Dialysis Withdrawal: Impact and Evaluation of a Multidisciplinary Deliberation Within an Ethics Committee as a Shared-Decision-Making Model.

Since dialysis withdrawal in maintenance dialysis patients with limited life expectancy results always in short-term death, nephrologists need a referenced process to make their decision. This study reviews 8 years of operation of an Ethics Committee in Nephrology (ECN). The ECN, within a multidisciplinary team, once a month explores cases reported by caregivers when maintaining dialysis seems not to be in the patient's best interest. Discussion is required when the vital prognosis is engaged by the evolution of the chronic kidney disease (CKD) or the occurrence of an acute medical event. Data are analyzed using a discussion guide. The informed decision is completed with an appropriated palliative care project involving the patient, and recorded in their file. Since 2006, the ECN has deliberated yearly for 10 sessions on 6-18 cases, concerning 380 identified maintenance dialysis patients. Characteristics of the population, cases, sessions and proposals are recorded and analyzed. The only variable associated with dialysis withdrawal was having at least one new comorbid condition. End of life is supported with the help of the palliative care team in the hospital or exceptionally at home. The ECN, through a multidisciplinary deliberation and resolution process, proposes an ethical shared-decision-making model ensuring that dialysis withdrawal follows professional guidelines, and is registered as a method for evaluating professional practice (EPP). Annual activity reports are submitted to the Hospital's Medical Evaluation and Quality Unit. Benefits are individual and collective for patients, relatives and caregivers. Prospects for reducing non-implemented decisions and identifying cases earlier would improve the Committee effectiveness.

Vascular access-induced hand ischemia: risks and safe management.

Hand ischemia is rare but complex and multifactorial. Distal arteriopathy below the vascular access (VA) is responsible in the vast majority of patients and not a problem of high flow of the VA. Therefore, surgical technique should focus on improving blood flow and pressure instead of reducing blood flow. We present an overview of the standard techniques which are recommended to treat VA-induced hand ischemia. The banding techniques, most of which empirical and not codified, have been abandoned by the majority of the authors because of a high rate of failure and reintervention. Ligation may be necessary in patients with severe ischemia and diffuse arterial lesions and in case of ischemic monomelic neuropathy.

[Ethics consultation unit in nephrology (UCEN): review of 10 years of operation in the Grenoble area]. / Unité de concertation éthique en néphrologie (UCEN) : bilan de fonctionnement à dix ans sur le bassin grenoblois.

The existence of an ethics consultation unit in nephrology (UCEN) gives to the nephrologist the collegiality required to meet the difficulties of therapeutic choice on a legislative level, particularly in indications of stop dialysis. The discussion conducted, outside the emergency, is guided by a tool for reflexion that details successive steps necessary to the identification of elements required for decision-making. Thanks to complementary skills provided by the participants and training acquired, the UCEN can approach other ethic issues encountered during practice such as contrindication for a kidney transplantation or maintenance of conservative treatment, or performing invasive procedures on patients refusing transfusion. Propositions are not always relevant due to opposition or ambivalence of some patients, their relatives, an external or disagreements between teams or a mismatch between the technical and the patient's condition. These non-conformities decrypted always have an explanation, sometimes they are understood and accepted by the teams, and sometimes they became source of regrets when they extend life in very poor conditions. The UCEN, if it does not solve every single point, remains a place and a time of sharing that face difficult situations, help the nephrologist positioning himself on maintaining treatments that were first to avoid and prevent the realization of unreasonable acts and accept their limits.

Treatment of hand ischemia following angioaccess surgery using the distal revascularization interval-ligation technique with preservation of vascular access: description of an 18-case series.

Hand ischemia is a rare complication of angioaccess surgery for hemodialysis. Management usually requires ligation of the arteriovenous fistula (AVF). The purpose of this report is to describe our experience with the use of the distal revascularization interval-ligation (DRIL) technique for treatment of ischemia without ligation of the AVF. From January 1999 to September 2002, the DRIL technique was used to treat 18 patients (10 men, 8 women, 10 diabetic patients) with severe paresthesia of the hand (n = 9) and finger necrosis (n = 10). The AVF was located at the elbow in 16 patients and at the wrist in 2 patients. Mean flow distal to the AVF was less than 10 mL in 5 patients, less than 5 mL in 10, and unmeasurable in 3. The conduit used for all DRIL arterial bypasses, including 15 brachiobrachial bypasses, 1 axillobrachial bypass, 1 brachioradial bypass, and 1 radioradial bypass, was the great saphenous vein graft. Trophic manifestations required finger amputation in five patients, pulpar necrosis resection in four, and transmetacarpal amputation of the index finger in one patient. Symptoms disappeared in 13 patients (73%) and improved in 5 (27%). The time required for healing of finger amputations and trophic manifestations ranged from 15 days to 2 months. Mean arterial flow through the DRIL bypass was 50 mL/min (range, 20-90 mL/min). With a mean follow-up interval of 16 months (range, 5-48 months), primary patency of the DRIL artery bypass and AVF was 94% and the limb salvage rate was 100%. The DRIL technique is the most effective procedure for treatment of angioaccess-induced hand ischemia. This technique can be used to achieve persistent relief of symptoms with continued access patency. The DRIL artery bypass improves vacularization of the hand, and ligature of the artery stops the vascular steal without affecting hemodialysis access. The DRIL technique should be proposed as first-line treatment for hand ischemia due to AVF for hemodialysis.