized technicians and then transported under ice at 4 ° C to the Laboratory of Biological Hazards of USL Toscana Centro for laboratory analyses.

Results 126 water samples were collected. Coliforms, E. coli, Staphylococcus aureus, enterococci were not detected. Pseudomonas aeruginosa was found in only one sample. Both for CFU at 37 ° C and at 22 ° C, the type of device represented the only statistically significant risk factor (OR 15.21 and OR 10.25 respectively): SDS devices had a significantly higher risk of being positive for CFU at 37 ° C and 22 ° C.

Conclusions As our study demonstrated, the system producing dialysis water must be constantly monitored, especially in cases of SDS devices which may be subjected more frequently to a higher contamination, due to their discontinuous use.

 

Keywords: surveillance, hemodialysis, infections

Sorry, this entry is only available in Italian.

Case of sialadenitis by iodinated contrast medium in a dialysis patient

Abstract

Background
Sialadenitis by iodinated contrast medium (i.c.m) or iodine mumps (IM) is a rare and late benign manifestation that occurs independently of intravenous or endoarterial administration modality. If renal function is normal, i.c.m. does not reach salivary glands concentrations able to induce sialadenitis. However, a critical glomerular filtration reduction may lead to salivary ducts edema and glandular swelling after i.c.m. injection. We report a rare case report of IM in a patient on chronic hemodialysis.
 
Methods
A 72-year-old woman affected by chronic kidney disease on chronic hemodialysis, underwent to endoscopic removal of a rectal cancer. For disease staging, a total body TC with i.c.m. was performed. The following morning, patient showed a soft and aching bilateral paroditidis swelling. Salivary glands ultrasound was diagnostic for sialadenitis. The patient was rapidly treated with betamethasone following by a 240 minutes post-dilution online hemodiafiltration session.
 
Results
Within the next 24h, a complete remission of IM was obtained.
Conclusion
In our patient, a compensatory hyperactivity of the sodium / iodine symporter (NIS) on salivary gland cells may have played a crucial role in IM induction. An high efficiency hemodialysis session within the few following hours after i.c.m injection is a fundamental tool in patients on renal replacement treatment to prevent IM that is an epiphenomenon of i.c.m. accumulation.

 

Keywords: Iodine mumps, chronic kidney disease, hemodialysis, iodine contrast medium, corticosteroids.

Sorry, this entry is only available in Italian.

Clinical practice for the diagnosis of cardiac arrhythmias in patients on renal replacement therapy: data from a Lombard survey

Abstract

Among dialysis patients, 40% of deaths are due to cardiovascular causes, and 60% of cardiac deaths are due to an arrhythmia. The purpose of this survey, carried out with the organizational support of the Lombard Section of the Italian Society of Nephrology, is to evaluate the frequency and mode of use of non-invasive instruments for the diagnosis of cardiac arrhythmias in the dialysis centers of Lombardy. Information on the prevalence and type of cardiac devices at December 1, 2016 in this population was also required. Data from 18 centers were collected for a total of 3395 patients in replacement renal therapy, including 2907 (85.6%) in hemodialysis and 488 (14.4%) in peritoneal dialysis. All centers use the 12-lead ECG in case of evocative symptoms of an arrhythmic event and 2/3 perform the exam with programmed cadence (usually once a year). Twenty four-hour ECG Holter is not used as a routine diagnostic tool. The proportion of cardiac devices is relatively high, compared to literature data: n=259, equal to 7.6% of the population. Pace-Maker patients are 166 (4.9%), those with intracardiac defibrillator 52 (1.5%), those with resynchronization therapy 18 (0.5%) and those with resynchronization therapy and intracardiac defibrillator 23 (0.7%). The survey provides interesting information and can be an important starting point for trying to optimize clinical practice and collaboration between nephrologists and cardiologists in front of a major problem like that of arrhythmic disease in patients on renal replacement therapy.

KEYWORDS: Arrhythmias, haemodialysis, peritoneal dialysis, electrocardiogram, echocardiogram, cardiac devices.

Sorry, this entry is only available in Italian.

Uremic Toxins: how can we improve the removal today?

Abstract

Uremic status results from a malfunctioning of kidneys due to the accumulation of compounds which, under normal conditions, are excreted or metabolized by the kidneys. If these compounds are biologically active, they are called uremic toxins. Such compounds have toxic effects on the cardio-vascular system. An useful classification, published by the European Uremic Toxin Work Group (EUTox) is: 1) small water-soluble compounds; 2) protein-bound compounds; 3) the larger “middle molecules”.

