Guía clínica española del acceso vascular para hemodiálisis / Spanish clinical guidelines on vascular access for haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support.

Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general / Outpatient surgeries of patients with arteriovenous fistulas for hemodialysis. Integrated activity in a general surgery unit

Introducción: El aumento de pacientes que precisan trata- miento renal sustitutivo, sobre todo en el grupo de pacien- tes sometidos a hemodiálisis, supone un reto en incremen- to de actividad y de ocupación de recursos para los servicios de cirugía. Las complicaciones relacionadas con los accesos vasculares son la causa fundamental de ingresos en muchas unidades de diálisis. La cirugía sin ingreso puede disminuir la ocupación de camas hospitalarias, reduce la lista de espe- ra y las complicaciones relacionadas con un ingreso innece- sario. Material y métodos: Hemos realizado un estudio prospectivo de las intervenciones realizadas en el período 1998-2009 para la creación o la reparación de fístulas arte- riovenosas (FAV) para hemodiálisis, con el objetivo de cono- cer el nivel de ambulatorización, resultados, complicaciones y su posible impacto en la tasa de ingresos de los pacientes en hemodiálisis. La actividad fue realizada dentro del fun- cionamiento global del servicio de cirugía general sin uni- dad específica de cirugía mayor ambulatoria (CMA). Las in- tervenciones las realizaron varios cirujanos del servicio interesados en el tema, pero sin dedicación exclusiva a éste (su actividad es la de cualquier cirujano general) y sin guar- dias específicas. La cirugía ambulatoria se organizó dentro de la actividad ordinaria del servicio de cirugía general sin una unidad específica, ni cirujanos especialmente dedica- dos a la misma. Resultados: Desde la apertura de nuestro hospital en 1998 hasta diciembre de 2009 hemos realizado un total de 2.413 intervenciones en 1.229 pacientes (prime- ros accesos y reparaciones de los mismos). La cirugía programada supuso el 74,8% de las intervenciones; el 25,2% res- tante fueron intervenciones urgentes. El porcentaje global cirugía ambulatoria fue del 82% (89% en cirugía programa- da y 60% en cirugía urgente). Se produjeron un 6% de in- gresos imprevistos. No hubo mortalidad postoperatoria. El número de ingresos fue de 0,09 episodios por paciente año con una estancia media de 0,2 días por paciente y año. Con- clusiones: La mayoría de las intervenciones relacionadas con las FAV, incluso la cirugía urgente, se pueden realizar en ré- gimen ambulatorio dentro de la actividad habitual de un servicio de cirugía. Se evitan así costes asociados con la ocu- pación de camas hospitalarias y se disminuyen las complicaciones relacionadas con el ingreso (AU)

ntroduction: The increase of prevalent haemodialysis patients is a challenge for surgery units. Vascular access related complications are the main cause of hospital admissions in many dialysis units. Outpatient surgery could decrease waiting lists, cost related and complications associated to vascular access. Material and methods: We have performed a prospective study of the vascular access related surgery in a ten years period. Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons. Results: Since 1998 to December 2009 we performed 2,413 surgical interventions for creating and repairing arteriovenous fistula in 1,229 patients, including elective and emergency surgery (74.8% and 25.2% respectively). Outpatient procedures were performed in 82% of cases (89% in elective and 60% in emergency surgery). There were unexpected admissions secondary to surgical complications in 6% of patients. There wasn’t postoperative mortality. The rate of admissions were 0.09 episodes and 0.2 days per patient/year. Conclusions: Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula, including emergency surgery. Vascular access surgery can be included in ordinary activity of a surgical unit. Outpatient vascular access surgery decreases unnecessary hospital admissions, reduces costs and nosocomial complications (AU)

[Outpatient surgeries of patients with arteriovenous fistulas for hemodialysis. Integrated activity in a general surgery unit]. / Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general.

