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PubMed2006

Access to water in the countries of the former Soviet Union.

BACKGROUND: During the Soviet period, authorities in the USSR invested heavily in collective farming and modernization of living conditions in rural areas. However, many problems remained, including poor access to many basic amenities such as water. Since then, the situation is likely to have changed; economic decline has coincided with migration and widening social inequalities, potentially increasing disparities within and between countries. AIM: To examine access to water and sanitation and its determinants in urban and rural areas of eight former Soviet countries. METHODS: A series of nationally representative surveys in Armenia, Belarus, Georgia, Moldova, Kazakhstan, Kyrgyzstan, Russia and Ukraine was undertaken in 2001, covering 18,428 individuals (aged 18+ years). RESULTS: The percentage of respondents living in rural areas varied between 27 and 59% among countries. There are wide urban-rural differences in access to amenities. Even in urban areas, only about 90% of respondents had access to cold running water in their home (60% in Kyrgyzstan). In rural areas, less than one-third had cold running water in their homes (44% in Russia, under 10% in Kyrgyzstan and Moldova). Between one-third and one-half of rural respondents in some countries (such as Belarus, Kazakhstan and Moldova) obtained their water from wells and similar sources. Access to hot running water inside the homes was an exception in rural households, reflecting the lack of modern heating methods in villages. Similarly, indoor access to toilets is common in urban areas but rare in rural areas. Access to all amenities was better in Russia compared with elsewhere in the region. Indoor access to cold water was significantly more common among rural residents living in apartments, and in settlements served by asphalt roads rather than dirt roads. People with more assets or income and living with other people were significantly more likely to have water on tap. In addition, people who had moved in more recently were more likely to have an indoor water supply. CONCLUSIONS: This was the largest single study of its kind undertaken in this region, and demonstrates that a significant number of people living in rural parts of the former Soviet Union do not have indoor access to running water and sanitation. There are significant variations among countries, with the worse situation in central Asia and the Caucasus, and the best situation in Russia. Access to water strongly correlates with socio-economic characteristics. These findings suggest a need for sustained investment in rebuilding basic infrastructure in the region, and monitoring the impact of living conditions on health.

Adolescent↗

PubMed1994

Hemodialysis access in the pediatric patient population.

BACKGROUND: Each year, three to five children per million develop chronic renal failure. Of these, 70% will require dialysis for short periods, and 23% will require prolonged hemodialysis support. It is in the latter group that difficulty is encountered in establishing dialysis access. METHODS: From 1985 to 1992, we provided hemodialysis access for a group of 24 children. There were 16 boys and 8 girls, with a mean age of 11.1 +/- 4 years (range 3 to 17). All children were significantly below the 50th percentile weight for their age and sex. Seven children entered hemodialysis following failed peritoneal dialysis after an average of 21 +/- 10.5 months. Seventeen patients received a renal transplant. Seven of these children have resumed hemodialysis. RESULTS: The technique for establishing hemodialysis was varied: 15 arteriovenous fistulae, 37 expanded polytetrafluoroethylene (ePTFE) bridge grafts, 9 bovine arteriovenous bridge grafts, and 29 chronic central venous catheters. The overall mean functional patency of the fistulae was 6.2 +/- 10.2 months. One third of these fistulae failed to mature sufficiently to permit their use for dialysis purposes. Twenty-one upper extremity ePTFE grafts were implanted, with a mean functional patency of 11 +/- 11.1 months. Sixteen groin loop grafts were utilized, with a primary patency of only 4.1 +/- 5 months. Thrombectomy was performed in 25 cases (patch or interposition in 8 cases), with a secondary patency in these grafts of 10.5 +/- 17 months. An inability to achieve access in 2 children resulted in the creation of unusual types of access: an aorto-caval fistula and an axillo-femoral fistula and a combination of single-needle puncture of an immature fistula with one lumen of a PermCath. There were eight ePTFE graft infections, with graft loss occurring in seven cases. Superior vena caval occlusion occurred in two patients, inferior vena caval thrombosis in one patient, and axillo-subclavian venous occlusion in two patients. Development of central venous occlusions significantly increased the difficulty in establishing dialysis access. The total dialysis period provided by the 90 primary procedures performed in this study was 658 months. Each procedure, therefore, provided access for a mean duration of only 7.3 months. CONCLUSION: Providing dialysis access in the pediatric population is a time-consuming and frustrating challenge. We believe that all patients with renal dysfunction should have their conditions managed as potential long-term dialysis candidates. Therefore, our philosophy is to achieve maximal use from each access site. Although the primary patency of upper-arm ePTFE grafts was greater than that for the forearm fistulae in this study, failure of the upper-arm graft can result in loss of that limb for the purposes of future dialysis access. Consequently, we strongly advocate the "distal before proximal" and "autogenous before prosthetic" dogma in providing pediatric hemodialysis access.

