**6. Final remarks and conclusions**

The radiocephalic and the humerobasilic AVF are the two types of VA with the longest duration of function, although a high rate of initial failure is seen with the radiocephalic AV fistula[141]. It is the preferred VA on account of the longest duration, its low complications rates and its ease of puncture [142-144].

Age, female gender, presence of diabetic nephropathy, start of dialysis with a catheter and failure to wait for initial maturation of the VA are risk factors and account for the majority of VA failures during RRT. Repeated VA failure has been identified as a risk factor for mortality [145].

The brachiocephalic AV fistula is the preferred type of VA, if the radiocephalic approach fails. In case of diabetic patients this seems to be the primary fistula if adequate vessels are not available, this is a frequent finding. Four year permeability rates of 80% have been reported [146]. In Rodriguez et al study, survival of brachiocephalic AV fistula was lower than radiocephalic; slightly more than one-half of patients have patent fistulae after 4 years and one –third after more than 8 years. It also shoed that more than two-thirds of patients in whom the first VA developed successfully did not have any subsequent VA failure, whereas initial failure increased the risk of subsequent failure. Female gender and presence of diabetes were risk factors related to VA failure [141].

The effort to create fistula first, has successfully increased the prevalence of AVFs [147]. However, the number of TCs has also increased, and those placed for bridging a patient to a functional AVF may stay in place longer [62]. Studies about fistula placement success from the US and European countries differ, significantly in the primary patency rate of AVFs at one year. US studies that include diabetic patients, report patency rates as low as 40%–43% [148, 149].

Konner et al reports a primary patency rate in diabetic patients of 69%–81%, depending on gender and age (results reported from 748 AVFs over 5 years) [150].

Chemla et al performed 552 AVFs in 4 years, achieving a primary patency rate at 22 months of 80% in 153 patients with radiocephalic fistulas [151].

addressed under fluoroscopic guidance. Among late causes of failure, are fibrin sheaths and thrombi around or at the catheter tip. Fibrinous sheaths can be disrupted by balloon angioplasty with improved flow through a new catheter in the same location. Symptomatic occlusions of the central veins usually require the removal of the catheter and system anticoagulation and must be weighed in the context of a continued need for dialysis and other available access options. Catheter use is linked to higher rates of infection and could compromise dialysis adequacy [136, 137]. Catheter related infections (CRI) are associated with increased all cause mortality and morbidity. 8-10% of MRSA bacteraemia in the UK occurs in patients receiving long term haemodialysis. It recently seems that the appropriately chosen antimicrobial lock solutions (ALS) reduce frequency of infections in HD patients [138]. Prophylaxis with gentamicin of the catheter lumens reduces bacterial infection morbidity and mortality related bacteremia of catheter without obvious bacterial resistance, making such use advisable [139]. Del Pozo et al in their prospective study showed that evaluation of tunnelled catheters with intra-catheter leukocyte culture helps in early HD catheters colonization, giving the possibility to eradicate biofilm without the

The radiocephalic and the humerobasilic AVF are the two types of VA with the longest duration of function, although a high rate of initial failure is seen with the radiocephalic AV fistula[141]. It is the preferred VA on account of the longest duration, its low complications

Age, female gender, presence of diabetic nephropathy, start of dialysis with a catheter and failure to wait for initial maturation of the VA are risk factors and account for the majority of VA failures during RRT. Repeated VA failure has been identified as a risk factor for

The brachiocephalic AV fistula is the preferred type of VA, if the radiocephalic approach fails. In case of diabetic patients this seems to be the primary fistula if adequate vessels are not available, this is a frequent finding. Four year permeability rates of 80% have been reported [146]. In Rodriguez et al study, survival of brachiocephalic AV fistula was lower than radiocephalic; slightly more than one-half of patients have patent fistulae after 4 years and one –third after more than 8 years. It also shoed that more than two-thirds of patients in whom the first VA developed successfully did not have any subsequent VA failure, whereas initial failure increased the risk of subsequent failure. Female gender and presence of

The effort to create fistula first, has successfully increased the prevalence of AVFs [147]. However, the number of TCs has also increased, and those placed for bridging a patient to a functional AVF may stay in place longer [62]. Studies about fistula placement success from the US and European countries differ, significantly in the primary patency rate of AVFs at one year. US studies that include diabetic patients, report patency rates as low as

Konner et al reports a primary patency rate in diabetic patients of 69%–81%, depending on

Chemla et al performed 552 AVFs in 4 years, achieving a primary patency rate at 22 months

removal of catheter [140].

mortality [145].

40%–43% [148, 149].