INTRODUCTION: The increase of prevalent haemodialysis patients is a challenge for surgery units. Vascular access related complications are the main cause of hospital admissions in many dialysis units. Outpatient surgery could decrease waiting lists, cost related and complications associated to vascular access. MATERIAL AND METHODS: We have performed a prospective study of the vascular access related surgery in a ten years period. Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons. RESULTS: Since 1998 to December 2009 we performed 2,413 surgical interventions for creating and repairing arteriovenous fistula in 1,229 patients, including elective and emergency surgery (74.8% and 25.2% respectively). Outpatient procedures were performed in 82% of cases (89% in elective and 60% in emergency surgery). There were unexpected admissions secondary to surgical complications in 6% of patients. There wasn't postoperative mortality. The rate of admissions were 0,09 episodes and 0,2 days per patient/year. CONCLUSIONS: Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula, including emergency surgery. Vascular access surgery can be included in ordinary activity of a surgical unit. Outpatient vascular access surgery decreases unnecessary hospital admissions, reduces costs and nosocomial complications.

[Vascular access models cause heterogeneous results in the centres of one community]. / Los modelos de atención al acceso vascular condicionan resultados heterogéneos en los centros de una misma comunidad.

INTRODUCTION: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area. PURPOSE: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results. MATERIAL AND METHODS: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared. MAIN VARIABLES: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery. RESULTS: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0). LIMITS: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated. CONCLUSIONS: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

[Clinical and economic repercussions of the use of tunneled haemodialysis catheters in a health area]. / Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria.

INTRODUCTION: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter in patient mortality and costs attributable to this procedure. METHODS: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260 patients with Charlson index 7.05 +/- 2.8 (age 65.5 years, 62.3% males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. RESULTS: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR: 7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. CONCLUSION: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysis and implies a higher net cost.

Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria / No disponible

Introducción: el uso de catéteres en hemodiálisis se asocia a un gran número de complicaciones. Sin embargo, se han realizado pocos estudios diseñados específicamente para evaluar este problema. Los objetivos del estudio han sido conocer el impacto en la supervivencia del paciente y el gasto económico que implica la utilización de catéteres. Métodos: estudio observacional y prospectivo histórico de siete años de duración en 260 pacientes incidentes en hemodiálisis en nuestra área de salud, ajustado a la comorbilidad y albúmina al inicio de la hemodiálisis. La media de edad fue de 65,5 ± 15,2 años, 62,3% varones, 25% diabéticos. La media del índice de comorbilidad de Charlson fue de 7,05 ± 2,8. Resultados: el 47,3% de los pacientes inicia hemodiálisis con catéter, el 41,5% con FAV-auto y 11,2% con FAV-PTFE. El seguimiento medio fue 2,31 años/paciente. El riesgo de mortalidad ajustado por comorbilidad fue mayor para los que inician hemodiálisis con un catéter, HR:1,86 (1,11-3,05). Este efecto negativo también se observó en el 57,3% de pacientes que a lo largo del seguimiento requirieron un catéter, HR: 1,68 (1,00-2,84) y, además, fue tiempo dependiente; a mayor tiempo con catéter, mayor mortalidad: HR 7,66 (3,34-17,54), tertil 3 vs. tertil 1. El coste del empleo mes/catéter fue de 561,31 euros. Conclusiones: el uso de catéteres tunelizados es un factor independientemente asociado con la mortalidad de los pacientes, tanto al inicio como a lo largo del seguimiento, es tiempo dependiente y conlleva un elevado coste económico (AU)

Introducction: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter inpatient mortality and costs attributable to this procedure. Methods: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260patients with Charlson index 7.05 ± 2.8 (age 65.5 years, 62.3%males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. Results: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR:7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. Conclusion: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysisand implies a higher net cost (AU)

Cinacalcet en pacientes en diálisis peritoneal con hiperparatiroidismo moderado-severoresistentes a tratamiento convencional. Estudio prospectivo a un año / No disponible

