BALLOON ANGIOPLASTY WITH CLOT LYSIS AS A FIRST LINE MEASURE FOR SALVAGE OF THROMBOSED ARTERIO-VENOUS ACCESS (AVA)

C WILKINSON1, M MANTHA1, S DHEDA1
1Cairns Base Hospital (Queensland Health), Cairns, Australia

Aim: To assess long-term outcome of thrombolysis plus balloon angioplasty of thrombosed fistulae.
Background: A thrombosed AVA often necessitates an emergent central catheter to facilitate immediate haemodialysis and then surgical intervention. Most thrombosis is due to significant stenosis limiting flow.  Early intervention may salvage the AVA.  We reviewed the immediate success and long-term outcomes of these interventions.
Methods: We present a retrospective observational study of the rates of percutaneous angioplasty of thrombosed AVAs from our health service since 2010.   Initial success was defined as on table return of flow. Ongoing patency was defined as effective dialysis at 3, 6 and 12 months in the absence of further intervention.   Data collected from the medical records included date of fistula creation, percutaneous and surgical interventions prior and following the thrombolysis events.
Results: 30 patients received 43 thrombolysis/angioplasty episodes.  The mean time to first thrombosis was 4.8 years with a prior mean 4.6 angioplasty procedures/ patient. All AVA were in the upper limbs; 80% were fistulae and 20% were grafts.  Cause of thrombosis was stenosis in 93% of the episodes.  Mean time to lysis was 1.6 days with 95% performed in outpatient setting.  The initial success rate was 97%.  15 episodes (35%) required central line access within the first week following procedure. AVA patency was 44% at 3 months, 36% at 6 months and 20% at 12 months.  By 12 months, 25% of AVAs had subsequent angioplasty and were functional, 10 patients required formation of new AVA; and 3 patients were dialysing via a permacath.
Conclusion: Following AVA thrombosis, percutaneous intervention avoided emergent central catheter insertion in 65% of patients, surgical intervention was avoided in 57% of patients.


Biography:
Dr Catherine Wilkinson is a advanced trainee in nephrology, currently based at Cairns Hospital.

URETERIC OBSTRUCTION AND HYDRONEPHROSIS SECONDARY TO HAEMATURIA AFTER RENAL BIOPSY

D O’HARA1, H CHEIKH HASSAN1
1Wollongong Renal Department, Wollongong, Australia

Background: Haemorrhagic complications of renal biopsy include perinephric haematoma formation in 11.6% of cases, macroscopic haematuria in 3.5% of cases, bladder outlet obstruction from blood clots in 0.3% of cases, and a 0.01% risk of nephrectomy. There is only a single published case of post-biopsy ureteric obstruction due to haematuria.
Case Report: A 60 year-old female underwent an outpatient right renal biopsy for investigation of gradually declining renal function (estimated glomerular filtration rate 82mL/min to 68 mL/min over 1 year), a urine protein:creatinine ratio of 80mg/mmol and microscopic haematuria, on a background of untreated mild systemic lupus erythematosis. Haemoglobin, platelet count, coagulation studies and blood pressure were normal prior to biopsy, and she was not taking anticoagulants. Post biopsy she developed macroscopic haematuria that abated by the afternoon with hydration. She was discharged home with instructions to re-present if bleeding recurred. She was contacted the following day and she reported no further haematuria, and was well apart from 1 hour of right-sided flank pain during the night. Five days post-biopsy she awoke during the night with severe flank pain and with recurrence of macroscopic haematuria. A non-contrast abdominal CT scan identified moderate to severe right hydronephrosis with hyperdensity within the right ureter consistent with a blood clot. She underwent a right ureteric stent insertion, with relief of symptoms. The renal biopsy showed no large arteries, as well as non-specific mildly increased mesangial cellularity and expansion.
Conclusions: Ureteric obstruction from post-biopsy haematuria is a rare but clinically important condition to recognise and treat. It could occur up to 5 days post biopsy. It could be considered as a component of informed pre-biopsy consent.


Biography:
Dr Daniel O’Hara is a second-year renal Advanced Trainee in the East Coast Renal Network. He has a keen interest in general nephrology, dialysis, obstetric medicine and global renal health.

