Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P ‫؍‬ 0.06) and more episodes of hypotension (22 versus 3%, P ‫؍‬ 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P ‫؍‬ 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.

Argatroban, administered by each treatment regimen, provides safe, adequate anticoagulation to enable successful hemodialysis in ESRD patients. Argatroban dialytic clearance by high-flux membranes is clinically insignificant.

Numerous studies have identified the fistula as the best access for hemodialysis with fewest complications. The radiocephalic fistula (RCF) is the first access of choice, but often results in poor maturation. Therefore, an increased number of brachiocephalic fistulas (BCF) have been placed. Cephalic arch stenosis (CAS) can occur in patients with fistula access. The current study was done to determine the incidence and associated comorbidities in patients with BCF or RCF who have CAS. A retrospective review of 450 hemodialysis patients in 3 outpatient hemodialysis units between July 1, 2000 and July 1, 2005 (60 months) was preformed. We reviewed demographics, medications, and indications for venograms. Interventional Radiologists reviewed the venograms for evidence of CAS. Radiology reports were screened to determine incidence of thrombosis, treatment with either angioplasty or stent placement and if a complication such as venous rupture occurred. One hundred and twenty-seven patients had fistula access with at least 1 venogram. Of these, 30 were RCF and 97 were BCF. Cephalic arch stenosis occurred in 77% of patients with BCF and in 20% of patients with RCF. Those with diabetes had a lower rate of occurrence than those without (p<0.01). Cephalic arch stenosis led to a high rate of thrombosis (p<0.01). The probability of having multiple radiology procedures was higher with CAS than without (p<0.01). Cephalic arch stenosis is an important problem in hemodialysis patients who have fistula access, and contributes to thrombosis. Diabetes was found to have a negative association with CAS for undefined reasons. Attempts to understand this relationship are important.

Purpose The purpose of this study is to accurately characterize the cephalic arch segments into four domains and to enable more specific evaluation of cephalic arch stenosis (CAS) and determine the frequency of stenosis in each domain. Methods After Institutional Review Board (IRB) approval, a retrospective chart review was done to define a population of patients receiving hemodialysis who developed CAS as apparent on clinically indicated radiologic imaging. A standardized approach was devised to categorize four domains of the cephalic arch. Domain I was defined as the peripheral portion of the arch and Domain IV was the distal portion of the cephalic vein near termination with the axillary vein. The magnitude of stenosis as measured by percentage was determined and compared in the four domains. Results The most frequent location for stenosis was found in domain IV when compared with domains II or I (p<0.01). The magnitude of stenosis differed across all domains (p<0.001) with the least common place for CAS in domain I. Treatment of CAS included angioplasty in all, thrombectomy in eight, and stent placement in five. Conclusions CAS occurs most commonly in the terminal portion of the arch. Four standardized domains have been defined; future work will validate these findings and determine the best intervention for each domain.