الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Chronic kidney disease (CKD) is a major health problem worldwide with an increasing incidence and prevalence. As ESRD is closely related with inflammation, one of the features of which is increased markers, where inflammation will consequently worsen with hemodialysis (HD) procedures.
Vascular access (VA) dysfunction is a major clinical complication in the HD population and has a direct effect on dialysis outcome. Neointimal hyperplasia causes vascular stenosis and subsequent thrombosis, which result in vascular access failure in patients undergoing HD. Interleukin-10 (IL-10), hs CRP, and tumor necrosis factor- (TNF--α) are involved in this inflammatory process. Early detection and treatment of these complications will decrease fistula thrombosis, and fistula replacement.
The aims of this study was to evaluate the value of routine physical examination, radiological investigation and inflammatory markers including high sensitive (hs) CRP, IL-10 and TNF-α in early detection of vascular access failure (VAF) in pediatric patients on regular HD and early intervention for correction of VA failure according to guidelines and follow up.
It was an observational and interventional study, which was conducted at Pediatric Dialysis and Nephrology Unit (PDNU), Children’s Hospital, Ain Shams University, between the period of December 2019 till December 2020, where we included 59 pediatric CKD patients’ stage 5, on regular HD (CKD5d), who were following up regularly with us for 1 year. Patients with nonfunctioning AVFs due to complications as thrombus occluding fistula, infections, or large aneurysm, were excluded from the beginning of the study.
Oral and informed consent was taken from the patients and caregivers and the work were approved by the Research Ethics Committee.
The most common etiology of CKD at our PDNU was CAKUT (50.7%), meanwhile hypertension was higher among our patients (60.9%).Monitoring of VA by physical examination, pre-cannulation, was performed to detect the physical signs of dysfunction, which included inspection, palpation, and auscultation, which were done at least once per month according to KDOQI guidelines. Venous pressure (VP) and trans-membrane pressure (TMP) were recorded at each HD session, to detect any abnormalities and to record the pressure changes with the appearance of any AVF complications.
Blood samples were collected from the patients every 2 weeks for 12 months, prior to HD sessions, where we included the most recent samples prior to (1), and at the time of development complications (2), which were clinically and radiologically confirmed. Investigations included CBC, PT, PTT, IL10, TNF, hs CRP. Doppler ultrasound (DUS) was performed routinely every 3 months for all HD patients, where we included the measurements prior to (1), and at the time of development AVF complications (2).
Thrombosis was the most common reported complication, followed by aneurysm formation, which was significant among hypertensive patients. Hs-CRP, TNF-α, IL-10 were elevated at timing of early development of complication, in comparison to their baseline levels, meanwhile serum IL10 (1 and 2), and TNF (2) were significantly higher among patients who developed AVF stenosis.
AVF diameter (2), and AVF flow volume (2) were found to be significantly lower among patients who developed AVF thrombosis, while AVF diameter (2), and AVF flow volume (2) and AVF flow volume (1) were found to be significantly higher in patients who developed AVF aneurysms.
The baseline hs-CRP (1) had related positively with (AVF diameter 2) at the time of the development of the complications; meanwhile, the baseline IL10 (1) related negatively to the baseline TNF-α (1).
Different modalities of intervention were supposed to be performed for patients where DUS examination confirmed VA abnormality including medical interventions, by using anticoagulants to reduce the risk of early fistula thrombosis and failure, and surgical interventions, which were established for salvage of a thrombosed access.
The re-creation of new AVF was preferred in fistulas with old thrombi, which was adherent to the wall and very difficult to be removed, in addition to treat symptomatic aneurysms.
It is recommended that AVFs should be routinely monitored, soon after their creation by physical examination, DUS surveillance, and inflammatory mediators to detect early signs of dysfunction.