Vascular access for hemodialysis in Italy: What a national survey reveals.

BACKGROUND: Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey. METHODS: A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation. RESULT: The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients. CONCLUSIONS: Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.

[The Cannulation of the Arteriovenous Fistula in the Presence of a Stent: Precautions, Risks, and Possibilities].

A proper management and tailored interventions represented two fundamental steps to ensure a long-term use of the arteriovenous fistula (AVF). AVF failure can be attributed to various factors, with stenosis being the most common cause. Different techniques are employed for treating complications, but percutaneous endovascular procedures are the most widely used. In addition to angioplasty (PTA), the possibility of utilizing stents, particularly stent grafts (SG), has further improved outcomes. However, the insertion of these devices involves commitment to a segment of the vessel, which may vary in length, making the indication necessitate a careful evaluation. The positioning of a stent graft indeed limits the space for needle insertion, and on the other hand, the cannulation of the device is considered off-label according to technical specification. This work addresses the issue of puncturing these devices. Alongside a rapid overview, we describe a clinical case of continuous cannulation of a multiply stented AVF, for over 9 years, which opens up the discussion about the possibility of long-term cannulation through proper planning.

Report on an Italian survey of 72 stuck hemodialysis catheters.

BACKGROUND: Reports of stuck hemodialysis catheters have been on the rise in recent years. Aim of this work is to report how this complication has been managed and the relative outcomes in a multicente Italian survey. METHODS: Since 2012, the Italian Society of Nephrology (SIN) Project Group of Vascular Access has collected data among nephrologists on this complication. Data regarding 72 cases of stuck tunnelled central venous catheter (tCVC) in 72 patients were retrieved thanks to this survey. RESULTS: In 11 patients (15%) the stuck catheter was directly buried or left in place. Sixty-one cases were managed through advanced removal techniques. Among these, 47 (77%) stuck tunnelled central venous catheters were successfully removed, while 14 (23%) failed to be withdrawn. Considering removed tCVCs, the use of endoluminal balloon dilatation alone or in combination with other tools showed a percentage of success of 88%. The removal procedure involved numerous specialists. Some complications occurred, such as breakage of the line or bleeding, and two cases of haemopericardium during an advanced procedure. CONCLUSION: The survey shows how the stuck catheter complication was managed in different ways, with conflicting results. When utilized, endoluminal balloon dilatation proved to be the most effective and most often utilized technique, while some cases had suboptimal management or failure. This underlines how delicate the procedure is, and the need for both precise knowledge of this complication and timely organization of removal attempts.

Increase of continuous treatments and regional citrate anticoagulation during renal replacement therapy in the ICUs of the North-West of Italy from 2007 to 2015.

BACKGROUND: Few reports have addressed the change in renal replacement therapy (RRT) management in the Intensive care Units (ICUs) over the years in western countries. This study aims to assess the trend of dialytic practice in a 4.5-million population-based study of the northwest of Italy. METHODS: A nine-year survey covering all the RRT provided in the ICUs. Consultant nephrologists of the 26 Nephrology and Dialysis centers reported their activities in the years 2007, 2009, 2012, and 2015. RESULTS: From 2007 to 2015 the patients treated increased from 1042 to 1139, and the incidence of RRT from 254 to 263 cases/10^6 inhabitants. The workload for dialysis center was higher in the larger hub hospitals. RRT for acute kidney injury (AKI), continuation of treatment in chronically dialyzed patients, or extrarenal indications accounted for about the stable rate of 70, 25 and 5% of all RRT sessions, respectively. Continuous modality days increased from 2731 days (39.5%) in 2007 to 5076 (70.6%) in 2015, when the continuous+prolonged treatment days were 6880/7196 (95.6% of total days). As to RRT timing, in 2015 only the classical clinical criteria, and no K-DIGO stage were adopted by most Centers. As to RRT interruption, in 2015 urine volume was the first criterion. Implementation of citrate anticoagulation (RCA) for RRT patients significantly increased from 2.8% in 2007 to 30.9% in 2015, when it was applied in all 26 Centers. CONCLUSIONS: From 2007 to 2015, current practice has changed towards shared protocols, with increasing continuous modality and RCA implementation.

Successful 8-year use of Venous Window Needle Guide for deep arteriovenous fistula cannulation.

We describe the case of a patient who had been on hemodialysis for 8 years using a native arteriovenous fistula cannulated through the Venous Window Needle Guide™ device (VWING). The overall outcome was excellent and complication-free with intact state of the underlying vessel and a high degree of patient satisfaction. The patient was able to carry out self-cannulation without any difficulty almost from the very beginning. The current unavailability of VWING is a missed opportunity in the field of vascular access.

