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R9 > Chapter 179 - Hemodialysis access - nonthrombotic complication > Flashcards

Chapter 179 - Hemodialysis access - nonthrombotic complication Flashcards

1
Q

KDOQI 2006 listed access complications

A

1) bleeding
2) infection
3) aneurysm/pseudoaneurysm
4) seroma
5) access-related hand ischemia
6) venous hypertension
7) neuropathy

Cardiopulmonary not listed

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2
Q

Bleeding associated with ESRD

A

1) PUD
2) retroperitoneal spontaneous bleed
3) hemorrhagic transformation of stroke

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3
Q

Causes of increased bleeding in ESRD

A

1) anemia
2) thrombocytopenia
3) acquired defects

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4
Q

Uremia-induced platelet dysfunction

A

1) reduce GPIb (plt cannot adhere to subendothelium)

2) change GPIIb/IIIa (inhibit fibrinogen binding)

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5
Q

Anemia causes platelet inhibition

A

Anemia –> increase NO activity –> vasodilation and plt inhibition

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6
Q

Drugs that accumulate that can cause bleeding

A

1) beta-lactam antibiotics

2) oral anticoagulation (DOAC)

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7
Q

Afib in CKD rate

A

20% have afib

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8
Q

Percentage of herald bleed or access infection prior to fatal hemorrhage from access

A

40%

herald within 6 month

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9
Q

Desmopressin activity

A

1) synthetic ADH (arginine vasopressin) = 1-deasmino-8-D-arginine vasopressin
2) dose 0.3-0.4 mcg/kg iv or sc
3) rapid release of vWF and FVIII and decrease protein C activity

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10
Q

Platelet transfusion in bleeding in ESRD

A

immediate activity but last 45 hours

inactivated in uremic environment

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11
Q

cryoprecipitate define

A

plasma derivative with

1) fibrinogen
2) vWF
3) factor VIII

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12
Q

Maximum effect of cryoprecipitate and lasting duration

A

4-12 hours max, last 24 hr

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13
Q

Complication with cryoprecipitate

A

1) anaphylaxis

2) hemolysis

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14
Q

Protamine dose

A

1-1.5 mg/100 Units heparin

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15
Q

Recombinant factor VIIa use in bleeding

A

Off label

risk of systemic thromboembolic complication

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16
Q

Percentage of ESRD patients with HGB < 100

A

20%

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17
Q

Conjugated estrogen for prophylactic against bleeding

A

25-50 mg (0.6 mg/kg/d IV x 5 days)

1) vWF synthesis
2) reduce protein S
3) reduce NO

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18
Q

Effect of estrogen for bleeding
onset
peak
duration

A

6 hours onset
peak 5-7 days
last 14 days

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19
Q

Infection grade of AV access as per SVS

A

Grade 0: none
Grade 1: resolved with antibiotics
Grade 2: loss of AV access due to ligation, removal, bypass
Grade 3: loss of limb

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20
Q

Most common access-related infection organism

A

Single organism Staphylococcus

Gram negative 25%

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21
Q

Risk of infection of AV graft, tunneled catheter and temp catheter compared to autogenous AVF

A

AVG 2.2
Tunneled catheter 13.6
Temporary catheter 32.6

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22
Q

Centers for Disease control and prevention on risk factors associated with dialysis

A

1) catheter use
2) specific dialysis units
3) malnutrition (albumin < 35)

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23
Q

Percentage of access loss due to infection

A

20%

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24
Q

1 year infection rate for autogenous vs prosthetic

A

4.5% vs 19.7%

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25
Q

Risk factors for infection

A

1) repeated cannulation
2) cannulation technique (buttonhole)
3) poor hygiene
4) repeated hospitalization
5) duration of prosthetic AV access use
6) age
7) LE location
8) diabetes