High-flux membranes and more efficient treatment techniques, like HDF, improve the removal of uremic toxins in the middle molecular-weight range, and recent studies suggest that these strategies have better results on the morbidity and mortality.

Today new membranes, medium cut-off membranes (MCO), with increased pore size, allow for the removal of higher molecular-weight toxins, such as kappa and lambda light chains and/or mediators of inflammation. For toxins in the 15 to 45 KD-size range, MCO membranes improve the removal in comparison with high-flux HD and/or HDF. Therefore MCO membrane simplifies the treatment of HD patients with a removal spectrum that extend the current possibilities of the best available therapies for End Stage Renal Disease.

Keywords: Uremic toxins, Middle molecules, High-flux membranes, Medium cut-off membranes, Hemodialysis, Hemodiafiltration

Sorry, this entry is only available in Italian.

Update on proteomic use in hemodialysis

Abstract

Application of proteomics has become one of the leading experimental disciplines for increased understanding of the key role played by proteins and protein–protein interactions in all aspects of cell function. There is an increasing use of proteomic technologies for investigation into renal replacement therapy such as hemodialysis. In the last 10 years, the application of shotgun bottom-up liquid chromatography-mass spectrometry/mass spectrometry approaches has been successfully applied to research in uremic toxicity, with the discovery of novel uremic toxins and the potential to delineate a precise molecular approach to defining the biochemical nature of uremia.
Major investigations of proteomics in hemodialysis therapy include molecular definition of uremic toxicity, identification of prognostic biomarkers, blood purification efficiency testing, and biocompatibility assessment of the dialyzer membrane materials.
In this article, we review the results of recent proteomic investigations in the setting of chronic hemodialysis therapy.

KEY WORDS: Proteomic, hemodialysis, membrane, uremic toxins, biocompatibility, adsorption, proteins.

Sorry, this entry is only available in Italian.

Taste disorders in patients with end-stage chronic kidney disease

Abstract

The authors aimed to explore taste distortion in patients with chronic kidney disease (CKD). One hundred and four patients were divided into a control group and a study group. The data was collected through a questionnaire and was statistically analyzed. The results showed that 28.7% of respondents had a loss of taste (96.60% CKD patients). There was a statistically significant correlation between the duration of treatment and taste loss, between patients’ age and taste impairment, and between patients’ age and the sense of a metallic taste in the mouth. Distortion in the sense of taste is an oral manifestation characteristic of CKD patients.

KEYWORDS: CKD, hemodialysis, metallic taste, oral manifestations, taste disorders.

Introduction

As a result of their treatment patients with end-stage chronic kidney disease commonly display characteristic oral manifestations such as taste alteration, taste loss, dry mouth, etc. [1,2,3,4,5]. They are usually the consequence of metabolic and physiological disturbances inherent to the disease. Dental literature provides evidence of the relationship between the duration of the dialysis treatment and the development of oral lesions [1, 6]. In a 2012 survey Asha [7] reported that high levels of urea, dimethyl and trimethyl amines and low levels of zinc might be associated with decreased taste perception in uremic patients. The cause of a metallic taste in uremic patients was reported to be due to urea content in the saliva and its subsequent breakdown to ammonia and carbon dioxide by bacterial urease [7]. Taste disorders (dysgeusia) are also often associated with ageusia, which is the complete lack of taste, and hypogeusia, which is a decrease in taste sensitivity [8, 9, 10].

Dysgeusia (taste disorder) is a taste disturbance associated with the distorted perception of taste or a persistent sense of taste in the absence of taste stimuli. These changes could lead to food aversion, reduced food intake and nutritional deficiencies, ultimately causing weight loss and in more severe cases malnutrition, weakness, fatigue [8]. The nutritional status is subsequently affected as there are reports of a correlation between taste distortion and low levels of serum albumin, creatinine, protein and sodium intake, chest measurements and the increased need for enteral nutrition. Furthermore, latest studies show that altered taste perception is associated with 17% higher rate of mortality, although not with increased rate of hospitalization [9].

There are objective methods for testing taste impairment. Gustometry involves the use of various substance, such as citric acid, caffeine, sucrose and others, where after each taste stimulus the oral cavity is to be rinsed. Another method of research is electrogustometry, which applies current of low-intensity (μA) over the dorsum of the tongue, designed to activate trigeminus nerve endings [11, 12]. Subjective test methods include questionnaires, interviews, etc. They are suited for patients who have undergone a long-term dialysis treatment, mostly due to their dependence on the dialysis machine, the observation of a strict diet and the negative impact on the mental equilibrium of patients. Recent years have seen the development of much used validated screening questionnaires [10, 11].

