Impact of the Type of Dialysis on Time to Transplantation: Is It Just a Matter of Immunity?

Background: Renal transplantation represents the therapeutic gold standard in patients with end stage renal disease (ESRD). Still the role of pre-transplant dialysis in affecting time to transplantation has yet to be determined. We wanted to verify whether the type of renal replacement therapy (hemodialysis vs. peritoneal dialysis) affects time to transplantation and to identify clinical features related to the longer time to transplantation. Methods: We performed a retrospective single-center observational study on patients who had received a transplant in the Bologna Transplant Unit from 1991 to 2019, described through the analysis of digital transplant list documents for sex, age, body mass index (BMI), blood group, comorbidities, underlying disease, serology, type of dialysis, time to transplantation, Panel Reactive Antibodies (PRA) max, number of preformed anti Human Leukocyte Antigens (HLA) antibodies. A p-value < 0.05 was considered statistically significant. Results: In the 1619 patients analyzed, we observed a significant difference in time to transplant, PRA max and Preformed Antibodies Number between patients who received Hemodialysis (HD) and Peritoneal dialysis (PD). Then we performed a multiple regression analysis with all the considered factors in order to identify features that support these differences. The clinical variables that independently and directly correlate with longer time to transplantation are PRA max (p < 0.0001), Antibodies number (p < 0.0001) and HD (p < 0.0001); though AB blood group (p < 0.0001), age (p < 0.003) and PD (p < 0.0001) inversely correlate with time to transplantation. Conclusions: In our work, PD population received renal transplants in a shorter period of time compared to HD and turned out to be less immunized. Considering immunization, the type of dialysis impacts both on PRA max and on anti HLA antibodies

MARS EFFICIENCY IN 38 PATIENTS WITH LIVER FAILURE

none8noneL. Colì; G. Donati; G. Cianciolo; C. Raimondi; E. Silvagni; F.Gozzetti; L. Bolondi; S. StefoniL. Colì; G. Donati; G. Cianciolo; C. Raimondi; E. Silvagni; F.Gozzetti; L. Bolondi; S. Stefon

Jugular vein-mammary artery fistula after catheterism for hemodialysis: case report

The demographic characteristics of hemodialysis (HD) patients increase the need for the tunneled cuffed permanent catheter (TCC) as a definitive vascular access (VA) for HD. The internal jugular vein is increasingly being used as a route for TCC or temporary catheter placement and can be associated with serious complications. Among them other authors have described arteriovenous fistula (AVF) creation between the common carotid artery and the right jugular vein. We describe a case of an AVF between the right internal jugular vein and the right internal mammary artery. The fistula was detected during the TCC placement in a patient who underwent several jugular and subclavian catheterisms for HD in her clinical history.The demographic characteristics of hemodialysis (HD) patients increase the need for the tunneled cuffed permanent catheter (TCC) as a definitive vascular access (VA) for HD. The internal jugular vein is increasingly being used as a route for TCC or temporary catheter placement and can be associated with serious complications. Among them other authors have described arteriovenous fistula (AVF) creation between the common carotid artery and the right jugular vein. We describe a case of an AVF between the right internal jugular vein and the right internal mammary artery. The fistula was detected during the TCC placement in a patient who underwent several jugular and subclavian catheterisms for HD in her clinical history

Anticoagulation therapy for the prevention of hemodialysis tunneled cuffed catheters (TCC) thrombosis

BACKGROUND: Chronic oral anticoagulation is currently used to avoid thrombosis and the malfunction of tunneled cuffed catheters (TCCs) for hemodialysis (HD). The aim of the study was to assess the efficacy of early warfarin administration, after TCC placement, in comparison to its administration after the first thrombosis or malfunction event of the TCC. PATIENTS AND METHODS: One hundred and forty-four chronic dialysis patients, who underwent TCC placement between June 2001 and June 2005, were randomized into two groups: 81 patients, group A, started oral anticoagulation 12 hr after the TCC placement (target international normalized ratio (INR) 1.8-2.5), in association with ticlopidine 250 mg/die; 63 patients, group B, started warfarin after the first thrombosis/malfunction episode (target INR 1.8-2.5) in association with ticlopidine 250 mg/die. The efficacy of oral anticoagulation therapy in preventing TCC thrombotic complications was evaluated in a 12-month follow-up period, after TCC placement, in terms of: a) the number of patients with thrombotic-malfunction events; b) the number of thrombotic-malfunction events with urokinase infusion (events/patient/year); c) intradialytic blood flow rate (BFR, ml/min); d) negative blood pressure (BP) from the arterial line of the TCC (AP, mmHg); e) positive BP, in the extracorporeal circuit from the venous line (VP, mmHg); and f) bleeding complications. RESULTS: Ten patients (12%) in group A showed TCC thrombosis/malfunction vs. 33 patients (52%) in group B (p < 0.01). In group A, 0.16 events of thrombosis/malfunction per patient/year vs. 1.65 in group B (p < 0.001) were ob-served. BFR was respectively 305 +/- 34 vs. 246 +/- 42 ml/min (p < 0.001). AP was -124 +/- 13 in group A vs. -174 +/- 21 mmHg in group B (p < 0.05). VP was 112 +/- 28 in group A vs. 168 +/- 41 mmHg in group B (p < 0.05). No patient showed any bleeding events. CONCLUSIONS: Early warfarin therapy allows a significant reduction in TCC thrombotic complications and an improvement in both arterial and venous fluxes in comparison with the same therapy administered after the first TCC thrombotic/malfunction event. This therapy did not induce any bleeding complications in the patients included in the study

Anti-neutrophil cytoplasmic autoantibody-associated vasculitis in the very elderly: a 90-year-old iron lady

Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides are characterized by blood vessel inflammation resulting in organ dysfunction or in the patient\u2019s death. The peak of incidence was observed in patients over 75 years of age. We describe an unusual ANCA vasculitis presentation in a 90-year old patient admitted to the emergency room for severe dyspnea, oliguria and a recent onset cutaneous purple rush. Plain chest radiography disclosed pulmonary edema and diffuse bilateral reticulonodular infiltrates. Creatinine was 7.3 mg/dl, azotemia 202 mg/dl, hemoglobin 6.8 g/dl. CPAP (continuous positive airway pressure), furosemide 20 ml/h, nitroglycerin 8\u3b3/kg/min, blood transfusions and i.v. methylprednisolone 60 mg/day were administered. On day 1 a femoral venous catheter was placed and hemodialysis (HD) treatment started for acute renal failure. The patient underwent 13 HD sessions without heparin (EVAL dialyzer). On day 7 renal function had still not recovered and a new plain chest radiogram was unchanged. Proteinase 3(PR3) ANCA were 81 IU/ml (ELISA), C-reactive protein (CRP) was 18 mg/dl, C3 42 mg/dl, C4 5 mg/dl. A high resolution computed tomography considering that the 53% of cases were managed with glucocorticoids alone. Nonetheless, Walsh et al\u2019s metanalysis showed that patients who received a course of glucocorticoid therapy for more than 12 months suffered fewer relapses of ANCA vasculitis. In patients older than 80 years any immunosuppressive therapy is associated with a significantly lower risk of ESRD and death, but the rate of infections is higher than in younger patients. In our patient the CY dose related to the body surface area was reduced to 200 mg in view of age, risk of infection and renal failure, but glucocorticoid therapy was maintained. During the 2 year follow-up no infections were reported, the Birmingham vasculitis score was lower than 10 and reached the 50% reduction of the initial disease activity score recommended. A good outcome was obtained and it seems to be related both to CY and to the long-term maintenance therapy with glucocorticoids