Jean Lee

ASYMPTOMATIC URINARY ABNORMALITIES: Hematuria and Proteinuria

Asymptomatic urinary abnormalities including hematuria and proteinuria are commonly detected in routine urinalysis. They may be of benign etiology or indicative of more serious underlying disease. This article is intended to give clinicians a guide for evaluation of hematuria and proteinuria.

Correlation of venography, venous pressure, and hemoaccess function

We analyzed the anatomic features of both grafts and fistulas and correlated these features with access function. We also attempted to determine venous pressures predicting access dysfunction (critical venous pressures) at various blood flow rates (BFRs). Therefore, accesses of 46 chronic hemodialysis patients were studied by venography in a prospective fashion. We defined the incidences of various lesions and the effects of venous collaterals on graft function, and determined critical venous pressures at various BFRs. Eighty-three percent of the accesses had outflow obstruction. Five types of anatomic lesions were identified. The incidences were venous stenosis of the draining vein immediately proximal to the venous anastomosis, 36.4%; central vein, 23.6%; venous anastomosis, 25.5%; arterial anastomosis, 10.9%; and intragraft hyperplasia, 3.6%. Twelve patients had multiple lesions. When the homogenous polytetrafluoroethylene arm graft population was studied for the effect of venous collaterals, we found that venous collaterals conferred protection but did not prevent graft failure. Venous pressure measurements were good predictors of access failure at the lower BFRs. Venous pressures increased with increasing BFRs. A critical venous pressure of 145 mm Hg was found for a BFR of 250 mL/min. At a BFR of 300 mL/min, the critical venous pressure was 170 mm Hg. A critical venous pressure could not be found for a BFR of 400 mL/min.

A multicenter, prospective, randomized, comparative evaluation of dual- versus triple-lumen catheters for hemodialysis and apheresis in 485 patients

BACKGROUND The purpose of this study is to compare a new temporary triple-lumen catheter (TLC) for dialysis that has a third lumen devoted to fluid and medication administration or blood sampling with a marketed dual-lumen catheter (DLC). METHODS Four hundred eighty-five patients referred for acute hemodialysis or apheresis were randomly assigned to either a TLC or DLC in a multicenter, prospective, randomized trial. RESULTS Analysis of blood flow rates was completed on 464 patients (228 patients, DLC; 236 patients, TLC) with a total of 1,681 hemodialysis (808 treatments, DLC; 873 treatments, TLC) and 82 apheresis treatments (37 treatments, DLC; 45 treatments, TLC). During hemodialysis, a median achieved flow rate (AFR) of 267 mL/min was realized for both groups (P = 0.58). During apheresis, a median AFR of 72.5 mL/min (range, 50 to 150 mL/min) was achieved in the DLC group, and 87 mL/min (range, 60 to 150 mL/min), in the TLC group (P = 0.14). Three hundred ninety-three patients (193 patients, DLC; 200 patients, TLC) had blood and catheter tip cultures performed on removal, and catheter-related bloodstream infection (CRBSI) status was determined. Thirty-one patients (7.9%) had a CRBSI: 16 patients (8.3%), DLC; and 15 patients (7.5%), TLC (P= 0.77). Incidence densities of CRBSI were 12.4/1,000 DLC-days and 10.2/1,000 TLC-days (P = 0.59). The CRBSI incidence of 18.2/1,000 catheter-days for femoral sites was significantly greater than the 7/1,000 catheter-days for jugular sites (P = 0.02) and 6.6/1,000 catheter-days for combined jugular and subclavian sites (P = 0.01). In multivariate analysis, antibiotic use was the only factor related to CRBSI (odds ratio, 0.30; 95% confidence interval, 0.12 to 0.76). There were no statistically significant differences in rates of other complications between the 2 catheters. CONCLUSION Results show that the new TLC is similar to the marketed DLC.

Diagnosis of Unexplained Bleeding from Tunneled Dialysis Catheter

Bleeding after hemodialysis catheter placement is commonly seen and can happen because of anticoagulation, poor platelet function in dialysis patients, and trauma to the vessel and tunnel tract during placement. We wish to present here two cases of prolonged exist site bleeding with tunneled dialysis catheters (SchonCath dialysis catheter, Angio-Dynamics, Queensbury, N.Y.) due to unsuspected catheter leak within the tunneled portion of the catheter, which was identified with angiogram.

Long-Term Outcomes of Fistula First Initiative in an Urban University Hospital—Is It Still Relevant?

Purpose: Dialysis access failure is a major cause of morbidity in patients with end-stage renal disease. The Fistula First Breakthrough Initiative (FFBI) dictates arteriovenous fistulae (AVFs) should be preferred over arteriovenous grafts (AVGs) as first line for surgically placed accesses. The purpose of this study was to compare patency rates of surgical dialysis accesses in our mature, urban population after the FFBI. Methods: Current dialysis patients with accesses placed between 2006 and 2011 were included. Patient characteristics, access outcomes, interventions, and survival outcomes were analyzed. Results: We report outcomes of 220 patients undergoing dialysis access. Of those 220, 75 received numerous accesses. All outcomes are evaluated as per access itself, that is, a patient may have numerous access types, each individually analyzed. Of the accesses, 138 were AVF and 190 were AVG. The average age of patients was 59.8 years. The groups were evenly matched in distribution of race and prevalence of hypertension, diabetes, coronary artery disease, and Peripheral Vascular Disease (PVD). Average number of complications requiring intervention per access were fewer with AVF than AVG (1.21 vs 1.72, P = .02). The AVF had greater rates of stenosis (51.4% vs 40.6%, P = .0182), whereas AVG had greater thrombosis rates (14.6% vs 31.9%, P < .001). Both AVF and AVG had similar primary patency (median: 186 vs 142 days, P = .1774) and 3-year secondary patency (59.2% vs 49.2%, P = .0945). Arteriovenous fistula in patients aged <60 years was found to have the greatest primary (P = .0078) and secondary patency (P = .0400). Outcomes did not differ between AVF and AVG in those aged >60 years. Conclusions: Although complications requiring intervention are greater with AVG, primary and secondary patency rates are similar between AVF and AVG, except when considering AVF in patients aged <60 years.