Gadolinium based contrast agents (GBCA) have been linked to the occurrence of nephrogenic systemic fibrosis (NSF) in renal impaired patients. The exact interaction between the various different available formulations and occurrence of NSF is not completely understood, but has been postulated. This association has triggered public health advisory bodies to issue guidelines and best practice recommendations on its use. As a result, the reported incidence of NSF, as well as the published use of GBCA-enhanced magnetic resonance imaging in renal impairment, has seen a decline. Understanding of the events that led to these recommendations can increase clinical awareness and the implications of their usage. We present a review of published literature and a brief overview of practice recommendations, guidelines and manuals on contrast safety to aide everyday imaging practice.Teaching Points• Low risk gadolinium based contrast agents should be the choice in renal insufficiency.• Higher doses have been linked to NSF development. Doses should be as low as possible.• Clear documentation of date,dose and type of formulation used should be noted.• Post-scan dialysis should be arranged as soon as possible and feasible.• Pre-existing inflammatory state is a risk factor;liver insufficiency is not a contraindication.

Aneurysms are a common and often difficult complication seen with arteriovenous vascular access for haemodialysis. The purpose of this narrative review is to define and describe the scale of the problem and suggested therapeutic strategies. A narrative review of the published literature illustrated by individual cases is presented with the aim of summarising the relevant literature. The definitions of aneurysm are inconsistent throughout the literature and therefore systematic review is impossible. They vary from qualitative descriptions to quantitative definitions using absolute size, relative size and also size plus characteristics. The incidence and aetiology are also ill defined but separation into true aneurysms and false, or pseudoaneurysms may be helpful in planning treatment, which may be conservative, surgical or radiological. The lack of useful definitions and classification along with the multitude of management strategies proposed make firm evidence based conclusions difficult to draw. Further robust well designed studies are required to define best practice for this common problem.

Chapter 2. Surgical and endovascular interventions for promoting arteriovenous fistula maturation 2.1. We suggest using regional block anaesthesia rather than local anaesthesia for arteriovenous fistula creation in adults with end-stage kidney disease. (2C) 2.2. We suggest there is insufficient evidence to support endof-vein to side-of-artery over side-of-vein to side-ofartery anastomosis for arteriovenous fistula creation in adults with end-stage kidney disease (2C) peri-and postoperative care of AV fistulas and grafts ii3

Current literature reports DeBs as being safe and may convey some benefit in terms of improved rate of restenosis when used to treat AV access disease. However, this body of evidence is small and clinically heterogeneous. A large multicentre RCT may help to clarify the role of DeBs in the percutaneous treatment of AV HD access stenosis.

It remains challenging to accurately predict whether an individual arteriovenous fistula (AVF) will mature and be useable for haemodialysis vascular access. Current best practice involves the use of routine clinical assessment and ultrasonography complemented by selective venography and magnetic resonance imaging. The purpose of this literature review is to describe current practices in relation to pre-operative assessment prior to AVF formation and highlight potential areas for future research to improve the clinical prediction of AVF outcomes.

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This meta-analysis confirms that adequate 12-month primary and secondary AVF patency rates can be achieved in elderly patients. Brachiocephalic AVFs have both superior primary and secondary patency rates at 12 months compared with radiocephalic AVFs. These important data can inform clinicians' and patients' decision-making about suitability of attempting AVF formation in older persons.

BackgroundRenal replacement therapy using dialysis has evolved dramatically over recent years with an improvement in patient survival. With this increased longevity, a cohort of patients are in the precarious position of having exhausted the standard routes of vascular access. The extent of this problem of failed access or ‘desperate measures’ access is difficult to determine, as there are no uniform definitions or classification allowing standardization and few studies have been performed. The aim of this study is to propose a classification of end-stage vascular access (VA) failure and subsequently test its applicability in a dialysis population.MethodsUsing anatomical stratification, a simple hierarchical classification is proposed. This has been applied to a large dialysis population and in particular to patients referred to the complex access clinic dedicated to patients identified as having exhausted standard VA options and also those dialysing on permanent central venous catheters (CVC).ResultsA simple classification is proposed based on a progressive anatomical grading of (I) standard upper arm options exhausted, (II) femoral options exhausted and (III) other options exhausted. These are further subdivided anatomically to allow ease of classification. When applied to a complex group of patients (n = 145) referred to a dedicated complex access clinic, 21 patients were Class I, 26 Class II and 2 Class III. Ninety-six patients did not fall into the classification despite being referred as permanent CVC.ConclusionsThe numbers of patients who have exhausted definitive access options will continue to increase. This simple classification allows the scope of the problem and proposed solutions to be identified. Furthermore, these solutions can be studied and treatments compared in a standardized fashion. The classification may also be applied if patients have the option of transplantation where iliac vessel preservation is desirable and prioritization policies may be instituted.