Clinical characteristics and preoperative ultrasound parameters related to low patency in radio-cephalic arteriovenous fistulas.

INTRODUCTION: Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). METHODS: A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. RESULTS: Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). CONCLUSIONS: A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.

The hand grip training device: A new therapeutic option in arteriovenous fistula maturation.

INTRODUCTION: Postoperative exercise improves arteriovenous fistula maturation for hemodialysis. However, scarce evidence exists about hand grip device on fistula maturation process. OBJECTIVE: To evaluate the efficacy of a hand grip training program on arteriovenous fistula maturation in population with Chronic Kidney Disease 5-5D. METHODOLOGY: Prospective study (15 months). Patients were randomized to handgrip (HG) or control group (CG) postoperatively. HG performed a training program using a hand grip device. CG received conventional care. Upper limb muscle strength (ULMS), Duplex ultrasonography, and clinical arteriovenous fistula maturation were assessed at 4 and 8 weeks postoperatively. RESULTS: At 8 weeks after fistula creation, upper limb muscle strength was increased only in the handgrip group (from 18 ± 6 to 23 ± 9 kg, p = 0.023). Clinical maturation was significantly greater in handgrip group versus control group, both at 4 weeks after intervention (62% vs 23%, p = 0.004) and at 8 weeks (65% vs 27%, p = 0.004). Similarly, the Doppler ultrasonography maturation rates were significantly greater in the HG, both at 4 weeks (HG: 84% vs CG: 47%; p = 0.004) and at 8 weeks (HG: 89% vs CG: 50%; p = 0.002). CONCLUSIONS: The hand grip is a useful and safety training device to improve the arteriovenous fistula maturation. This device results a new therapeutic option for maturation in arteriovenous fistula, particularly in distal arteriovenous fistula. Further studies are required to support these results.

Upper limb isometric exercise protocolled programme and arteriovenous fistula maturation process.

INTRODUCTION: Arteriovenous fistula (AVF) is the gold standard for vascular access (VA) for end-stage chronic kidney disease (CKD) patients. Post-operative exercises may help to improve maturation. Nevertheless, scarce scientific evidence has been reported about their utility to date. Our objective was to assess the effect of a post-operative isometric exercise programme on native VA maturation in patients with stage 5-5D CKD. METHODS: We performed a 24-month prospective study. After surgery, patients were randomized to the isometric exercise group (EG) or control group (CG). An isometric exercise protocolled programme was performed in the EG. The CG received usual care. Demographic data, muscle strength using a hand-grip (HG) dynamometer, main Doppler ultrasound (DUS) measurements, clinical and DUS maturation and VA complications were assessed at 4 and 8 weeks post-operatively. RESULTS: For 60 sixty patients (30 in the EG), demographic data and HG and DUS measurements at baseline were similar. A significant increase in HG was observed only in the EG at the end of the study (20.7 ± 8.1 versus 25.1 ± 10.3 kg, P = 0.001). The EG obtained the highest clinical maturation at 4 (CG 33.3% versus EG 70%, P = 0.009) and 8 weeks (CG 33.3% versus EG 76.7%, P = 0.002). Similarly, DUS maturation was better in the EG at 4 (CG 40% versus EG 80%, P = 0.003) and 8 weeks (CG 43.3% versus EG 83.3%, P = 0.003) and remained so in the EG for both distal and proximal VA territories for all these periods. CONCLUSIONS: The upper limb isometric exercise protocolled programme improved clinical and DUS maturation in our patients in both the distal and proximal VA territories. Further studies are required to support these results.

Thermotherapy: Improving the vascular access cannulation procedure.

