All posts by В. Пенчев

When it comes time to start hemodialysis, among many other questions, the question of vascular access – AVF or PermCat (or more simply fistula or catheter) invariably arises.

In this article, we will try to look at this choice from all sides in order to give patients the most general idea and to facilitate their choice as much as it is possible to talk about it.

Fistula (AVF): Let’s start with the fistula, because of the two options, building a dialysis fistula is definitely the better option.

The fistula is easier to handle, maintain, less affects the daily routine, way and quality of life of the patients.

It is also much less risky in terms of future infections.

What exactly is an arm fistula?

Here we will try to avoid medical language and explain in an easily accessible way what a fistula in general is a “splicing, fusion” of a vein and an artery of the arm, which is a medical manipulation under anesthesia.

A small incision is made around the wrist or a little higher up the patient’s arm, depending on the doctor’s judgment – this is the so-called “high” (around the bend of the elbow) or “low” (around the wrist) fistula, the vein and

the artery is “merged”, then they are sutured and a certain period is waited for the fistula to heal and work. This may take a month, even two, and it may not work at all – these are precisely the risks of fistula. As for the location – whether the fistula is high or low, it is better if it is low – next to the wrist. The reason for this lies in the fact that if something happens to this fistula and it stops functioning, it can then “walk” up the arm and make a new one. Unfortunately, doctors rarely decide to make low fistulas, perhaps due to the fact that the vessels are much better expressed in the upper part of the arm, accordingly, it is easier to work there and the chances of success are greater.

Fistula positives:

– reduced risk of infections to a minimum

– preserved quality of life and routine

– you can swim, do any kind of work, without, of course, heavy physical work and strain.

Maintenance of daily hygiene occurs without change – as it was before the onset of the disease.

– among the positives, it is important to mention that what worries the patients, namely – pricking with fistula needles for each dialysis – will be painful – no!

The place loses its sensitivity and no pain is felt when it is turned on.

Of course, there is a moment of discomfort, but it is by no means an extremely painful manipulation.

Disadvantages of fistula:

– Time.

Each fistula takes time to develop and become usable, sometimes over two months.

There is a risk that it will never develop, ie. to remain unusable. This is one of the main concerns of hemodialysis patients – how will I continue my treatment if my fistula doesn’t work?

Fistula is not an option for patients who have high values and need to be put on dialysis quickly or urgently.

But, being the best option for vascular access in general, our advice to such patients is to get a catheter but at the same time seek advice from their dialysis center to refer them to a good vascular surgeon to do the fistula. In this way, the necessary dialysis treatment will be started through the catheter, but it will be thought in the perspective of building a good fistula to be used for the patient’s hemodialysis needs in the future.

– another common negative is the sudden stoppage of the fistula.

The reasons for this could be many and varied, but often the culprit is again high blood pressure, left unchecked – it causes the vessels to constrict and the fistula to spontaneously close.

Such an unexpected event puts the patient in an extremely unpleasant, stressful situation where suddenly, without warning, he finds himself with absolutely no vascular access through which to perform dialysis.

In such a case, of course, a temporary / permanent catheter is immediately placed and a new option for fistula construction is sought again. – “Why do they advise me not to make a fistula, but to go directly for a catheter?” – here is an extremely common question from patients. Usually the explanation from doctors is that the patient’s vessels are not good, he is too old, or he has diabetes.. This is not the case. Anyone could get a nice, quality, working fistula.

The trick is to find a good enough specialist to do it for him. We return to infections again to mention how risky they are for hemodialysis patients. When the treatment, the medical staff at the dialysis center are up to standard and professional, patients with fistulas can be absolutely calm that they are not vulnerable to infections introduced into their body.

TYPES OF VASCULAR ACCESS – AV FISTULA

Alport syndrome is an inherited renal condition that damages kidney tissue and glomeruli and leads to kidney failure.

Its name comes from the scientist Arthur Cecil Allport, who at the beginning of the last century first described what was shown, defining it as “hereditary, familial, congenital hemorrhagic nephritis”.

What is the cause of Alport syndrome?

The disease is genetic, which also explains the heredity in patients.