Management of acute kidney injury in frail patients with biopsy-proven cast nephropathy: a combined approach with chemotherapy plus Supra-hemodiafiltration with post-adsorption endogenous reinfusion.

BACKGROUND: Patients with multiple myeloma often have kidney involvement with acute kidney injury which is frequently due to cast nephropathy. Hemodiafiltration with endogenous reinfusion (HFR) allows removal from the circulation of significant amounts of free light chains (FLCs) responsible for tubular damage. METHODS: Between 2014 and 2018, 13 patients affected by multiple myeloma (64% λ chain and 36% k), including 10 cases with biopsy-proven cast nephropathy, were treated with this technique. Each patient had high free light chains levels at diagnosis: median 8586 mg/l for λ and 4200 mg/l for k, and stage III acute kidney injury (median serum creatinine 7.5 mg/dl). We initially performed daily HFR-Supra sessions and then modulated them based on renal response (mean 10 sessions/patient). At the same time, the patients also received various chemotherapy regimens, depending on their hematological criteria. RESULTS: Forty-six percent of patients showed at least partial renal function recovery within the third month, thus allowing dialysis discontinuation; 38% remained on dialysis. Two patients died. The mean reduction rate of free light chains at the end of the HFR-Supra cycle was 85% (k) and 40% (λ), respectively. Serum albumin remained stable during the whole treatment. DISCUSSION: In our experience, the synergistic effect of chemotherapy and HFR-Supra led to a recovery of renal function in 6 out of 13 patients presenting with severe dialysis-requiring acute kidney injury. HFR-Supra allowed stable albumin levels, with high free light chains removal rate, at a relatively low costs.

Ultrasound in central venous access for hemodialysis.

Central venous cannulation is a frequent need for urgent or scheduled hemodialysis. Many studies confirmed the pivotal role of ultrasound in this procedure. Vascular access guidelines strongly recommend ultrasound guidance. Its usefulness has been demonstrated not only in reducing complications of venipuncture but more recently for the evaluation of central venous catheter (CVC) placement and real-time check for possible complications. The use of ultrasound requires a precise technique for the correct handling of the probe and the needle movement. Different approaches as the out-of-plane, in-plane, and oblique methods are available, enabling the most appropriate for the individual case. Although the learning curve for CVC ultrasound placement is usually fast, formal training and certification for beginners are strongly recommended.

Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell'Emostasi e della Trombosi (SISET).

Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism and an increased use of DOAC in daily practice is recorded also in elderly patients. Aging is associated with a reduction of glomerular filtration rate and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. There is uncertainty on the safety profile of DOAC in patients with CKD, particularly in those with severely impaired renal function or end stage renal disease, due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.

Position paper on the safety/efficacy profile of direct oral anticoagulants in patients with chronic kidney disease. Consensus document from the SIN, FCSA and SISET.

Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism, and an increased use of DOAC in daily practice has been recorded also in elderly patients. Ageing is associated with a reduction in glomerular filtration rate, and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. The safety profile of DOAC in patients with CKD has not been defined with any certainty, particularly in those with severely impaired renal function or end stage renal disease. This has been due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.

High success rate in salvage of catheter-related bloodstream infections due to Staphylococcus aureus, on behalf of project group of Italian society of nephrology.

BACKGROUND: Catheter-related bloodstream infections caused by Staphylococcus aureus represent one of the most fearful infections in chronic haemodialysis patients with tunnelled central venous catheters. Current guidelines suggest prompt catheter removal in patients with positive blood cultures for S. aureus. This manoeuvre requires inserting a new catheter into the same vein or another one and is not without its risks. METHODS: A protocol based on early, prompt diagnosis and treatment has been utilized in our renal unit since 2012 in an attempt to salvage infected tunnelled central venous catheters. We prospectively observed 247 tunnelled central venous catheters in 173 haemodialysis patients involving 167,511 catheter days. RESULTS: We identified 113 catheter-related bloodstream infections (0.67 episodes per 1000 days/tunnelled central venous catheter). Forty were caused by S. aureus, including 19 by methicillin-resistant S. aureus (79% saved) and 21 by methicillin-sensitive S. aureus (90% saved), of which 34 (85%) were treated successfully. Eight recurrences occurred and six (75%) were successfully treated. A greater than 12 h time to blood culture positivity for S. aureus was a good prognostic index for successful therapy and tunnelled central venous catheter rescue. CONCLUSION: Our data lead us to believe that it is possible to successfully treat catheter-related bloodstream infection caused by S. aureus and to avoid removing the tunnelled central venous catheter in many more cases than what has been reported in the literature. On the third day, it is mandatory to decide whether to replace the tunnelled central venous catheter or to carry on with antibiotic therapy. Apyrexia and amelioration of laboratory parameters suggest continuing systemic and antibiotic lock therapy for no less than 4 weeks, otherwise, tunnelled central venous catheter removal is recommended.