Adolescent↗

PubMed1998

Limited access to a dietary fat option affects ingestive behavior but not body composition in male rats.

Restricting access to high-fat foods is a common strategy utilized to promote health. This strategy may contribute to episodes of overconsumption, however, when the restricted foods subsequently become available. The present study utilized a rat feeding procedure to determine if restricting access to an optional source of dietary fat would increase later consumption of that food under nonenergy-deprived conditions. Five groups of male Sprague-Dawley rats were used, all of which had continuous access to a standard rodent diet and water. The control group had no access to shortening. The low-restriction group had 2-h access to shortening every day. The high-restriction group had 2-h access to shortening on Monday, Wednesday, and Friday. Two additional groups were switched between the high and low conditions. Two-hour and 24-h food intakes were measured every day for 6 weeks. At the end of the study rats were sacrificed and carcass composition determined. As access to the shortening decreased, consumption during the 2-h access period increased. Rats compensated for the increased shortening consumption by decreasing intake of the standard diet. Thus, cumulative energy consumption did not differ among the groups. When switched between the high and low conditions, rats rapidly adjusted to the change in shortening availability. There were no effects of access schedule on carcass composition. These results indicate that restricting access to an optional high-fat food, even under nonenergy-deprived conditions, can promote significant increases in the consumption of that food when it subsequently becomes available.

Analysis of Variance↗

PubMed1997

Microbiologic evaluation of needleless and needle-access devices.

OBJECTIVE: This study was carried out to determine whether needleless intravenous access devices are more likely to allow microorganisms to enter the fluid pathway than intravenous needle-access devices. METHODS: A laboratory study was conducted with two needleless and one intravenous needle-access devices and Enterococcus faecium as a bacterial challenge. Inocula of E. faecium were prepared on the basis of the numerical estimates of 1000 to 10,000 colony-forming units (CFU)/cm2 of bacterial flora on dry regions of skin (arms, legs, and hands). The septum of each access device was inoculated with 10 to 20 microliters of a 10(4) to 10(5) CFU/ml challenge suspension, which was allowed to dry on the surface of the septum. In the first part of the experiment, the needleless or needle-access cannula of each device was used to puncture the corresponding septum without previously disinfecting the top of the septum. In the second part, the contaminated septum was punctured after disinfecting the septum with a 70% isopropyl alcohol wipe. After each puncture, trypticase soy broth was flushed through the fluid pathway of the intravenous access device, collected, and cultured by the membrane filtration technique. The septum of each injection-site cap and the needleless or needle-access cannula were sampled with sterile premoistened swabs. Swabs were cultured on blood agar plates. RESULTS: The rate of fluid pathway contamination was 100% (40/40) for one of the needleless intravenous access devices and 80% (20/25) for the other when septa were contaminated with E. faecium and not disinfected before puncture. The rate for the intravenous needle-access device was 72% (18/25). When the septa of the three different devices tested were disinfected with 70% isopropyl alcohol, E. faecium was isolated on only one septum from all devices tested in part two (1/74, 1.3%). CONCLUSIONS: These laboratory studies demonstrate that there is no statistically significant difference in the rate of fluid pathway contamination between needleless and intravenous needle-access devices. However, if the septa of either needleless or needle systems are not disinfected before puncture, a high rate of fluid pathway contamination may occur.

Catheters, Indwelling↗

PubMed2003

Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review.

