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Interpreting evidence in the arteriovenous (AV) access literature is challenged by the heterogeneity in terminology and the lack of standardization in outcomes. Below some of the terms used in this guideline are listed and how they have been interpreted in the context of this document. Because guideline development necessarily relies on aggregate data from systematic reviews and other individual studies, we can only hope to provide the user with conceptual definitions for certain concepts and outcome domains. At present, there is insufficient consensus to go beyond that point and define specific outcome measures or measurements. [...]

Quality assessment in vascular access procedures for hemodialysis is not clearly defined. The aim of this article is to compare various guidelines regarding recommendation on quality control in angioaccess surgery. The overall population of end-stage renal disease patients and patients in need for hemodialysis treatment is growing every year. Chronic intermittent hemodialysis is still the main therapy. The formation of a functional angioaccess is the cornerstone in the management of those patients. Native (autologous) arteriovenous fistula is the best vascular access available. A relatively high percentage of primary failure and fistula abandonment increases the need for quality control in this field of surgery. There are very few recommendations of quality assessment on creation of a vascular access for hemodialysis in the searched guidelines. Some guidelines recommend the proportion of native arteriovenous fistula in incident and prevalent patients as well as the maximum tolerable percentage of central venous catheters and complications. According to some guidelines, surgeon’s experience and expertise have a considerable influence on outcomes. There are no specific recommendations regarding surgeon’s specialty, grade, level of skills, and experience. In conclusion, there is a weak recommendation in the guidelines on quality control in vascular access surgery. Quality assessment criteria should be defined in this field of surgery. According to these criteria, patients and nephrologists could choose the best vascular access center or surgeon. Centers with best results should be referral centers, and centers with poorer results should implement quality improvement programs.

This report provides a summary of the 2013 Slovenian renal replacement therapy (RRT) data, obtained from 24 renal centers: 23 dialysis and one transplant center, referring from 31 December 2013, with 100% response rate to individual patient questionnaires. Slovenia had a population of 2 061 085 on 1 January 2014. The total number of patients treated by RRT was 2077, i.e. 1008.3 per million of population (pmp); 1349 (65%) were treated by hemodialysis, 52 (2.5%) by peritoneal dialysis, and 676 (32.5%) had a functioning kidney graft. A total of 260 incident patients, 126.2 pmp (at day one), started RRT, their median age was 69 years, 59.8% were men,. 58.5% of hemodialysis patients were treated with on-line hemodiafiltration. Vascular access was arteriovenous fistula in 79%, polytetrafluoroethylene graft in 8%, and catheter in 13% of patients, mean blood flow 276 ± 41 mL/min, 5.5% dialyzed in a single-needle mode. The crude death rate was 11.4% in all RRT patients (incident patients day 1 included, 15.9% in hemodialysis, 12.3% in peritoneal dialysis, 2.1% in transplant recipients). 60 kidney transplantations were performed in 2013, from deceased donors.

Vascular access problems lead to increased patient morbidity and mortality. Autologous arteriovenous fistulas (AVFs) are preferred over grafts. An increase in utilization of AVFs results in an increased incidence of early AVF failure and nonmaturation. A thorough evaluation of a new AVF after 4-6 weeks after creation should be considered mandatory. Experienced persons can examine AVF and predict its utility as a dialysis access. Detailed physical examination of the access performed by educated and trained staff can provide, in most cases, adequate information about the main causes for AVF dysfunction in case of nonmaturation or in case of late access complications. Physical examination has been shown to be very accurate in assessing fistula and is not difficult to learn. Doppler ultrasound (DU) is an additional diagnostic method to predict the ultimate maturation of newly created AVFs and is also very useful in further defining problems that have been detected by physical examination. DU also provides additional information that is of the utmost importance for the surgical or interventional treatment. In this review, basic principles of physical examination and of DU examination of early and late AVF/graft complications are shown.

Radio-cephalic arteriovenous fistula is a prototype hemodialysis access with small incidences of infection and distal ischemia, it spares proximal veins for future access use and it helps in the maturation of veins that may be used for more proximal access creations. This access type is prone to higher early failure rates compared to more proximal fistulas and there are unsolved uncertainties regarding exact ultrasound parameters predictive of fistula outcome. Evolution of ultrasound use has yielded several functional parameters that can be measured in addition to anatomical lumen sizes, which remain core parameters on which the decision to construct fistula in radio-cephalic forearm position is based. We propose to use arterial hyperemic response and wall morphology to aid in this decision when radial artery diameter falls in the interval with predictive uncertainty of 1.6-1.9 mm and to use venous flow pattern, respiratory variation, radial artery status and possibly venous distensibility when cephalic vein augmented diameter lies in the borderline interval of 2-2.4 mm. Ultrasound preoperative mapping and planning should be followed by expert surgical technique and several technique modifications of the classical end-to-side approach are possible to enhance operation outcome and diminish the incidence of stenosis most often present at juxta-anastomotic location. In our experience radio-cephalic arteriovenous fistula remains the golden standard for hemodialysis access and preoperative ultrasound the single best imaging modality to plan the operation and predict its success.