Objetivos: Estudiar la eficacia de Cinacalcet(R) en el cumplimiento de las recomendaciones K/DOQI en pacientes en diálisis peritoneal (DP) y estimar el tiempo necesario para alcanzarlos. Métodos: Estudio observacional prospectivo de cohorte, con pacientes con hiperparatiroidismo-HPTH moderado severo(PTH > 500 pg/ml) con más de 4 meses en DP resistentes a tratamiento convencional con dieta, quelantes y vitamina D. Los objetivos óptimos son los recomendados por las Guías NKF-K/DOQI para ERC-5D y para el análisis de objetivos subóptimos se utilizan las referencias de PTH< 350 pg/ml.; fósforo < 6 mg/dl o calcio < 10,4 mg/dl (siempre ue simultáneamente CaxP < 55 mg2/dl2).Resultados: Al inicio del tratamiento con Cinacalcet(R) los 18 pacientes llevaban 15,56 meses (DE 0,78) en DP, todos tenían una PTH > 500 pg/ml, y ninguno cumplía los objetivos K/DOQI ni los subóptimos propuestos. El seguimiento medio en tratamiento con Cinacalcet(R) fue de 12 meses. El porcentaje de pacientes con PTH < 350 pg/ml fue de 66,7%a los 3 meses 60% a los 6 y 100% al año. A los tres meses el 33,3% cumplen todos los objetivos subóptimos, a los 6 meses el 33,3% y al año el 66,7%. El tiempo medio necesario para alcanzar un valor de PTH en rango fue de 2,33meses IC al 95% [1,35-3,32] y para alcanzar todos los objetivos óptimos de 16,94 meses [11,38-22,5]. La tolerancia a la medicación ha sido buena, no se suspendió Cinacalcet(R) en ningún caso y sólo en uno se redujo la dosis por efectos secundarios. Conclusión: La utilización de Cinacalcet® en pacientes en DP con HPTH resistente a tratamiento convencional ha resultado eficaz y segura y ha permitido mejorar el cumplimiento de objetivos de las guías (AU)

Background: Cinacalcet(R) has improved the management of hyperparathiroidism(HPTH) in hemodialysis. To our knowledge there are no specific studies on peritoneal dialysis (PD).Aim: The aim of the present study was to evaluate the efficacy of Cinacalcet(R) on the achievement of optimal and suboptimal targets on treatment of hyperparathiroidism (HPTH) in PD patients. As secondary objectives we have studied the safety of treatment and estimate the mean time to reach these targets, and evaluate economic cost. Methods: Eighteen patients undergoing more than 4 months on PD with a severe HPTH (PTH > 500 pg/ml) resistant to conventional treatment with diet, chelants and vitamin D were included in this prospective open-label study. We have used the targets of K/DOQITM-clinical guidelines as optimal target. We have selected as suboptimal targets: PTH < 350 pg/ml, phosphorus< 6 mg/dl and calcium < 10.4 mg/dl (only when simultaneous CaxP was under 55 mg2/dl2). Oral Cinacalcet(R) was given with main meal in a single daily start dose of 30 mg and titrated thereafter monthly. We considered the first value on target as an event and used a Kaplan-Meyer survival analysis to estimate mean time to reach target. Results: On inclusion all patients have at least two previous PTH values over 500 pg/ml, PTH mean 695.3 (SD 96) and they were on PD with an appropriate efficacy during a mean of15.56 months (SD 0.78). Mean follow-up time under Cinacalcet(R) treatment was 12 months. The percentage of patients with a PTH under 350 pg/ml was 66.7% on month 3, 60% on month 6 and 100% after 1 year. The percentage of patients that reach an aggregate of all suboptimal targets (PTH < 350 pg/ml, phosphorus < 6 mg/dl and calcium < 10.4 mg/dl (only when simultaneous CaxP was under 55 mg2/dl2). Oral Cinacalcet(R) was given with main meal in a single daily start dose of 30 mg and titrated thereafter monthly. We considered the first value on target as an event and used a Kaplan-Meyer survival analysis to estimate mean time to reach target. Results: On inclusion all patients have at least two previous PTH values over 500 pg/ml, PTH mean 695.3 (SD 96) and they were on PD with an appropriate efficacy during a mean of 15.56 months (SD 0.78). Mean follow-up time under Cinacalcet(R) treatment was 12 months. The percentage of patients with a PTH under 350 pg/ml was 66.7% on month 3, 60% on month 6 and 100% after 1 year. The percentage of patients that reach an aggregate of all suboptimal targets (PTH < 350 pg/ml and calcium < 10.4 mg/dl and phosphorus < 6 mg/dl and CaxP < 55 mg2/dl2) was 33.3% on month 6 and 66.7% after 1 year. The mean time to reach PTH target was 2.33 months with a 95% confident interval [1,35-3,32] and to reach the aggregate of all target was 16.94 months [11,38-22,5]. Cinacalcet ® has been well tolerated, we reduced the dose in a single patient due to secondary effects, but treatment was not discontinued in any case. Conclussion: In summary the addition of Cinacalcet(R) to conventional treatment in PD patients with resistant HPTH has improved the achievement of targets, and has been reasonably safe in our patients (AU)

