If correctable pathology is detected in patients with early fistula failure, the incidence of correctable lesions is relatively high and an aggressive therapeutic approach can be expected to have a high yield.

No abstract

The LifeSite Hemodialysis Access System, when used with 70% isopropyl alcohol as an antimicrobial solution, provides superior performance with a lower infection rate and better device survival than a standard cuffed tunneled hemodialysis catheter.

No abstract

A nephrology practice in Alabama did not feel in control of vascular access management. Scheduling delays, as well as variable techniques and outcomes, leading to high morbidity and mortality, caused frustration with the existing care system for vascular access. Our objective was to develop an integrative system of vascular access care, involving nephrologists along with the other caregivers, and to demonstrate an improvement in outcomes. Nephrology Vascular Labs (NVL), a recent RMS-Lifeline acquisition, opened a vascular access center (VAC) as an extension of the nephrology practice. Both pre-ESRD and ESRD patients are evaluated and treated in the VAC. Treatment is rendered in a timely fashion, to the benefit of the patients. Nephrologists serve as the interventionists. More than 90% of vascular access problems detected at dialysis are treated at the VAC. More than 2000 procedures have been performed over 2 years. Procedures carried out include thrombolysis with angioplasty, fluoroscopy alone or with angioplasty, placement of cuffed and noncuffed catheters, removal of cuffed catheters, and minor surgeries. Success rates have been high. Minor and major complications have been relatively low. Referrals to both surgeons and radiologists are shown to emphasize the role of the VAC as part of an integrative system of vascular access care. Results of a patient satisfaction survey were excellent. The VAC has fulfilled the vision of creating a seamless integration of care for vascular access. Hospitalization rate has been reduced and it is suspected that the global cost of access care is markedly lower than prior to the VAC. Multiple nephrologists can rotate as the VAC's interventionist and jointly obtain good outcomes and have little variability among them. Several reasons for using a nephrologists as the interventionist are discussed.

No abstract

Uptake of alpha-aminoisobutyric acid (AIB) was examined in Ehrlich ascites tumor cells treated with the cation-exchange ionophore nigericin (20 microgram/ml). Membrane voltages were measured using the voltage-sensitive dye diethyloxadicarbocyanine (DOCC). In normal phosphate-buffered media, nigericin changed the distribution ratios of Na+ and K+ (the ratio of intra- to extracellular concentrations) nearly to unity, but AIB was still accumulated to a distribution ratio of approximately 9.0. When all but 40 mM Na+ in the medium was replaced by choline, nigericin resulted in K+ loss and Na+ gain and both cation distribution ratios approached 2.8-3.4, as would be expected if both ions were distributing near electrochemical equilibrium with a membrane voltage in the range of -28 to -33 mV. This conclusion was supported by the observation that the addition of 5 X 10(-7) M valinomycin to the nigericin-treated cell suspension produced no change in DOCC absorbance. In spite of the apparent zero electrochemical potential gradients for Na+ and K+, AIB was accumulated to a distribution ratio of 5.4 in the low-Na+ medium. Addition of 0.1 mM oubain or 50 microM vanadate did not alter the extent of AIB accumulation as would have been expected if a large component of the membrane voltage were due to electrogenic operation of the (Na+ + K+)-ATPase. Addition of lactate, pyruvate or glucose increased the AIB distribution ratios to 11.9, 9.4 and 15.3, respectively. The effect of glucose could be explained, at least in part, by an enhanced Na+ electrochemical potential gradient. However, neither lactate nor pyruvate produced any change either in membrane voltage or the intracellular Na+ concentration. Therefore, these results confirm the existence of a metabolic energy source which is coupled to AIB accumulation and operates in addition to the Na+ co-transport mechanism, and which is augmented by metabolic substrates such as lactate and pyruvate.

The Fistula First Breakthrough Initiative (FFBI) has improved the awareness of the value of fistula creation in patients with end-stage renal disease (ESRD). The FFBI Health Policy Workgroup has been charged with reviewing the relationship of policy and economic issues to this project. This article reviews the efforts and successes of renal community clinical activities and reemphasizes the economic impact of fistula creation and catheter reduction on the health care system. Major obstacles are discussed, and existing tools and efforts designed to address them are outlined. The FFBI Health Policy Workgroup then identifies less frequently recognized barriers to the achievement of the FFBI goals and suggests solutions to them. It concludes that nephrologists need to assume the leadership role and drive fistula creation and central venous catheter reduction to achieve programmatic success.