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.

Are continued policies of prioritizing native vascular access in patients on hemodialysis programs useful?

The guidelines recommend establishing native vascular access as opposed to prosthetic or catheter-based access despite information relating to its effectiveness being scarce from a patient-orientated perspective. We analyzed the effectiveness of a continued policy of native vascular access (CPNVA) in patients undergoing hemodialysis. A retrospective, observational study, including 150 patients undergoing hemodialysis between 2006 and 2012 at our center, and who underwent a CPNVA. Statistical analysis was based on treatment intention. In 138 patients (92%), the first useful access (FUA) was native, and in 12 patients (8%), it was prosthetic. In 50 patients (33.3%), more than one procedure had to be carried out in to order to achieve FUA. The probability of dialysis occurring via a FUA was 67.1% and 45.3% at 1 and 5 years respectively. Over the follow-up period (mean time = 30 months), 84 patients (56%) required repairs or new access, extending the effectiveness of the CPNVA to 88.3% and 73.2% at 1 and 5 years respectively. The effectiveness of the CPNVA was reduced if the patient: required a catheter initially (HR: 3.6, p = 0.007); in cases of initially elevated glomerular filtration rate (HR: 1.1, p = 0.040); in cases of history of previous access failure before FUA (HR: 3.9, p = 0.001); and in female patients (HR: 2.4, p = 0.031). The long-term effectiveness of a CPNVA is high. However, the percentage of patients requiring diverse procedures in order to achieve FUA and the need for re-interventions yield the necessity to optimize preoperative evaluation and postoperative follow-up.

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.

Elderly patients, isometric exercise, and native vascular access maturation: An unsolved question?

INTRODUCTION: The number of elderly patients undergoing hemodialysis is steadily increasing. The choice and management of vascular access (VA) in these patients are difficult, and the role of postoperative isometric exercises on native VA maturation in the elderly population is not clearly established. OBJECTIVES: To assess the effect of postoperative isometric exercises on native VA maturation in patients older than 75 years with advanced chronic kidney disease. METHODOLOGY: This was a randomized single-center study over a 24-month period. Postoperative isometric exercises were performed in the exercise group (EG), while the control group (CG) received usual care. Demographic data, muscle strength (using handgrip [HG] dynamometer), Doppler ultrasound (DUS), incidence of VA complications, and clinical and DUS maturation were assessed at 4 and 8 weeks. RESULTS: A total of 27 patients were included (EG: 14, CG: 13). The mean age of the patients was 79.9 ± 2.8 years; 74.1% were men, and 59.2% had radiocephalic VA. Demographic data, HG, and DUS measurements were similar at baseline. DUS measurements significantly increased in both groups at the end of the study. A significant increase in HG (19.1 ± 7.8 kg vs. 22.9 ± 9.7 kg, P = 0.001) and the highest clinical (CG vs. EG: 46.2% vs. 78.6%; P = 0.049) and DUS maturation (CG vs. EG: 30.8% vs. 71.4%; P = 0.041) were observed in the EG at 8 weeks. Globally, medical or surgical VA complications were lower in the EG and mainly included significant stenosis (CG vs. EG: 23.1% vs. 7.1%), although no significant differences were observed. CONCLUSIONS: Once a native VA is indicated in elderly patients, postoperative isometric exercise should be considered in order to improve the odds of achieving a mature functional arteriovenous fistula. Further studies are required to support our findings in this population.

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.

Benefits of a low intensity exercise programme during haemodialysis sessions in elderly patients.