[Cinacalcet in patients on peritoneal dialysis with moderate to severe hyperparathyroidism resistant to conventional treatment, a one-year, prospective study]. / Cinacalcet en pacientes en diálisis peritoneal con hiperparatiroidismo moderado-severo resistentes a tratamiento convencional. Estudio prospectivo a un año.

BACKGROUND: Cinacalcet has improved the management of hyperparathiroidism (HPTH) in hemodialysis. To our knowledge there are no specific studies on peritoneal dialysis (PD). AIM: The aim of the present study was to evaluate the efficacy of Cinacalcet on the achievement of optimal and suboptimal targets on treatment of hyperparathiroidism (HPTH) in PD patients. As secondary objectives we have studied the safety of treatment and estimate the mean time to reach these targets, and evaluate economic cost. METHODS: Eighteen patients undergoing more than 4 months on PD with a severe HPTH (PTH > 500 pg/ml) resistant to conventional treatment with diet, chelants and vitamin D were included in this prospective open-label study. We have used the targets of K/DOQITM-clinical guidelines as optimal target. We have selected as suboptimal targets: PTH < 350 pg/ml, phosphorus < 6 mg/dl and calcium < 10.4 mg/dl (only when simultaneous CaxP was under 55 mg2/dl2). Oral Cinacalcet was given with main meal in a single daily start dose of 30 mg and titrated thereafter monthly. We considered the first value on target as an event and used a Kaplan-Meyer survival analysis to estimate mean time to reach target. RESULTS: On inclusion all patients have at least two previous PTH values over 500 pg/ml, PTH mean 695,3 (SD 96) and they were on PD with an appropriate efficacy during a mean of 15.56 months (SD 0.78). Mean follow-up time under Cinacalcet treatment was 12 months. The percentage of patients with a PTH under 350 pg/ml was 66,7% on month 3, 60% on month 6 and 100% after 1 year. The percentage of patients that reach an aggregate of all suboptimal targets (PTH< 350 pg/ml and calcium < 10.4 mg/dl and phosphorus< 6 mg/dl and CaxP < 55 mg2/dl2) was 33.3% on month 6 and 66.7% after 1 year. The mean time to reach PTH target was 2.33 months with a 95% confident interval [1.35-3.32] and to reach the aggregate of all target was 16.94 months [11.38-22.5]. Cinacalcet has been well tolerated, we reduced the dose in a single patient due to secondary effects, but treatment was not discontinued in any case. CONCLUSION: In summary the addition of Cinacalcet to conventional treatment in PD patients with resistant HPTH has improved the achievement of targets, and has been reasonably safe in our patients.

Desarrollo de un sistema de monitorización clínica para hemodiálisis: propuesta de indicadores del Grupo de Gestión de Calidad de la SEN / Developing a clinical performance measures system for hemodialysis, quality group, Spanish Society of Nephrology

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Seguimiento prospectivo del acceso vascular en hemodiálisis mediante un equipo multidisciplinar / Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team