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26
Q

Antibiotics in access infection

A

Vancomycin and gentamicin

If low MRSA then nafcillin, oxacillin or cefazolin

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27
Q

Antibiotic duration for autogenous infection

A

2-4 weeks

4-6 weeks if endograft exist

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28
Q

Recurrent infection rate in prosthetic infection salvage

A

20%

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29
Q

Rate of pseudoaneurysm in PTFE grafts

A

2-10%

usually in older grafts

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30
Q

Open revision of pseudoaneurysm in AV access

A

1) bypass
2) resection and interpositional repair
3) aneurysmorrhaphy

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31
Q

Endovascular repair of AV access pssudoaneurysm

A

Covered stent
concurrent treatment of outflow stenosis

cost ineffective
risk of infection and thrombosis
not justified to be done

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32
Q

Causes of true aneurysms in AV access

A

1) post-stenotic at arterial anastomosis
2) cannulation area
3) near vein junctions
4) near valves

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33
Q

Open repair of AV aneurysm

A

1) aneurysmorraphy

2) aneurysmectomy

34
Q

Arterial inflow aneurysm associated with

A

1) renal transplant
2) immunosuppression

rare complication

35
Q

Perigraft seroma grades

A

Grade 0: no collection
Grade 1: observed, resolved
Grade 2: involves aspiration or surgical drainage
Grade 3: results in loss of graft

36
Q

Incidence of seroma with PTFE

A

< 2%

36% if gel coated PTFE - not to be used for dialysis

37
Q

Location of seroma in AV access

A

near arterial anastomosis

38
Q

Causes of seroma in AV access

A

1) immature fibroblast lining graft
2) immunologic reaction
3) graft damage
4) occult infection

39
Q

Typical symptoms with seroma

A

1) appear within 1 month of creation
2) painless
3) enlarge over time
4) graft sweating can be seen

40
Q

Treatment of AV access seroma and successes

A

1) Observation and aspiration 68-69%
2) cyst removal 72%
3) I&D 53%
4) Graft excision and cyst excision 100%

41
Q

Infection after seroma attempted treatment different types

A

1) Aspiration 8% infection/thrombosis
2) Cyst removal 12% infection/thrombosis
3) I&D 7% infection/thrombosis

42
Q

Access related hand ischemia first described by

A

1969 Storey et al

43
Q

Rate of significant hand ischemia after wrist and brachial access creation

A

Brachial 4-8%
Wrist 1-2%

10% will get some tingling that are self limiting
80% will have reduced flow but most asymp

44
Q

Grades of hand ischemia

A

Grade 0: no symptom
Grade 1: mild - cool extremity, flow augmentation with access occlusion
Grade 2 moderate - intermitted ischemia during dialysis
Grade 3 severe - ischemic pain at rest, tissue loss

45
Q

Definition of ARHI

A

locoregional hypoperfusion secondary to inadequate arterial compensation

failure to increase CO and vasodilate hand vascular bed

46
Q

Risk factors for ARHI

A

1) PAD
2) DM (hyperglycemia reduces shear-induced vasodilation)
3) CAD
4) brachial-based access
5) female
6) history of steal
7) multiple previous procedures

47
Q

Digital brachial index likely to develop steal

A

< 1.0

48
Q

Timing of onset of ARHI

A

Weeks to months

< 24hr is rare and usually with prosthetic

49
Q

Differential of ARHI

A

1) carpal tunnel syndrome
2) venous hypertension
3) ischemic monomelic neuropathy

50
Q

Diagnostic testing to support ARHI

A

1) digital pressure measurement
2) photoplethysmography
3) pulse oximetry
4) color duplex ultrasound
5) angiography

all performed with/without access compression

51
Q

Goal of treating ARHI

A

1) symptom resolution

2) access preservation

52
Q

ARHI treatment options

A

1) banding
2) RUDI
3) PAI
4) DRIL
5) angioplasty
6) ligation

53
Q

Banding key points

A

1) patency 1 year 38-84%
2) symptom resolution 86-100%
3) maintain access > 700 ml/min

