Multicentre Study on the Efficacy of Brachial Artery Transposition Among Haemodialysis Patients.

OBJECTIVE: Brachial artery transposition (BAT) is not a well known method for obtaining vascular access (VA) for maintenance haemodialysis. This study evaluated the outcomes of BAT. METHODS: This multicentre retrospective cohort study included 233 consecutive patients who underwent BAT between January 2012 and December 2013. The indications were inadequate vessels for obtaining VA, severe heart failure, hand ischaemia, central vein stenosis/occlusion, or a history of catheter/graft infection. The transposed brachial artery was used only for arterial inflow and other routes were used for outflow. RESULTS: BAT was successful in 227 patients, and adequate blood flow was achieved during dialysis sessions. The first successful cannulation was after a median of 18 days. BAT was performed using superficial veins as the return route in 127 patients and arteriovenous fistula (AVF) creation in 63 patients to prevent maturation failure. In 41 patients with central venous catheterisation, the transposed brachial artery was used for arterial inflow. The complications of BAT were impaired wound healing in 14 patients, including skin necrosis in two; large aneurysms in six, including a mycotic pseudo-aneurysm in one; arterial thrombosis in five; hand ischaemia in five; lymphorrhoea in four; and haematoma/bleeding in three. The transposed brachial artery was abandoned in four, three, three, and one case of arterial thrombosis/stenosis, haematoma/bleeding, skin necrosis, and large aneurysm, respectively. Access to the return routes failed in 48 cases because of vein damage caused by cannulation in 22, AVF thrombosis/stenosis in 14, catheter infection in six, and catheter occlusion in six. At two years, the primary patency rates of the transposed brachial artery and access circuit were 88% and 54%, respectively. CONCLUSION: BAT is a safe and effective technique. The patency was high for the transposed brachial artery but adequate for the access circuit. BAT can be considered for patients with an unobtainable standard arteriovenous access.

Combined cyclosporine and prednisolone therapy using cyclosporine blood concentration monitoring for adult patients with new-onset minimal change nephrotic syndrome: a single-center pilot randomized trial.

BACKGROUND: Minimal change nephrotic syndrome (MCNS) responds well to steroids, but some patients show frequent relapses. Long-term steroid administration leads to various adverse effects. We previously reported the effectiveness in refractory nephrosis patients of administrating microemulsified CyA (ME-CyA) once before meals and setting the target value of the CyA blood concentration at 2 h after ME-CyA administration (C2) to 600-1200 ng/ml. On this trial we evaluate the effectiveness and safety of ME-CyA for suppressing relapse of adult new-onset MCNS patients using C2 monitoring. METHODS: Adult new-onset MCNS patients were randomly allocated to a ME-CyA + prednisolone group ("CyA + PSL") (n = 11) and a PSL-alone group ("PSL-alone") (n = 10). The drug administration period was 18 months followed by an observation period of 12 months. RESULTS: The duration of remission tended to be longer in CyA + PSL with C2 >600 ng/ml than in PSL-alone (P = 0.112). The relapse rate up to 18 months was significantly lower in CyA + PSL with C2 >600 ng/ml than in PSL-alone (P = 0.02). C2 was significantly higher in the patients with no relapse at 18 months than that in the patients with relapse (P = 0.048). In CyA + PSL, the total dose of PSL was significantly reduced compared with PSL-alone (P = 0.002). Cosmetic adverse effects tended to be fewer in CyA + PSL. CONCLUSIONS: The combination treatment regimen of ME-CyA and PSL with C2 >600 ng/ml has potential to be an important treatment option for adult new-onset MCNS patients. However, after ME-CyA dosage reduction and discontinuation, the relapse rate increased. It is thus necessary to establish a better dose-reduction method.

Early Postoperative Complications of Peritoneal Dialysis Catheter Surgery Conducted by Nephrologists: A Single-Center Experience Over an Eight-Year Period.

The results of several recent studies indicate that the practice of peritoneal dialysis catheter (PDC) insertion by nephrologists is safe. However, few studies have addressed the important issue of safety in surgeries related to PD, including PDC removal and other types of surgery. In the present study, we aimed to verify whether the incidence of early postoperative complications for surgical procedures related to PD and performed by nephrologists meets the audit standards of clinical practice guidelines for peritoneal access.Between April 2008 and July 2016 at our hospital, 282 patients underwent various types of PD-related surgery conducted by 17 nephrologists. The surgery types were the Moncrief-Popovich technique (n = 74), PDC exteriorization (n = 62), conventional laparotomy insertion (n = 29), PDC removal (n = 70), partial replacement (n = 32), unroofing or cuff shaving (n = 7), and others (n = 8).Bowel perforation and significant hemorrhage did not occur at the time of PDC insertion and removal. Although peritonitis was not evident, exit-site and tunnel infection within 2 weeks of PDC insertion by conventional laparotomy or exteriorization after the Moncrief-Popovich technique occurred in 3 of 91 patients (3.3%). The PDC malfunctioned in 2 of 103 patients (1.9%) after the Moncrief-Popovich technique because of PDC occlusion with a fibrin plug. Dialysate leaks occurred in 2 of 103 patients (1.9%). Partial replacement and unroofing or cuff shaving for refractory PDC infection and other type of surgeries were not associated with serious complications.The incidence of complications after surgery related to PD was low at our institution. The incidences of complications met the audit standards in the guidelines, indicating that surgery by nephrologists is safe and effective.

