Nephrol. Dial. Transplant.-1999-Agroyannis-2520-1

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					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 [5]. 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) [1], 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 ) [2]. 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%) [2]. 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 [3]. 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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