54
Q

MILLER technique

A

Minimally invasive limited ligation endoluminal-assisted revision

1) 4-5 mm balloon placed and inflated
2) small incision made near anastamosis to tie knot around the balloon

55
Q

Revision using distal inflow first described

A

Minion 2005

someone actually described previously

56
Q

RUDI key points

A

1) ligation of fistula at arterial anast
2) new inflow from more distal artery
3) translocation of a vein branch or bypass

57
Q

RUDI patency of fistula and clinical improvement

A

84% secondary patency 1 year

90% clinical improvement

58
Q

Proximalization of arterial inflow first described by

A

Zanow

59
Q

PAI key points

A

1) ligate AV anastomosis

2) PTFE 4-5 mm from more proximal inflow

60
Q

PAI resolution and patency

A

86% symptom resolution

Patency 87% 12 months

61
Q

Distal revascularization-interval ligation first described by

A

Schanzer 1988

62
Q

DRIL key points

A

1) bypass inflow from proximal to access and terminate distal to access
2) ligate artery distal to access
3) locate origin of bypass 7-10 cm above inflow anastomosis to avoid pressure sink

63
Q

DRIL access and bypass patencies

A

access patency 83%
bypass patency 90-100%

1 year

64
Q

Distal radial artery ligation key points

A

1) retrograde flow from palmar arch results in palmar arch steal syndrome (PASS)
2) evaluate patency of ulnar artery and palmar arch prior to ligation

65
Q

High flow ARHI definition and treatment preference

A

Autogenous > 800 ml/min
Prosthetic > 1200 ml/min

more likely to have adequate inflow
Therefore banding and RUDI ok

Low flow states require revasc: DRIL, PAI, angioplasty

66
Q

Rate of central stenosis in failing AV access

A

17-26%

67
Q

KDOQI mandates venography in this patient population prior to access creation

A

Previous subclavian lines

68
Q

Open treatment for venous hypertension and central stenosis

A

1) GSV spiral graft
2) prosthetic bypass
3) jugular turndown to ipsilateral subclavian vein

69
Q

Endo treatment for venous hypertension central stenosis:

elastic vs non-elastic lesions

A

Elastic: stent

non-eastic: dont stent? balloon only

70
Q

Neuropathy grades after AV ccess

A

Grade 0: asymptomatic
Grade 1: mild - intermittent changes (pain, paresthesia, sensory deficit)
Grade 2: moderate - persistent sensory change
Grade 3: severe - motor loss and muscle wasting

71
Q

Neuropathy category in CKD

A

1) systemic disease neuropathy: progressive and gradual
2) mononeuropathies: compression, compartment syndrome and entrapment
3) ischemic monomelic neuropathy: acutely after AV access

72
Q

Systemic disease neuropathy in CKD

A

1) diabetes 46% of CKD

2) uremic polyneuropathy 50-70% of CKD

73
Q

Compressive mononeuropathies rate in HD patients

A

10x more

increases with time on HD
50% at 10 years

74
Q

Etiology of compressive mononeuropathy

A

venous HTN and congestion –> median nerve compression and chronic irritation –> carpal ligament thickening

75
Q

Ischemic monomelic neuropathy rate of occurence

A

0.5%

76
Q

Define IMN

A

Acute vascular compromise of neurologic structures

77
Q

Risk factors of IMN

A

1) older
2) diabetic
3) preexisting peripheral neuropathy
4) PAD
5) brachial-based access ONLY or proximal

78
Q

Findings with IMN

A

1) warm palpable pulse
2) audible signal in radial and ulnar
3) pain out of proportion
4) digital pressure index > 0.3

79
Q

rate of CHF with HD patients

A

1/3

80
Q

Access flow/cardiac output ratio higher than this suggest risk of high output cardiac failure

A

> 0.3

81
Q

Coronary steal syndrome

A

IMA CABG on same side as AV access

28% develop signs of malperfusion on HD

R9 (200 decks)

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