Tomasz Gołębiowski

A program of physical rehabilitation during hemodialysis sessions improves the fitness of dialysis patients.

Aim: The aim of the present study was to evaluate the influence of cycle exercise during hemodialysis (HD) on patients’ physical proficiency, muscle strength, quality of life and selected laboratory parameters. Patients and Methods: In a group of 29 (15 female, 14 male) HD patients (age 64.2 ± 13.1 years), 3 months of cycle training during dialysis sessions was performed. The following data were analyzed: strength of lower extremities (six-minute walk test, isokinetic knee extension, flexion peak torque), nutrition parameters (albumin, BMI), inflammation intensity (CRP, IL-6), and quality of life (SF-36v2). Results: In the six-minute walk test, the increase in walk velocity was 4% (3.56 km/h before and 3.73 km/h after cycle training; p < 0.01). At angular velocity (AV) of 60°/s, extension peak torque in the knee joint rose by 7% and at AV of 300°/s by 4% (p = 0.04). Flexion peak torque at AV of 180°/s increased by 13% (p = 0.0005). The program does not influence nutrition or inflammation parameters. No complications directly related to exercise were observed. Conclusion: Cycle exercise during dialysis is safe even in older HD patients with multiple comorbidities. It results in a significant increase in general patient walking ability and in a gain in lower extremity muscle strength.

Creation of arteriovenous fistulae for hemodialysis in octogenarians.

Elderly patients, defined as octogenarians and nonagenarians, are an increasing population entering renal replacement therapy. Advanced age appears as an exclusive factor negatively influencing dialysis practice. Elderly patients are referred late for the initiation of hemodialysis and more likely are offered catheters rather than arteriovenous fistulae (AVF), which increase mortality and negatively affect quality of life. We present our approach to the creation of vascular access for hemodialysis in this demanding population. In 2006–2012, 39 patients aged 85.9 ± 2.05 with end‐stage renal disease, mainly resulting from ischemic nephropathy, were admitted to the Department of Nephrology to establish permanent vascular access for hemodialysis: preferably AVF. Temporary dialysis catheters were implanted in uremic emergency to bridge the time to fistula creation/maturation. AVF was attempted in 87.2% of the patients. Primary AVF function was achieved in 54% of the patients. Cumulative proportional survival of AVF at months 12 and 24 was 81.5%. Ninety‐four percent of AVF were localized on the forearm: 74% in the distal and 20% in the proximal part. Mean duration of hemodialysis therapy was 20.80 ± 19.45 months. The mean time of AVF use was 15.9 ± 20.2 months. Until present, 38% have been dialyzed using AVF for 31.0 ± 18.8 months. Five patients died with functioning fistula. Eight patients initiated hemodialysis therapy with fistula. During further observation, the use of AVF increased to 62%. Elderly patients should not be denied creation of AVF as a rule. The outcome of AVF benefits more from acknowledging individual vascular conditions rather than age of the patient.

Arteriovenous fistula reconstruction in patients with kidney allograft failure

Abstract: Background:  Kidney recipients with failing allograft function face the vascular access problem again before returning to hemodialysis. An autologous arteriovenous fistula (AVF), according to the recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, is the optimal vascular access and the use of prosthetic grafts and catheters should be limited. The objective of this study was to assess the feasibility of AVF reconstruction in patients reentering hemodialysis after kidney allograft failure.

The Level of Anxiety and Depression in Dialysis Patients Undertaking Regular Physical Exercise Training - a Preliminary Study

Background/Aims: The aim of the study was to evaluate the effects of a six-month physical training undertaken by haemodialysis (HD) patients, on the depression and anxiety. Methods: Patients with end stage renal disease (ESRD) were recruited from the dialysis station at the Department of Nephrology and Transplantation Medicine in Wroclaw. Physical training took place at the beginning of the first 4-hours of dialysis, three times a week for six months. A personal questionnaire, Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) were used in the study. Results: A total of 28 patients completed the study: 20 were randomised to endurance training and 8 were randomised to resistance training. Statistical analysis of depression and anxiety at the initial (t1) and final examination (t2) indicated a significant reduction in depression and anxiety, particularly anxiety as a trait (X2) in the whole study group. The change in anxiety as a state correlated with the disease duration, duration of dialysis and the initial level of anxiety as a state (t1X1). The change in anxiety as a trait significantly correlated with age and the initial level of anxiety (t1X2). Conclusions: Undertaking physical training during dialysis by patients with ESRD is beneficial in reducing their levels of anxiety and depression. Both resistance and endurance training improves mood, but only endurance training additionally results in anxiety reduction.