[Assessing the quality of life in patients with a vascular access].

Patients undergoing haemodialytic treatment have a lower quality of life than the general population because of several factors. Their wellbeing can be assessed through a clinical evaluation or through the subjective point of view of the patients themselves: the perceived Health-Related Quality of Life (HRQoL) is an index calculated on the basis of the patients' own perspective. A well-functioning vascular access (VA) and the absence of complications are certainly associated with better health in patients on dialysis but unfortunately VA-related perceived HRQoL has so far been a subject of little interesting literature, even though the choice of the most appropriate access in the individual patient is today increasingly articulate and difficult. Information about subjective perception of health is typically collected through generic or specific questionnaires. The most used reproducible questionnaires available are SF-36, EuroQoL5D, SONG-HD, WHOQoL-BREF, VAQ, although not all of them have been used for a targeted assessment of the issues concerning HRQoL and VA function. This review confirms that the VAQ questionnaire is currently the simplest and most reliable tool to assess patient satisfaction with their VA.

[Cost analysis of haemodialysis catheter related bloodstream infection through the DRG system, "on behalf of Project Group of Vascular Access of Italian Society of Nephrology"].

Catheter related bloodstream infections (CRBSI) represent a complication that often requires hospitalization and the use of economic resources. In Italy, there is no literature that considers the costs of CRBSI for tunneled catheters (CVCt). The aim of this work is to evaluate the relative costs of CRBSI through the DRG system. From 2012 to 2017 we examined 2.257 hospital discharge forms, 358 of which relating to haemodialysis patients. Patients with CVCt (167), compared to FAVs (157), on average stay in hospital longer (10 vs. 8 days), entail higher costs (+8.5%) and higher admissions rate for infections (+114%). The incidence of CRBSI was 0.67 episodes per 1000 CVCt/days. CRBSI accounts for 23% of the cases of hospitalization of patients with CVCt and 5.2% of total hospitalization costs. Complicated CRBSI involve a 9% increase in average costs compared to simple ones, with patients staying in hospital three times longer. The cost of a CRBSI varies from €4,080 up to €14,800, with an average cost of €5,575. The costs calculated here are less than a third of that reported in American literature but this can be explained by the different reimbursement rates systems. The methodology of CRBSI costs through DRGs appears simple, and its main limit is the correct compilation of the discharge form. This is a reminder that discharge forms are an integral part of the medical record and can become important in recognizing the cost of the medical services provided.

Acute renal infarction: a single center experience.

BACKGROUND: Acute renal infarction is a rare condition whose diagnosis is often delayed. Major risk factors include atrial fibrillation, valvular or ischemic heart disease, renal artery thrombosis/dissection and coagulopathy. METHODS: We reviewed the medical records of 18 patients admitted to our Nephrology Department between 1999 and 2015 for acute renal infarction diagnosed by computed tomography. Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy was performed in some patients during follow-up to assess parenchymal lesions and estimate differential kidney function. RESULTS: Mean age was 59.8 years. Major associated risk factors included hypertension (44 %), obesity (33 %), atrial fibrillation (28 %), peripheral vascular disease (17 %), smoking (17 %), prior thromboembolic event (11 %), diabetes (11 %), estroprogestinic therapy (11 %). Seventy-two percent of patients presented with flank pain. Mean serum creatinine was 1.2 ± 0.6 mg/dl. Acute kidney injury occurred as the initial manifestation in two patients. Patients were managed conservatively, with low molecular weight heparin (83 %) or aspirin (11 %). At the end of follow-up serum creatinine was 1.1 ± 0.3 mg/dl; one patient remained on chronic hemodialysis. 58 % of patients who underwent renal scintigraphy after a median of 8 months had a reduced contribution of the previously affected kidney to total renal function. CONCLUSION: Risk factors associated with the development of chronic kidney disease following renal infarction are unknown. In our subjects, renal function remained stable in all but one patient who developed end stage renal disease. Further studies should focus on etiology and evolution of kidney function in patients with acute renal infarction.

Venous Window Needle Guide for deep vessels and difficult arteriovenous fistula cannulation.

