Piotr Andziak

A High Red Blood Cell Distribution Width Predicts Failure of Arteriovenous Fistula

In hemodialysis patients, a native arteriovenous fistula (AVF) is the preferred form of permanent vascular access. Despite recent improvements, vascular access dysfunction remains an important cause of morbidity in these patients. In this prospective observational cohort study, we evaluated potential risk factors for native AVF dysfunction. We included 68 patients with chronic renal disease stage 5 eligible for AVF construction at the Department of General and Vascular Surgery, Central Clinical Hospital Ministry of Internal Affairs, Warsaw, Poland. Patient characteristics and biochemical parameters associated with increased risk for AVF failure were identified using Cox proportional hazards models. Vessel biopsies were analyzed for inflammatory cells and potential associations with biochemical parameters. In multivariable analysis, independent predictors of AVF dysfunction were the number of white blood cells (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.24 to 2.25; p<0.001), monocyte number (HR 0.02; 95% CI 0.00 to 0.21; p = 0.001), and red blood cell distribution width (RDW) (HR 1.44; 95% CI 1.17 to 1.78; p<0.001). RDW was the only significant factor in receiver operating characteristic curve analysis (area under the curve 0.644; CI 0.51 to 0.76; p = 0.046). RDW>16.2% was associated with a significantly reduced AVF patency frequency 24 months after surgery. Immunohistochemical analysis revealed CD45-positive cells in the artery/vein of 39% of patients and CD68-positive cells in 37%. Patients with CD68-positive cells in the vessels had significantly higher white blood cell count. We conclude that RDW, a readily available laboratory value, is a novel prognostic marker for AVF failure. Further studies are warranted to establish the mechanistic link between high RDW and AVF failure.

Significance of cytomegalovirus infection in the failure of native arteriovenous fistula

High cytomegalovirus (CMV) IgG levels have been identified as a risk factor for arteriovenous fistula (AVF) failure. None of the 68 patents in our study were CMV IgM positive, although 96% were CMV IgG positive. CMV antigens were detected in the radial artery or cephalic vein of 46% of patients who received an AVF. The presence of CMV antigens or high serum CMV IgG levels had no prognostic value for AVF failure.

Ultrasound-guided angioplasty of dialysis fistula - technique description.

Summary Endovascular procedures are commonly used for treatment of vascular pathologies. These interventions are routinely performed under angiographic control. Angioplasty is increasingly more often used for correction of dialysis fistula – especially dilatation of stenosis. We describe the technique of dialysis fistula angioplasty under ultrasound control. Benefits of this procedure include lack of nephrotoxic contrast, what is especially important in chronic kidney disease patients in pre-dialysis period. Advantages of ultrasound guidance during dialysis fistula angioplasty lead to cause more and more frequent employment of this technique.

The role of alpha-1-antitrypsin protein in the pathogenesis of abdominal aortic aneurysm

Alpha-1-antitrypsin is a potent antiprotease playing an important role in maintaining protease-antiprotease balance. It protects the structures of extracellular matrix against destruction by proteolytic enzymes. Loss of elasticity occurs when increased protease activity is accompanied by qualitative impairment or reduced concentrations of antiproteases. Alpha-1-antitrypsin deficiency is a risk factor for obstructive lung disease, including emphysema, liver and kidney disorders and, less often, follicular panniculitis, granulomatosis with polyangiitis (previously Wegener’s granulomatosis). Literature also emphasises the role of AAT in the development of aortic aneurysms, and results of biochemical studies support this theory. Aortic aneurysm is an important clinical problem, unceasingly associated with high mortality. For this reason, it is exceptionally important to identify its risk factors. Studies on the relationship between AAT and development of AAA (abdominal aortic aneurysm) have been conducted since the 1990s. Due to the development in molecular diagnostic techniques, new reports on the topic appeared over the last decade.

Upper limb ischaemia after formation of dialysis fistula.