Introducción: Las guías de expertos recomiendan programas de monitorización del acceso vascular (AV) en hemodiálisis mediante equipos multidisciplinares. Material y métodos: Presentamos la experiencia, de 5 años de seguimiento prospectivo del AV mediante un equipo multidisciplinar. Describimos los indicadores de calidad alcanzados y los factores asociados a supervivencia en AV incidentes. Resultados: Se estudiaron 317 AV, 73% fístulas arteriovenosas autólogas (FAV) y el resto PTFE, en 282 pacientes. Se produjeron 88 trombosis: tasa de trombosis/acceso año de 0,06 para FAV y 0,38 en PTFE. El 66,6% de reparaciones del AV fueron electivas, realizándose cirugía urgente en el 76% de las trombosis. No precisaron catéter el 62,5% de los pacientes. Los ingresos relacionados con las complicaciones de FAV y PTFE fueron el 11,4% del total. El 80% de pacientes valorados previamente en la consulta de prediálisis comenzó hemodiálisis con un AV desarrollado. La supervivencia media de las FAV incidentes fue de 1.575 ± 55 días vs 1.087 ± 102 de los PTFE (p < 0,008). La supervivencia al año, 2 años y 3 años de las FAV fue del 89%, 85% y 83% y en los PTFE de 83, 67 y 51% respectivamente. La regresión de Cox demostró que el tipo de AV es el factor más importante asociado a supervivencia, OR 0,4 [0,2-0,8] para las FAV (p < 0,01). La supervivencia añadida de todos los AV incidentes reparados tras disfunción fue de 1.062 ± 97 días vs 707 ± 132 en los reparados por trombosis; log rank 5,17, p < 0,02. El aumento de riesgo en los AV reparados tras trombosis frente a disfunción fue de 4,2 p <: 0,01. Conclusiones: El seguimiento del AV de forma multidisciplinar ha conseguido: tasa baja de trombosis, elevado número de reparaciones tanto electivas como después de una trombosis, poca necesidad de catéteres y pocos ingresos. Las FAV se asociaron a una mejor supervivencia. Los AV reparados por disfunción vs trombosis presentaron mayor supervivencia

Porpuse: Now a day the expert guide line recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team. Material and method: We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA. Results: Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas (AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous presion (42,5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0,15 access/year, which were distributed in 0.06 for AVF and 0,38 in PTFE grafts. Two hundred and one repair of the VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgery were done in 76% of the thrombosis. The 62,5% of the patients do not needed a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11,4% of the total patientes hemodialysis hospitalizations. The 65,2% of the VA were new access. The 57% of patients were properly review in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575 ± 55 days vs 1,087 ± 102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression have proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 ± 97 days vs 707 ± 132 due to thrombosis, log rank 5,17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4,2 p < 0,01. Conclusions: The monitoring of the vascular access by a multidisciplinary team has reached: low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. The AVF are associated a greater survival that PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well

[Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team]. / Seguimiento prospectivo del acceso vascular en hemodialisis mediante un equipo multidisciplinar.

PURPOSE: Nowadays, expert guidelines recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team. MATERIAL AND METHOD: We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA. RESULTS: Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas(AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous pressure (42.5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0.15 access/year, which were distributed in 0.06 for AVF and 0.38 in PTFE grafts. Two hundred and one repairs of VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgeries were done in 76% of the thrombosis. 62.5% of the patients did not need a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11.4% of the total patients hemodialysis hospitalizations. 65.2% of the VA were new access. 57% of patients were properly reviewed in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575+/-55 days vs 1,087+/-102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression has proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 +/- 97 days vs 707 +/- 132 due to thrombosis, log rank 5.17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4.2 p < 0,01. CONCLUSIONS: The monitoring of the vascular access by a multidisciplinary team has reached:low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. AVF are associated with greater survival than PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well.

[Hypophosphatemia in dialysis units]. / Hipofosforemia en unidades de diálisis crónica.