OBJECTIVE: Patency rates for autogenous accesses are presumed to be better than for polytetrafluoroethylene (PTFE) accesses, although the strength of the supporting evidence is limited. We undertook this study to test the hypothesis that patency rates for upper extremity autogenous hemodialysis arteriovenous accesses in adults are superior to those for PTFE counterparts. METHODS: A systematic review of relevant literature and meta-analysis of the patency data were performed. Studies were considered acceptable if patency data were reported by either life table or Kaplan-Meier method, including number of patients at risk. RESULTS: The thirty-four studies that satisfied the inclusion criteria were composed predominantly of case series or nonrandomized controlled studies; no randomized, controlled studies comparing autogenous and PTFE accesses were included. The primary patency rate for autogenous accesses was 72% (95% confidence interval [CI], 70%-74%) at 6 months and 51% (95% CI, 48%-53%) at 18 months, and the corresponding primary patency rate for PTFE accesses was 58% (95% CI, 56%-61%) and 33% (95% CI, 31%-36%), respectively. The secondary patency rate for autogenous accesses was 86% (95% CI, 84%-88%) at 6 months and 77% (95% CI, 74%-79%) at 18 months, and the corresponding secondary patency rate for PTFE accesses was 76% (95% CI, 73%-79%) and 55% (95% CI, 51%-59%), respectively. CONCLUSIONS: The patency rate for autogenous upper extremity arteriovenous hemodialysis accesses in adults is superior to that for PTFE counterparts, although the overall quality of the studies in the meta-analysis was less than ideal. Randomized, controlled studies to further examine the differences in outcome between these two access types are necessary.

Arteriovenous Shunt, Surgical↗

PubMed2001

Allelopathy, DIMBOA production and genetic variability in accessions of Triticum speltoides.

A screening was conducted to study the allelopathic potential of Australian-held accessions of Triticum speltoides. Of 26 accessions, four were found to inhibit root growth in the indicator species, lettuce (Lactuca sativa). The methanol leaf extracts of these accessions significantly reduced the root length of wild oat (Avena spp.). In all but one case, alellopathic accessions contained higher amounts of DIMBOA than did nonallelopathic accessions. Since some variation in allelopathic response was detected within lines, random amplified polymorphic DNA (RAPD) markers were used to estimate genetic diversity between and within the allelopathic accessions of Triticum speltoides L. The average genetic similarity between all possible pairs of selected accessions was found to be 55% and ranged from 44% to 88%. Comparison of DNA extracted from different single seedlings within the same accession revealed significant intraaccession genetic diversity (4-24%), although this was much less than that observed between accessions tested. This intraaccession diversity has significant implications for the selection of T. speltoides accessions in breeding or screening programs.

Benzoxazines↗

PubMed2006

Dedicated outpatient vascular access center decreases hospitalization and missed outpatient dialysis treatments.

Dedicated outpatient vascular access centers (VAC) specializing in percutaneous interventions (angiography, thrombectomy, angioplasty and catheter placement) provide outpatient therapy that can obviate the need for hospitalization. This paper reports the impact of one VAC staffed by interventional nephrologists on vascular access-related hospitalization and missed outpatient dialysis treatments. We performed a retrospective analysis of vascular access-related hospitalized days and missed vascular access-related outpatient dialysis treatments from 1995 to 2002 in 21 Phoenix Arizona Facilities (5928 cumulative patients) and 1275 cumulative Fresenius Medical Care North America (FMCNA) facilities (289,454 cumulative patients) to evaluate the impact of the introduction of a VAC in Phoenix. Vascular access-related hospitalized days/patient year and missed dialysis treatments/patient year declined from 1997 to 2002 across all access types. The decline was greater in Phoenix and coincided with the creation of a VAC in 1998. By 2002, there were 0.57 fewer hospitalized days/patient year and 0.29 fewer missed treatments/patient year than in the national sample (P<0.01). In 2002, the relative risk for vascular access hospitalized days was 0.38 (95% confidence interval (CI) 0.27-0.5) (P<0.01) and for vascular access-related missed outpatient dialysis treatments was 0.34 (95% CI 0.24-0.49) (P<0.01) in Phoenix vs FMCNA after adjustment for age, gender, diabetic status duration of dialysis and access type. VAC development was associated with a significant decrease in vascular access-related hospitalization and missed outpatient dialysis treatments. Further studies are necessary to demonstrate this effect in other communities.

Adult↗

PubMed2005

Roles of initiation and responsiveness in access and participation for children with specific language impairment.