 

Objective

To explore distortion of the taste sense in patients with end-stage chronic kidney disease (CKD) on renal replacement therapy (RRT).

 

Material and methods

The clinical study was approved by the Research Ethics Committee at the Medical University of Varna with Protocol No. 55/ 16 June 2016. It involved 104 patients (61 female patients – 58.65% and 43 male patients – 41.35%), aged 46.9 ± 21.2 years (with the youngest participant being 19 years old and the oldest – 80 years old). The patients were divided into 2 groups: a Control group, involving 34 participants without any common diseases and a Study group of 70 patients in end-stage chronic kidney disease. The Study group patients were provisionally divided according to the duration of their chronic dialysis treatment into 2 subgroups:   5-year Treatment group and Over 5-year Treatment group.

All participants signed an Informed Consent after being informed in detail of the purpose and terms of participation in the study. The data was collected through a questionnaire, consisting of a basic section (name of participant, gender, and age) and three questions related to the subjective sense of taste, experienced by the CKD patients:

  1. Can you feel any loss of taste?
  2. Can you feel a metallic taste in your mouth?
  3. Can you feel any taste alteration?

The answering options needed to be either Yes or No. The accurate and truthful representation of the data collected was entrusted to the good faith of patients.

The statistical evaluation of results was carried out using SPSS software package for epidemiological and clinical data analysis (V. 17.00). Non-parametric statistical methods were applied to verify statistical hypotheses (chi-square test for independence), as well as cross tabulation, calculating relative distributions, graphical representation of data, etc.

 

Results

The analysis of question 1 (Can you feel any loss of taste?) showed that 28.70% of respondents had returned the unfavorable answer Yes, where 96.60% belonged to the Study group of CKD patients and only 1 patient from Control group responded positively. The remaining 71.30% of patients had marked No as an answer to that question. According to expectations, the negative answer was provided by 97.10% of representatives of the Control group and by only 58 CKD patients (20%). The chi-square test of independence  incorporating Yates’s  correction for continuity showed that there was a statistically significant correlation between the patients’ group and the taste loss perception ( χ2 (1, n = 101) = 14.78, p <0.001, phi = 0,41).

It was interesting to observe that to question 2 (Can you feel a metallic taste in your mouth?) positive answer was given solely by CKD patients (22 respondents, 21.20% of all patients surveyed) (Table 1).

More than 1/3 of CKD patients (31.40%) confirmed that they felt a metallic taste in the mouth. This percentage is relatively high in the CKD group since taste buds adapt slowly and depend on the concentration of dissolved ions in the saliva, produced as by-products as a result of the treatment of patients. As expected, no participant from the Control group responded positively to this question.

The statistical analysis of the dependence between patients’ group and the subjective perception of a metallic taste confirmed the presence of a statistically significant correlation (χ2 (1, n = 104) = 11.734, p = 0.001, phi = 0.36).

Similar results were obtained in the distribution of the answers to question 3 (Can you feel any taste alteration?). More than half of all respondents (61.50%) replied negatively, whereas 38.50% (40 patients) gave a positive answer. The relative proportion of CKD patients who indicated Yes as an answer was 52.90%, as opposed to 47.10% who replied with a No . Within the Control group the Yes/No distribution was 8.80%/ 91.20%, respectively. The positive answer was selected by 92.50% of CKD patients and by only 7.50% of participants from the Control group. It is safe to conclude that the sense of taste alteration can be manifested also in healthy patients however less frequently and among fewer of them. Taste detection thresholds vary widely across individuals. They are determined not only by the concentration of the food substance but also by food temperature. The data obtained confirmed that CKD patients experienced change in taste as a typical oral manifestation.

The chi-square test of independence  incorporating Yates’s  correction for continuity showed that there was a statistically significant correlation between the patients’ group and the subjective perception of loss of taste (χ2 (1, n = 104) = 16.93, p <0.001, phi = 0.43) (Figure 1).

 

As shown in Fig. 1 none of the patients in the Control group felt a metallic taste in the mouth and only 8% (1 or 2 patients) reported taste alteration or a loss of taste. When using subjective methods for measuring taste, the distinctions in the intensity of separate tastes can be elusive for a person to detect. It is well known that at least 30% change in the concentration of a substance is often needed in order to register a difference in the intensity of gustatory stimuli [13, 14]. Certain flavors are known to alter the taste sense itself, for example, acids can reduce the sweetness of sucrose, fructose, and NaCl dulls sweet taste sensitivity [15].