At a certain stage of the development of the embryos, a gene mutation occurs, which leads to changes in the kidney membranes (glomeruli, Bowman’s capsule) and, accordingly, the manifestation of what is shown at a later stage.

There are 3 types of inheritance according to the type of mutation:

1. The X-linked mutation. It is also the most common manifestation of the mutation in which Alport syndrome occurs.

In this case, the disease is transmitted from the mother to the son, but not from the father to the son, since the defect occurs on the X chromosome.

2. Autosomal recessive form It is observed at approx. 15% of cases of patients with Alport syndrome

3. Autosomal dominant form A relatively small number of patients with Alport syndrome have this mutation – only approx. 5%.

These patients manifest the symptoms shown significantly later and better.

How do we know?

Clinical picture: The first symptoms (especially with the Encounter mutation) appear in early childhood, approx. 3 years of age, but there are cases of even earlier manifestation of the syndrome – in infancy from several months to a year).

They include:

– hematuria (blood in the urine) that occurs spontaneously and has no other cause

– proteinuria (loss of protein through the kidneys, excreted in the urine)

– increased serum creatinine and arterial pressure – the increase in these parameters occurs in a slightly later stage of the disease.

– deafness – manifested in early childhood, parallel to the first manifestation of the symptom, often leads to mental retardation and is irreversible, due to damage to the auditory nerve.

– eye changes in the cornea and lens of approx The diagnosis is made by biopsy methods

– kidney, skin biopsy, as well as a genetic test to prove the format and type of Alport syndrome.

Treatment: Unfortunately, there is no cure.

Possible approaches aim to maximize the progress of the disease, as well as kidney transplantation, a stage for hemodialysis has been reached. The good news is that transplant patient syndrome can’t happen again to Alport.

Every patient who has started hemodialysis and after the initial emotional shock begins to hard and feverishly prepare for a kidney transplantation – the only possible way to “get his life back”.

Of course, it is very important to note that hemodialysis is often only a stopover for people with CKD on their way to being on the kidney transplantation waiting list, as well as the most important moment – the call that a donor situation has arisen and the patient with CKD is called in for a new organ transplant procedure.

However, how important is it to perform quality hemodialysis until the moment of transplantation?

We will dwell on this question in a little more detail…

Recently, Dr. Georgi Hristov, director of the Medical Oversight Executive Agency, stated that many of the potential kidney recipients who are on the waiting list are called for transplants, but, after tests, they are found to be in such deteriorated health state that they are declared unfit to receive a donor organ.

Perhaps this is also the reason why very few transplants are done in Bulgaria – less than 20 per year – one of the saddest statistics, which causes many people with CKD to become health emigrants.

But why is the level of hemodialysis in Bulgaria bad? The low price of the procedure, paid by the NHIF, the many services that are included under the umbrella of the dialysis procedure and that are not directly related to the healing process also detract from the amount that could otherwise be directed 100% to the essence of the procedure – many explanations , but one bottom line..

High-quality hemodialysis means one thing – a maximally preserved organism for the cherished moment of transplantation.

Good dialysis has several main pillars:

1. Quality and especially NEW equipment of the highest class. We cannot help but mention the name of the leader in dialysis equipment – FRESENIUS. Every center equipped with new FRESENIUS devices is guaranteed to perform excellent dialysis.
2. Consumables – once again FRESENIUS are on the front line – dialyzers from the brand, blood lines – grant the best possible and fine cleaning, maximally reduced blood loss, good physical condition after the procedure, etc.
3. Medicines – when the patient is in the final phase of CKD, respectively undergoing dialysis treatment, his body does not produce the relevant substances and elements necessary to maintain good levels of hemoglobin, for normal levels of phosphorus, calcium, potassium, iron, etc. This requires many and expensive medications, which are part of the procedure, paid for by the NHIF, and are not at the patient’s expense.

However, many of the dialysis centers save on these drugs, at the expense of greater profit for the clinic.

Regular monthly examinations of patients, their physical condition are the best guarantee for the good work of the hemodialysis center.

This is the only way to control medication intake and maintain good levels of elements in the body.