This study compared the abilities of children with specific language impairment (SLI; n = 10) and typically developing (TD) children (n = 13) to access and participate in an ongoing interaction between two unfamiliar peer partners. Results revealed that all children in the study accessed by either making an unprompted initiation toward their peers (access initiation) or by responding to a question or play invitation directed toward them (access response). However, 4 children with SLI were unsuccessful in achieving successful access initiation during the 10-min play period. Children with SLI required a longer period of time to achieve access initiation. Following access, children with SLI were addressed significantly less by their play partners, participated in less group play, and engaged in more individual play and onlooking behavior. Among the SLI group, language levels were negatively related to the time children required to achieve their first successful access and first access initiation. Expressive language levels were positively related to the percentage of utterances children produced postaccess and the percentage of utterances they were addressed postaccess by their play partners. Differences in receptive skills among SLI children were less strongly related to the time they required in achieving their first access and were unrelated to their ability to participate in the interaction.

Child↗

PubMed2000

Vascular access for haemodialysis.

BACKGROUND: The recent expansion of renal replacement therapy programmes has been associated with an increase in the number and complexity of patients requiring permanent vascular access. The introduction of strategies designed to maximize secondary access patency is, therefore, increasingly important as a means of prolonging patient survival on dialysis, reducing morbidity and reducing the escalating cost of such programmes. METHODS: A review of the current literature on the planning of vascular access, access surveillance methods and treatment of the most common complications was performed. RESULTS: Multidisciplinary vascular access planning, increased use of preoperative imaging and the preferential use of autogeneous vein are essential to obtain the best long-term results. While vascular access surveillance, in particular protocols involving direct measurement of access flow, enables the prospective detection and treatment of venous stenosis, the precise indications for treating venous stenosis remain unclear. Surgical revision remains the gold standard for the treatment of failing arteriovenous fistulas, but recent advances in interventional radiological techniques along with the suitability of arteriovenous fistulas for percutaneous intervention may offer an effective alternative. The effect of both these interventions on access patency requires comparison in a randomized trial. CONCLUSION: The introduction of strategies to improve access patency rates will change vascular access surgical practice away from the construction of new fistulas towards an increase in outpatient percutaneous intervention and surgical revisional procedures. The role of surgical interventions requires clearer definition.

Arteriovenous Shunt, Surgical↗

PubMed2003

A grounded theory study of the role that nurses play in increasing clients' willingness to access community mental health services.

Clients and caregivers frequently encounter difficulties in accessing mental health services. Early intervention to care and treatment is essential to recovery as delays can adversely affect the severity and the duration of the illness. This paper reports the factors that encouraged and deterred young adults with schizophrenia and their caregivers when trying to seek early access to community mental health services, and examines how community mental health nurses made themselves accessible to these individuals in order to increase their access to services. The findings showed that several factors simultaneously encouraged and inhibited individuals initiating contact at community mental health centres, and these had serious implications for care and treatment, and recovery. There were two client access pathways to care: a direct access pathway where an individual recognized signs of being unwell and sought help early; and an indirect access pathway where others, such as caregivers, general practitioners, police, and inpatient facilities initiated contact on an individual's behalf. Nurses used three strategies to enhance client and caregiver access to services: 'promoting favourable experiences to enhance approachability', 'using technology to promote access' and 'being available'. The findings have significance for nursing practice because they reinforce the importance of having good relationships with clients and caregivers, and the need to take account of the needs of caregivers. They highlight the benefits and drawbacks of using telecommunications to enhance accessibility, and why it is necessary to analyse nurses' workloads and time management skills.

Adult↗

PubMed2000

Determinants of type and timing of initial permanent hemodialysis vascular access.