Hypophosphatemia (Hf) is infrequently reported in chronic hemodialysis patients. The objective of this report is to describe the incidence, etiology, symptoms and treatment of Hf in a Dialysis Unit (defined as phosphorus < 2.5 mg/dL). In a retrospective study over a period of three years, we identified 22 cases of Hf, occurring on 11 among 149 patients. A two-groups distribution was made: Group A, patients with more than one episode (n = 3, 14 episodes of Hf) and Group B, patients with only one isolated episode of Hf (n = 8, 8 episodes of Hf). Plasma Ca, P, Albumin and nPCR were significant lower in group A (p < 0.05). Only two patients of group B had symptoms. Cases of Hf were: Group A: low-protein diet and alcoholism, Group B: decreased dietary intake due to non-digestive problems (n = 2) or due to digestive problems plus antacids (n = 4), phos-phate binders (n = 1) and dietary phosphorus restriction (n = 1). Three patients had secondary hyperparathyroidism. Treatment consisted on oral supplementarion by diet and changes in oral calcium salts. Intravenous supplementation was required acutely to raise serum P in a patient with auricular fibrilation. Two group A patients who has plasma 1.25 vitamin D < 5 pg/mL received vitamin D, and the third oral supplements of P. In all the cases, Hf resolved with these measures. We concluded that Hf is not so infrequent in hemodialysis. In patients with low-protein diet and low vitamin D concentration, Hf can be sustained. On the other hand, a decreased dietary intake maintaining similar phosphate binder's supplementation is the most frequent cause of occasional and symptomatic Hf, even in patients with secondary hyperparathyroidism.

Hipofosforemia en unidades de diálisis crónica / Hypophosphatemia in dialysis units

La hipofosforemia (Hf) se describe raramente en los pacientes en hemodiálisis (HD) crónica. Hemos recogido retrospectivamente los casos de Hf ocurridos durante 3 años en un mismo centro. Revisamos todas las determinaciones de P realizadas (n = 2.201), considerándose Hf una concentración de P plasmático menor de 2,5 mg/dL. Posteriormente, se recogieron los datos clínicos y bioquímicos de cada caso para analizar las causas, síntomas y el tratamiento aplicado. Recogimos 22 episodios de Hf (0,9% del total de mediciones de P) en 11 pacientes sobre un total de 149 enfermos (7,3%) en tratamiento con HD convencional. Separamos dos grupos según presentaran Hf repetida (grupo A, n = 3) o aislada (grupo B, n = 8). Las concentraciones de P y albúmina y la nPCR, fueron menores en el grupo A, mientras que el B presentaba un calcio plasmático significativamente mayor (p 3 mg/dL. Concluimos que la Hf en HD no es tan infrecuente como se suele considerar, pudiendo aparecer de forma mantenida en pacientes con baja ingesta. La disminución aguda de la ingesta manteniendo los ligantes habituales, unida a la administración de antiácidos es la causa más frecuente de Hf esporádica en pacientes con buen control del P, que pueden tener incluso un hiperparatiroidismo secundario

Hypophosphatemia (Hf) is infrequently reported in chronic hemodialysis patients. The objective of this report is to describe the incidence, etiology, symptoms and treatment of Hf in a Dialysis Unit (defined as phosphorus < 2,5 mg/dL). In a retrospective study over a period of three years, we identified 22 cases of Hf, ocurring on 11 among 149 patients. A two-groups distribution was made: Group A, patients with more than one episode (n = 3, 14 episodes of Hf) and Group B, patients with only one isolated episode of Hf (n = 8, 8 episodes of Hf). Plasma Ca, P, Albumin and nPCR were significant lower in group A (p < 0,05). Only two patients of group B had symptoms. Cases of Hf were: Group A: lowprotein diet and alcoholism, Group B: decreased dietary intake due to non-digestive problems (n = 2) or due to digestive problems plus antacids (n = 4), phosphate binders (n = 1) and dietary phosphorus restriction (n = 1). Three patients had secondary hyperparathyroidism. Treatment consisted on oral supplementarion by diet and changes in oral calcium salts. Intravenous supplementation was requiered acutely to raise serum P in a patient with auricular fibrilation. Two group A patients who has plasma 1,25 vitamin D < 5 pg/mL received vitamin D, and the third oral supplements of P. In all the cases, Hf resolved with these measures. We concluded that Hf is not so infrequent in hemodialysis. In patients with lowprotein diet and low vitamin D concentration, Hf can be sustained. On the other hand, a decreased dietary intake maintaining similar phosphate binder’s supplementation is the most frequent cause of occasional and symptomatic Hf, even in patients with secondary hyperparathyroidism

[Application of process management in nephrology. Hemodialysis process management]. / Aplicación de la gestión por procesos en nefrología. Gestión del proceso hemodiálisis.