4. Staff – an extremely important component in the dialysis structure is the staff, in the form of experienced nurses and a doctor who does NOT leave the dialysis room for a single moment. In dialysis, the worst can happen in a minute – lines are severed, a catheter is pulled out, while the patient’s blood is literally outside their body as the machine filters it – these are just examples of extremely critical and potentially deadly situations. Which can only be mastered by an experienced nurse with a doctor by his side.

Contrary to the initial impression – everything happens extremely dynamically in dialysis, and only the experienced hands of the nurses can prevent it from ending tragically.

These are just a few points of support on the path of each patient’s choice to protect his right to the best treatment he deserves.

A good diet, strict control over fluid intake, regular monitoring by all kinds of specialists, especially a cardiologist, endocrinologist, pulmonologist, etc. pave the way for transplantation, which is the normal and logical conclusion of the problem called “end-stage CKD”.

STAGES OF CHRONIC KIDNEY DISEASE

Let’s start from the beginning – what is the function of the kidneys?

And the answer is – our kidney system is multi-component: kidneys are not just a filter, but also play an important role in:

– excretory function – through the kidneys – excess water, salts and nitrogen-containing substances, which are formed as a result of the exchange of substances in the body of each person, are excreted in the urine.

– maintenance of an optimal balance in the “internal environment” – this is the so-called “homeostasis” – In case of changes in the water-salt and acid-alkaline internal environment of the body, the kidneys include a number of compensatory mechanisms with which they restore this balance.

– stimulating the production of red blood cells (erythrocytes) – specific kidney cells produce the hormone “erythropoietin”, whose task is to stimulate the bone marrow to produce blood cells.

– maintenance of normal strength and structure of human bones – the kidneys are also actively involved in the production of vitamin D3, which is responsible for the strength of bones in the human body.

When do we start talking about chronic kidney failure (CKD)?

When these renal functions begin to decrease until they are completely lost (last stage of renal failure, when creatinine has already reached levels of approx. 850 µmol/l.

Sometimes, quite imperceptibly, the degree of kidney failure is reached, which necessitates frequent examination of the state of kidney function.

Of course, it takes time to reach the end stage of CKD, but eventually, the kidneys are irreversibly damaged.

The first signs are a decrease in the amount of urine excreted – an important symptom, which, however, is not always manifested.

Sometimes the exact opposite symptom is present – excessive excretion of urine (polyuria). This happens when, in an attempt to excrete substances the body does not need, the damaged kidneys excrete more water because they cannot concentrate the urine.

Patients excrete up to 3 or more liters of urine per day, urges to urinate are frequent even at night!

  For comparison – a healthy person usually urinates within 1.5 l/24 hours.

  Other characteristic complaints are easy fatigue, high blood pressure that is not affected by medication, or at least not subject to normal regulation and control, nausea, nocturnal shortness of breath and difficulty breathing, which are due to pulmonary edema, drowsiness. Diabetes is also a ‘first aid in the development of CKD’

That is why prevention and regular monitoring of kidney health by a nephrologist is so important.

If you have any of the symptoms described above, accompanied by frequent urinary infections, kidney pain, if you have been suffering from diabetes for several years – contact a nephrologist who will prescribe preventive tests, including creatinine and urea, and consult you subsequently.

CHRONIC KIDNEY FAILURE AND CARDIOVASCULAR DISEASES

Diabetic nephropathy is the name used to describe kidney damage caused by diabetes. It develops slowly over several years. Almost one in five people with diabetes eventually need treatment for diabetic nephropathy. Despite these alarming statistics, there are many things that can reduce the risk of developing the complication. If detected early enough, diabetic nephropathy can also be delayed with treatment.

What causes kidney disease?

One of the main jobs of your kidneys is to filter your blood by removing excess fluids and waste products from your body through urine.

High blood glucose (sugar) levels can damage the small blood vessels and tiny filters in your kidneys. When the blood vessels are damaged, the kidneys are unable to clean the blood in an optimal way. For this reason, excess fluids, salts, toxic products accumulate in the body and swelling and weight gain begin to be observed.

The earliest sign of diabetic nephropathy is the so-called microalbuminuria, which means an increased level of the albumin protein in the urine.

What is albumin?