Long-Term Prognosis of Peritoneal Dialysis Patients with a Re-embedded Catheter.

Upon peritoneal dialysis (PD) discontinuation in frail patients, we have re-embedded the catheter and left it subcutaneously buried. However, we have not evaluated the long-term prognosis of those patients after the procedure or the complications associated with buried catheters. We therefore aimed to clarify the long-term prognosis of patients with a re-embedded catheter and to identify any associated complications.The outcomes of 10 patients having a catheter that was re-embedded between February 2010 and May 2016 were assessed by interviewing the patients or their families (when possible), and by reviewing medical records.Catheter re-embedding to reduce the surgical burden was elected by 7 patients, and 3 patients underwent re-embedding because they wanted to resume PD in the future. By the time of the interviews, 6 patients had already died of causes that were unrelated either to the buried catheter or infection. No abnormality was found in any buried catheter. A re-embedded catheter was later externalized to resume PD in 1 of the 4 patients who survived.Catheter re-embedding is safe and allows for PD resumption at the terminal stage of dialysis.

Using a Peritoneal Dialysis Access Simulator in Surgical Training for Nephrologists.

In Japan, peritoneal dialysis (PD) catheter insertion has been performed by both nephrologists and surgeons. However, nephrologists have fewer opportunities to train in the insertion procedure. We therefore used a PD access simulator to provide training in this operative technique for nephrologists. A PD access simulator developed by Terumo Medical Corporation was used for the training. The simulator uses a mannequin made of acrylic resin. The abdominal wall of a pig is attached to the abdominal area, and a plastic bag represents the abdominal cavity. The simulator enables the surgical procedure to be performed from skin incision to PD catheter insertion. Between October 2011 and December 2013, 3 supervising doctors used the simulator to guide 17 nephrologists with no experience through a PD catheter insertion. One-on-one training was provided in a single 2- or 3-hour session. In a questionnaire survey after the training, trainees gave high marks to the handling of surgical instruments, the environment of the operating room, and the surgical guidance during training. However, the supervising doctors required the ability to respond flexibly, because trainees had individual differences in skills. The PD access simulator might be useful for providing guided training in operative technique for PD catheter insertion.

Subcutaneous pathway diversion for peritoneal dialysis catheter salvage.

Peritoneal dialysis (PD) catheter-related infection is still is the most troublesome problem for continuation of PD without the need to switch to hemodialysis. We have been performing subcutaneous pathway diversion (SPD) as a surgical treatment for refractory exit-site and tunnel infection (ESTI). To clarify the efficacy and safety of SPD, we conducted a retrospective study. From August 2008 to August 2013, 30 SPDs were performed in 26 patients (16 men, 10 women; mean age: 58 +/- 13 years; 54% with diabetes; mean body mass index: 23.9 +/- 3.5 kg/ m2). The reasons for the SPDs were ESTI in 25 patients, and outer cuff extrusion in 1 patient. All patients resumed PD immediately after SPD, and the duration of hospitalization was 11.7 +/- 10.1 days. After SPD, one patient experienced a dialysate leak, and another patient experienced a mild subcutaneous hematoma. Another 4 patients developed exit-site infection (ESI) and underwent a second SPD. Of those 4 patients, 3 presented with another ESI unrelated to the first episode, and all developed an ESI after 6 months or more. The remaining 20 patients experienced no such complications. Furthermore, catheter survival after SPD was 17.4 +/- 13.4 months. To eradicate ESTTI we suggest that SPD, which does not require catheter removal or interruption of PD, is useful compared with the unroofing technique or catheter removal.

Risk factors associated with inadequate veins for placement of arteriovenous fistulas for hemodialysis.

