Vascular access complications, including thrombosis, are associated with significant patient morbidity and mortality. Currently, up to 60% of new patients and 30% of prevalent patients are using a catheter for dialysis. To prevent interdialytic catheter thrombosis, these devices are routinely locked with concentrated heparin solutions. Several recent studies have elucidated the potential for abnormal coagulation markers (aPTT) that may arise from this practice. This abnormal elevation in aPTT may be explained by significant early and late leakage from the catheter that occurs after performing a catheter lock. To date no study has evaluated the impact of this practice, or the elevation in aPTT that may result from it, on bleeding complication rates. We conducted a retrospective analysis comparing bleeding rates in subjects who received concentrated heparin catheter lock (5000 u/cc) [group 1, n = 52] to those who received citrate or dilute heparin catheter lock (1000 u/cc) [group 2, n = 91] immediately after tunneled hemodialysis catheter insertion. Baseline characteristics did not differ between the groups except for the preprocedure INR, which was higher in the postpolicy group compared with the prepolicy group (1.29 vs. 1.21, p = 0.04). Results from logistic regression analyses revealed that the likelihood of a composite bleeding event in group 1 was 11.9 times that of a composite bleeding event in group 2, p = 0.04. Concentrated heparin (5000 u/ml) is associated with increased major bleeding complications posttunneled catheter placement compared with low-dose heparin (1000 u/ml) or citrate catheter lock solution, p = 0.02. Given the findings of this study, a randomized controlled trial comparing the safety and efficacy of common anticoagulation lock solutions is warranted.

Background and objectives Permanent hemodialysis vascular access is crucial for RRT in ESRD patients and patients with failed renal transplants, because central venous catheters are associated with greater risk of infection and mortality than arteriovenous fistulae or arteriovenous grafts. The objective of this study was to determine the types of vascular access used by patients initiating hemodialysis after a failed renal transplant.Design, setting, participants, & measurements Data from the US Renal Data System database on 16,728 patients with a failed renal transplant and 509,643 patients with native kidney failure who initiated dialysis between January 1, 2006, and September 30, 2011 were examined.Results At initiation of dialysis, of patients with a failed transplant, 27.7% (n=4636) used an arteriovenous fistula, 6.9% (n=1146) used an arteriovenous graft, and 65.4% (n=10,946) used a central venous catheter. Conversely, 80.8% (n=411,997) of patients with native kidney failure initiated dialysis with a central venous catheter (P,0.001). Among patients with a failed transplant, predictors of central venous catheter use included women (adjusted odds ratio, 1.75; 95% confidence interval, 1.63 to 1.87), lack of referral to a nephrologist (odds ratio, 2.00; 95% confidence interval, 1.72 to 2.33), diabetes (odds ratio, 1.14; 95% confidence interval, 1.06 to 1.22), peripheral vascular disease (odds ratio, 1.31; 95% confidence interval, 1.16 to 1.48), and being institutionalized (odds ratio, 1.53; 95% confidence interval, 1.23 to 1.89). Factors associated with lower odds of central venous catheter use included older age (odds ratio, 0.85 per 10 years; 95% confidence interval, 0.83 to 0.87), public insurance (odds ratio, 0.74; 95% confidence interval, 0.68 to 0.80), and current employment (odds ratio, 0.87; 95% confidence interval, 0.80 to 0.95).Conclusions Central venous catheters are used in nearly two thirds of failed renal transplant patients. These patients are usually followed closely by transplant physicians before developing ESRD after a failed transplant, but the relatively low prevalence of arteriovenous fistulae/arteriovenous grafts in this group at initiation of dialysis needs to be investigated more thoroughly.

The rope-ladder (RL) technique is the most common technique used for cannulation of arteriovenous fistulae (AVF). Buttonhole cannulation (BHC), or constant-site technique, is recommended by the National Kidney Foundation's Kidney Disease Outcome Quality Initiative (NKF/KDOQI) vascular access guidelines. We compared outcomes of primary patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores between RL and BHC patients. Using a prospectively collected, vascular access database, a total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12 months (inter-quartile range: 4-27 months). The two groups did not differ significantly in demographics except that diabetes was more common in those using BHC as compared to rope-ladder (69% vs. 34%; p = 0.002). Risk factors associated with lack of primary patency were age (hazards ratio [HR] = 1.02 per decade; 95% CI: 1.00-1.03; p = 0.04) and female gender (HR = 1.92; 95% CI: 1.08-3.40; p = 0.03). Use of the buttonhole technique was not associated with improved primary patency (HR = 1.22, 95% CI: 0.65-2.28; p = 0.53). Episodes of bacteremia and mean scores from KDQOL-36 did not differ significantly between the groups. This study demonstrates for the first time that BHC use is not associated with improved access patency.

No abstract

Objectives Long-term experience of patients on peritoneal dialysis (PD) in general, and in diabetic patients specifically, is limited. Few patients have been followed on PD for over 8 years. Our aim was to evaluate and characterize long-term survivors (L TS) on PD for more than 100 months. A retrospective analysis of 20 patients who survived on PD for more than 100 months was performed. Data on long-term survivors was compared to data of 103 patients who died or switched to hemodialysis (HD) in less than 100 months. Design The study included all patients starting PD prior to 1 January 1986. Demographic, biochemical, dialysis prescription, and morbidity data were obtained on these patients. Characteristics of long-term survivors on PD (more than 100 months), was compared with those who died or switched to HD in less than 100 months, using Student t-test. Setting An experienced single center, university-based dialysis program. Patients 165 patients started PD at the University of Wisconsin prior to 1 January 1986. Forty three had type I diabetes mellitus and 24 had type II diabetes mellitus as the cause of their renal failure. Results Twenty patients survived on PD more than 100 months (L TS). Long-term survival of type I diabetic patients was seen in 7 of 43 patients at risk. Seventeen type I diabetics received renal transplants and ten died. 103 patients either died or switched to HD in less than 100 months. Long-term survivors were significantly younger, weighed less, had fewer episodes of peritonitis, fewer hospital days, and were prescribed more dialysis per kg body weight, than those who died or switched to HD prior to 100 months. Conclusions Long-term survival on CAPD for longer than 100 months is possible with survival periods up to 18 years in both males and females and in nondiabetics as well as patients with type I diabetes mellitus. No patient with type II diabetes mellitus survived longer than 100 months on CAPD. In comparison to short-term survivors, long-term survivors were characterized by being younger, weighing less, having fewer episodes of peritonitis, fewer hospital days, and were prescribed more dialysis/kg body weight.