This report provides a summary of the 2011 Slovenian renal replacement therapy (RRT) data. Data were obtained from 24 renal centers: 23 dialysis and one transplant center, referred as of 31 December 2011, with 100% response rate to individual patient questionnaires. Slovenia has a population of approximately 2 million (2 052 496 in 2011). The total number of patients treated by RRT was 2011,that is, 980 per million of population (pmp); 0.4% decrease compared to 2010. 1347 (67.0%) were treated by hemodialysis, 60 (3.0%) by peritoneal dialysis, and 604 (30.0%) had a functioning kidney graft. A total of 236 incident patients, 115 pmp (at day one), started RRT, their median age was 68 years, 64.8% were men, 36.4% were diabetics. Regarding hemodialysis patients, 59.3% were treated with on-line hemodiafiltration, 86% with ultrapure dialysis fluid. Median weekly duration of hemodialysis was 12.5 h, median dry body weight 70 kg, mean blood flow 275 ± 46 mL/min, 7.1% were dialyzed in a single-needle mode. Vascular accesses were native arteriovenous fistula in 79%, polytetrafluoroethylene graft in 6%, and catheter in 15%. The crude death rate was 15.9% in dialysis patients, 1.9% in transplant recipients, and 12.0% in all RRT patients (both dialysis and transplant, incident patients at day 1 included). Slovenia has been a member of Eurotransplant since 2000. Forty-six kidney transplantations were performed in 2011, all from deceased donors. A slight decrease in prevalent number of RRT patients was observed in 2011, for the first time in 40 years. The number and proportion of patients with functioning kidney grafts is increasing, reaching 30% in 2011.

This report provides a summary of the 2013 Slovenian renal replacement therapy (RRT) data, obtained from 24 renal centers: 23 dialysis and one transplant center, referring from 31 December 2013, with 100% response rate to individual patient questionnaires. Slovenia had a population of 2 061 085 on 1 January 2014. The total number of patients treated by RRT was 2077, i.e. 1008.3 per million of population (pmp); 1349 (65%) were treated by hemodialysis, 52 (2.5%) by peritoneal dialysis, and 676 (32.5%) had a functioning kidney graft. A total of 260 incident patients, 126.2 pmp (at day one), started RRT, their median age was 69 years, 59.8% were men,. 58.5% of hemodialysis patients were treated with on-line hemodiafiltration. Vascular access was arteriovenous fistula in 79%, polytetrafluoroethylene graft in 8%, and catheter in 13% of patients, mean blood flow 276 ± 41 mL/min, 5.5% dialyzed in a single-needle mode. The crude death rate was 11.4% in all RRT patients (incident patients day 1 included, 15.9% in hemodialysis, 12.3% in peritoneal dialysis, 2.1% in transplant recipients). 60 kidney transplantations were performed in 2013, from deceased donors.

Access to the circulation is an "Achilles' heel" of chronic hemodialysis. According to the current guidelines, autologous arteriovenous fistula is the best choice available. However, the impossibility of immediate use and the high rate of non-matured fistulas place fistula far from an ideal hemodialysis vascular access. The first attempt at constructing an angioaccess should result in functional access as much as possible. After failed attempts, patients and nephrologists lose their patience and confidence, which results in high percentage of central venous catheter use. Predictive models could help, but clinical judgment still remains crucial. Early referral to the nephrologist and vascular access surgeon, careful preoperative examinations, preparation of patients and duplex sonography mapping of the vessels are very important in the preoperative stage. In the operative stage, it is crucial to understand that angioaccess procedures should not be considered as minor procedures and these operations must be performed by surgeons with demonstrable interest and experience. In the postoperative stage, appropriate surveillance of the maturation process is also important, as well as good cannulation skills of the dialysis staff. The purpose of this review article is to stress the importance of success prediction in order to avoid unsuccessful attempts in angioaccess surgery.

Anemia is a common and important complication of chronic kidney disease. Treatment includes the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation. However, the optimal schedule of iron supplementation remains to be defined. Thirty-one long-term hemodialysis patients were treated for 1 year (period 1) with ESAs and an intermittent pulse regimen consisting of 100 mg of iron sucrose administered after different dialysis sessions depending on serum ferritin and other laboratory values, but no more than once per week. During the next 3 years (period 2), patients were treated with ESAs and need-based, continuous, low-dose iron. Iron doses were determined on the basis of values and changes of serum ferritin and transferrin saturation every fourth week after the longest interdialysis time interval. Iron doses ranged from 10 to 60 mg of iron sucrose and were given 1-3 times per week. If grounded, we gradually reduced or even abolished the iron doses. A significant increase in the hemoglobin concentration and hematocrit during period 2 in comparison with period 1 was observed. The use of ESAs did not change significantly during period 2 in comparison with period 1, while the use of iron was significantly lower in period 2. Significantly lower values were obtained for serum ferritin, saturation of transferrin, serum iron, and total serum iron-binding capacity during period 2. A better response to ESA therapy (increase in hemoglobin and hematocrit) is achieved with need-based, continuous, low-dose iron replacement.