SURGEON VERSUS NEPHROLOGIST-INSERTED PERITONEAL DIALYSIS CATHETERS: EXPERIENCES FROM A METROPOLITAN CENTRE IN SYDNEY

N SHAH1, A GOSWELL2, C CUESTA3, I KATZ3
1St George-Sutherland Basic Physician Training Network, Kogarah, Australia, 2St George Hospital, Kogarah, Australia, 3Department of Renal Medicine, St George Hospital, Kogarah, Australia

Background: Peritoneal dialysis (PD) is an effective home-based form of renal replacement therapy. Delays in insertion, higher costs, primary catheter failure, and patient choices are contributors to its under-use and lower rates of penetration
Aim: To describe and compare outcomes of percutaneous PD catheter insertion (PDCI) by a nephrologist compared with surgical insertion.
Methods: A retrospective study at St. George Tertiary Hospital, Sydney, using a prospectively-collected database over 8-years. The data analysed included195 PD catheters inserted using two techniques (72 percutaneous (PCDI), 123 surgical). Analysis included patient demographics, date of catheter insertion, and complications.
Results: Patients were well matched for age, and primary cause of renal failure. Those receiving PDCI had lower BMIs versus surgically inserted lines (p = 0.027). Time-to-insertion was significantly shorter with the PDCI (p = 0.0014). The over-all complication rate was similar (44% vs. 36%, p =0.24). Significant differences in the type of adverse outcomes were seen. Patients with surgically-inserted catheters experienced more exit site leaks (p = 0.026), and peritonitis (p =0.028). Nephrologist-inserted catheters had more technical complications. These included bowel puncture (p = 0.0085) or procedure cancelation due to inadequate preparation (p=0.0008). There were no differences in primary failure between the techniques (p = 0.436), and increasing BMI did not confer an increased risk of primary failure in either cohort (p= 0.601).
Conclusions:  The study confirms the complementary roles of nephrologist and surgical insertion. With fewer delays to catheter insertion and similar absolute complication rates, a nephrologist-inserted PD catheter, using the percutaneous technique, is a good option to consider in the right patient in metropolitan areas. Especially in Australia where higher uptake of home based therapies is so important.


Biography:
Nasir Shah is a basic physician trainee in the St George-Sutherland Basic Physician Training Network in Kogarah, NSW. Througout his academic and clinical career his research has focused on renal medicine. Currently, his clinical curiosity lies in the up-and-coming subspecialty of interventional nephrology. In particular, dialysis access, and the vascular biology underlying arterio-venous fistula maturation.

AN AUDIT OF POST-RENAL BIOPSY COMPLICATION RATE AND DIAGNOSTIC YIELD OF ALLOGRAFT AND NATIVE KIDNEYS

A KHAN1, B NANKIVELL1, A KHAN2, J CHAPMAN1

1Renal Medicine Department Westmead Hospital , Westmead , Australia, 2Storr Liver Center, Westmead Institute of Medical Research, University of Sydney, Westmead , Australia

Background/Aims: Real time ultrasound guided percutaneous kidney biopsy (PCKB) is considered a standard procedure worldwide, for the pathological diagnosis of native and transplant kidneys. Monitoring the adequacy of sample and post biopsy complications is important as quality indicators. We thus monitor safety and adequacy of the real time ultrasound guided biopsy technique to correlate with the level of experience of the operator.
Method: A total of 449 (398 transplant and 51 native) elective day case biopsies performed at Westmead Hospital Sydney over one year were retrospectively reviewed to determine the overall complication and adequacy rates.
Results: A total of 355 biopsies (group 1) were performed by a consultant by either ultrasound guidance or assistance and 94 biopsies (group 2) were performed by supervised trainees using ultrasound guidance. The overall tissue specimen adequacy was 97.1 %, however, it differed significantly, between group 1 (97.7% adequacy) and 2 (94.7% adequacy, p< 0.03). The overall biopsy complications rate was 3.3%, with a statistically significant difference between group 1 (1.1%) and group 2 (11.7%, p<0.001). Overall, post biopsy transient haematuria was detected in 3.1% patients (p<0.001), 1.6% cases had a diagnosed haematoma, 1.6% cases had gross haematuria and 0.4% patient developed an AV fistula. A total of 97.6% patients were discharged after 4 hours observation and 2.4% required admission.
Conclusion: Complication rates following PCKB are low and are reduced when performed by experienced nephrologists. It remains important to provide rigorious education and supervision programs to train nephrologists to perform safe and effective native and transplant renal biopsies.


