The middle arm arteriovenous fistula is an additional option to expand autogenous hemodialysis access.

PURPOSE: The native arteriovenous fistula is the gold standard for hemodialysis access. Unfortunately, the wrist fistula is often not practical and the upper arm fistula is hindered by several complications. The aim of this study is to assess the safety of the middle-arm fistula as additional native access. METHODS: We reviewed and compared the patency rates at 12, 48, and 60 months of distal, middle, and upper arm fistula performed from January 2003 to December 2008. For diabetic and old patients we compared distal and middle-arm fistulas. RESULTS: Of 273 native access, 149 (54.6%) were distal, 92 (33.7%) middle-arm, and 32 (11.7%) upper fistula. Patency rates were 81%, 58%, and 52% for distal, 85%, 69%, and 69% for middle-arm, and 82%, 46%, and 29% for upper arm fistula (P NS). Patency rates were 92%, 70%, and 54% in middle-arm fistula as first access and 80%, 71%, and 71% in middle-arm fistula as a rescue access (P NS). Among patients > 75 years patency rates were 78%, 62%, and 62% for distal and 87%, 67%, and 67% for middle-arm fistula. Among diabetic subjects patency rates were 81%, 58%, and 58% for middle-arm and 65%, 57%, and 57% for distal fistula at 12, 48, and 60 months (P NS) respectively. CONCLUSIONS: A middle-arm fistula is as safe as a distal fistula among dialyzed patients, even diabetic and elderly. This could be considered a reliable option to expand native accesses.

Plasma B-type natriuretic peptide in dialyzed patients: marker of cardiovascular disease or link to plasma refilling.

BACKGROUND: B-type natriuretic peptide (BNP) is released in response to extracellular volume and blood pressure (BP) overload and is a risk factor for cardiovascular diseases (CVD). BNP is increased in dialyzed patients (HDpts). The aim of this study was to evaluate the relationships between BNP and renin, aldosterone and blood volume reduction rate (BV/WL), with the presence of CVD and mortality. METHODS: Fifty-one HDpts aged 70 ± 14 years were enrolled. BP, BV/WL, BNP, aldosterone, renin, C-reactive protein (CRP), troponin I and routine biochemistry were measured. According to the predialytic plasma BNP levels, the patients were divided into group A with higher BNP and group B with lower BNP than the median value of 330 pg/mL. Follow-up was 1 year. RESULTS: After HD, plasma BNP (449.6 ± 582.2 pg/mL vs. 264.1 ± 269.8 pg/mL, p=0.0008) and aldosterone (421.8 ± 573.4 pg/mL vs. 265.1 ± 566.2 pg/mL, p=0.0003) decreased, but not rennin. BNP decreased more after hemodiafiltration than after standard HD (-55.1% ± 28.5% vs. -26.5% ± 19.5%, p=0.002). Patients in group A exhibited more diabetes (58% vs. 28%, p=0.03), ischemic heart disease (42% vs. 16%, p=0.04), left ventricular hypertrophy (88.8% vs. 33.3%, p<0.001), elevated levels of troponin I, CRP (50% vs. 24%, p=0.05), and low BV/BWL in a lower percentage (8% vs. 32%, p=0.03). After 11.2 ± 3.5 months, 8 patients (33.3%) had died in group A and 2 (8%) in group B (p=0.02). CONCLUSION: This study demonstrates that BNP is high in HDpts and decreases after HD. It is correlated with a good capacity for plasma refilling, with diabetes, CVD and short-term mortality risk.

[Native vascular access for hemodialysis in patients with diabetes: a single-center experience]. / L'accesso vascolare per dialisi su vasi nativi nel paziente diabetico: esperienza di un singolo centro.

With 135 million cases the prevalence of diabetes mellitus (DM) is very high worldwide. Diabetic nephropathy is a major complication of DM. In many countries diabetic nephropathy has become the most frequent cause of endstage renal disease. It is believed that in diabetic patients the creation of a native vascular access (NVA) might be difficult. We evaluated 274 occurrences of NVA creation during the period January 2003 to December 2008: 68 in diabetic patients (group 1) and 206 in nondiabetics (group 2). We compared the type of NVA, primary failure, and primary patency in these groups. Age was significantly higher in diabetic patients (68 vs 64 years; p < 0.05). No statistical differences in primary failure between groups were found for any NAV. Wrist vascular access survival rates were higher in diabetic versus nondiabetic patients (56.9% vs 20.7% at 72 months). No statistical differences were observed between groups in primary patency rates for middle- and upper-arm vascular access. According to our experience diabetes does not lead to additional difficulties in the creation of permanent vascular access, provided proper physical and instrumental examination is performed. Despite the advanced age of the diabetic patients in our study, wrist vascular access showed better results in this group than in nondiabetic patients on long-term follow-up.