BACKGROUND: We undertook a population-based study of hemodialysis (HD) patients to determine which factors are important in predicting the type of permanent access initially placed and if a functional permanent access is in place at the start of HD. METHODS: Selected characteristics were abstracted from the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Study (DMMS) Wave 2. Logistic regression was used to estimate the independent contribution of specific characteristics in predicting whether the initial permanent access placed was an arteriovenous (AV) fistula compared with a polytetrafluoroethylene (PTFE) graft, and in predicting whether permanent access (fistula or graft) was in place at the initiation of dialysis. RESULTS: Sixty-seven percent of the patients had an AV graft placed as their first permanent access. Characteristics important in predicting if a fistula was initially placed included age (per decade; aOR = 0.84, P < 0.001), female gender (aOR = 0.52, P < 0.001), body mass index (per standard deviation; aOR = 0.70, P = 0.09), avoiding blood draws (aOR = 1.96, P < 0.001), ability to ambulate (aOR = 2.24, P = 0.008), underlying renal disease (glomerular compared with diabetes, aOR = 2.19, P = 0.009), college education (aOR = 1.72, P = 0.002), and sharing in decision making (aOR = 1.50, P = 0.02). Thirty-four percent of patients (34.4%) had functional permanent access at the start of HD. Characteristics important in predicting which patients had functional permanent access included serum albumin (per 1 mg/dL increase, aOR =1.55, P = 0.003), erythropoietin prior to starting HD (aOR = 1.79, P = 0.002), fewer predialysis nephrologist visits (aOR = 0.21, P < 0.001), and when the patient was told they had renal disease (aOR = 0.33, P = 0.002). CONCLUSIONS: PTFE grafts were the most common initial permanent access. The majority of patients did not have permanent access at the start of dialysis. Factors that are thought to compromise identification of adequate veins were important predictors of PTFE graft placement. Permanent access at the start of HD was largely a function of early patient education and early referral to a nephrologist.

Aged↗

PubMed2001

A prospective study of vascular access infections at seven outpatient hemodialysis centers.

Vascular access infections are a major cause of morbidity and mortality in hemodialysis patients, and the use of antimicrobials to treat such infections contributes to the emergence and spread of antimicrobial-resistant bacteria. To determine the incidence of and risk factors for vascular access infections, we studied hemodialysis patients at 7 outpatient dialysis centers (4 in Richmond, VA, and 3 in Baltimore, MD) during December 1997 to July 1998. Vascular access infections were defined as local signs (pus or redness) at the vascular access site or a positive blood culture with no known source other than the vascular access; and hospitalization or receipt of an intravenous (IV) antimicrobial. A total of 796 patients were followed for 4,134 patient-months. The vascular access infection rate was 3.5/100 patient-months, ie, patients had a 3.5% risk of infection each month. Independent risk factors were the specific dialysis unit where the patient was treated (relative hazard varying from 1.0 to 4.1 among the 7 centers), catheter access (relative hazard, 2.1 v implanted access), albumin level (relative hazard, 2.4 for lowest v highest quartile), urea reduction ratio (relative hazard, 2.2 for lowest v highest quartile), and hospitalizations during the previous 90 days (relative hazard, 4.9 for >/=6 v zero hospitalizations). These data confirm that vascular access infections are common in hemodialysis patients and that infection rates differ substantially among different centers. Catheter use should be minimized to reduce these infections. Additionally, the possibility that improved serum albumin and urea reduction ratio could reduce vascular access infections should be evaluated.

Aged↗

PubMed1999

The morbidity of secondary vascular access. A lifetime of intervention.

OBJECTIVES: to examine the outcome and incidence of access-related procedures in patients who dialyse via PTFE secondary access grafts. DESIGN: retrospective case note study. RESULTS: recipients of secondary access procedures face a lifetime of haemodialysis access interventions. In total, 639 access-related procedures were performed on the 72 patients studied. At the end of the study five patients were wholly reliant on central venous catheters for dialysis access. Patients with secondary access grafts have little hope of transplantation; only six of 72 patients received a transplant after a secondary access procedure. CONCLUSION: the increasing number of patients coming to synthetic access-graft procedures and the morbidity of such procedures mean that surgeons should adopt strategies to minimise the use of grafts and limit the number of interventions performed. Careful planning will also reduce the number of central line placements and help to reduce the morbidity associated with long-term haemodialysis. Increasing resources will be required to meet the rising demand for secondary access provision.

Adult↗

PubMed2006

Investigation of infertility management in primary care with open access hysterosalpingography (HSG): a pilot study.

Infertility affects one in seven couples in the United Kingdom. The National Institute for Clinical Excellence (NICE) issued guidance on the management of the infertile couple in February 2004, which included the statement "for the assessment of tubal damage, women not known to have co-morbidities (pelvic inflammatory disease, endometriosis or previous ectopic pregnancy) should be offered hysterosalpingography (HSG)". We made HSG available to six general practices in Newcastle upon Tyne as an open access investigation. Our aim was to evaluate the uptake of open access HSG, speed of access to specialist services and the quality of the information recorded in the referral letter. Using hospital clinical records we tracked the outcome of all infertile couples from the six pilot practices over a nine-month period. Of the 39 referrals identified, 10 women were eligible for open access HSG, of which six HSGs were organized by GPs. Couples who had open access HSG reached a diagnosis and management plan four weeks earlier than those who were referred directly (mean difference 4.0 weeks, 95% confidence interval (CI) -8.8 to 0.4 weeks). The information recorded in the referral letter was generally poor. However, all referrals made via the open access HSG service had the prerequisite tests done. Open access HSG allowed prompter access to specialist services with more complete information passed on in the referral letter. Open access HSG was used in 15% of all infertile couples and 60% of those who fitted the criteria for its use. Open access HSG together with semen analysis and endocrine blood tests may allow GPs to manage the initial stages of the infertile couple and make a diagnosis.