Biography:
Dr Asrar Khan is a consultant Nephrologist specialised in all aspects of nephrology including haemodialysis, peritoneal dialysis and renal transplantation.
Dr Khan has worked as Fellow in Renal and Transplant Medicine at Westmead Public Hospital and as a Staff Consultant Nephrologist at Mildura Base Hospital. He is a Consultant Nephrologist at Mildura, Wollongong and Nowra Private Hospital. Dr Khan has been actively involved in teaching of both under and post graduate medical students throughout his career. He worked as a Senior Lecturer at Monash University and now as a Senior Clinical Lecturer at School of Medicine University of Wollongong.

THE PURSUIT OF ENDOVASCULAR PROCEDURES FOR TUNNELED DIALYSIS CATHETER INSERTIONS.

D FERNANDES1, C SAJIV1, B PAWAR1, S THOMAS1, S NAYAR1, P GEORGE1, J OLAPALLIL1, M HAMILTON1
1Alice Springs Hospital, Alice Springs, Australia

The numbers of patients on hemodialysis (HD) is increasing exponentially in the Northern territory. Most of the patients are young and 50% of the patients in Central Australia start HD with a temporary access. The challenge for the practicing Nephrologists in remote Central Australia is to maintain a good vascular access. Nephrologists in this region have gained expertise in interventional skills (including endovascular skills) and have been able to contribute significantly to the maintenance of vascular access. There is a growing number of young patients who present with complex vascular requirements including temporary bridging semi-permanent catheter insertions.

Aim: We present a series of cases that required additional endovascular techniques for successful deployment of tunneled catheters.
Methods: Retrospective analysis of six patients in whom endovascular interventions were required at the time of line insertions
Results: 5 out of the 6 were females with an average age of 48.33 years (33-72). The average vintage on dialysis was 10.33 years (2-18). Most of them (5/7) had multiple fistulae constructed in both the arms and forearms along with multiple line insertions in the Internal Jugular and the Femoral veins.
Two patients required balloon assisted dilatation of the left brachiocephalic vein and one of them the left common iliac vein for successful insertion of tunneled catheters into the respective sites. The remaining cases required manipulation of guide wires into the target veins using guiding sheaths. No complications were observed during these procedures.
Conclusion: Endovascular techniques can be safely utilized to assist in the deployment of difficult tunneled catheter insertions.


Biography:
Sajith has been practicing nephrology in Alice Springs for the past 4 years. The interventional service in Central Australia has slowly expanded from primarily fistula related procedures to complex catheter insertions. Sajith is one pf the nephrologists who has been actively pursuing interventional procedural work at Alice Springs.

 

PERCUTANEOUS PERITONEAL DIALYSIS CATHETER INSERTION THROUGH LINEA ALBA – INITIAL EXPERIENCE.

HA HAKIM1, S DHEDA1, V LEE1, D PRATT1, M MANTHA1
1Cairns Hospital, Cairns,, Australia

