Cardiovascular implantable electronic devices (CIEDs) are frequently utilized for management of cardiac dysrhythmias in patients with chronic kidney disease or end-stage renal disease receiving hemodialysis. The survival benefit from use of implantable cardioverter defibrillators in patients with CKD or ESRD is not as clear as in the general population, particularly when used for primary prevention of sudden cardiac death. Transvenous CIED leads are associated with central vein stenosis resulting in significant adverse consequences for existing or future arteriovenous access. Venous hypertension from CIED lead-related central vein stenosis is a challenging clinical problem and may require repeated percutaneous interventions, replacement of the CIED, or creation of alternative arteriovenous access. Infections associated with transvenous CIED leads are more frequent and associated with worse outcomes in patients with renal disease. Epicardial CIED leads or other nontransvenous devices may reduce complications of both central venous stenosis and endovascular infection in these vulnerable patients. Consensus recommendations are offered for avoidance and management of complications arising from the use of CIEDs and arteriovenous hemodialysis access.
BackgroundThe National Kidney Foundation has formulated clinical practice guidelines for patients with chronic kidney disease (K/DOQI). However, little is know about how many patients actually achieve these goals in a dedicated clinic for chronic kidney disease.MethodsWe performed a cross-sectional analysis of 198 patients with an estimated glomerular filtration rate of less than 30 ml/min/1.73 m2 and determined whether K/DOQI goals were met for calcium, phosphate, calcium-phosphate product, parathyroid hormone, albumin, bicarbonate, hemoglobin, lipids, and blood pressure.ResultsWe found that only a small number of patients achieved K/DOQI targets. Recent referral to the nephrologist, failure to attend scheduled clinic appointments, African American ethnicity, diabetes, and advanced renal failure were significant predictors of low achievement of K/DOQI goals.ConclusionWe conclude that raising awareness of chronic kidney disease and K/DOQI goals among primary care providers, early referral to a nephrologist, the exploration of socioeconomic barriers and cultural differences, and both patient and physician education are critical to improve CKD care in patients with Stage 4 and 5 CKD.
The arteriovenous graft (AVG) is one of the major types of permanent vascular access used to provide hemodialysis. Complications encountered with AVG use include stenosis, infection, thrombosis, and pseudoaneurysm formation. Venous outflow stenosis along with frequent needle cannulation at the same site can lead to breakdown of the graft material, resulting in pseudoaneurysm formation. In the following case, we illustrate common management principles used to treat pseudoaneurysms. While stent-grafts have been utilized for pseudoaneurysm repair, stent-graft usage is not always optimal. Surgical management may be an ideal choice of treatment. The role of educating the dialysis staff and patients is essential to identify and minimize the risk of pseudoaneurysm formation.
Intravascular ultrasound allows for detailed imaging of the dialysis access anatomy. Accurate visualization and precise measurements of the anatomy can be obtained using intravascular ultrasound, while limiting contrast usage and radiation exposure. Intravascular ultrasound allows for a true appreciation of stenosis morphology and can further guide endovascular management decisions, with a particular benefit in management of central venous lesions. Here, we describe a series of cases that together highlight the advantages of using intravascular ultrasound in the evaluation and management of dialysis access care.
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