Balloon angioplasty for disruption of tunneled dialysis catheter fibrin sheath

Purpose Management of failing tunneled hemodialysis catheters, sometimes the only vascular access for hemodialysis, presents a difficult problem. In spite of various techniques having been developed, no consensus has been reached about the preferred technique, associated with the longest catheter patency. Methods We report disruption of the fibrin sheath covering dysfunctional tunneled hemodialysis catheter by means of angioplasty, followed by over guidewire catheter exchange. Results Following the procedure, the catheter placed in the recovered lumen of the vessel presented correct function. Conclusions The described procedure allowed maintenance of vascular access in our patient. Additionally, dilatation of the concomitant central vein stenosis opens an option for another attempt for arteriovenous fistula creation.

The snuffbox fistula should be preferred over the wrist arteriovenous fistula

OBJECTIVE The snuffbox arteriovenous fistula (SBAVF) is the most distal native vascular access. Although published data show a favorable outcome, the SBAVF is not strongly recommended by the guidelines. The present study compared the patency of SBAVFs and wrist AVFs (WAVFs). METHODS All 416 AVFs created by the same nephrologist from March 2006 to October 2014 were reviewed. From 416 procedures, 47 SBAVFs and 77 WAVFs with vessels suitable for a SBAVF were selected. RESULTS Although vessel diameters used for construction of the SBAVFs were smaller than those used for WAVFs, the outcome of vascular access was similar. At 18 months, primary patency was 72% for SBAVF and 65% for WAVF (P = .48), and secondary patency was 93% for SBAVF and 94% for WAVF (P = .89). CONCLUSIONS In our experience, a SBAVF performs as well as a WAVF up to 18 months after creation. We suggest favoring SBAVF, especially in young patients without comorbidities, as the primary vascular access.

The Effects of Aquatic Exercises on Physical Fitness and Muscle Function in Dialysis Patients

Purpose. The aim of this study was to assess the impact of a 3-month physical training program, conducted in an aquatic environment with end-stage renal disease patients (ESRD), on the physical fitness and functional parameters of the knee joint muscles. Patients and Methods. The study included 20 ESDR patients with mean age 64.2 ± 13.1 y. treated with hemodialysis in Dialysis Center of the University Hospital in Wroclaw. Before and 3 months after the physical training in water, a test was performed to evaluate the physical fitness of each patient; additionally, a measurement was taken of force-velocity parameters. The 3-month training program took place on nonhemodialysis days, in the recreational pool of the University of Physical Education in Wroclaw. Results. After aquatic training cycle, an improvement was observed in all parameters measured using the Fullerton test. The value of peak torque and its relation to body mass increased in the movement of flexors and extensors of left and right lower extremities in all tested velocities. Conclusions. In assessing the physical fitness of studied women, the biggest improvement was achieved in tests assessing the strength of upper and lower extremities as well as lower body flexibility. Higher values of force-velocity parameters are conducive to women achieving better physical fitness test results.

Anatomical vascular variations and practical implications for access creation on the upper limb

Background A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis. Methods Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review. Results Over a dozen arterial anatomical anomalies of the upper limb, the most common is “high origin” of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described. Conclusions The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.

Superficialization of the radial artery – an alternative secondary vascular access

Purpose The standard approach in patients with a clotted arteriovenous fistula (AVF) on the forearm is the creation of another vascular access on the arm using the patients own vessels or a prosthetic graft. Here we propose another option as secondary angioaccess for chronic hemodialysis (HD): superficialization of the radial artery. Methods Indications for the procedure were 1) long-standing forearm AVF that has irreversibly clotted and/or central vein stenosis resistant to angioplasty; 2) patients who have no other prospect for forearm or even brachial AVF. The procedure was undertaken in 7 chronic HD patients dialyzed by forearm AVF for 27±26 months. Results In one case the superficialization was abandoned intra-operatively due to small diameter of the artery (<4 mm). Five of 6 elevated arteries were patent and the follow-up period ranges from 11 to 15 (median 12) months. In 1 male patient with prothrombin G20210a mutation the artery clotted after 13 months of usage. Conclusions Superficialized radial artery was successfully used for hemodialysis over one year. The only prerequisite for safe repeated puncture is a patent and enlarged radial artery. Due to avoidance of arteriovenous shunt this access type may be particularly suitable for patients with cardiac failure.

Balloon Dilatation for Removal of an Irretrievable Permanent Hemodialysis Catheter: The Safest Approach.

Long-term hemodialysis catheter dwell time in the central vein predisposes to fibrin sheath development, which subsequently causes catheter malfunction or occlusion. In very rare cases, the catheter can be overgrown with fibrin and rigidly connected with the vein or heart structures. This makes its removal almost impossible and dangerous because of the possibility of serious complications, namely vein and heart wall perforation, bleeding, or catheter abruption in deep tissues. We describe two cases in which standard retrieval of long-term catheters was not possible. Balloon dilatation of catheter lumens was successfully used to increase the catheter diameter with simultaneous tearing of the fibrin sheath surrounding it. This allowed the catheter to be set free safely. Based on this experience, we present recent literature and our point of view.