Human albumin is a small globular protein consisting of 585 amino acids. Albumin is synthesized in the liver, after which it is excreted into the bloodstream. It plays an important transport role – for hormones, vitamins or medicines.

An important indicator is the amount of albumin and the ratio with total potein in various disease processes: chronic liver diseases, chronic kidney failure, oncological diseases or in the diagnosis of edematous conditions.

Once this damage is present, the remaining kidney filters must work extra to compensate for the deficiencies in the system’s proper functioning. Once the kidneys start working at less than 15% of their capacity, a diagnosis of kidney failure is made and the patient usually goes on dialysis.

There is no specific treatment for diabetic nephropathy, but disease progression can be slowed by controlling blood pressure, optimizing blood sugar levels, and changing diet. Once kidney disease is present, the most important thing to focus on is controlling blood pressure.

Renal colic is a condition that can occur to anyone, without a previous cause of manifestation. This spasm is characterized by extremely intense pain that occurs suddenly and completely unexpectedly, most often in the lower back, where it is strongest.

The patient remains restless with nausea, less frequent regurgitation, abdominal distension, possible sweating and traces of blood in the urine.

In addition, the presence of renal colic should never be considered as a physiological condition, since pain associated with it is a clear manifestation of a problem that requires a visit to a doctor and intervention aimed at resolving the problem.

At its core, renal colic affects the two specific organs responsible for filtering blood and excreting waste in the urine, namely the kidneys. They represent a porous structure extremely rich in small channels, tubules and blood vessels, which act as a mechanical filter.

Colic is caused by a sudden obstruction of the patency of the urethra. Usually, the movement of stones is provoked by physical exertion, high fluid intake, alcohol, caffeine or diuretics. During this passage, the stones inflame their walls and cause the acute clinical manifestation of renal colic.

Renal colic can last from a few minutes to a few hours, and in rare cases – a few days.

It is important to diagnostically rule out other diagnoses such as pyelonephritis, acute pancreatitis, cholecystitis, acute appendicitis, ectopic pregnancy, ovarian cyst, etc.

The disease is proven by ultrasound as this method is safe, highly informative and allows tracking of the person’s condition. In the laboratory, a blood test and urinal analysis are recommended.

The treatment includes the combined use of analgesics and antispasmodics, thus controlling the pain and removing the existing spasm of the ureter. From natural remedies, diuretic and anti-inflammatory-antiseptic teas can be used.

Recurrent nephrolithiasis and urinary tract obstruction eventually lead to chronic renal failure and permanent damage to the urinary tract. Therefore, its timely detection, treatment and prevention are important.

Chronic kidney disease (CKD) is a partial or complete reduction of kidney function and it has five stages, where stage 5 is called renal failure. The disease progresses slowly and is determined by the extent to which kidney function is reduced.

In its initial stages, CKD is asymptomatic. Often, patients do not even know they have a kidney problem, but find out during the course of treatment for another disease, or when their condition is already in an advanced stage.

Symptoms of CKD may include: heaviness or pain in the lower back, high blood pressure, swelling, decreased urine output.

Organs and systems in the body are interconnected. Therefore, a problem in one place affects the whole body. Moreover, the risk factors for these 3 diseases are similar: hyperglycemia (high blood sugar), arterial hypertension, being  overweight, family history and low physical activity.

DIABETES AND CHRONIC KIDNEY DISEASE

Nowadays, diabetes is quite prevalent. Nearly 1 in 3 diabetes patients suffers from some degree of chronic kidney disease.

High blood sugar damages the blood vessels, leading to arterial hypertension, which in turn damages the kidneys and their function. On the other hand, hyperglycemia itself leads to kidney damage.

Therefore, maintaining normal blood sugar levels is crucial. Here, not only the medications your endocrinologist will prescribe are important, but also a healthy lifestyle: body weight control through appropriate diet and exercise, as well as avoiding nephrotoxic (kidney-damaging) medications and taking them only when absolutely necessary.

HEART DISEASE AND CHRONIC KIDNEY DISEASE

Kidney disease often leads to heart complications, while heart problems lead to kidney dysfunction.

