Seminars in dialysis
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Seminars in dialysis · Sep 2008
Secondary arteriovenous fistulas: converting prosthetic AV grafts to autogenous dialysis access.
As existing arteriovenous grafts (AVGs) fail, the National Kidney Foundation KDOQI Guidelines and the AV Fistula First Breakthrough Initiative ("Fistula First") project recommend that each patient be re-evaluated for conversion to an arteriovenous fistula (AVF). AVFs created following failure of an AVG have been termed secondary fistulas (SAVF). We review our experience and outcomes converting AVGs to SAVFs, utilizing the mature outflow vein of the AVG when possible, otherwise creating a new AVF at a remote site. ⋯ Vessel mapping is critical in the evaluation of failing AVGs and in preparation for a SAVF. Cumulative patency rates exceeded 90% at 12 months for SAVFs in both patient groups in this report. The need for catheters was dramatically less in the patient group with an established SAVF conversion plan.
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Seminars in dialysis · May 2008
EditorialPalliative care: misconceptions that limit access for patients with chronic renal disease.
There is an urgent need to incorporate palliative care into the treatment of patients with end-stage renal disease (ESRD). These patients have a shortened lifespan and face end-of-life decisions as renal function declines and renal replacement therapy becomes necessary. ⋯ Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life-limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.
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Seminars in dialysis · May 2008
Retrospective analysis of catheter recirculation in prevalent dialysis patients.
Catheter recirculation (CR) occurs when blood returning from the venous limb of the catheter re-enters the arterial limb of the catheter without passage through the circulation. Adequacy of dialysis is influenced by the degree of access recirculation. In this study we evaluate factors influencing the degree of dialysis central venous catheter (CVC) recirculation in prevalent hemodialysis patients. ⋯ These results are borderline significant if temporary catheters are included (p = 0.052); however, the overall p-value is only 0.80 for tunneled dialysis catheters. There was no correlation between CR and time on dialysis (p = 0.66) or time on the current catheter (p = 0.48). The current study suggests that the CVC recirculation is independent of catheter brand, type, time on dialysis, or time on current catheter.
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The role of the dialysis unit Medical Director has evolved over time to an expanded set of roles from one that used to be strictly "medical" to one that is more "managerial." Physicians providing these Medical Director services are facing increasing demands for a leadership role regarding clinical quality improvement and measurement of performance in core areas of care within the dialysis program. The dialysis Medical Director is asked to lead in group decision-making, in analyzing core process and patient outcomes and in stimulating a team approach to Continuous Quality Improvement (CQI) and patient safety. ⋯ Medical Directors are usually contractually linked to the dialysis programs for which they provide oversight and their contracts are explicit about the relationship they maintain and the role they are expected to play within dialysis companies (often called "provider organizations"). The evolution of the Medical Director role has led to a close relationship between the company that provides the dialysis services and the physician providing the medical oversight.
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Seminars in dialysis · Nov 2007
Ultrasound/fluoroscopy-assisted placement of peritoneal dialysis catheters.
Peritoneal dialysis (PD) catheters may be inserted blindly, surgically, and either by laparoscopic, peritoneoscopic, or fluoroscopic approach. A modified fluoroscopic technique by adding ultrasound-assistance was performed in the present study to ensure entry into the abdominal cavity under direct ultrasound visualization. From March 2005 to May 2007, ultrasound-fluoroscopic guided placement of PD catheters was attempted in 32 end-stage renal disease (ESRD) patients. ⋯ None of the patients had bleeding related to arterial injury as ultrasound was able to visualize the epigastric artery. Our experience shows that ultrasound-fluoroscopic technique is minimally invasive and allows for accurate assessment of the entry into the abdominal cavity. This technique can avoid the risk of vascular injury altogether.