Total Quality Management techniques have recently been introduced into clinical practice. We describe the application of process management to hemodialysis therapy in a Spanish public hospital. The "ownership" of the hemodialysis process and its limits have been defined. We present a flowchart with all the activities involved in the process and the task description. Monitoring indicators have been selected according to the recommendations of the US Committee on the National Report on Health Care Delivery. Data sources for indicators have also been described.

Aplicación de la gestión por procesos en nefrología. Gestión del proceso hemodiálisis / Process management in nephrology. Management of the hemodialysis process

Las técnicas de gestión de calidad total han sido introducidas recientemente en la práctica clínica. Este artículo describe la aplicación de la gestión de procesos a la hemodiálisis (HD), como tratamiento renal sustitutivo de la insuficiencia renal crónica, en un hospital público español. Se ha definido el proceso con un diagrama de flujo en el que aparecen todas las actividades del mismo. Los indicadores para su monitorización han sido seleccionados siguiendo las recomendaciones del Committee on the National Report on Health Care Delivery norteamericano. Se describen los estándares y las fuentes de datos para los indicadores (AU)

Role of type of vascular access in erythropoietin and intravenous iron requirements in haemodialysis.

BACKGROUND: Recent data have suggested the existence of a relationship between the use of synthetic vascular accesses and increased erythropoietin (Epo) requirements. The present study aimed to evaluate the possible role of the type of vascular access in both Epo and intravenous (i.v.) iron requirements. METHODS: One-hundred-and-seven individuals without recognized causes of Epo resistance, 62 of them undergoing chronic haemodialysis through native arteriovenous fistulae (AVF) and 45 through PTFE grafts, were retrospectively studied (one-year follow-up). Sixty-nine patients, i.e. all but three with a PTFE graft and 27 with native AVF, were taking anti-platelet agents. Doses of i.v. iron and Epo and laboratory parameters were recorded. RESULTS: Erythropoietin and i.v. iron requirements were higher in the patients dialysed through PTFE grafts compared with those with native AVF (Epo: 103.8+/-58.4 vs 81.0+/-44.5 U/kg/week, P=0.025; i.v. iron: 178.9+/-111 vs. 125.9+/-96 mg/month, P=0.01). On a yearly basis, the difference in Epo dose represented a total of 94582+/-16789 U Epo/patient/year. Moreover, the patients with PTFE grafts received more red blood cell transfusions than patients with native AVF (P=0.021). No differences between laboratory, dialysis kinetics, demographic or comorbidity parameters were found. The type of vascular access was the best predictor of the requirement of > or =150 U/kg/week Epo (P=0.03). Even though the patients who received anti-platelet therapy required more i.v. iron (167.5+/-103.6 vs. 114.5+/-101.4 mg/month, P=0.008) but not more Epo (P=NS), the possibility of an accessory role of anti-platelet agents in the increased Epo requirements with PTFE grafts cannot be ruled out. CONCLUSIONS: The use of a PTFE graft and anti-platelet drugs represents a previously undescribed association related to higher Epo and i.v. iron requirements. The association described herein adds new arguments to the debate concerning the choice of vascular access in chronic haemodialysis patients.

Ultrafiltración aislada, ¿unipunción o bipunción? / Isolated infiltration, single or double punction?

La excesiva ganancia de peso interdiálisis es un importante problema en la población en hemodiálisis que requiere, en ocasiones, la realización de sesiones extra de Ultrafiltración (UF) aislada, lo que supone un mayor número de punciones del acceso vascular. Por este motivo, nos planteamos utilizar técnicas de unipunción para realizar estas sesiones y así mejorar la supervivencia del acceso vascular y con ello la calidad de vida de los pacientes. Para ello estudiamos 38 sesiones de UF aislada en 10 pacientes; 25 en bipunción y 13 en unipunción. El análisis de los parámetros clínicos y bioquímicos, no reveló diferencias significativas entre ambos grupos, por lo que concluimos que las sesiones de UF aislada son igualmente efectivas con ambas técnicas. Además el número de punciones del acceso vascular fue menor con la técnica de unipunción lo que supone un mejor cuidado del acceso vascular y un aumento de fa calidad de vida de estos pacientes (AU)

[Why do ambulatory hemodialysis patients go to hospital emergency services? / Por qué acuden los pacientes de hemodiálisis extrahospitalaria a los servicios de urgencia hospitalarios?

