Clemente Neves Sousa

Frequency of intradialytic hypotensive episodes: old problem, new insights

Symptomatic intradialytic hypotension (IDH) continues to be an important complication of hemodialysis treatment. There is some evidence that besides an IDH episode, repeated episodes could represent an even more important independent risk factor for mortality in hemodialysis patients. A retrospective cross-sectional study was performed to study 18 dialysis treatments in 43 patients during 6 weeks. Relationships of IDH episodes with baseline variables were examined using a Poisson regression model (generalized linear model). IDH was frequent (93% of patients) and highly variable by patient (0%-100%). Multivariate analysis showed that patients who experienced frequent hypotensive episodes had a lower dry weight (90% confidence interval [CI]: 0.95-0.99), higher phosphorus levels (90% CI: 1.07-1.47), greater prevalence of diabetes mellitus (90% CI: 1.11-2.71), and hypertension (90% CI: 1.04-2.45). Dry weight, hypertension, and phosphorus levels are modifiable risk factors to possibly reduce the rate of IDH episodes. The potential protective role of phosphorus warrants further investigation.

Physical examination: How to examine the arm with arteriovenous fistula

Physical examination has demonstrated its effectiveness in identifying complications of arteriovenous fistula (AVF). It should be initiated at the stage prior to the construction of the AVF and continue in its accomplishment, maturation, and subsequent use in the treatment of hemodialysis. Nurses should incorporate the physical examination in their practices, in order to preserve the vascular net of patients and assist in the recognition of complications of AVF. It is intended to describe aspects of the physical examination that enable the identification of the AVF complications including: infection, accessory veins, venous stenosis, steal syndrome, high‐output cardiac failure, and venous hypertension.

HAEMODIALYSIS FOR CHILDREN UNDER THE AGE OF TWO YEARS

Less than 10% of children under 2 years old with end-stage renal failure in Europe and in the United States of America are treated with haemodialysis. For small children, peritoneal dialysis is often the preferred treatment. Haemodialysis is chosen for a very small number of children, and is only used in some selected centres because of its highly complex technique, the difficulties related to vascular access, and the need to have a skilled and experienced nursing and medical team. With the technological development of recent years, the quality of dialysis treatment offered to paediatric patients has improved considerably and haemodialysis is presently considered to be a safe and efficient treatment for acute or chronic paediatric renal impairment. However, because a successful renal transplant continues to be linked to a better quality of life for children with terminal chronic renal impairment, dialysis ought to be regarded as a temporary treatment method, while waiting for a renal transplant.

Construction and validation of a scale of assessment of self-care behaviors with arteriovenous fistula in hemodialysis

Several guidelines recommend the importance of educating the patient about the care of vascular access. Nurses have a key role in promoting the development of self‐care behaviors by providing the necessary knowledge to patients, so that they develop the necessary skills to take care of the arteriovenous fistula (AVF). This article describes the process of building a scale of assessment of self‐care behaviors with arteriovenous fistula in hemodialysis (ASBHD‐AVF). This is a cross‐sectional study in which the development, construction, and validation process followed the directions of the authors Streiner and Norman. This is a convenience sample, sequential, and nonprobabilistic constituted by 218 patients. The study was conducted in two stages during 2012–2014. The first phase corresponds to the scale construction process, 64 patients participated, while the second corresponds to the evaluation of metric properties and 154 patients participated. The principal component analysis revealed a two‐factor structure, with factorial weights between 0.805 and 0.511 and between 0.700 and 0.369, respectively, explaining 39.12% of the total variance of the responses. The Cronbachs alpha of the subscale management of signs and symptoms is 0.797 and from the subscale prevention of complications is 0.722. The ASBHD‐AVF revealed properties that allow its use to assess the self‐care behaviors in the maintenance and conservation of the AVF.

Radio-cephalic fistula recovered with drainage to forearm basilic vein: Case Report

Dysfunction problems with vascular access are a concern to patients and dialysis units. The vascular surgeon should analyse such dysfunction and perform a careful assessment of the vascular network in order to find new fistula layouts. We introduce and discuss the case of creation of a radio‐cephalic fistula with outflow into the forearm basilic vein through rotation of the forearm basilic vein toward the cephalic vein in the forearm of an 88‐year‐old hemodialysis male patient. This technique enables extending fistula patency and improves cost efficiency.