The aim of our study was to evaluate vascular access in patients treated with chronic hemodialysis for 30 years or more. Patients who had started dialysis in 1978 or earlier were identified from the Slovenian Renal Replacement Therapy Registry. The data on vascular access on April 2008 are presented. Sixteen patients were still alive, seven men and nine women aged 62 +/- 12 years (46-84), and they had been treated for 32 +/- 1.7 years (30-35), mainly with chronic HD. They had started HD at the age of 30 +/- 12 years (13-50), and none had diabetes. The vascular access in nine was a native arteriovenous (AV) fistula, on the forearm in eight patients, and a brachiobasilic fistula in one patient. Four patients had their primary AV fistulas still in use (maximum 35 years). In the remaining five patients, multiple salvage procedures had been performed or new AV fistulas created. The vascular access in four patients was the polytetrafluoroethylene (PTFE) graft, functioning for 1-8 years. In three patients, a non-cuffed, single-lumen hemodialysis catheter (a precurved jugular in two patients and a subclavian in one) locked with 30% citrate, with mupirocin at the exit site, was used for 5-12 years. The catheters were exchanged approximately once every two years over a guide-wire because of mechanical damage. None of these three patients had had catheter-related sepsis or exit-site infection. Before catheters, these patients had had multiple AV fistulas and PTFE grafts. Although native AV fistula is the predominant type of vascular access, a greater than 30-year survival on hemodialysis is possible with the combined use of AV fistula, PTFE graft, and a non-cuffed hemodialysis catheter locked with citrate.

Adsorption onto the dialyzer membrane is a contributing factor to the elimination of beta2-microglobulin (beta2M) from the sera of uremic patients. The purpose of this prospective study was to ascertain the influence of the blood flow rate on adsorption of beta2M onto the polyacrylonitrile (AN69) hollow-fiber dialyzer membrane in 8 patients during regular hemodialysis (HD). Blood first passed through a low-flux polysulfone dialyzer and then through an AN69 dialyzer, which was not in contact with the dialysis fluid. During the investigation period (first hour of the HD session), the blood flow rate was 100 ml/ min (first part of the study), 200 ml/min (second part of the study), and 300 ml/min (third part of the study). Ultrafiltration was not performed during the investigation period. At the start of the HD sessions, the serum concentration of beta2M in the afferent blood line did not differ significantly among the 3 parts of the study. Serum beta2M was measured in samples taken from the afferent and efferent blood lines of the AN69 dialyzer at 5, 10, 15, 30, 45, and 60 min. The serum beta2M concentration decreased significantly in blood that had passed through the AN69 dialyzer. This decrease, indicating membrane adsorption, was maximal during the first part and minimal during the third part of study. The decrease in the contact time between the blood and the AN69 could be the underlying cause. The calculated quantities of beta2M adsorbed onto the AN69 membrane (44.2 +/- 10.2, 43.2 +/- 12.1, and 42.6 +/- 17.3 mg) did not differ significantly among the 3 parts of the study. These results suggest that an increase in blood flow rate from 100 to 300 ml/min did not significantly affect the quantity of beta2M adsorbed onto the AN69 membrane.

Chronic kidney disease (CKD) is a major public health problem worldwide. Early detection and treatment of CKD can often prevent or delay some of the negative outcomes of CKD. This chapter shows how treatment of hypertension, proteinuria and metabolic disorders slow down the deterioration of renal function. Irrespective of the mode of renal replacement therapy, maintaining the veins in the upper extremities is of vital importance. Below are suggestions on how to protect blood vessels of the upper limbs and when to start preparing for the construction of vascular access. In this chapter, it is also shown how necessary it is to conduct a clinical evaluation of the blood vessels, which is required before the start of vascular access management. The methodology of noninvasive evaluation of vessels by duplex sonography is also presented. This method is very useful, especially if the vessels are not clinically visible, as well as the information concerning the morphological and functional properties of blood vessels.

Chronic kidney disease (CKD) is a major public health problem worldwide. Early detection and treatment of CKD can often prevent or delay some of the negative outcomes of CKD. This chapter shows how treatment of hypertension, proteinuria and metabolic disorders slow down the deterioration of renal function. Irrespective of the mode of renal replacement therapy, maintaining the veins in the upper extremities is of vital importance. Below are suggestions on how to protect blood vessels of the upper limbs and when to start preparing for the construction of vascular access. In this chapter, it is also shown how necessary it is to conduct a clinical evaluation of the blood vessels, which is required before the start of vascular access management. The methodology of noninvasive evaluation of vessels by duplex sonography is also presented. This method is very useful, especially if the vessels are not clinically visible, as well as the information concerning the morphological and functional properties of blood vessels.

