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Cephalic arch stenosis is a common complication in maintenance hemodialysis (MHD) patients with brachial artery-cephalic vein fistulas and frequently leads to loss of the functioning brachial artery-cephalic vein fistula. There is paucity of conclusive data to guide appropriate management. We examined the risk of recurrence of cephalic arch stenosis after angioplasty compared to angioplasty after stent placement determined by angiography of the involved upper extremity over time in a contemporary cohort of MHD patients treated in two interventional nephrology practices from March 2008 through May 2011. We retrospectively identified 45 MHD patients with evidence of cephalic arch stenosis (age 60 ± 30 years, 45% men) on elective angiograms. The median number of days until another angioplasty was required decreased, starting with a median of 91.5 days after the first, 70.5 days after the second, 85 days after the third, and 56 days after the fourth. Angioplasty is associated with a faster rate of recurrence of cephalic arch stenosis. The placement of intravascular stent seems to prolong the patency compared to angioplasty alone. Clinical trials with a larger sample size will better elucidate the value and timing of angioplasty versus stent placement in cephalic arch stenosis., (© 2014 Wiley Periodicals, Inc.)

Background: Biofilm occurring on the surface of tunneled hemodialysis (HD) catheters is difficult to eradicate and often is associated with recurrent bacteremia. We studied biofilm formation on catheters from patients with and without bacteremia to identify the location of bacterial growth and measure biofilm thickness., Study Design: Prospective observational study., Setting & Participants: 76 adult HD patients; 26 had HD catheters removed for bacteremia and 50 had catheters removed for reasons other than infection., Predictors: Segment of catheter, reason for catheter removal., Outcomes & Measurements: Microbiological growth and biofilm thickness on the outer and luminal surfaces of extravascular and intravascular catheter segments., Results: Catheter cultures were positive in 16 (62%) patients with bacteremia and 15 (30%) when the catheter was removed for non-infection-related reasons. In catheters with positive cultures, the outer surface of the extravascular segment was the most common site of bacterial growth (15/16 [94%] and 11/15 [73%] for bacteremic and nonbacteremic patients, respectively). Bacteremic patients had significantly thicker biofilm on all catheter surfaces, and in bacteremic patients, the biofilm was significantly thicker on the outer compared with the luminal surface for both extravascular (14.53 ± 6.17 vs 11.97 ± 5.01 μm; P < 0.001) and intravascular (12.21 ± 5.3 vs 9.46 ± 3.71 μm; P < 0.001) segments. Extravascular segments had significantly thicker biofilm compared with intravascular segments on both the outer (P < 0.001) and luminal (P < 0.001) surfaces. Similarly, in patients for whom the catheter was removed for non-infection-related reasons, the catheter had thicker biofilm on the outer compared with the inner surface in both extravascular (2.19 ± 2.84 vs 1.62 ± 2.33 μm; P < 0.001) and intravascular (1.92 ± 2.62 vs 1.29 ± 2.33 μm; P < 0.001) segments. Similar to catheters from bacteremic patients, the outer and luminal surfaces of the extravascular segments of the catheters had significantly thicker biofilm compared with their corresponding surfaces on the intravascular segments., Limitations: Observational study., Conclusions: The outer surface of the extravascular segment of tunneled dialysis catheters in both bacteremic and nonbacteremic HD patients has the thickest biofilm and highest microbiological yield, and biofilm is thicker in patients with bacteremia. This knowledge is important for designing preventive strategies and also in the management of patients with catheter infection., (Published by Elsevier Inc.)

Aims: Anemia and cardiovascular (CV) events are major complications of chronic kidney disease (CKD) during dialysis. We conducted a retrospective observational study in CKD patients with anemia to evaluate the association between predialysis use of erythropoiesis-stimulating agents (ESAs) and postdialysis CV outcomes., Methods: The study analyzed claims data on incident hemodialysis patients aged > or = 18 years (identified between January 2000 and November 2005). Patients were identified as anemic and ESA-treated prior to dialysis. ESA treatment was categorized into 4 consistency groups (from least to most consistent ESA use)., Results: Of 5,848 hemodialysis patients, 52% were identified as anemic prior to onset of dialysis. Predialysis ESA treatment was received by 62% of anemic patients, with only 23% receiving the most consistent treatment. The risk of a CV event was significantly lower for the ESA-treated compared with ESA-untreated patients (relative risk (RR) 0.70, 95% (95% confidence intervals (CI) 0.61 - 0.82)). Compared with ESA-untreated, those who received ESAs had significantly lower risk of acute myocardial infarction (RR 0.65 (95% CI 0.44 - 0.95)) or inpatient mortality (RR 0.52 (95% CI 0.40 - 0.68)). ESA-treated patients in each of the 4 consistency groups had significantly lower risk of CV events compared with ESA-untreated patients, with the greatest benefit seen in patients who received most consistent ESA (RR 0.61 (95% CI 0.48 - 0.76))., Conclusions: This analysis suggests consistent ESA use to treat anemia of CKD in the predialysis period is associated with improved cardiovascular outcomes in postdialysis patients.

Infectious complications of the vascular access are a major source of morbidity and mortality among hemodialysis (HD) patients. Numerous reports implicate the vascular access in up to 48 to 73% of all bacteremias in HD patients. The incidence of vascular access-related infection is highest when central venous dialysis catheters are employed. Native arteriovenous fistulas carry the lowest risk of infection. Unfortunately, prosthetic arteriovenous grafts, which represent the most common type of HD access in the United States, have been repeatedly shown to be a risk factor for bacteremic and nonbacteremic infections. Silent infection in old nonfunctional clotted prosthetic arteriovenous grafts has recently been recognized as a frequent cause of bacteremia and morbidity among HD patients. High proportions of infections related to the vascular access are caused by staphylococcal organisms, which carry high rates of mortality, recurrence, and metastatic complications. Management of vascular access-related infection has two aspects: The first relates to the choice, duration, and mode of administration of antibiotic therapy. Empiric antibiotic therapy, guided by demographic data and severity of illness, should be employed when the causative organisms are unknown. Prolonged administration of specific parenteral antibiotics is crucial in decreasing complications of infection, especially in cases of staphylococcal bacteremia. The second aspect relates to management of the vascular access. Efforts directed toward bacteriological cure should be concurrent with efforts to preserve native venous access sites whenever possible. Efforts to prevent vascular access-related infection should focus on increasing placement of arteriovenous fistulas and minimizing insertion of central venous dialysis catheters. Careful inspection and monitoring of the vascular access is of paramount importance in early detection of vascular access site-related infections. Several new approaches aimed at preventing catheter and prosthetic graft-related infection are being explored.