2520 Nephrol Dial Transplant (1999) 14: 2520 Neither nationalism nor regionalism are scientiﬁc attitudes, while ‘candor’ and honesty are. Service de Nephrologie-Dialyse ´ Jose Guiserix ´ Centre Hospitalier Sud Reunion ´ Saint-Pierre Ile de la Reunion ´ France 1. Chantrel F, Enache I, Bouiller M et al. Abysmal prognosis of patients with type 2 diabetes entering dialysis. Nephrol Dial Transplant 1999; 14: 129–136 2. Friedman EA. Haemodialysis for French diabetics patients. Nephrol Dial Transplant 1999; 14: 30–31 3. Guiserix J, Finielz P. Insuﬃsance renale chronique terminale dans ´ le sud de la Reunion. Epidemiologie, survie en dialyse. ´ ´ ´ Nephrologie 1997; 18: 107–115 Ringed Gore-Tex for haemodialysis access Sir, In uraemic patients with ESRD, in whom peripheral veins have been exhausted or are inadequate for the creation of Fig. 1. A ringed PFTE Gore-Tex graft. native A-V ﬁstula, prosthetic grafts are used for arterio- venous anastomosis [1–3]. In this report we present a case with unusual central vein complications after recurrent cath- eterization, because two native and one with prosthetic graft ﬁstula had been thrombosed. At present the patient is haemodialysed adequately from a left unilateral subclavian- jugular (A-V ) anastomosis, by a ringed prosthetic graft. Case: the patient is a 60-year-old woman with ESRD. She suﬀered from hypertension, atrial ﬁbrillation and short bowel due to resection of a large part of the bowel after mesenteric embolism 1 year ago. A good radial cephalic ﬁstula at the wrist was created in advance of need. This ﬁstula was occluded after a small number of HD sessions. In the same side another native ﬁstula was created, by the anastomosis of the median cubital vein and brachial artery. This ﬁstula presented a serious haematoma and occlusion in the ﬁrst 24 h. After these unsuccessful native ﬁstula a prosthetic graft was placed in the same side between branchial artery and the proximal brachial vein in the axilla. This prosthetic graft was occluded after 1 month of adequate function. After evaluation of the vessels by colour Doppler ultrasound another prosthetic graft (ringed Gore-Tex) between the sub- clavian artery and jugular vein was placed in the left side (Figure 1). During 10 months, as problems with the AV ﬁstula occurred in our patient, multiple catheterizations of central veins were required to continue HD. Recurrent cannulation Fig. 2. The tip of the Permcath is located in the inferior vena cava. was performed in the right jugular and subclavian vein and in both femoral veins, but not in the left subclavian and jugular which were preserved, anticipating the placement of thetic graft, the patient keeps on dialysing from for more a prosthetic graft. By the repeated cannulation of central than 10 months. veins, serious thrombosis and stenosis were developed. Comment: central venous catheters are commonly placed However, two events related to the catheterization procedure in uraemic patients with ESRD who are either awaiting for should be emphasized. First, a Permcath in the right jugular creation or for maturation of the ﬁstula [4–6 ]. The central vein did not function well. The radiologists veriﬁed that the vein catheter is associated with complications during the tip of the catheter had been entered in the inferior vena cava, insertion procedure (pneumothorax, perforation of vessels resulting in catheter removal (Figure 2). Secondly, we wall etc.) and with later complications such as infection and attempted to put a usual double-lumen catheter in the central stenosis, or thrombosis of the central vein . It has also veins, but this was impossible as the veins had developed been reported that stenosis can be present after temporary stenosis and thrombosis. At this time we decided in access catheters have been removed. cooperation with the radiologists to put two Super Arrow- Our patient showed two unusual events by the cannulation Flex Sheath catheters in the stenotic left femoral vein (Figures of central veins. First, the Permcath in the right jugular vein 3 and 4). By these catheters, HD was adequately performed was advanced from the right atrium to the inferior vena for 50 days. During that time the above mentioned subcla- cava. The blood ﬂow was poor