Patients presenting for initial access evaluation in contemporary practice are less likely to have arteries and veins suitable for native fistula (AVF) formation in the classic location. Physical examination of the upper extremity alone may be inadequate for selection of arteries and veins that will mature into a functioning AF. The purpose of this paper is to determine how duplex ultrasonography can be used as an effective modality for the preoperative evaluation of vessels before construction of arteriovenous fistula for hemodialysis. The author have used duplex ultrasound (DU) to assess upper-extremity vasculature for planning of dialysis access procedures. Criteria for selection of arteries and veins and a detailed description of DU examination protocol are reviewed. Routine use of upper-extremity DU has identified many patients with veins that are suitable for use and determined arteries with optimal arterial inflow for successful AFV creation.

Duplex sonography recently has been recognized as an objective and noninvasive method to assess morphological and functional parameters of vessels that could predict arteriovenous fistula (AVF) patency and time of adequate maturation. To prospectively study prognostic indicators of native AVFs, forearm arteries and veins of patients with end-stage renal disease were examined by duplex sonography before AVF construction. Several anatomic parameters, including feeding artery internal diameter (IDA), resistance index (RI), and arterial blood flow (Q(A)) before and at reactive hyperemia (RH) and internal diameter of the vein (IDV) before and after proximal vein compression (PVC), were measured. Measurements of the feeding artery were repeated at different periods after native AVF construction. One hundred sixteen patients were included on the study. The primary patency rate (successful constructed AVF) of native AVFs was 80.2%. In this group, mean values for IDA were 0.264 cm; RI at RH, 0.50; and Q(A), 54.5 mL/min. IDV increased after PVC for 59.3%. In the group with failed AVFs (19.8%), mean IDA was 0.162 cm; RI at RH, 0.70; and Q(A), 24.1 mL/min. IDV increased after PVC for only 12.4%. Patency rates after surgery in a group with IDAs greater than 0.16 cm was 93%, and with IDAs of 0.16 cm or less, 32%. In a group with RIs at RH less than 0.7, the patency rate was 95.3%, and with RIs of 0.7 or greater, 38.7%. An AVF feeding artery Q(A) of 300 mL/min was achieved in the group with IDAs greater than 0.16 cm, those with RIs at RH less than 0.7 after 1 week, those with IDAs of 0.16 cm or less between 3 and 8 weeks, and those with RIs of 0.7 or greater between 8 and 12 weeks. This study shows that duplex sonography may provide useful data on preoperative morphological and functional characteristics of vessels used for AVF construction. Increase in IDA, Q(A), RI at RH, and IDV after PVC are important to predict AVF primary patency rate. Based on these measurements, the most adequate location for AVF construction, as well as time of optimal AVF development, can be determined, particularly for patients at greater risk for primary failure, such as the elderly and patients with diabetes.

The long-term survival and quality of life of patients on hemodialysis is dependent on the adequacy of dialysis via an appropriately placed vascular access. Recent clinical practice guidelines recommend the creation of native arteriovenous fistula or synthetic graft before start of chronic hemodialysis therapy to prevent the need for complication-prone dialysis catheters. The direct involvement of nephrologists in the management of referral patterns, predialysis follow-up, policy of venous preservation, pre-operative evaluation, vascular access surgery and vascular access care seems to be important and productive targets for the quality of care delivered to the patients with end-stage renal disease. Early referral to nephrologists is important for delay progression of both kidney disease and its complications by specific and adequate treatment, for education program which should include modification of lifestyle, medication management, selection of treatment modality and instruction for vein preservation and vascular access. Nephrologists are responsible for on-time placement and adequate maturation of vascular access. The number of nephrologists around the world who create their own fistulas and grafts is growing, driven by a need for better patient outcomes on hemodialysis. Nephrologists have also a key role for care of vascular access during hemodialysis treatment by following vascular access function using clinical data, physical examination and additional ultrasound evaluation. Timely detection of malfunctioning vascular access means timely surgical or radiological intervention and increases the survival of vascular access.