UNLABELLED Limb ischaemia caused by formation of dialysis fistula is rare but serious complication. The severity of symptoms may vary but rest pains and necrotic lesions are observed in most advance cases. In these patients different invasive procedures for treatment are performed - from simplest dialysis fistula ligation to complicated vascular reconstructions. The aim of the study was to evaluate treatment results of upper limb ischaemia triggered by dialysis fistula. MATERIAL AND METHODS We have analysed methods and results of treatment of 14 patients with symptomatic upper limb ischaemia caused by dialysis fistula treated in our department between 1st January, 2006 and 30th June, 2013. Treatment was subject to anatomical situation and clinical symptoms. In three patients the ligation of dialysis fistula was performed, four patients underwent inflow reconstruction - in one case by ligation of ligation of vein branch, in three patients by cephalic transfer of arterial anastomosis. In 2 patients hyperkinetic fistula aneurysm was excised and replaced by PTFE bypass, in three patients fistula reconstruction with DRIL method (distal revascularization - interval ligation) was performed, in one patient surgical operation of brachial artery stenosis was conducted. One patient underwent brachial artery angioplasty. RESULTS Rest pains occurred in all patients (100%), regressive changes in 10 patients (71.4%). Eight patients (57.2%) had concomitant diabetes, seven (50%) ischaemic heart disease, five (35.5%) chronic lower limb ischemia and hyperparathyroidism was observed in fivepatients (35.5%). The imaging studies in all patients revealed pathological steal syndrome (stealing blood to the fistula), in majority concurrent with other pathologies - obstruction stenosis of peripheral artery, defects in blood out flow from the limb. As a result of the surgical treatment, symptoms of limb ischaemia subsided in all patients. CONCLUSIONS Critical limb ischaemia caused by dialysis fistula is a dangerous complication. In most cases there are several causes of ischaemia. Treatment methods should be selected individually for each patient and clinical situation. Clinical symptoms should subside as a result of optimal choice of treatment and, if possible, maintaining of dialysis access.

The recommendations for perioperative pain relief in general surgery

Post-operative pain is caused by intra-operative damage to the tissue/organs; its intensity and range are usually proportional to the extent of surgery. Post-operative pain occurs when intra-operative analgesia stops acting. It is caused by damaged superficial tissues (skin, subcutaneous tissue, mucous membranes), as well as deeper structures (muscles, fascias, ligaments, periosteum). If an injury is large, apart from superficial and deep somatic pain, also a visceral component of post-operative pain appears, resulting from the contraction of smooth muscles, caused by crushing or stretching of visceral structures along with inflammatory changes, pulling or twisting of the mesentery. Post-operative pain is a „self-limiting phenomenon”. It is the most intense on the first and second day after surgery and much smaller on the third or fourth day. Pain is the most irritating in patients after thoracotomy and abdominal surgeries, while the procedures on integuments and limbs are much less painful. The following factors are crucial in patient’s perception of pain: the location of surgery, its extent, a degree of tissue trauma, a direction of skin cutting and perioperative analgesia techniques. Pain relief is a fundamental right of the patient. We know that the proper treatment of postoperative pain (POP) significantly reduces perioperative morbidity, including the number of postoperative complications, the duration and costs of hospitalization, especially in patients at the high risk (ASA III-V), those undergoing extensive surgery and hospitalized at intensive care units. Therefore, relieving acute pain, including post-operative pain must be one of the priority institutional objectives and an integral part of treating a „perioperative disease” covering pain relief, early mobilization and enteral nutrition along with active physiotherapy). In Poland, a team of experts appointed by the Association of Polish Surgeons, Polish Society for the Study of Pain, the Polish Society of Anaesthesiology and Intensive Care, has established the following criteria for proper organizing the system aimed to improve the quality of pain management in the postoperative period: – the assessment of pain intensity in all operated patients, at least 4 times a day, – informing patients before surgery, about the possible methods of postoperative pain management, – recording the measurements of pain and the management in accordance with the recommendations of pain relief, – monitoring possible side effects of the treatment on a special form designed to report adverse drug reactions. Appropriate patient education is a crucial element of pain management in the perioperative period. It involves oral and written information on post-operative pain and its methods of treatment. This information should include the most important data on: – methods of measuring the pain, – methods of pain relief, – the importance of post-operative pain relief for the therapeutic process. Preoperative talk to the patient, his legal guardians or relatives should focus on: – obtaining information on patient’s previous experiences with pain and preferences for analgesic treatment,