Adult↗

PubMed1995

In situ accessibility of murine macrophage gangliosides.

Gangliosides are implicated in cell signal transduction. Prior to investigating this phenomenon in macrophages, the in situ accessibility of gangliosides to macromolecules was assessed for peritoneal macrophages isolated from normal C3H/HeN and endotoxin-hyporesponsive C3H/HeJ mice. C3H/HeJ resident and thioglycolate-elicited macrophage ganglioside patterns are the same as normal strains, and no strain differences in galactose oxidase accessibility for resident or thioglycolate-elicited macrophage gangliosides were found. The only gangliosides accessible to galactose oxidase in resident macrophages are GM1a structures. In thioglycolate-elicited macrophages, an additional ganglioside is accessible. For Escherichia coli-activated macrophages, where ganglioside distribution differs between strains, a difference in galactose oxidase-accessible gangliosides also exists. Escherichia coli-activated C3H/HeN patterns show three triplets absent in C3H/HeJ patterns. There were no differences in ganglioside accessibility to Vibrio cholerae sialidase between the thioglycolate-elicited C3H/HeJ and C3H/HeN macrophages. However, despite differences in sialidase-sensitive ganglioside content between E.coli-activated macrophages of these strains, sialidase accessibility for E.coli-activated macrophages was also similar. Sialidase-susceptible GM3 was cryptic in either strain under all conditions examined. The accessibility of murine macrophage gangliosides to galactose oxidase or sialidase was independent of their sialic acid species and chain length of the ceramide fatty acid. With the exception of GM3, major murine macrophage gangliosides are accessible in situ to macromolecules, especially to exogenous pathogenic bacterial sialidase which can alter macrophage cell surface characteristics. Altered macrophage ganglioside accessibility appears sometimes as a consequence, but not a cause, of C3H/HeJ endotoxin hyporesponsiveness.

Animals↗

PubMed1999

Association of plasma fibrinogen concentration with vascular access failure in hemodialysis patients.

BACKGROUND: Elevated plasma fibrinogen is an important risk factor for coronary artery disease in the general population and patients with chronic renal failure. High plasma fibrinogen may trigger thrombus formation in arteriovenous fistulas. We performed a prospective, cohort study to evaluate the association of plasma fibrinogen concentration with vascular access failure in patients undergoing long-term haemodialysis. METHODS: Between September 1989 and October 1995, 144 patients underwent a vascular access operation. In March 1997, 102 patients (56 M, 46 F) who had been followed up for more than 18 months (median; 37 months, range; 18-102 months) were included in the study. The median age of the patients was 52 years (range; 19-78 years). In 35 patients, renal disease was secondary to diabetes mellitus. The type of vascular access was a polytetrafluoroethylene (PTFE) graft in 17 patients. Seventy-seven patients received recombinant human erythropoietin (r-HuEPO) therapy during the follow-up period. Plasma fibrinogen, albumin, total cholesterol, hematocrit, platelets and creatinine were measured at the time of operation. Vascular access failure was defined as the occurrence of complications requiring transluminal angioplasty, thrombolytic therapy or surgical repair. RESULTS: Thirty-eight patients had at least one vascular access failure and the incidence was 0.3 (range; 0-2.4) episodes per patient-year. The survival rate of vascular access was 78% (native fistula; 80%, PTFE graft; 71%) after 12 months and 70% (native fistula; 73%, PTFE graft; 51%) after 24 months. Older age, a PTFE graft, r-HuEPO therapy, higher hematocrit, lower albumin and higher fibrinogen levels were significantly associated with vascular access failure, whereas gender, diabetes mellitus, total cholesterol and platelet count were not. Plasma fibrinogen was inversely correlated with albumin (r=-0.38, P=0.001). The cumulative vascular access survival was significantly lower in patients with high plasma fibrinogen levels (> or = 460 mg/dl) compared with patients with low levels (< 460 mg/dl) (P=0.007). Independent risk factors for vascular access failure analysed by Cox's proportional hazards model were older age (RR; 1.36 by 10-year increment), higher fibrinogen level (RR; 1.20 by 100 mg/dl increment), PTFE graft (RR; 2.28) and r-HuEPO therapy (RR; 3.79). CONCLUSION: High plasma fibrinogen level is an independent risk factor for vascular access failure in haemodialysis patients.