Background: The success of peritoneal dialysis depends on a well-functioning peritoneal dialysis (PD) catheter. Both open surgical or laparoscopic techniques that allow rectus sheath tunnelling, adhesiolysis and omentopexy are resource intense and timely access to them is difficult. Ultrasound and fluoroscopy guided placement of PD catheter is minimally invasive and appears to be equivalent to laparoscopic surgical placement but anchoring the deep cuff in to the rectus muscle is difficult with this method.
Aim: We report our initial experience of a simple percutaneous PD catheter insertion technique through linea-alba obviating the need for deep cuff placement in the rectus muscle, hence minimising the discomfort and trauma.
Methods: All patients who underwent ultrasound and fluoroscopy guided Tenchoff insertion between 1st January 2017 and 31 March 2018 at Cairns Hospital were included.
Medical records of all identified cases were reviewed to collect data with regards to catheter-related information including insertion dates, commencement of PD and early complications (first 30 days of insertion) including PD peritonitis, exit site infections, leaks and catheter malfunction.
Results: Twenty-six patients had Argyle (™) curled tip PD catheters inserted under radiological guidance during the study period. Early complications occurred in 16% of catheters, including 2 episodes of peri catheter leak (7.6%) which did not require surgical intervention, 1 episode of peritonitis (3.8%) and 1 case of early exit site infection (3.8%). There were no cases of early catheter migration or primary malfunction.
Conclusion: The Seldinger technique of percutaneous peritoneal catheter insertion through linea-alba is an effective and simple procedure with a desirable technical success and complication rates.


Biography:
Consultant Nephrologist at Cairns hospital with clincal interests in home therapies, vascular access and interventional nephrology.

HOW MANY ABDOMINAL SCARS ARE TOO MANY FOR PD CATHETER INSERTION

V WIJERATNE1, K MCNAMARRA1, S May1
1Tamworth Hospital, Tamworth, Australia

Background: Many interventional Nephrologists will not place PD catheters in abdomens where there has been previous abdominal surgery.At Tamworth all patients wanting to do PD have catheters inserted by an interventional nephrologist apart from occasional patient who needs concurrent hernia surgery.
Aim: To describe successful insertion and use of PD catheters in higher risk patients as demonstrated by 3 patients who on initial assessment may have appeared not suitable for insertion of a PD catheter and/or successful PD. Focus on failed SPK patients given a comment from a senior transplant physician that they had not had success with CAPD in failed SPK.
The procedure uses real time ultrasound and a Seldinger technique placing a hydrophilic wire in the pelvis with Xray and then catheter insertion over the wire.Case 1 – 53 year old with ESRF due to T1DM had a SPK in 2005 with a pancreatectomy in same year. Had slowly progressive CKD. Was started on PD in Nov 2016. Catheter inserted without complications with no technical problems since. Remains on CAPD.
Case 2 – 37 year old female with ESRF secondary to Type 1 DM. Had a SPK in 2012. Developed acute rejection and started on CAPD Oct 2017. Catheter inserted without complications with no technical issues since. Remains on CAPD.
Case 3 – 65 year old male ESRF of uncertain cause. Previously had suffered a shot gun wound to the abdomen with multiple surgeries. PD catheter inserted without complications. Awaiting to start PD.
Conclusion – PD catheters can be successfully inserted by interventional nephrologist in patients with multiple abdominal scars using appropriate techniques.


Biography:
Dr Viduranga Wijeratne is a Renal Advanced Trainee in Tamworth Rural Referral Hospital. He completed his BMed MD at UNSW and his basic physicians training at Concord Repatriation General Hospital.

ENDOVASCULAR RENAL DENERVATION IN LOIN PAIN HAEMATURIA SYNDROME

E HOURN1, A PARNHAM1, A RAHMAN1
1Gold Coast University Hospital, , Australia

Loin pain haematuria syndrome (LPHS) is a chronic pain syndrome diagnosed by exclusion; patients are often opioid-dependent and have failed multiple surgical and radiological treatments. This series details the novel use of catheter-based endovascular renal denervation for treatment of LPHS in four patients. The procedure was performed unilaterally or bilaterally and had varying success in a diverse patient population inclusive of patients with underlying anatomical abnormalities of medullary sponge kidney, congenital single kidney and autosomal dominant polycystic kidney disease. Two of the four patients have had complete resolution of pain and an additional patient gained significant pain reduction. We hypothesise that repeated procedures may be successful based on one patient with resolution of pain after endovascular denervation that recurred post auto-transplant. The pre-existing comprehensive safety data and this proof of concept case series bolsters the existing theoretical benefit of this procedure for this indication and make it an attractive avenue for further studies.


Biography:
Ellen Hourn is a nephrology advanced trainee at the Gold Coast University Hospital.

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