UNLABELLED: An important number of Hospital admissions (HA) occurs through Hospital Emergency Departments (HED). This is a indicator of quality and have to be lower than 50%. However there are almost no data available on the causes of emergency consultation by outpatient hemodialysis patients (HD). For this reason, we prospectively examined a population of 83 outpatient HD patients dialyzed in a peripheral unit under the surveillance of a University Hospital. OBJECTIVES: 1) To know the diagnosis of HED and days of hospitalization for which HD patients came to the HED in 1998. 2) To know the possible risk factors associated with the patients with frequent assistance in HED. 3) To compare the number and causes of emergency consultation in 1998 with a group of patients treated in the same Unit in 1991 (n = 39). RESULTS: The percentage of patients who used the HED in 1998 was 66.3% (55/83). The total number of emergency episodes in 1998 was 118 (mean of 55 patients 2.27 +/- 1.51). Fifty one percent of the emergency episodes were due to patients initiative. The 4 more frequent diagnoses of HED in 1998 were infectious, 19.5% (23/118); traumatologic emergencies, 15.3% (18/118); digestive disease 15.3% (18/118); relationed problem vascular access, 11.9% (14/118). Thirty percent (36/118) of the emergency consultations needed HA leading to a mean hospitalitation of 10.2 +/- 9.3 days. The infectious disease were the highest percentage of HA (36.1%) and the longest days of hospitalitation (12.7 +/- 11.2 days). The risk factors for repeated emergency consultation (more than 3 times) were: age (68.9 vs 61.4), lower hematocrit (31.6 vs 34.4%), lower hemoglobin (10.2 vs 11), high EPO dose (166.3 vs 109.7 unit/kg/week) and lower Kt/V (0.99 vs 1.11). If we compare these results with 1991 the percentage that used the HED was similar 66.2% (pNS); the number of emergency episodes was higher (mean 2.99 +/- 1.96) than 1998 (p < 0.006) and there are a significant differences in the diagnoses of HED between 1998 and 1991: acute pulmonary edema 1.7 vs 11.2% (p < 0.003); hiperkalemia 0.8 vs 7.9% (p < 0.009); gastrointestinal disease 15.3% vs 4.5% (p < 0.008) and infectious 19.5% vs 7.9% (p < 0.01). In conclusion our study provides data previously not available on the epidemiology of Emergency Consultation by outpatient HD patients treated in the same peripheral unit. The data obtained albeit limited because of the number provide information of potential protocol usefulness for the possible reduction in the frequency of Hospital Emergency Consultations by outpatient HD patients.

Influence of post haemodialysis sampling on Kt/V result.

The recommended Kt/V is 1.2. Unfortunately there is no written policy for nurses on the procedure for taking blood urea nitrogen samples post haemodialysis. The aim of this study was to establish the Kt/V variability of haemodialysis patients depending on the method of collection of post-haemodialysis blood urea nitrogen. Twenty-two patients were analysed. A Kt/V was performed every 15 days during a period of 2 months. It was taken five times on each patient: 30 minutes before the end of a haemodialysis session (Kt/V30), at the end of haemodialysis (Kt/V1), after slowing flows (50 ml/min) for 2 minutes (Kt/V2) and after the blood circuit had been returned to the patient at 5 and 15 minutes respectively. (Kt/V5, Kt/V15). The Kt/V results were: Kt/V1 1.23 +/- 0.2 Vs Kt/V2 1.14 +/- 0.19 (p < 0.003); Kt/V5- 1.05 +/- 0.19 (p < 0.002 Vs Kt/V2); Kt/V15 1 +/- 0.16 (p < 0.05 Vs Kt/V5); Kt/V30 1.12 +/- 0.21 (pNS Vs Kt/V2). In conclusion, there was a large variability in the Kt/V depending on the method of collection of the blood urea nitrogen sample post-haemodialysis.