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.

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.

Administration of calcimimetics after dialysis: same effectiveness, better gastrointestinal tolerability.

INTRODUCTION: Cinacalcet has proved effective to control secondary hyperparathyroidism in patients on haemodialysis (HD). Some studies have reported an appropriate secondary hyperparathyroidism control and a better compliance after intradialytic use of calcimimetics. OBJECTIVES: To assess the effect of post-dialysis calcimimetics use on mineral bone disorders and calcimimetics gastrointestinal tolerability in our HD unit. MATERIAL AND METHODS: A 12-week single-centre prospective study in HD patients treated with cinacalcet (>2 months). Two study periods: Usual outpatient use (Stage 1) and use after HD session (Stage 2). ENDPOINTS: 1) Biochemical MBD data; 2) Gastrointestinal Symptom Rating Scale (GSRS) for gastrointestinal tolerability, and visual analogic scale (VAS) for satisfaction; 3) Adherence: Morisky-Green test (MG) and final tablet count (TC). RESULTS: Sixty-two HD patients. Fourteen received cinacalcet (22.5%). TEN patients were included, mean age was 60.9 years; patients had received HD for 80.9 months. Mean Charlson index: 9. Biochemical data: Stage 1 (initial vs. final): Ca 8.8 ± 0.5 vs. 9.1 ± 0.7 mg/dl (p<0.05); P 5.2 ± 0.8 vs. 4.5 ± 1.6 mg/dl, iPTH 360.3 ± 232.7 vs. 349 ± 122 pg/ml. MG: 70%. Stage 2 (initial vs. final): Ca 9.1 ± 0.7 vs. 8.8 ± 0.6 mg/dl; P 4.5 ± 1.6 vs. 4.6 ± 1.3 mg/dl, iPTH 360.3 ± 232.7 vs. 349 ± 122 pg/ml. TC: 89%. GSRS and VAS were better in Stage 2 (GSRS 7.5 ± 5.2 vs. 4.3 ± 1.9; VAS 4.8 ± 2.3 vs. 6.9 ± 2.8). No significant changes were observed in calcimimetic dose (201 vs. 207 mg/wk), number of phosphate binders (9 vs. 8.2 pts/day), native vitamin D (70 vs. 60%), selective vit D receptor activators (30%), or suitable dialysis parameters. CONCLUSIONS: Post-dialysis use of calcimimetic was effective in secondary hyperparathyroidism control, improved gastrointestinal tolerability and ameliorated patients' satisfaction. Based on our findings, post-dialysis use of calcimimetics should be considered in selected patients with low therapeutic compliance.