BACKGROUND: Vascular access is "the life line" for patients on chronic hemodialysis. The autogenous arteriovenous fistula provides the best access to the circulation because of low complication rate, long-term use, and lower cost, compared to arteriovenous graft and central venous catheter. The primary objective of this prospective study was to investigate the predictive value of vein diameter after intraoperative dilatation with vessel probes on hemodialysis fistula maturation. ----- MATERIAL AND METHODS: Ninety-three fistulas were performed by a single surgeon from February 1, 2006 to January 31, 2009. Intraoperative vein dilatation with vessel probes was attempted in all fistulas. Measurements of the feeding artery diameter, vein diameter and the increased vein diameter after intraoperative dilatation were performed and immediate failure, early patency, early failure, primary patency, and fistula survival outcomes were recorded during 48-month follow-up. ----- RESULTS: Early failure occurred in 20% of fistulas and 70% matured sufficiently for cannulation. Variables with significant impact on the failure to mature by univariate analysis were: body-mass index (P=0.041), artery diameter (P

The prospective study was aimed at estimating the value of duplex sonography for imaging arteries before arteriovenous fistula (AVF) construction and of evaluating the influence of this method on the outcome of fistula construction.A total of 35 patients with end stage renal disease were examined by duplex sonography (DS) before AVF construction, and 27 of them with patent AVF were examined 1, 7 and 21 days after the operation. Filling artery flow was evaluated at 8 and 12 weeks. All AVFs were constructed on the forearm using native veins. Direct measurements of the arterial internal diameter during the operation were also performed.The mean internal diameter of the arteries (IDA) detected by sonography 2.3 +/- 0.62 mm, with a direct measurement of 2.1 +/- 0.52 mm (mean +/- SD). The correlation coefficient of DS IDA with direct measurement IDA was 0.86. In group A (IDAor = 1.5 mm), immediate patency of the AVF was present in 45% (5/11), and in group B (IDA1.5 mm) 92% (22/24) (P0.001). Before the construction, the mean volume flow through the radial arteries was 22 +/- 6.8 ml/min in group A and in group B 46 +/- 6.3 ml/min (P0.01). If there was conversion of high-resistance triphasic Doppler flow signal to low-resistance biphasic flow signal after release of a fist (group D), the AVF was patent in 95% (21/22), compared with a 46% (6/13) rate of patency in the group without such a response (group C). In 27 patients with patent AVF fistula, arterial volume flow the first day after construction was 138.1 +/- 10.1 ml/min in group A and 184.2 +/- 12.6 ml/min in group B. After 1 week, the volume flow was 169 +/- 11.1 ml/min and 202.4 +/- 13.5 ml/min, respectively. After 3 weeks the arterial flow was 274.4 +/- 17.3 ml/min, and 366.2 +/- 39.6 ml/min, respectively. After 12 weeks, the arterial flow was 438.5 +/- 87.7 ml/min in group A, and 561.8 +/- 131.3 ml/min in group B. The patency rate after 12 weeks was 36% in group A and 83% in group B.Duplex sonography could be a useful non-invasive method to evaluate arterial vessels prior to AVF construction. The relevant parameters measured by duplex sonography to evaluate the potential patency of the AVF are the arterial internal diameter and changes in the arterial Doppler flow signal.

This report provides a summary of the 2011 Slovenian renal replacement therapy (RRT) data. Data were obtained from 24 renal centers: 23 dialysis and one transplant center, referred as of 31 December 2011, with 100% response rate to individual patient questionnaires. Slovenia has a population of approximately 2 million (2 052 496 in 2011). The total number of patients treated by RRT was 2011,that is, 980 per million of population (pmp); 0.4% decrease compared to 2010. 1347 (67.0%) were treated by hemodialysis, 60 (3.0%) by peritoneal dialysis, and 604 (30.0%) had a functioning kidney graft. A total of 236 incident patients, 115 pmp (at day one), started RRT, their median age was 68 years, 64.8% were men, 36.4% were diabetics. Regarding hemodialysis patients, 59.3% were treated with on-line hemodiafiltration, 86% with ultrapure dialysis fluid. Median weekly duration of hemodialysis was 12.5 h, median dry body weight 70 kg, mean blood flow 275 ± 46 mL/min, 7.1% were dialyzed in a single-needle mode. Vascular accesses were native arteriovenous fistula in 79%, polytetrafluoroethylene graft in 6%, and catheter in 15%. The crude death rate was 15.9% in dialysis patients, 1.9% in transplant recipients, and 12.0% in all RRT patients (both dialysis and transplant, incident patients at day 1 included). Slovenia has been a member of Eurotransplant since 2000. Forty-six kidney transplantations were performed in 2011, all from deceased donors. A slight decrease in prevalent number of RRT patients was observed in 2011, for the first time in 40 years. The number and proportion of patients with functioning kidney grafts is increasing, reaching 30% in 2011.

Vascular access management is central to maintain the health and quality of life of end-stage renal disease (ESRD) patients. Early referral to a nephrologist for a decision about replacement therapy, preservation, clinical evaluation of vessels and planning for timely placement of an arteriovenous fistula (AVF) should be done. The number of patients with diabetes, peripheral vascular disease and older age continues to increase. In order to select the most functional vessels for the creation of an AVF, duplex ultrasound is recommended in this group of patients. Distensibility of the vein at proximal compression, measurement of the internal diameter of the artery, change of arterial resistance index at reactive hyperaemia and arterial blood flow are important parameters for the decision on the location and time of AVF construction in patients with marginal quality of vessels. Expansion of blood volume at the time of AVF surgery could be helpful in this group of patients. The consequences of such a procedure include fewer surgical interventions, earlier maturation of the AVF, less stress for the patients and, last but not least, lower costs of AVF surgery.