Brachio-brachial Arteriovenous Fistula Superficialization with Short Skip Incisions

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites.

Brachial-cephalic fistula recovered with drainage for the basilic vein: Case report

Vascular access is essential for the implementation of hemodialysis (HD). The arteriovenous fistula (AVF) can be constructed in various locations using various veins. However, the quality of the veins will influence the construction site, as well as the functioning of the AVF. Careful analysis of the vascular network allows options for the development of new fistulas presentations. We present and discuss the case of a woman aged 69 years in HD in which a brachial‐cephalic fistula with drainage to basilic vein was created, through rotation of the cephalic vein on the forearm level. This kind of access serves to prolong the time spent dialyzing through native fistulae, with their reduced complications and greater cost‐effectiveness.

Construction and validation of a scale of assessment of self-care behaviours anticipatory to creation of arteriovenous fistula.

AIMS AND OBJECTIVES We developed a scale to assess the self-care behaviours developed by patients with end-stage renal disease to preserve the vascular network prior to construction of arteriovenous fistula. BACKGROUND The possibility of creation of an arteriovenous fistula depends on the existence of an arterial and venous network in good condition, namely the size and elasticity of the vessels. It is essential to teach the person to develop self-care behaviours for the preservation of the vascular network, regardless of the modality of dialysis selected. DESIGN Methodological study. METHODS The scale was developed based on clinical experience and research conducted by the researcher in the area of the vascular access for haemodialysis. The content of the scale was judged by two panels of experts for content validity. The revised version of the scale was administered to a convenience sample of 90 patients with end-stage renal disease. In the statistical analysis, we used the Cronbachs alpha, the Kaiser-Meyer-Olkin and scree plot and the principal component analysis with varimax rotation. RESULTS A principal component analysis confirmed the univariate structure of the scale (KMO = 0·759, Bartletts sphericity test-approximate χ(2) 142·201, p < 0·000). Cronbachs α is 0·831, varying between 0·711-0·879. CONCLUSION This scale revealed properties that allow its use to assess the patients self-care behaviours regarding the preservation of the vascular network. RELEVANCE TO CLINICAL PRACTICE This scale can be used to evaluate educational programmes for the development of self-care behaviours in the preservation of vascular network. This scale can identify not only the patients that are able to take care of their vascular network but also the proportion of patients who are not able to do it, that need to be educated.

Two-Stage Basilic Vein Transposition: Second Stage Results: Basilic Transposition: 2nd Stage Results

The increasing survival of hemodialysis patients results in the depletion of superficial venous capital justifying the use of the basilic vein. Many groups still prefer an arteriovenous graft due to transposition complexity and the time needed to achieve maturation. In this work we review the results of our series of basilic vein transpositions (BVT). BVTs were performed in two stages: first, creation of the fistula; second, transposition of the vein using three small incisions in the arm. All patients had to have direct arterialization of the basilic vein, therefore, patients with previous ipsilateral wrist fistulas also followed a two‐stage protocol. Data were retrospectively revised from all transposition procedures made between September 2005 and November 2012. Patency and complication rates were the primary outcomes evaluated. A total of 276 basilic veins were transposed. Usage rate was 82.2%. 8% (N = 22) of the fistulas were never used due to thrombosis. Secondary patency rates at 1 and 2 years were, respectively, 84% and 66.3%. Complications occurred in 61.6% (N = 170) of fistulas and 65.9% (N = 112) of which had to undergo surgical or endovascular revision. The most frequent complication was vein stenosis (39.7% of late complications, N = 92). Albeit its greater technical complexity, the transposed basilic vein represents a hemodialysis access with good patency rates. Complication rates, although high, are less than those of CVC or prosthetic grafts. These results support the use of the transposed basilic vein as hemodialysis access after the brachiocephalic fistula.

Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein: RC-AVF drainage into the brachial vein

Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio‐cephalic fistula with outflow into the brachial vein in 64‐year‐old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.