INTRODUCTION AND OBJECTIVES: Vascular access is essential to perform an adequate hemodialysis. Needle cannulation in vascular access is usually painful. There is little scientific evidence on the analgesic effect of thermotherapy. The aim of this study was to evaluate the analgesic effect of thermotherapy on vascular access cannulation. METHODS: We performed a 2-week single center prospective study. Demographic data and vascular access location were collected. The main outcome was pain perceived in vascular access cannulation measured by the visual analog scale. We performed two phases of study: phase I was performed with usual cannulation procedure, and in phase II, we applied local thermotherapy for 15 min (hot packs: 60 s, 600 W). Also, main hemodynamic data, local, and vascular access-related complications were recorded. RESULTS: A total of 34 patients were enrolled, with a mean age of 67.3 ± 16.4 years and 49.1 ± 66.3 months on hemodialysis. Main cardiovascular risk factors are hypertension (81.8%) and diabetes mellitus (39.4%). Most common vascular access is left radiocephalic fistula (45.5%). Mean weekly/patient cannulation is 6.03 ± 0.2. Mean visual analog scale is 3.8 ± 2.4. At the end of the study, thermotherapy on the vascular access revealed a significant decrease in visual analog scale (3.9 ± 2.4 vs 2.6 ± 2.0, p = 0.002), without hemodynamic changes pre- and post-intervention, nor changes in analgesic or antihypertensive treatment. One patient had a mild surface erythema. No further complications related to vascular access were observed. CONCLUSION: (1) Thermotherapy on the vascular access reduced the pain caused by needle cannulation in our patients, without complications related to vascular access. (2) We will consider its clinical application in those painful vascular access cannulations at our hemodialysis unit. (3) Further studies are required to assess other potential beneficial effects added to thermotherapy in vascular access cannulation procedure.

Administration of calcimimetics after dialysis: same effectiveness, better gastrointestinal tolerability.

INTRODUCTION: Cinacalcet has proved effective to control secondary hyperparathyroidism in patients on haemodialysis (HD). Some studies have reported an appropriate secondary hyperparathyroidism control and a better compliance after intradialytic use of calcimimetics. OBJECTIVES: To assess the effect of post-dialysis calcimimetics use on mineral bone disorders and calcimimetics gastrointestinal tolerability in our HD unit. MATERIAL AND METHODS: A 12-week single-centre prospective study in HD patients treated with cinacalcet (>2 months). Two study periods: Usual outpatient use (Stage 1) and use after HD session (Stage 2). ENDPOINTS: 1) Biochemical MBD data; 2) Gastrointestinal Symptom Rating Scale (GSRS) for gastrointestinal tolerability, and visual analogic scale (VAS) for satisfaction; 3) Adherence: Morisky-Green test (MG) and final tablet count (TC). RESULTS: Sixty-two HD patients. Fourteen received cinacalcet (22.5%). TEN patients were included, mean age was 60.9 years; patients had received HD for 80.9 months. Mean Charlson index: 9. Biochemical data: Stage 1 (initial vs. final): Ca 8.8 ± 0.5 vs. 9.1 ± 0.7 mg/dl (p<0.05); P 5.2 ± 0.8 vs. 4.5 ± 1.6 mg/dl, iPTH 360.3 ± 232.7 vs. 349 ± 122 pg/ml. MG: 70%. Stage 2 (initial vs. final): Ca 9.1 ± 0.7 vs. 8.8 ± 0.6 mg/dl; P 4.5 ± 1.6 vs. 4.6 ± 1.3 mg/dl, iPTH 360.3 ± 232.7 vs. 349 ± 122 pg/ml. TC: 89%. GSRS and VAS were better in Stage 2 (GSRS 7.5 ± 5.2 vs. 4.3 ± 1.9; VAS 4.8 ± 2.3 vs. 6.9 ± 2.8). No significant changes were observed in calcimimetic dose (201 vs. 207 mg/wk), number of phosphate binders (9 vs. 8.2 pts/day), native vitamin D (70 vs. 60%), selective vit D receptor activators (30%), or suitable dialysis parameters. CONCLUSIONS: Post-dialysis use of calcimimetic was effective in secondary hyperparathyroidism control, improved gastrointestinal tolerability and ameliorated patients' satisfaction. Based on our findings, post-dialysis use of calcimimetics should be considered in selected patients with low therapeutic compliance.

Administración de calcimiméticos posdiálisis: igual efectividad, mejor tolerancia gastrointestinal / Administration of calcimimetics after dialysis: same effectiveness, better gastrointestinal tolerability