Anemia is a common and important complication of chronic kidney disease. Treatment includes the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation. However, the optimal schedule of iron supplementation remains to be defined. Thirty-one long-term hemodialysis patients were treated for 1 year (period 1) with ESAs and an intermittent pulse regimen consisting of 100 mg of iron sucrose administered after different dialysis sessions depending on serum ferritin and other laboratory values, but no more than once per week. During the next 3 years (period 2), patients were treated with ESAs and need-based, continuous, low-dose iron. Iron doses were determined on the basis of values and changes of serum ferritin and transferrin saturation every fourth week after the longest interdialysis time interval. Iron doses ranged from 10 to 60 mg of iron sucrose and were given 1-3 times per week. If grounded, we gradually reduced or even abolished the iron doses. A significant increase in the hemoglobin concentration and hematocrit during period 2 in comparison with period 1 was observed. The use of ESAs did not change significantly during period 2 in comparison with period 1, while the use of iron was significantly lower in period 2. Significantly lower values were obtained for serum ferritin, saturation of transferrin, serum iron, and total serum iron-binding capacity during period 2. A better response to ESA therapy (increase in hemoglobin and hematocrit) is achieved with need-based, continuous, low-dose iron replacement.

The aim of our prospective study was to find out if the expansion of blood volume can improve early arteriovenous fistula (AVF) function after construction in patients with marginal vessel quality. Before AVF construction, the arteries of the upper arm were examined by duplex sonography. Patients with critical values of internal artery diameter (IDA)1.6 mm, resistance index (RI) at reactive hyperemia (RH)0.7 and feeding artery blood flow (ABF)24 mL/min were divided into two groups by random sampling. One group received plasma expander (hydroxyethyl starch) during surgery and the other did not. During the surgical procedures to construct 43 AVFs in 37 patients with critical artery quality, the patients received a mean volume of 720 mL (range 320-1000 mL) of plasma expander. The primary patency rate in this group was 86% (37/43). In the other group of 37 patients with critical artery quality, 42 AVFs were constructed and no plasma expander was given during surgery. The primary patency rate was 26.2% (11/42, P0.001). The two-year survival of the AVF in the group given plasma expander was 66.3%, and in the other group it was 13.3%. In our study, the infusion of plasma expander in patients with critical artery quality increased the primary patency rate after AVF construction. Based on the morphological and functional characteristics of arteries determined by pre-operative duplex sonography, the need for blood volume expansion could be predicted.

The long-term survival and quality of life of patients on hemodialysis (HD) is dependant on the adequacy of dialysis via an appropriately placed vascular access. The optimal vascular access is unquestionably the autologous arteriovenous fistula (AVF), with the most common method being the conventional radio-cephalic fistula at the wrist. Recent clinical practice guidelines recommend the creation of native fistula or synthetic graft before the start of chronic HD therapy to prevent the need for complication-prone dialysis catheters. This could also have a beneficial effect on the rapidity of worsening kidney failure. A multidisciplinary approach (nephrologists, surgeons, radiologists and nurses) should improve the HD outcome by promoting the use of AVF. An important additional component of this program is the Doppler ultrasound for preoperative vascular mapping. Such an approach may be realized without unsuccessful surgical explorations, with a minimal early failure rate and a high maturation, even in patients with diabetes mellitus.

The use of epoetin has, in Europe, been restricted to the intravenous (i.v.) route in patients on hemodialysis. This study is aimed at investigating impacts of this change in policy. We retrospectively compared 45 hemodialysis patients treated with epoetin (alpha, beta) subcutaneously (subcutaneous [s.c.] period) for 12 months before and 12 months after changing the route from s.c. to i.v., and 38 patients of the i.v. period who underwent long-term, i.v. low-dose iron therapy (i.v. iron period) for 6 months. During the study period, the dose of epoetin increased in the i.v. period compared to the s.c. period by 6.4% (7379 +/- 3556 IU/week [median 7846] vs 6907 +/- 3842 IU/week [median 5846], respectively [NS]). During the i.v. iron period, patients began to receive regular i.v. iron. The postiron epoetin dose was 5923 +/- 4779 IU/week (median 4500). The dose was decreased in comparison with the s.c. and i.v. periods by 14.2% and 19.7%, respectively. Hemoglobin decreased in the i.v. period compared to the s.c. period (120.4 +/- 8.0 g/L vs 123.5 +/- 6.7 g/L [P < 0.01]), and increased in the i.v. iron period compared to the s.c. and i.v. periods ([126.5 +/- 9.9 g/L vs 123.5 +/- 6.7 [P < 0.01]), and vs 120.4 +/- 8.0 (P < 0.01)]. Changing the route of administration of epoetin required an insignificant increase in dosage. Regular low-dose iron improves the response to epoetin and lowers the dose of epoetin, even in cases when the intravenously administration route is used.

