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Международная научная хирургическая ассоциация
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Международная научная хирургическая ассоциация

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A.Zenelaj, M.Brati, *V.Zenelaj, ‡ A.Idrizi, ‡ A.Strakosha

PREVISION IN PATIENTS WITH CHRONIC RENAL FAILURE IMPROVES THEIR OF LIFE

Department of Surgery. Central Military University Hospital.
*Department of General Medicine.”Mother Teresa” University Hospital.
‡Dialyses-Transplant Service.”Mother Teresa” University Hospital.
Tirana/Albania.

Аннотация: With the aim to improve quality of life in patients with end stage kidney insufficiency we studied the results of arteriovenous fistula and possible factors of their failure. Our study includes 74 patients were vascular access for hemodialysis was necessary. The period of the study is May 2005-September 2008.As it will come in the results a better selection of the patients who will need hemodialises will result in better avf creation results which will improve patient’s quality of life

Ключевые слова: CHRONIC RENAL FAILURE


INTRODUCTION

The earliest vascular access was achieved by the introduction of intravenous glass cannulae in the early 1990; these were replaced in the 1950s by plastic cannulae which allowed prolonged intravenous infusion. Attempts to extend the duration of infusion and to use more concentrated solutions for intravenous feeding in the 1950s led to the development of central venous cannulation, made possible by the development of longer catheters and less thrombogenic plastics .This technology advanced in the 1970s with the introduction of Teflon and Silastic coated catheters.

The advent of haemodialysis, pioneered by Kolff in 1944, introduced a new requirement for repeated high volume blood flow both into and out of the circulation .Cannulation of the arteries resulted in early thrombosis. A major advance was the realization that the formation of an artificial arteriovenous fistula [avf] resulted in massive enlargement of veins sufficient to allow repeated cannulation and the Brescia-Cimino forearm fistula, first described in 1966, remains the mainstay of haemodialysis access today.

Aim of the study is to have the attention of all medical team toward patients under haemodialysis in order to better follow their disease advance, in order to improve patients’ quality of life.

Material and Methods:

This is a study done in 74 patients that underwent the operation for arteriovenous fistula creation. All patients were in end stages of chronic renal insufficiency [CRI].Median age is been 40 years old, 30 patients were males and 33 females. In 100% of the cases high stage of secondary anemia and blood hypertension were present as associated disease. In 95 % of patients a central venous catheter was inserted before arteriovenous access creation. In 28 cases radio-cephalic, 40 cases brachial-cephalic, 6 cases ulno-basilica fistulas were created.

All patients had a blood creatinine level ranging 7.5-13 mg/dl.No one of the avf exceeded 6 weeks till in the first puncture. Study is of the retrospective character.

Results:

In 50 patients avf continue to work. In 24 patients reoperation is needed.

Reoperations have consisted:

New avf 2 procedures, angioplasty 16 procedures, hemostasis due to wound bleeding 4 cases.

Reoperated cases suffered also: Diabetes mellitus, kidney abscess, phlebothrombosis, colostomy, exhausted vascular net.

Arteriovenous fistula patency is: 1 month 97%, three months 95, 6%, six months 90.2 %, one year 80 %, and two year 78,7 %.

Discussion:

In comparison with results referred to serious studies our results are worse .In such studies the one year patency is about 90%, in our cases is 80 %.

What we should improve?

Following the Recommendations of Dialysis Outcomes Quality Initiative [DOQI].

A patient CRI should be referred for avf creation when:

1-Creatinine clearance is < 25 ml/min.

2-Blood creatinine > 4 mg/dl.

3-Tha patient will need hemodialises within one year.

A part of the above mentioned, preservation of the venous net, a better study of the limb vascular net, are necessary. Also a better preparation of the patient who will undergo operation is needed. It is important that patients are neither fluid neither overloaded nor dehydrated. Postoperative care is important too. The patients must take care of the wound, inadvertent local pressure, dehydration, hypotension and accurate their health in proper time.

Basilic vein transposition
 

Intimae hyperplasia of cephalic vein
 

Patient with good venous net
 

Conclusions:

The patency of avf can improve if:

1-The patient has no associated disease.

2-Have good vascular net.

3-The patients have their best clinic and biochemical parameters.

References:

  1. Graham, W.B. Historical Aspects of Hemodialysis. Transplant. Proc. 1997, 9, 1.
  2. Quinton, W.E.; Dillard, D.; Scribner, B.H. Cannulation of Blood Vessels for Prolonged Hemodialysis. Trans. Am. Soc. Artif. Intern. Organs 1960, 6, 104.
  3. Brescia,M.J.;Cimino, J.E.;Appel,K.; Harwich, B.J. Chronic Hemodialysis Using Venipuncture and Surgically Created Arteriovenous Fistula. N. Engl. J. Med. 1966, 275, 1089.
  4. Sterling, W.A.; Hazel, L.T.; Diethelm, A.G. Vascular Access for Hemodialysis by Bovine Graft Arteriovenous Fistulas. Surg. Gynecol. Obstet. 1975, 141, 69.
  5. Dardik, H.; Ibrahim, I.M.; Dardik, I. Arteriovenous Fistulas Constructed with Modified Human Umbilical Cord Vein Graft. Arch. Surg. 1976, 111, 60.
  6. Culp, K.; Flanigan, M.; Taylor, L.; Rothstein, M. Vascular Access Thrombosis in New Hemodialysis Patients. Am. J. Kidney Dis. 1995, 26, 341.
  7. Cohen, M.A.H.; Kumpe, D.A.; Durham, J.D.; Zwerdlinger, S.C. Improved Treatment of Thrombosed Hemodialysis Access Sites with Thrombolysis and Angioplasty. Kidney Int. 1994, 46, 1375.
  8. Marston, W.A.; Criado, E.; Jaques, P.F.; et al. Prospective Randomized Comparison of Surgical Versus Endovascular Management of Thrombosed Dialysis Access Grafts. J. Vasc. Surg. 1997, 26, 373.

 

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