The nature of kidney disease and its treatment cause different substances in various quantities to dissolve in the oral fluids, which in turn trigger the trigeminal chemoreceptor cells and stimulate the microvilli on the taste buds. The mechanisms are not fully grasped. This accounts for the research into other factors that may lead to taste distortions in CKD patients:

Duration of treatment: The results showed that the duration of the disease did not affect taste alteration and the subjective perception of a metallic taste in the mouth (χ2 (1, n = 70) = 0, p = 1.00, and χ2 (1, n = 70) = 0.066, p = 0.797, respectively). However, there was a statistically significant correlation between the duration of treatment and the subjective perception of taste loss: χ2 (1, n = 70) = 5.84, p = 0.02, phi = 0.326.

When examining the dependencies between taste alteration and the sense of a metallic taste, a very strong statistically significant correlation was established: χ2 (1, n = 70) = 25.922, p <0.001, phi = 0.639. The analysis revealed that CKD patients most often associated taste change with a metallic taste. As seen in Table 2, all patients (100%) who responded positively to the question 3 (Can you feel any taste alteration?) also admitted having a metallic taste in the mouth.

Gender: The results indicated that there was no statistically significant correlation between the patient’s gender and the subjective perception of a metallic taste: χ2 (1, n = 70) = 2.6, p = 0.11. The same applied for the dependency between the patient’s gender and the subjective sense of taste alteration: χ2 (1, n = 70) = 3.38, p = 0.07.

Age: The effects of patients’ age on the subjective perceptions of taste were also examined. Patients were divided into groups according to WHO age classification [16]. The results from the chi-square test of independence revealed strong statistically significant correlations between the Age group and taste alteration (χ2 (1, n = 70) = 39.528, p <0.001, phi = 0.751), as well as between the Age group and the sense of a metallic taste (χ2 (1, n = 70) = 42.319, p <0.001, phi = 0.778). The results obtained by cross-tabulation showed that 88.30% of patients, who reported any taste distortion, were young or middle-aged. All 10 patients in older age had not registered any taste alteration. Similar results were observed on the correlation between the Age group and the sense of a metallic taste. 95.50% patients, who experienced a metallic taste in the mouth, were young or middle-aged. Likewise, none of the older patient had reported of a metallic taste. Such dependencies, which are often observed for certain phenomena of the visual system, can be explained with age-related transformations and are due to the central neuronal interactions [17, 16].

 

Discussion

Taste receptors belong to the group of contact chemoreceptor cells. They play an important role in the selection of food and the regulation of the digestive system [18]. It is well known that nutritional status has a significant impact on the overall health and the quality of life in patients with systemic diseases [19]. This shifts the scientific interest towards the study of taste distortion in CKD patients, who exhibit variations in the type and concentration of ions dissolved in the saliva as a result of the disease and chronic dialysis treatment. There are further studies on the low level of zinc in the blood and the taste impairment in CKD patients, undergoing hemodialysis, which cannot be corrected through interventional treatment methods [20].

The correlation between the subjective sense of taste distortion in CKD patients and that of Control group patients proved the critical role of kidney disease as a contributing factor for taste alteration: (χ2 (1, n = 104) = 16.93, p <0.001 , phi = 0.43). It was established that the duration of treatment did not affect taste sense, ether metallic or altered taste (χ2 (1, n = 70) = 0.066, p = 0.797). However, over time CKD patients reported a loss of taste (χ2 ( 1, n = 70) = 5.84, p = 0.02, phi = 0.326).

Strong statistically significant relationships were observed between patients’ age and taste alteration (χ2 (1, n = 70) = 39.528, p <0,001, phi = 0.751), and between their age and the sense of a metallic taste (χ2 (1, n = 70) = 42.319, p <0.001, phi = 0.778). CKD patients at a younger or middle age proved to be more sensitive to taste alterations compared to older patients.

 

Conclusions

Taste impairment is regarded as a characteristic oral manifestation observed in CKD patients.  Since the mechanism behind taste receptors has not been fully grasped, research interest should be directed towards the effects of taste distortion on the body’s digestive cycle and subsequently on nutritional deficiencies. The issue is particularly relevant owing to its relationship to the quality of life of CKD patients.