and the catheter was removed. vian-jugular anastomosis was performed by a ringed pros- This complication may be due the insertion of a full sized Nephrol Dial Transplant (1999) 14: 2521 2521 by a ringed prosthetic graft in the left side by which the patient is haemodialysed over two months now. The unusual and frequent thrombosis of central veins in our patient may be due to recurrent cannulation, to some infections and to short bowel syndrome which may cause apolipoprotein abnormalities. We decided that the last placed prosthetic graft between subclavian artery and jugular vein should be a ringed Gore-Tex, to avoid kinking and the risk of easy thrombosis. Our patient has been adequately haemo- dialysed by this prosthetic graft for more than 10 months without any disorders and bleeding by the puncture site. Department of Nephrology1 Basil Agroyannis1 Interventional Radiology2 Dimitrios Mourikis2 Vascular Surgery3 Costas Fourtounas1 Aretaieon University Hospital Helen Tzanatos1 Athens Ioannis Kopelias1 Greece Achilles Chatzioannou2 Panagiotis Dimakakos3 1. Burger H, Kooistra G, de Charro F, Leﬀers P. A survey of vascular access for haemodialysis in the Netherlands. Nephrol Dial Transplant 1991; 6: 5–10 2. Butler CE, Tilney NL. Hemodialysis access part B-Permanent. In: Jacobs C, Kjellstrand CM, Koch KM, Winchester JF (eds). Fig. 3. Severe stenosis and thrombosis of both femoral veins. Replacement of Renal Function by Dialysis. Kluwer Academic Publishers, Dordrecht, The Netherlands 1996: 277–292 3. Hakaim AG, Scott TE. Durability of early prosthetic graft cannulation: Results of a prospective non randomized clinical trial. J Vasc Surg 1997; 25: 1002–1006 4. Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary hemodialysis. Nephron 1990; 54: 154–61 5. Uldall R. Hemodialysis access part A-Temporary, In: Jacobs C, Kjellstrand CM, Koch KM, Winchester JF (eds). Replacement of Renal Function by Dialysis. Kluwer Acadenic Publishers, Dordrecht, The Netherlands 1996: 277–292 6. Schnabel KJ, Simons ME, Zevallos GF, Pron GE, Fenton SSA, Sniderman KW, Vanderburgh LC. Image-Guided insertion of the Uldall Tunneled hemodialysis catheter. Technical success and clinical follow-up. JVIR 1997; 8: 579–586 Insulin resistance in patients with adult polycystic kidney disease Sir, Insulin resistance has been reported in patients with adult polycystic kidney disease (APKD) , and Ducloux and coworkers recently suggested in a preliminary report that renal transplant recipients with APKD were at increased risk of post-transplant diabetes mellitus (PTDM ) . In a retro- spective case-control study including 26 APKD recipients Fig. 4. Two Super-Arrow Flex-Sheath catheters entered the inferior (cases) and 26 controls matched for age, gender and immuno- vena cava through the left femoral vein. suppressive therapy, a signiﬁcantly higher prevalence of PTDM was observed in the former group than the latter (34.6 vs 15.3%) . However, the authors did not include catheter, while the patient was rather small. Secondly, the patients with impaired glucose tolerance (IGT ) after renal patient developed unusual thrombosis and stenosis in the transplantation, which is important to assess whether recipi- central veins and the usual double-lumen catheter could not ents with APKD are predisposed to develop post-transplant be advanced into the veins. For this reason we decided, in glucose intolerance. cooperation with the radiologists, to insert in the stenotic In a single centre study we examined glucose intolerance left femoral vein two Super Arrow-Flex Sheath catheters, prospectively in 173 consecutive renal transplant recipients which are designed to successfully negotiate tortuous vessels. at 10 weeks after transplant . In the majority (n=167) an These catheters were advanced higher from the location of oral glucose tolerance test (OGT ) was performed. Patients the stenosis and thrombus and HD was adequately performed with pretransplant diabetes mellitus were excluded. Thirty- for 50 days. This time period was suﬃcient for the creation one patients (18%) had PTDM, 53 (31%) IGT and 89 (51%) and maturation of the subclavian-jugular (A-V ) anastomosis normal glucose tolerance (NoGT ).
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