BACKGROUND: Elderly patients on haemodialysis (HD) are a steadily increasing group. They show a high complexity, dependency and comorbidity. Multiple benefits from exercise in HD patients have been reported; however, they have not been specifically evaluated in an elderly population. OBJECTIVE: To assess the effect of an adapted low intensity intradialytic exercise programme on muscle strength, functional capacity and health-related quality of life in our elderly patients (> 80 years) on HD. MATERIAL AND METHODS: HD patients were non-randomly assigned to an exercise training group (E) or a control group (C) in a 12-week single-centre prospective study. E included a combined exercise programme using balls, weights, elastic bands and cycle movements in the first 2 hours of HD sessions. C group patients received standard HD care. Endpoints were: 1) main biochemical data; 2) maximum quadriceps length strength (MQLS) and hand-grip (HG); 3) functional capacity tests: "Sit to stand to sit" (STS10) and "six-minutes walking test" (6MWT); 4) Beck Depressive Inventory (BDI); and 5) Health-related quality of life questionnaire: EuroQol-5D (EQ-5D). RESULTS: A total of 22 patients were included (50% men). Mean age was 83.2 years; patients had received HD for 44.1 month. Charlson index was 9.5. Main aetiology was diabetes mellitus (36.4%). Eleven patients were assigned to E group and 11 to C group. No related adverse effects were observed. At the end of the study, E group showed an overall improvement in tests (*P<.05): MQLS 10.5 ± 7.6 vs. 12.9 ± 10.1 kg, HG* 16.6 ± 8.7 vs. 18.2 ± 8.9 kg, STS10* 29.9 ± 10.6 vs. 25 ± 7.87 sec, 6MWT* 14.6%, 234.4 vs. 274.7 m, BDI* 14.4 ± 11.5 vs. 11.7 ± 10.8 and EQ-5D 49 ± 19.1 vs. 59.5 ± 20.3. No similar changes were observed in C group. Significant differences between groups were also found for HG, MQLS, STS10, 6MWT, BDI and EQ-5D. No significant changes were found in biochemical and anthropometric data, antidepressant treatment or suitable dialysis parameters at the end of the study. CONCLUSIONS: 1) An adapted low intensity exercise programme improved muscle strength, functional capacity and health-related quality of life in our elderly patients on HD. 2) Our results highlight the benefits from exercise in HD patients even in this elderly population. 3) In elderly patients on HD, it is worth considering an adapted low intensity intradialytic exercise programme as a part of a comprehensive care.

Beneficios del ejercicio físico de baja intensidad durante la sesión de hemodiálisis en el paciente anciano / Benefits of a low intensity exercise programme during haemodialysis sessions in elderly patients

Introducción: Los pacientes ancianos constituyen un grupo en continuo crecimiento en los programas de hemodiálisis (HD). Estos se caracterizan por su elevada complejidad, dependencia y comorbilidad asociada. Múltiples beneficios del ejercicio físico en los pacientes en HD han sido descritos, si bien no han sido completamente evaluados en la población anciana. Objetivos: Analizar el efecto de un programa adaptado de ejercicio físico intradiálisis sobre la fuerza muscular, la capacidad funcional y la calidad de vida relacionada con la salud en nuestros pacientes ancianos (>80 años) en HD. Material y métodos: Estudio prospectivo unicéntrico no aleatorizado (12 semanas) con 2 grupos comparativos. El grupo ejercicio (E) incluía un programa de ejercicio físico adaptado mediante pelotas medicinales, pesas, bandas elásticas y cicloergómetros en las primeras 2 h de HD. El grupo control (C) recibía el cuidado habitual en HD. Analizamos: 1) Parámetros bioquímicos. 2) Fuerza de extensión máxima de cuádriceps (FEMQ) y «hand-grip» (HG). 3) Tests de capacidad funcional: «sit to stand to sit» (STS10) y «six-minutes walking test» (6MWT). 4) Sintomatología depresiva: inventario Beck (BDI). 5) Calidad de vida: EuroQol-5D (EQ-5D). Resultados: Un total de 22 pacientes incluidos: 50% hombres. Edad media 83,2 años y 44,1 meses en HD. Charlson medio: 9,5. Principal etiología: DM (36,4%). Un total de 11 pacientes asignados al grupo E y 11 al grupo C. No se observaron efectos adversos relacionados. Al final del estudio, el grupo E presentó de forma global una mejoría en las pruebas realizadas (*p<0,05): FEMQ 10,5±7,6 vs. 12,9±10,1kg; HG* 16,6±8,7 vs. 18,2±8,9kg; STS10* 29,9±10,6 vs. 25±7,87sec; 6MWT* 14,6%, 234,4 vs. 274,7 m; BDI* 14,4±11,5 vs. 11,7±10,8 y EQ-5D 49±19,1 vs. 59,5±20,3. Estos cambios no se observaron en el grupo C al final del estudio. Del mismo modo, el análisis entre grupos mostró una diferencia significativa para HG, FEMQ, STS10, 6MWT, BDI y EQ-5D. No observamos cambios relevantes en los datos bioquímicos ni antropométricos, en la medicación antidepresiva ni en los parámetros de adecuación dialítica a la finalización. Conclusiones: 1) El programa adaptado de ejercicio físico intradiálisis mejoró la fuerza muscular, la capacidad funcional y la calidad de vida relacionada con la salud de nuestros pacientes ancianos en HD. 2) Aun en población anciana, nuestros resultados realzan los beneficios del ejercicio físico en los pacientes en HD. 3) Ante un paciente anciano en HD, merece la pena considerar la realización de ejercicio físico adaptado intradiálisis como una parte más del cuidado integral en HD (AU)