 

References

  1. Block GA, Martin KJ, deFrancisco AL. Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med 2004;350:1516–1525.
  2. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician 2010;82:1381-1388.
  3. Souza CM, Braosi A, Luczyszyn S.et al. Oral health in Brazilian patients with chronic renal disease. Rev Méd Chile 2008; 136: 741-746.
  4. Nenova- Nogalcheva А, Konstantinova D. Halitosis in Patients with End-Stage Chronic Kidney Disease Undergoing Chronic Dialysis Treatment. 2016; 5(12):875-878.
  5. Sobrado MJS, Tomás CI, Loureiro A et al. Oral health status in patients with moderate-severe and terminal renal failure. Med Oral Patol Oral Cir Bucal. 2007;12(4):E305-10.
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  10. Beberashvili I, Azar A, Sinuani I, Yasur H, Feldman L. et al. Objective Score of Nutrition on Dialysis (OSND) as an alternative for the malnutrition-inflammation score in assessment of nutritional risk of haemodialysis patients. Nephrol Dial Transplant 2010; 25(8):2662-71.
  11. Oliveira CM, Kubrusly M, Mota RS, Silva CA, Choukroun G, Oliveira VN. The phase angle and mass body cell as markers of nutritional status in hemodialysis patients.J RenNutr. 2010; 20(5):314-20.
  12. Schiffman SS. Taste and smell in disease. NEnglJ Med.1983;308:1275-12791, 337-1343.
  13. Mott A, Leopold D.Disorders in taste and smell. Medical Clinics of North America1991;75(6):1321-1353.
  14. Stillman JA, Morton RP, Hay KD, Ahmad Z, Goldsmith D. Electrogustometry: strenghts, weaknesses, and clinical evidence of evidence of stimulusboundaries. Clin Otolaryngol Allied Sci. 2003;28(5):406-10.
  15. Klimacka-Nawrot E, Suchecka W. Methods of taste sensitivity examination. 2008, 61(7-9):207-10.
  16. Barrett KE, Barman SM, Boitano S, Brooks HL.Ganong’s Review of Medical Physiology. 2010, 23rd Edition, 451 – 469.
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Superior Cava Vein stenosis in a hemodialysis patient with long-term central venous catheter and vascular graft: a case report

Abstract

Recently, the use of central venous catheters (CVC) as a vascular access in patients undergoing hemodialysis is significantly increased, mainly because of the aging of this population and the presence of several comorbidities. However, the implantation and the long stay of CVC are associated with many complications. Among them, central venous stenosis represents one of the most common problems that, if not properly diagnosed, could lead to vascular thrombosis and consequent vascular access malfunction.
Here, we report a case of a 38-year-old patient, who underwent hemodialysis firstly by a CVC long-term into right jugular vein and then by a prosthetic fistula in the ipsilateral limb. The patient presented many episodes of vascular access thrombosis that required endovascular interventions. The ultrasound screening and CT-angiography revealed an asymptomatic stenosis of the superior cava vein, which treatment with the implantation of vascular stent resulted in an initial improvement of vascular access performance. However, in the following months, a restenosis was observed that required new interventions to reestablish a satisfactory vascular access function.
This case highlights that patients on hemodialysis should undergo proper clinical and instrumental follow-up in order to prevent or early recognize vascular access complications.

KEYWORDS: echocolordoppler, hemodialysis, vascular access, graft.

Sorry, this entry is only available in Italian.

Vascular calcifications in subjects with and without chronic renal failure: types, sites and risk factors

Abstract

Vascular calcifications worse outcomes in the general population and in patients on dialysis

We investigated 146 patients on chronic hemodialysis and 63 healthy controls with normal renal function under 65 years of age. All subjects underwent B-mode ultrasonography of common and internal carotid artery, abdominal aorta, common and superficial femoral artery and posterior tibial artery to assess the presence of intimal and medial calcifications.

Intimal and media calcifications were present at the level of the carotid vessel, the abdominal aorta, the common femoral artery, the superficial femoral artery and the posterior tibial artery, respectively in 45%, 50%, 45%, 50%, 42% of patients on dialysis and in 5%, 15%, 24%, 5%, 2% of controls (p <0,01).

On multivariate logistic analysis of regression, after adjustment for potential confounders,    carotid intimal calcification, abdominal aortic calcification, medial calcification of the superficial femoral artery and posterior tibial artery calcification were associated with dialysis and with cardiovascular disease. Only intimal arterial calcification were associated with older age and smoking.

Vascular calcifications are extremely common in middle-aged patients on chronic hemodialysis. Ultrasonography currently available in Nephrology, is a sensitive, reproducible, inexpensive imaging technique to identify arterial intimal and medial calcification in high-risk cardiovascular subjects.

Key words: arterial calcifications, arterial intimal calcifications, arterial media calcification, chronic renal failure, hemodialysis, vascular calcifications

Sorry, this entry is only available in Italian.