Patients presenting for initial access evaluation in contemporary practice are less likely to have arteries and veins suitable for native fistula (AVF) formation in the classic location. Physical examination of the upper extremity alone may be inadequate for selection of arteries and veins that will mature into a functioning AF. The purpose of this paper is to determine how duplex ultrasonography can be used as an effective modality for the preoperative evaluation of vessels before construction of arteriovenous fistula for hemodialysis. The author have used duplex ultrasound (DU) to assess upper-extremity vasculature for planning of dialysis access procedures. Criteria for selection of arteries and veins and a detailed description of DU examination protocol are reviewed. Routine use of upper-extremity DU has identified many patients with veins that are suitable for use and determined arteries with optimal arterial inflow for successful AFV creation.

Background Regional citrate anticoagulation (RCA) during hemodialysis is alternative to heparin in patients at high risk of bleeding. It enables excellent antithrombotic effect in the circuit, but requires strict monitoring during the procedure. The aim of our retrospective clinical study is to evaluate safety and efficacy of RCA performed according to our unit protocol. Methods Data from 40 protocols for RCA performed between April and June 2004 were analyzed. Double-needle vascular access was obtained via either arteriovenous fistula or hemodialysis catheter. Hollow-fiber dialyzer Polyflux 14 S (Gambro, Lund, Sweden) was used in all dialysis sessions. Calcium-free dialysate was used and set to: Na 137 mEq/L, bicarbonate 28 mEq/L, magnesium 0.5 mEq/L, potassium 2.0 mEq/L, glucose 0 mEq/L. Potassium and glucose were added into the dialysate or intravenously if needed, respectively. Blood flow rate was maintained between 250–300 mL/min. 4% trisodium citrate was infused in the arterial line of the circuit, proximally from the arterial bubble trap, at the initial rate 300 mL/hour and adjusted accordingly to the blood flow rate and targeted clotting time (15–20 minutes in the circuit). One molar CaCl2 was infused in the venous line (distally from the venous bubble trap) at the initial rate 13 mL/h and was adjusted to maintain ionized calcium concentration (iCa) within normal range. Clotting time, iCa, Na, and bicarbonate were measured during hemodialysis. Clot formation in the dialyzer was estimated by counting the number of clotted fibers and assessment of clot presence in bubble traps. Results (see Table A26) Table A26. preHD At 60 min At 120 min At 180 min Post HD Clotting time (min) – 11.0 ± 3.4 11.0 ± 3.3 11.2 ± 3.0 11.2 ± 2.7 iCa (mmol/L) 1.15 ± 0.31 1.0 ± 0.12 1.03 ± 0.09 1.04 ± 0.10 1.07 ± 0.20 Sodium (mmol/L) 137 ± 4 139 ± 3 139 ± 4 140 ± 3 140 ± 3 Bicarbonate (mmol/L) 21.4 ± 3.0 – – – 25.02 ± 3.3 pH 7.39 ± 0.04 – – – 7.45 ± 0.07 At 60 min At 120 min At 180 min At 240 min Blood flow rate (mL/min) 268 ± 24 266 ± 25 267 ± 23 267 ± 23 Citrate infusion rate (mL/h) 297 ± 11 298 ± 23 297 ± 22 300 ± 15 1M CaCl2 inf. rate (mL/h) 12.95 ± 0.45 13.12 ± 1.4 13.17 ± 1.55 13.35 ± 1.1 Assessment of clotting in the circuit 23/40 dialyzers (57.5%) were estimated as excellent (

Introduction It was noticed that the decline of renal function was slower in patients (pts) with end stage renal disease (ESRD) after early arteriovenous fistula (AVF) construction. The aim of this prospective study was to find out the influence of AVF on the progression of renal failure. Patients and methods Sixty ESRD pts with serum creatinine level (SCL) between 400 and 500 µmol/L were included and randomized in two groups. One group of pts received AVF and the other did not. Serum creatinine level, creatinine clearance (CC), and mean arterial pressure (MAP) were followed every two months for one year. All pts were clinically evaluated for signs of cardiac insufficiency. Hemodialysis (HD) was started when SCL was 850 µmol/L or CC 10 mL/min or when signs of uremia were presented. Results In Group A, 30 ESRD pts, 17 males and 13 females, age 61 ± 7.3 years, mean SCL 446.4 ± 30.5 µmol/L, mean CC 29.3 ± 4.1 mL/min, native forearm AVFs were constructed. No AVFs were constructed in Group B, 30 pts, 12 males and 18 females, mean age 62.8 ± 8.2 years, mean SCL 447.6 ± 37.6 µmol/L, mean CC 29.1 ± 4.7 mL/min. Mean SCL during a 12 month period in both groups is shown in Table A20. Table A20. Serum creatinine in a 12 month period (µmol/L) Group A Group B * P