Uncontrolled hypertension (blood pressure above 140/90) is one of the causes of CKD. On the other hand, CKD can lead to arterial hypertension and subsequently heart disease.

Many factors that can cause kidney disease also damage the heart and blood vessels. Among them, firstly, come high blood pressure and diabetes, which many patients with CKD have. In second place come obesity and smoking.

There is a strong connection between chronic kidney disease, heart disease and diabetes and it is not rare for one patient to have all three of them.  In their early stages, all of these diseases can be asymptomatic. Therefore, regular check-ups (for example, every year), even if you don’t have any complaints, can significantly increase your quality of life.

CHRONIC KIDNEY FAILURE AND CARDIOVASCULAR DISEASES (nephrolife.bg)

Kidney dysplasia (Renal dysplasia) is a defect in the intrauterine development of the kidneys, which means that one or both kidneys have abnormal appearance (cysts, increased amount of connective tissue, etc.) and impaired function.

IS THIS CONDITION COMMON?

The condition occurs in 1:1000 to 1:4000 live births. It may go undiagnosed when only one kidney is affected and there are no symptoms.

Renal dysplasia in the majority of cases is a consequence of genetic mutations. Usually it is not an isolated condition, but is accompanied by defects in other organs and systems.

  The use of illegal substances and certain prescription medications during pregnancy also increases the risk of giving birth to a child with renal dysplasia. Therefore, it is important that the intake of any medication by the pregnant woman be discussed with an obstetrician-gynecologist.

WHAT ARE THE SYMPTOMS?

Unilateral dysplasia can be asymptomatic or in combination with other defects of the urinary tract. Those affected often develop arterial hypertension and proteinuria (protein in the urine) at a later stage. Lumbar or abdominal pain, frequent urinary tract infections, and slower growth are also possible.

Bilateral dysplasia is one of the most common causes of chronic kidney disease in newborns. It can also be associated with the presence of oligohydramnios (reduced amount of amniotic fluid) during pregnancy.

Kidney changes can be diagnosed in utero by fetal ultrasound. After birth, some characteristic changes in laboratory parameters are also important for the diagnosis.

PROGNOSIS AND TREATMENT

The prognosis depends on the severity of the disease and especially on whether only one or both kidneys are affected.If a child has one functional kidney, a normal life is possible, provided that the condition is monitored regularly (blood pressure, laboratory parameters, urinalysis).

Children born with bilateral dysplasia must be strictly followed up by a pediatric nephrologist, who will order the necessary tests. It is possible for the condition to progress, necessitating hemodialysis or a kidney transplant.

PREVENTION

Genetically determined renal dysplasia cannot be prevented. It is important for pregnant women to lead a healthy life and to let their gynecologist know if they take any medications or have family history of renal dysplasia.

Historically, Dr. Willem Kolff is considered as the father of dialysis. This young Dutch doctor constructed the first dialyzer (artificial kidney) in 1943. The path to creating this innovation for its time began in the late 1930s when he worked in a small ward at the University Hospital in Groningen, the Netherlands.

The idea of ​​developing a blood purification machine was born for Dr. Kolf after observing a patient suffering from kidney failure. He decided to find a way to develop a machine to replace the work of the kidneys. When his invention was complete, he attempted to treat over a dozen patients with acute kidney failure over the next two years. Although only one of the treatments performed proved successful, he continued to experiment in improving his design. However, Kolf’s device only treats acute kidney failure, not end-stage renal disease (ESRD).

Dr. Kolff’s invention is considered the first modern drum dialyzer and remained the standard for the next decade. After the end of World War II, he donated the five machines he made to hospitals around the world. One of those hospitals was Mount Sinai in New York, where he later moved to continue his research and scientific work.

The first patient in the world to be treated with repeated hemodialysis was Clyde Shields, whose first dialysis was in Seattle, USA, on March 9, 1960.

Dr. Belding Scribner, a professor of medicine at the University of Washington, has developed a way for patients with end-stage kidney failure to receive treatment through an access point in their arm. In 1962, Dr. Scribner opened the first formal dialysis clinic for patients. Subsequently, he also developed a portable dialysis machine that allows patients to receive this type of treatment at home.