AVF failure in the first year after creation is common and results in substantially higher health care costs. Compared with patients whose AVFs maintained primary patency, vascular access costs were 2 to 3 times higher for patients whose AVFs experienced primary or secondary patency loss and 4 times higher for patients who never used their AVFs. There is a need to improve AVF outcomes and reduce costs after AVF creation.

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This retrospective study compares outcomes of transposed brachiobasilic fistulae (avf), nontransposed avf, and grafts (avg). There were 161 (21%) transposed avf, 321 (42%) nontransposed avf, and 285 (37%) avg placed and followed over a 3-year period. Of the nontransposed avf, 203 (63%) were forearm radiocephalic avf and 118 (37%) were upper arm brachiocephalic avf. Grafts were able to be used in shorter time than avf and had a lower primary failure rate. However, avg had a significantly higher infection rate (0.23/patient/year vs. 0.07/patient/year) and required more procedures over the life of the access than avf (2.90/patient/year vs. 0.51/patient/year). Despite a higher primary failure rate, avf had better overall patency. Among nontransposed avf, brachiocephalic avf had significantly better primary patency than radiocephalic avf (p < 0.0001). Transposed avf had better cumulative patency than either nontransposed avf or grafts (p < 0.0001). Cumulative patency was best for transposed avf, intermediate for brachiocephalic avf, and worst with radiocephalic avf and avg. There was no difference in cumulative patency between radiocephalic avf and grafts (p = 0.5601). This analysis supports the current recommendation to prefer transposed avf over avg. In addition, the data suggest that both nontransposed brachiocephalic avf and transposed brachiobasilic avf outcomes may be superior to radiocephalic fistulae.

SummaryBackground and objectives Referring hemodialysis patients for elective access angiography and percutaneous transluminal angioplasty (PTA) is commonly done to prevent access failure, yet the effectiveness of this procedure remains unclear.Design, setting, participants, & measures An observational matched cohort analysis among 40,132 Medicare beneficiaries receiving hemodialysis with a fistula or graft was performed. Cox regression was used to determine whether access intervention was associated with improved 1-year access survival.Results Nonsurgical access intervention was found to be frequent at a rate of 20.9 procedures per 100 access years. In the 1-year period after intervention using angiography and PTA, the overall access failure rate was 53.7 per 100 access years in the intervention group and 49.6 in the nonintervention group (HR ϭ 1.02; 95% CI, 0.96 to 1.08). Similar findings were also seen when the analysis was repeated in only fistulas (HR ϭ 1.06; 95% CI, 0.98 to 1.15) and grafts (HR ϭ 0.95; 95% CI, 0.86 to 1.05). In patients with a low intraaccess flow rate (HR ϭ 0.86; 95% CI, 0.75 to 0.99) or a new access (HR ϭ 0.79; 95% CI, 0.71 to 0.89), angiography and PTA significantly increased access survival when compared with nonintervention (P for interaction was Ͻ0.0001). Angiography-PTA-related upper-extremity hematoma, vessel injury, or embolismthrombosis occurred in 1.1% of all patients.Conclusions Access characteristics significantly modify the survival benefits of angiography and PTA intervention where the benefits of these interventions are most seen in newer accesses or accesses with insufficient flow.

Hemodialysis vascular access dysfunction owing to stenosis and thrombosis in polytetrafluoroethylene dialysis access grafts is a huge clinical problem for which there are currently no long lasting durable therapies. Vascular brachytherapy has been used successfully for the prevention of coronary restenosis following angioplasty and stent placement. The Beta Radiation for Treatment of Arterial-Venous Graft Outflow I study was a pilot study of vascular brachytherapy in hemodialysis patients with patent but dysfunctional grafts. Twenty-five patients were randomized to receive either radiation therapy (a single dose of 18.4 Gy) or sham radiation, following angioplasty. The primary efficacy end point of the study was target lesion primary patency at 6 months. The primary safety end point was a composite of death, emergency surgery on the graft, venous rupture, or aneurysm formation. Forty-two percent of the radiated grafts achieved the target lesion primary patency end point at 6 months as compared to 0% of the control group (P = 0.015), but this did not translate into an improvement in secondary patency at either 6 or 12 months. Radiation therapy was found to be safe in the setting of hemodialysis vascular access dysfunction. Our results suggest that vascular brachytherapy is an intervention that is worthy of further examination in the setting of non-thrombosed dialysis access grafts.

In contrast to hemodialysis (HD), peritoneal dialysis (PD) remains an underutilized form of renal replacement therapy in the United States. Although a variety of factors have been deemed responsible, timely insertion of a PD catheter may also be a contributory factor. We conducted a multicenter analysis to examine whether the establishment of a program for PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD. Data for catheter insertion performed by nephrologists were collected from three centers. Any change in the prevalent PD population at each respective center was compared to the number of PD patients during the period having the traditional surgical approach. Nephrologists at the three centers used the peritoneoscopic technique and performed catheter insertion under local anesthesia. In center 1, the PD population remained stable at between 38 and 45 patients (approximately 16% of the total end-stage renal disease [ESRD] population) from 1993 to 2001. Nephrologists initiated a program for PD catheter insertion in 2001. The number of PD patients has increased to 101 (32% of the ESRD population). In center 2, the PD population remained stable at between 70 and 78 patients (approximately 17%) between 1988 and 1990. Catheter insertion by interventional nephrologists began in 1991. The number of PD patients has increased to 125 (22%). In center 3, the PD population remained at 20-30 patients (approximately 18%) between 1988 and 1991. Catheter placement by nephrologists was initiated in 1991. The number of PD patients increased to 97 (27%). Catheter insertion by interventional nephrologists was suspended in 2001. The number of PD patients has gradually declined to 25 (6%). This study suggests that catheter insertion by the nephrologist can have a positive impact on the utilization of PD.

Patency was comparable between fAVG and uAVG despite the larger caliber veins often encountered in the upper arm in carefully selected patients. Our findings support the traditional view that, in order to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.

Emergency fluid resuscitation of hypovolemic patients begins with an accurate assessment of the degree of volume depletion as well as identification of the cause and associated abnormalities. On the basis of this information, the proper resuscitative fluid can be chosen and administered by the appropriate route, as guided by the urgency of the situation. Patients with severe volume depletion and those in shock require intravenous fluids. In other situations, oral rehydration is often appropriate. Specific fluids then can be tailored to the individual patient's needs and adjusted as warranted by ongoing monitoring.