Introducción: Cinacalcet resulta efectivo en el control del hiperparatiroidismo secundario de los pacientes en hemodiálisis (HD). Algunos estudios han reportado un buen control del hiperparatiroidismo secundario y un mejor cumplimiento terapéutico tras la administración de calcimiméticos intradiálisis. Objetivos: Analizar el efecto de la administración de calcimiméticos posdiálisis sobre el metabolismo óseo mineral y la tolerancia gastrointestinal en nuestra unidad de HD. Material y métodos: Estudio prospectivo unicéntrico de 12 semanas de duración en pacientes en HD tratados con cinacalcet (>2 meses). Dos períodos de estudio (6 semanas): Administración habitual ambulatoria (fase 1) y posthemodiálisis (fase 2). Datos analizados: 1.- Datos bioquímicos metabolismo óseo mineral. 2.-Test síntomas gastrointestinales (Gastrointestinal Symptom Rating Scale [GSRS]) y grado de satisfacción (escala visual analógica [EVA]). 3.-Adherencia: Test de Morisky-Green (MG) y recuento final comprimidos (RC). Resultados: Sesenta y dos pacientes en HD. Catorce recibían cinacalcet (22,5%). Diez pacientes incluidos, edad media 60,9 años y 80,9 meses en HD. Charlson medio: 9. Datos bioquímicos: fase 1 (inicio vs. fin): Ca 8,8±0,5 vs. 9,1±0,7mg/dl (p<0,05); fósforo 5,2±0,8 vs. 4,5±1,6mg/dl, PTHi 353±129 vs. 360±232pg/ml. Adherencia (MG): 70%. Fase 2 (inicio vs. fin): Ca 9,1±0,7 vs. 8,8±0,6mg/dl; fósforo 4,5±1,6 vs. 4,6±1,3mg/dl; PTHi 360,3±232,7 vs. 349±122pg/ml. Adherencia (RC): 89%. Con relación al GSRS y el grado de satisfacción, fueron mejores en la fase 2 (GSRS 7,5±5,2 vs. 4,3±1,9; EVA 4,8±2,3 vs. 6,9±2,8). No se objetivaron cambios significativos en la dosis de calcimiméticos (201 vs. 207mg/sem), número captores fósforo (9 vs. 8,2pac/día), vitamina D nativa (70 vs. 60%) o activadores selectivos receptor vitD (30%), ni en los parámetros de adecuación dialítica. Conclusiones: La administración de calcimiméticos post diálisis permitió controlar el hiperparatiroidismo secundario de forma eficaz, mejorando la sintomatología gastrointestinal y el grado de satisfacción. Se debe considerar la administración de calcimiméticos post diálisis en aquellos pacientes con escaso cumplimiento terapéutico (AU)

Introduction: Cinacalcet has proved effective to control secondary hyperparathyroidism in patients on haemodialysis (HD). Some studies have reported an appropriate secondary hyperparathyroidism control and a better compliance after intradialytic use of calcimimetics. Objectives: To assess the effect of post-dialysis calcimimetics use on mineral bone disorders and calcimimetics gastrointestinal tolerability in our HD unit. Material and methods: A 12-week single-centre prospective study in HD patients treated with cinacalcet (>2 months). Two study periods: Usual outpatient use (Stage 1) and use after HD session (Stage 2). Endpoints: 1) Biochemical MBD data; 2) Gastrointestinal Symptom Rating Scale (GSRS) for gastrointestinal tolerability, and visual analogic scale (VAS) for satisfaction; 3) Adherence: Morisky-Green test (MG) and final tablet count (TC). Results: Sixty-two HD patients. Fourteen received cinacalcet (22.5%). TEN patients were included, mean age was 60.9 years; patients had received HD for 80.9 months. Mean Charlson index: 9. Biochemical data: Stage 1 (initial vs. final): Ca 8.8±0.5 vs. 9.1±0.7mg/dl (p<0.05); P 5.2±0.8 vs. 4.5±1.6mg/dl, iPTH 360.3±232.7 vs. 349±122 pg/ml. MG: 70%. Stage 2 (initial vs. final): Ca 9.1±0.7 vs. 8.8±0.6mg/dl; P 4.5±1.6 vs. 4.6±1.3mg/dl, iPTH 360.3±232.7 vs. 349±122 pg/ml. TC: 89%. GSRS and VAS were better in Stage 2 (GSRS 7.5±5.2 vs. 4.3±1.9; VAS 4.8±2.3 vs. 6.9±2.8). No significant changes were observed in calcimimetic dose (201 vs. 207mg/wk), number of phosphate binders (9 vs. 8.2 pts/day), native vitamin D (70 vs. 60%), selective vit D receptor activators (30%), or suitable dialysis parameters. Conclusions: Post-dialysis use of calcimimetic was effective in secondary hyperparathyroidism control, improved gastrointestinal tolerability and ameliorated patients’ satisfaction. Based on our findings, post-dialysis use of calcimimetics should be considered in selected patients with low therapeutic compliance (AU)