Introduction Renal anemia is a major problem of patients with chronic kidney disease (CKD). Target hemoglobin concentration (Hb) in these patients should be > 110 g/dL and hematocrit (Ht) > 0.33. Treatment of renal anemia with epoetin is a well established practice. The purpose of this review in one dialysis center was to analyze the quality of such treatment and to find which parameters could influence success of treatment Patients and Methods Patients (pts) on HD were included in this analysis. The properties Hb, Ht, epoetin (alpha or beta intravenously) dose (EPO), ferritin, transferrin saturation (TSAT), hypochromic red cells (HYPO), CRP, albumin, parathyroid hormone (PTH) Kt/V were followed during 10 months period. Results 58 pts, 29 female and 29 male, mean age 60.5 ± 12.5 (range 32–82) years, HD treatment mean 8.4 ± 7.8 (range 0.7–30.7) years were observed. Mean Hb was 119.9 g/L ± 2.1 (range 79–142), mean Ht 0.36 ± 0.01, mean EPO 6970 ± 456.7 IE/week. EPO 110.3 ± 7.9 IE/kgBW/week, ferritin 603.5 ± 46.2 µg/L, TSAT 25.8 ± 3.3%. HYPO 2.1 ± 0.1, CRP 7.4 ± 0.21, albumin 41.9 ± 0.37 g/L, PTH 281.5 ± 47.9, Kt/V 1.68 ± 0.34. The female and male groups were analyzed and compared (Table A23) Table A23. Female Male w, week; *P

Introduction Hyperparathyroidism continues to be a major problem in patients with chronic kidney disease (CKD). Hypocalcemia and hyperphosphatemia are crucial for the development of secondary hyperparathyroidism (SHP). Preventing hyperphosphatemia ameliorates the progression of SHP. Vitamin D analogs (Alpha D3) per oral after hemodialysis (HD) could be used in the therapy of SHP. The purpose of this review in one dialysis center was to analyze the quality of such treatment. Patients and methods Patients (pts) on HD in one dialysis center were included in this analysis. Calcium (Ca) and phosphate (P) were followed during a 10 month period every 3 weeks and intact parathyroid hormone (iPTH) every three months. Vitamin D was given after HD per oral under nurse control. Results Sixty-four pts, 34 female and 30 male, mean age 59.9 ± 11.5 (range 32–82) years, HD treatment length mean 8.8 ± 7.2 (range 0.7–30.7) years were observed. Mean Ca was 2.46 ± 0.04 mmol/L, (range from 1.06 to 2.72), mean P 1.52 ± 0.08 mmol/L (range from 0.62 to 3.53), mean iPTH 211.9 ± 36.7 ng/L (range from 1 to 699). Mean calcium concentration in dialysis fluid was 1.51 ± 0.02 mmol/L and mean dose of vitamin D was 0.35 ± 0.11 mg. Mean values of parameters during the 10 months observation are shown in Table A21. Table A21. December 2003 February 2004 April 2004 June 2004 Ca (mmol/L) 2.46 2.44 2.35 2.38 P (mmol/L/ 1.52 1.56 1.71 1.53 iPTH (ng/L) 204.8 173.1 272.3 196.5 Ca in fluid (mmol/L) 1.52 1.53 1.49 1.49 Dose of vitamin D (mg) 0.47 0.28 0.21 0.43 Conclusions Regular evaluation of Ca, P, iPTH and strict correction of calcium concentration in dialysis fluid, per oral vitamin D are very helpful in prevention of SHP. Critical elevation of iPTH was in pts with low compliance in hypophosphatemic diet and therapy. If concentration of phosphate is normal, elevated iPTH could be diminished very effective by titration of vitamin D.

Introduction There is strong evidence from randomized trials that subcutaneous (s.c.) epoetin is as effective as intravenous (i.v.) and may allow a lower dose to be used, thereby reducing costs. Dose requirements for s.c. are reported to be from 22–32% lower than those of i.v. epoetin. The purpose of these analyses was to find out what was increasing the epotein dose after the beginning of i.v. administration. Patients and methods Patients (pts) on HD treated with epoetin s.c. for 10 months (group A), and then with epoetin i.v. for 10 months (group B) were included in this analysis. Hemoglobin (Hb), epoetin (alpha or beta) dose (EPO), and ferritin were evaluated. Results 46 pts, 25 females and 21 males, mean age 58.2 ± 12.6 (range 30–80) years, HD treatment mean 9.1 ± 7.7 (range 0.2–29.2) years were observed. In Group A, mean Hb was 123.8 g/L ± 2.4 (range 119–127), mean EPO 6914 ± 810 IE/week, ferritin 603.5 ± 46.2 µg/L. In Group B mean Hb was 120.3 g/L ± 2.3 (range 117–125) (P