Background and Aims Functioning vascular access is an essential element for life-saving hemodialysis therapy. Surgical creation of a radiocephalic arteriovenous fistula (AVF) is the gold standard of vascular access for hemodialysis. However an endovascular approach to arteriovenous fistula creation (endoAVF) has increasingly gained acceptance over the last years as an alternative to the conventional surgical method. It offers a minimally invasive method for the formation of arteriovenous shunts and allows the creation of fistulas with minimal vessel trauma. There are currently two technologies available for this purpose, the Ellipsys Vascular Access System (Medtronic, Avenu Medical, San Juan Capistrano, Calif) and the Wavelinq endoAVF System (BD Medical, Franklin Lakes, NJ). At our centre (Careggi University Hospital, Florence), we developed an integrated service, based on a multidisciplinary approach between Interventional Radiology and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing both Ellipsys and Wavelinq. We describe our experience with a case series of 39 patients, showing feasibility and outcome of this treatment option. Method Between December 2020 and January 2023 we created an endoAVF in 39 patients. Patients were suitable for the procedure after a pre-therapeutic ultrasound vascular mapping showed adequate brachial, radial and ulnar vessels and no ipsilateral central venous stenosis. After procedure, we performed a regular clinical and ultrasound monitoring. Therefore, we collected data regarding patient characteristics, initial technical success rate, number of access lost and number of endoAVF meeting primary and secondary patency. Results Of the total of 39 patients treated with endoAVF, 29 (74.3%) were male, with a mean age of 60.1 ± 33.9 years. The Wavelinq procedure was performed in 32 patients (82.0%) and the Ellipsys procedure in 7 patients (17.9%). Initial technical success was achieved in 38 (97.4%) cases, while in 1 case we had a primary failure of the fistula (Figure 1). Among these 38 patients, 4 (10.5%) were lost to follow-up because of death from other causes (3 patients) and because of kidney transplantation (1 patient), while 2 other patients (5.2%) have not required hemodialysys yet. Of the remaining 32 patients, we had 2 fistulas lost because of complications and a cumulative functional patency of 93.7% (30 fistulas), with a primary patency rate of 76% (23 fistulas). Conclusion The endoAVF appears to be feasible and safe for the creation of arteriovenous fistula suitable for hemodialysis access. Our data show an high functional cumulative patency of the endoAVF and a good primary patency, reducing the necessity of further interventions. Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improving long wait times for vascular access creation. Further studies with more patients and multicentric data are needed to assess long-term outcomes.
Background: Approximately one forth of patients treated with SGLT2 inhibitors (SGLT2i) experience an acute estimated glomerular filtration rate (eGFR) reduction of more than 10% (“dippers”). High sodium and protein intake can increase intraglomerular pressure and predispose to a decline of renal function. We investigated whether measured creatinine clearance (CrCl) is a sensitive enough method to detect the initial dip of GFR and if dietary sodium and protein intake might influence the extent of the early change in GFR. Methods: 28 subjects with type 2 diabetes (T2D) were enrolled. 24h urinary samples for sodium and urea determination were collected, to estimate sodium and protein intake respectively before and 1, 3 and 6 months after SGLT2i initiation. Results: Mean CrCl was 83.23±25.52 ml/min/1.73 m2 (eGFR 67.32±16.07) and dropped by 19% at month 1 (eGFR by 6%). Dippers were 64% and 40%, according to CrCl and eGFR respectively. Exploring the potential correlation between changes in renal function and salt intake, ΔCrCl and baseline urinary sodium were inversely related at month 1 (r= -0,61; p<0.01), at month 3 (r= -0.51; p =0.01) and month 6 (r= -0,48; p<0.05). Likewise, an inverse correlation between ΔCrCl and baseline urinary urea was demonstrated at month 1 and 3 (r= -0.46; p<0.05 for both), at month 6 a similar trend was observed (r= -0.47; p=0.054). Conclusions: The present study suggests that a higher dietary sodium and protein intake may amplify the extent of early dip in GFR, as detected with measured CrCl, in diabetic patients undergoing SGLT2i treatment.
BACKGROUND AND AIMS SGLT2 inhibitors (SGLT2i) are able to decrease proteinuria and slow down eGFR decline in DKD patients. The effect is mainly obtained by increase of natriuresis and glucose-induced osmotic diuresis, resulting in a reduction in intraglomerular pressure. These hemodynamic changes are beneficial in long-term period, but up to 28% of patients treated with SGLT2i experience an acute, usually transient, eGFR reduction of more than 10% [1]. Moreover, in some case, the decrease of eGFR can be more pronounced and compromise the maintenance of therapy. High sodium and protein intake can lead to intraglomerular pressure increase and predispose to a deeper fall of eGFR. We aimed at investigating whether measured creatinine clearance (CrCl) is a more sensitive method to detect the initial dip of GFR in patients with T2D treated with SGLT2i, and if dietary sodium and protein intake can influence the extent of the early change in GFR. METHOD Subjects with type 2 diabetes (T2D) were consecutively recruited among those referring to the inpatients of combined Nephrology and Diabetology clinic in years 2020–2021. Those eligible for treatment with SGLT2i were asked to collect 24-h urinary samples for sodium and urea determination, to estimate sodium and protein intake, respectively, before and 1, 3 and 6 months after treatment initiation. RESULTS At baseline, 27 patients (M 23/F 4; age 69 ± 7 years; BMI 28.2 ± 3.6 kg/m2; HbA1c 56 ± 16 mmol/mol) had a CrCl of 83.23 ± 25.52 mL/min/1.73 m2 (eGFR 67.32 ± 16.07), which dropped by 19% at month 1 (eGFR by 6%, although not significantly) and then increased to comparable baseline values at month 6. Exploring the potential correlation between changes in renal function and salt intake, ΔCrCl and baseline urinary sodium were inversely related at month 1 (r = −0.61; P <0.01), at month 3 (r = −0.51; P = 0.01) and month 6 (r= −0,48; P < 0.05) (Fig. 1). Likewise, an inverse correlation between ΔCrCl and baseline urinary urea (Fig. 2) was demonstrated at month 1 and 3 (r = −0.46; P <0.05 for both), at month 6 a similar, not significant, trend was observed (r = −0.47; P = 0.054). Proteinuria showed a significant reduction from baseline (P < 0.05); no significant relationship between change in proteinuria and urinary sodium or urea was observed. CONCLUSION The present study suggests that a higher dietary sodium and protein intake may amplify the extent of early dip in glomerular filtration rate, detected with measured CrCl, in diabetic patients undergoing SGLT2i treatment. We believe that measured creatinine clearance is a very sensitive method to detect it. Further studies are needed to confirm the results of our pilot study.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.