An arteriovenous fistula (AVF) between the radial artery and cephalic vein at the wrist is the preferred type of hemodialysis vascular access. However, in the practice of access placement, we are aware that some patients fail to form the standard forearm radial-cephalic AVF, owing to naturally small veins or acquired abnormal lesions of the veins. To identify the risk factors for failure to form the standard AVF, we examined 305 consecutive patients who underwent first-time access surgery at our hospital from January 2006 to December 2010. We compared the patients' characteristics between those having normal vessels and successfully forming the standard AVF, and those having apparently abnormal vessels and thus forming alternative types of access instead. Histories of major and minor surgery were specifically evaluated, assuming that surgical procedures in the past could potentially damage the superficial veins. We created 207 standard and 98 alternative accesses during the period and found that significantly more patients with alternative accesses (31 %) had undergone major surgery of a variety of specialties, in comparison with those with the standard AVF (15.0 %). Multivariate logistic analysis revealed that a history of major surgery (OR = 2.39, 95 %CI 1.29-4.47, p = 0.006) and female gender (OR = 1.87, 95 %CI 1.10-3.20, p = 0.02) were independent risk factors associated with failure to construct the standard AVF. Our results indicate that previous surgery can damage the superficial veins and cause venous abnormality, which makes construction of the standard AVF difficult. We propose that care should be taken to preserve the superficial veins when patients for whom dialysis therapy is a future possibility undergo surgical procedures, especially invasive ones.

Impact of vascular access intervention therapy on cardiac load in hemodialysis patients.

Vascular access intervention therapy (VAIVT) has been positioned as the first choice of treatment for stenosis lesions frequently observed in arteriovenous fistula (AVF) for hemodialysis patients in Japan. Furthermore, increased blood flow can provide a stable dialysis. In contrast, it has been reported that excess blood flow of AVF causes high-output heart failure. Although VAIVT is used to increase blood flow of AVF, the impact of VAIVT on cardiac load has been rarely reported. We examined the factors associated with cardiac load in hemodialysis patients undergoing VAIVT by measuring levels of α human atrial natriuretic polypeptide (hANP) and brain natriuretic peptide (BNP) before and after VAIVT. Data were extracted on hemodialysis patients who underwent measurements of αhANP and BNP in before and after VAIVT at our facility and related facilities between February 2014 and December 2014. Nineteeen patients (median age, 73.0 [66.5-80.5] years; male, 52.6%; 36.8% with diabetes; median duration of dialysis treatment, 50.0 [21-109] months) were enrolled in this study. Flow volume of AVF was higher after VAIVT than that before VAIVT (442.0 vs. 758.0 mL/minute, P < 0.001). Moreover, resistance index (RI) of AVF after VAIVT was lower than that before VAIVT (0.61 vs. 0.53, P < 0.01). Although αhANP did not change before and after VAIVT (55.6 vs. 54.9 pg/mL, P = 0.099), BNP after VAIVT was significantly higher than that before VAIVT (145.2 vs. 175.0 pg/mL, P < 0.05). Factors correlated with the increase in BNP were flow volume of AVF before VAIVT (r = -0.458, P = 0.049) and levels of BNP before VAIVT (r = 0.472, P = 0.041). There was no significant correlation between the increase in αhANP with flow volume of AVF before VAIVT, levels of αhANP before VAIVT. Patients with high levels of BNP and low flow volume of AVF before VAIVT were considered to have a high risk of developing heart failure after VAIVT.

Change in skin perfusion pressure after the creation of upper limb arteriovenous fistula for maintenance hemodialysis access.

Arteriovenous fistula (AVF) is the most important vascular access method for hemodialysis (HD). However, ischemic steal syndrome occasionally develops. This study evaluated the change in skin perfusion pressure (SPP) after the creation of upper limb AVF and analyzed the relationship between blood flow measurements and the change in SPP. The subjects included 21 patients who underwent radiocephalic AVF creation for the first time between November 2012 and September 2013. We measured SPP on the palm side of the third finger of both hands and assessed blood flow measurements using ultrasound examination before and after the creation of AVF. The subjects consisted of 15 men and 6 women (average age: 65.3 ± 12.7 years, including 12 diabetic patients). Observational period between before and after surgery was 4.9 ± 5.2 days. None of the patients had ischemic steal syndrome after the creation of AVF. Skin perfusion pressure tended to decrease after creation of AVF on the finger of AVF side (100.0 ± 20.9 vs. 87.9 ± 26.5 mmHg, P = 0.063). In contrast, SPP did not change in the limb without AVF (97.9 ± 20.7 vs. 101.0 ± 19.4 mmHg, P = 0.615). The rate of change in SPP was significantly decreased on the finger of AVF side compared with that of limb without AVF (0.055% vs. -0.112%, P = 0.014). There was no correlation between the change in SPP and blood flow measurements. Skin perfusion pressure is possible to detect ischemic steal syndrome after the creation of upper limb AVF.