[Midarm arteriovenous fistula: single-center experience]. / Fistola artero venosa midarm: esperienza monocentrica.

In uremic patients on hemodialysis, a first vascular access using native vessels tailored into a radiocephalic arteriovenous fistula (AVF) on the wrist is the gold standard in vascular access quality. However, among the uremic population the percentage of older patients affected by diabetes or by severe generalized vascular disease is growing. In these patients distal radiocephalic AVFs often have a limited survival. This induced us to design a technique for tailoring vascular accesses at a proximal site. In the past two years (2006-2007) we created 19 AVFs at the midarm position (midarm AVF) using the proximal section of the radial artery. Midarm AVF was the second choice in 70% of patients after failure of a distal AVF and the first choice in 30% of patients. The survival of this type of access has been excellent. We have registered only one thrombosis after 6 months. In four cases access was interrupted because of the death of the patients. The remaining 14 accesses are working perfectly well. Our experience leads us to conclude that midarm AVF is not only an important intermediate step after the failure of a distal AVF and before the application of a proximal AVF, but in a population of patients with diabetes and generalized vascular disease it should probably be proposed as the AVF of choice.

[Experience in the surveillance of arteriovenous fistula in Verbania, Italy]. / Esperienza di Verbania nella sorveglianza delle fistole arterovenose.

One hundred forty-five patients are receiving renal replacement therapy at our center: 127 are on hemodialysis, 18 on peritoneal dialysis. From 2000 through 2005 a total of 215 arteriovenous fistulas (57% distal, 31% proximal, 12% prosthesis) were created. After some time we felt the necessity to design a vascular access surveillance system because the uremic population was increasingly constituted by aged people, including many diabetics and people suffering from hypertension with generalized vascular disease. The system comprised objective examination of the access at every dialysis session; kinetic Kt/V every 3 months; and a recirculation test (GIT) every 6 months. When there were anomalies in one of the above test results, color Doppler was performed. Detection of major stenosis with altered velocity parameters was a clear indication for angiography, possibly followed by angioplasty (PTA). In the indicated period, 15 patients underwent this procedure, and PTA was performed in all of them, often with placement of an endovascular stent. The results showed a survival of 12 months in 85% of patients and 18 months in 71% of patients. On the whole these data are comparable with others in the medical literature. The incidence of restenosis can be considered acceptable: it occurred in 3 cases out of 15 and could be corrected by PTA. In conclusion, PTA plus stent implantation is a valid method allowing quick and reliable correction of stenosis; a vascular access surveillance protocol and color Doppler imaging allow patient selection for angiography. PTA is to be considered an intermediate phase in stenosis correction before suggesting a new vascular access intervention to the patient.

Are serum albumin and cholesterol reliable outcome markers in elderly dialysis patients?

Albumin and cholesterol are considered reliable outcome markers in dialysis patients; their influence, however, may also be related to non-independent factors, such as age and presence of co-morbid conditions. The aim of the study was an analysis of four outcome markers, assessed at start of dialysis: age, high risk conditions, cholesterol and albumin levels. Data were obtained from the Piedmont Dialysis and Transplantation Registry (northern Italy, about 4,400,000 inhabitants, 21 dialysis centres, open acceptance since mid-1970s, 5661 patients on file at 31 December 1992). Prevalence of albumin and cholesterol in the normal range increases with age; in each age group prevalence in the range is higher in patients at high risk. However, influence of these biochemical parameters is evident also in no-risk cohorts, thus identifying a subgroup with poorer prognosis also in the population without any identified classic risk factor. The influence of albumin, more evident in the population studied compared with cholesterol, is reflected by impaired survival of low-albumin patients (age > or = 65 high risk at 1 year: 60.7% vs 76.6%, P = 0.0052; age > or = 65 non-high risk, at 1 year: 76.5% vs 90.7%, P = 0.0001). In conclusion, albumin and cholesterol, assessed at start of dialysis, are reliable outcome markers even in elderly patients, identifying, in this high mortality cohort, a subgroup with poorer prognosis. If and how their effect may be reversed by dialysis therapy remains to be assessed.

Indium-111-labeled granulocyte head accumulation in patients with Wegener's granulomatosis.

Among the symptoms of systemic vasculitis, purulent rhinorrhea with painful sinusitis is thought to be relatively specific to Wegener's granulomatosis (WG). Sixteen patients with rapidly progressive glomerulonephritis (GN), arteritis and extensive crescents in renal biopsy were studied by head indium-111 (111In)-granulocyte scanning. They included 8 WG, 5 microscopic polyarteritis, 2 necrotizing and crescentic GN and 1 classic polyarteritis nodosa. Autologous granulocytes labeled with 12.3 MBq of 111In-oxine were administered intravenously. Scintigraphic studies were performed at 4 and 24 h post-injection. Compared to the non-WG cases, considered as a whole, significant accumulation of tracer in sinuses was observed in WG patients (Fisher's p = 0.02). Substantial scintigraphic amelioration was obtained in a WG case treated with methylprednisolone pulses and, in another WG case, after high doses of intravenous gamma-globulins. The complete disappearance of facial uptake was obtained after 2 months of intensive therapy (i.e., steroid, cyclophosphamide and plasma exchange) in another WG patient. 111In-oxine granulocyte imaging may be useful in clinical practice as an additional marker of disease activity and a tool of identification of upper respiratory tract involvement.

Clotrimazole treatment for prevention of oral candidiasis in patients with acute leukemia undergoing chemotherapy. Results of a double-blind study.

Fungal infections have become an increasing cause of morbidity in patients with acute leukemia undergoing chemotherapy. Oral candidiasis is prone to develop in these patients, and there is also a risk of the development of esophageal Candida infection. Clotrimazole troches have been previously reported to be effective in the treatment of documented oral Candida infection. This report documents a double-blind controlled study in 30 patients with acute leukemia in which the effectiveness of clotrimazole troches in preventing oropharyngeal candidiasis was assessed. Patients were randomly assigned to receive 10 mg troches of clotrimazole or a placebo three times per day. Mucosal scrapings were obtained weekly and examined directly by smear and culture. There were 28 evaluable patients. Of 12 patients with oral Candida infection, 11 were taking placebo and one received clotrimazole (p = 0.0002). Clotrimazole is effective in preventing oropharyngeal candidiasis.

Clotrimazole treatment of oral candidiasis in patients with neoplastic disease.

A double-blind controlled study was performed to evaluate the effectiveness of clotrimazole in the treatment of oral candidiasis in patients with neoplastic disease. Six of seven patients who received clotrimazole had resolution of symptoms and signs of oral candidiasis. In five of six patients who received placebo, clinical progression of signs and symptoms occurred, esophagitis developed, and amphotericin B therapy had to be given. No toxicity was observed that could be attributed to clotrimazole. The results were statistically significant (p = 0.025 by Fisher's exact test). Clotrimazole is effective therapy for oral candidiasis in patients with neoplastic disease, and may prevent the development of esophagitis.