Background: Elderly patients on haemodialysis (HD) are a steadily increasing group. They show a high complexity, dependency and comorbidity. Multiple benefits from exercise in HD patients have been reported; however, they have not been specifically evaluated in an elderly population. Objective: To assess the effect of an adapted low intensity intradialytic exercise programme on muscle strength, functional capacity and health-related quality of life in our elderly patients (> 80 years) on HD. Material and methods: HD patients were non-randomly assigned to an exercise training group (E) or a control group (C) in a 12-week single-centre prospective study. E included a combined exercise programme using balls, weights, elastic bands and cycle movements in the first 2 hours of HD sessions. C group patients received standard HD care. Endpoints were: 1) main biochemical data; 2) maximum quadriceps length strength (MQLS) and hand-grip (HG); 3) functional capacity tests: "Sit to stand to sit" (STS10) and "six-minutes walking test" (6MWT); 4) Beck Depressive Inventory (BDI); and 5) Health-related quality of life questionnaire: EuroQol-5D (EQ-5D). Results: A total of 22 patients were included (50% men). Mean age was 83.2 years; patients had received HD for 44.1 month. Charlson index was 9.5. Main aetiology was diabetes mellitus (36.4%). Eleven patients were assigned to E group and 11 to C group. No related adverse effects were observed. At the end of the study, E group showed an overall improvement in tests (*P<.05): MQLS 10.5 ± 7.6 vs. 12.9 ± 10.1 kg, HG* 16.6 ± 8.7 vs. 18.2 ± 8.9 kg, STS10* 29.9 ± 10.6 vs. 25 ± 7.87 sec, 6MWT* 14.6%, 234.4 vs. 274.7 m, BDI* 14.4 ± 11.5 vs. 11.7 ± 10.8 and EQ-5D 49 ± 19.1 vs. 59.5 ± 20.3. No similar changes were observed in C group. Significant differences between groups were also found for HG, MQLS, STS10, 6MWT, BDI and EQ-5D. No significant changes were found in biochemical and anthropometric data, antidepressant treatment or suitable dialysis parameters at the end of the study. Conclusions: 1) An adapted low intensity exercise rogramme improved muscle strength, functional capacity and health-related quality of life in our elderly patients on HD. 2) Our results highlight the benefits from exercise in HD patients even in this elderly population. 3) In elderly patients on HD, it is worth considering an adapted low intensity intradialytic exercise programme as a part of a comprehensive care (AU)