**6. Final remarks and conclusions** 

rates and its ease of puncture [142-144].

diabetes were risk factors related to VA failure [141].

of 80% in 153 patients with radiocephalic fistulas [151].

gender and age (results reported from 748 AVFs over 5 years) [150].

Korsheed et al report that AVF formation resulted in a sustained reduction in arterial stiffness and BP as well as an increase in LVEF. These data state that the lower mortality of these patients with AVF, may be due to factors beyond VA associated infections and dysfunctions [152].

However, data from 1996 to 2006 collected from DOPPS indicate a growing use of catheters in many countries [153]. Also, our data in 2011 shows increased patency for TCs in female gender patients. Rayener et al report growing use of catheter according to DOPPS data. They also indicate that in facilities with the practice of early cannulation of AVF (within 4 weeks from their creation) and promptly performed VA surgeries with success in creating VA in older, diabetic women greatly enhance the odds of their patients for using a permanent access rather than TC [153]. In new dialysis patients, early referral to a nephrologist and early patient education strongly predict a successful functioning permanent VA at dialysis initiation and it also seems that the patients have better metabolic and clinical situation at the beginning of HD, lower long-term morbidity and higher survival for the first two years [154-158]. AV fistula is better when used for the first haemodialysis treatment compared to starting haemodialysis with a catheter [55, 159, 160]. Graft is, however, a better alternative than catheter for patients, where the creation of an attempted AVF failed or could not be created for different reasons [161].

In conclusion, as far as literature and our experience are concerned, arteriovenous fistula has to be the first choice in vascular access when suitable vessels are available. Arteriovenous grafts and Central Venous Catheters may be also a good alternative as fist choice when suitable vessels are not available or as a second choice when there is AVF failure. Female gender and old patients are more likely to start hemodialysis with a TC. Finally, a well matured vascular access is important for long access survival and early referral to nephrologists is mandatory.

#### **7. Acknowledgements**

Acknowledgements to Ioannis T. Papadakis Director of Nephrology Department Hippokration General Hospital and to the patients of Renal Unit who gave us the permission to add their pictures in our chapter. Also acknowledgements must be given to Mrs Sofia Andrikou for her designs of VA.

#### **8. References**


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**5** 

*Brazil* 

**Subjective Well-Being Measures** 

*Sobral School of Medicine, Federal University of Ceará* 

In recent years the frequency of intra-dialytic symptoms has been decreasing, improving the patient well-being during treatment sessions. This has mainly been due to technical advances, such as more reliable monitoring devices, better water quality, physiological bicarbonate-based dialysate and machines to control ultrafiltration. Nowadays during hemodialysis (HD), patients suffer less from hypotension, cramps, headache, dizziness, nausea and vomiting (Himmelfarb & Ikizler, 2010; Al-Hilali et al., 2004). However, instead of well-being during dialysis, this chapter examines the well-being of patients between sessions, in their daily lives, focusing on how they perceive their quality of life (QOL). Unfortunately, technical advances in HD have not brought changes in the characteristics of renal replacement therapy: severe dietary restrictions, lost time, dependence on a machine, common occurrence of clinical complications and high mortality. Treatment of end-stage renal disease (ESRD) with HD is thus inherently distressing, causing social and family changes, and interferes profoundly in patients' well-being (Cukor et al., 2007; Tsutsui et al.,

ESRD treated with HD should be highlighted among other chronic diseases concerning its treatment, evolution and life consequences. Treatment depends not only on polypharmacy, but also on artificial replacement of kidney function by a machine – still a deficient method that cannot prevent various complications: ostheodystrophy, atherosclerotic disease and risk for infections. This inefficacious replacement of kidney function causes these patients to have a twenty-fold higher chance of death than in the general population (Parmar, 2002). HD patients must adhere to a very restricted diet with controlled ingestion of water. In conventional HD, the patient is submitted to sessions of dialysis for approximately four hours three times a week in a renal unit (plus the time spent commuting to and from the renal unit), a time loss that influences employment, leisure and relationships. It is not surprising, then, that ESRD treated with HD affects QOL more intensely than heart failure,

Therefore dialytic therapy is associated with powerful stressors. The literature shows that successful adaptation to dialysis depends more on personal stress modulators than on objective treatment variables (Tsay et al., 2005; Curtin & Mapes, 2001). Personal modulators are mainly subjective, due to psychology, personality and behaviour (Cukor et al., 2007). These subjective factors cannot be discovered by traditional medical measures like physical signs, laboratory and radiological data. The assessment of these

diabetes, chronic lung disease, arthritis and cancer (Mittal et al., 2001).

**1. Introduction**

2009; Low et al., 2008).

**of Hemodialysis Patients** 

Paulo Roberto Santos

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