The Venous Window Needle Guide (VWING™) has recently been proposed for patients with difficult arteriovenous fistula (AVF) access for hemodialysis due to deep vessels or other cannulation-related problems. This totally subcutaneous titanium device is sutured onto the upper wall of the matured fistula and may facilitate cannulation by the button-hole technique. We describe our initial experience with nine implants in six patients with a cumulative follow-up of 83 months, and make some experience-based technical suggestions for implant and surveillance radiological imaging. The indication for implantation was deep vessel, previous failure of cannulation or unsuitable site for direct cannulation. No infectious complications were observed during follow-up and proper blood flow was constantly achieved. Some difficulties were occasionally encountered with regard to cannulation; nonetheless, patient satisfaction was not significantly affected. VWING seems to be an interesting option in some patients provided that surgical implantation is carefully carried out and preventive measures against infections are strictly observed.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology.

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

"Two is better than one": a composite graft made of two different vascular prostheses for urgent hemodialysis access in a troublesome case.

BACKGROUND: Multiple failed hemodialysis access and poor vascular anatomy can jeopardize an end-stage renal disease patient's survival, frequently leading to the urgent need for rapid and durable new vascular access. In these circumstances, the extensive use of central venous catheters (CVC) can led to serious complications, such as infection, thrombosis, and often vessel scarring with obstruction of the central veins. More recently, new self-sealing prosthetic grafts may be cannulated within a few days after implantation, avoiding the need for extensive CVC. However, similar to all synthetic arteriovenous grafts (AVG), the new grafts are prone to rapid and aggressive venous neointimal hyperplasia (VNH), which is responsible for outflow stenosis and access thrombosis. Endoluminal sutureless anastomosis has been demonstrated to have better hemodynamics at the venous outflow with a supposed reduction of VNH, thus potentially improving graft patency. METHODS: We report a case of a successful creation of a composite prosthetic access in a patient with severe comorbidities and nearly complete exhaustion of all vascular sites and with the need for immediate access for hemodialysis. Two relatively novel vascular expanded polytetrafluoroethylene prostheses were used jointly in this patient for a brachial-axillary AVG to allow early cannulation and with the aim of being less vulnerable to outflow stenosis. A multilayer self-sealing graft and a graft with a nitinol reinforced section, which permits endoluminal sutureless anastomosis, were sewed together to create a unique prosthesis with both features. RESULTS: The composite graft was cannulated 48 hr after implantation and continued to function well at 10 months of follow-up without signs of venous stenosis. CONCLUSIONS: This simple technique allows the creation of a customized composite graft with self-sealing properties and improved hemodynamics at the venous outflow.

Dealing with stuck hemodialysis catheter: state of the art and tips for the nephrologist.

The term stuck catheter refers to the condition in which a catheter is not removable from a central vein using standard techniques. Although it is a rare complication, in the last few years it has been reported ever more frequently in hemodialysis due to the widespread use of tunneled catheters. Poor knowledge of the correct procedures and limited experience and training of the specialist in facing this problem are the main reasons for catheter internalization. Stuck catheter is often diagnosed by the nephrologist, who should be competent enough to manage this clinical complication. Among the many options for removing a stuck catheter from the fibrin sleeve, an interventional radiology approach, mainly with endoluminal balloon dilatation, probably provides the best solution. Vascular surgery should be reserved to selected cases in which percutaneous techniques have failed. Nephrologists must play a central role in organizing the treatment of this complication with other specialists in order to avoid making mistakes that may preclude future positive results.

A refinement of Hong's technique for the removal of stuck dialysis catheters: an easy solution to a complex problem.

AIM: A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety. METHODS: We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists. RESULTS: All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel. CONCLUSIONS: Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.

Indications for vascular grafts as hemodialysis access: consensus from experience in Italy.

INTRODUCTION: In Italy, the use of arteriovenous grafts (AVG) is limited (1-5 %) due to different approaches to vascular access (VA) management as compared to other countries, where guidelines (which may not apply to the Italian setting) have been produced. Therefore, the Study Group (GdS) on VA of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines. METHODS: The most controversial and innovative issues of existing guidelines have been summed up in 12 different statements. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their agreement/disagreement on each issue, thus creating a new method to share and exchange information. RESULTS: Most of them agreed (consensus > 90%) on specific criteria set to choose AVG over native AVF (nAVF) and tunnelled venous catheter (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients, in patients at risk of developing ischemia, on the priority of AVG as an alternative to brachial-basilic fistula with vein transposition, and in case of a poorly organized setting regarding graft maintenance. Keeping in mind that the nAVF should be preferred whenever is feasible, AVGs are indicated when superficial veins are unavailable or to repair a nAVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to guarantee its clinical benefits.