Adult↗

PubMed2001

Long-term experience with the Thomas shunt, the forgotten permanent vascular access for haemodialysis.

BACKGROUND: Vascular access complications are the main cause of hospitalization in dialysis patients. The difficulty in creating and maintaining vascular access after several years on haemodialysis (HD) remains the primary problem in these patients. The femoro-femoral Thomas shunt is a permanent vascular access that was used in the 1970s and is all but forgotten at present. We analysed our experience with the Thomas shunt since 1979 in patients with no other possibility of regular vascular access. METHODS: We retrospectively studied 27 Thomas shunts implanted in 10 patients, aged 27-75 years at the time of first shunt implantation. Prior to implantation of the Thomas shunt, these patients had experienced 80 failed vascular accesses (plus four patients on CAPD), with an average of 8.6 accesses per patient. All Thomas shunts were implanted in femoral vessels. Clinical data were extracted from hospital and dialysis unit records and were analysed for efficacy, complications, and duration of patency. RESULTS: Total follow-up was 1176 months, with an average shunt duration of 43.7 months (range 3-151 months). One-, 2-, 3- and 6-year survival rates were 85, 57, 49 and 25% respectively. Five patients spent more than 10 years on HD using the Thomas shunt, and one patient had the same unit for 12.5 years. A high blood flow (450 ml/min) was obtained, without recirculation, due to the characteristics of this shunt. Efficacy, measured as percentage urea reduction (PRU), was high (on average 77.8+/-1.5%). The infection incidence was one episode every 37.5 patient-months, Staphylococcus species being the most commonly isolated. There were no shunt removals because of infection. The most important cause of shunt withdrawal was thrombosis, with an incidence of one episode every 7 patient-months. Percutaneous angioplasty was successful in the majority of stenosis episodes. CONCLUSIONS: This study indicates that the Thomas shunt provides a good permanent vascular access for HD patients who have no other possibility of a regular vascular access. This shunt offers high dialysis efficacy without recirculation and an access duration comparable to AV fistulae. For these reasons the Thomas shunt should continue to be used as a vascular access in HD.

Adult↗

PubMed2004

Vascular access survival and morbidity on daily dialysis: a comparative analysis of home and limited care haemodialysis.

BACKGROUND: Concerns about vascular access failure may have limited the widespread use of daily haemodialysis (DHD). We assessed the incidence and type of vascular access complications during DHD and other schedules, both at home and on limited care haemodialysis. METHODS: All patients were treated in a limited care and home haemodialysis unit with a stable caregiver team (November 1998-November 2002). Vascular access failure, surgical treatment, angioplasty and declotting were studied alone or in combination by univariate and multivariate models. We analysed the effects of age, sex, comorbidity, previous vascular events, schedule, setting of treatment (home, limited care), dialysis follow-up, vascular access (native vs prosthetic, first vs subsequent) and setting of vascular access creation. 'Intention to treat' and 'per protocol' analyses were performed. RESULTS: In 2160 patient-months (home dialysis: DHD 400 months, non-DHD 655 months; limited care: DHD 208 months; non-DHD 897 months), 57 adverse events occurred (27 failures), in which 30 were at home (nine DHD) and 27 were in limited care (five DHD). The probability of remaining free from adverse events at 6 and 12 months was 89% and 80% on DHD and 79% and 76% on other schedules ('intention to treat'). Univariate analyses revealed a significant difference for the setting of the vascular access creation (lower risk of vascular access complications in our centre) and sex (male sex was protective). Logistic regression and Cox analyses confirmed the role for the setting of the vascular access creation. CONCLUSIONS: Although DHD did not appear as a risk factor for vascular access morbidity or failure at home or in a limited care centre setting, the setting of vascular access creation may influence its success.

Adult↗