RESUMEN
Physical examination has recently been demonstrated to detect vascular access stenosis in patients with arteriovenous fistulae. However, its accuracy in the identification of stenoses when compared with the gold standard (angiography) in patients with arteriovenous grafts has not been studied in a systematic fashion. We conducted a prospective study to examine the accuracy of physical examination in the detection of stenotic lesions when compared with angiography. Forty-three consecutive cases referred for an arteriovenous graft dysfunction were included in this analysis. Preprocedure physical examination was performed. The findings of the examination and diagnosis were recorded and secured in a sealed envelope. Angiography from the feeding artery to the right atrium was performed. The images were reviewed by an independent interventionalist with expertise in endovascular dialysis access procedures and the diagnosis was rendered. The reviewer was blinded to the physical examination. Cohen's Kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. There was a strong agreement between the physical examination and the angiography in the diagnosis of vein-graft anastomotic stenosis (kappa = 0.52). The sensitivity and specificity for this lesion was 57% and 89%, respectively. There was a moderate agreement beyond chance regarding the diagnosis of intragraft (kappa = 0.43) and inflow stenoses (kappa = 0.40). The sensitivity and specificity for the intragraft and inflow stenosis was 100%, 73% and 33%, 73%; respectively. The findings of this study demonstrate that physical examination can assist in the detection and localization of stenoses in arteriovenous grafts.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/efectos adversos , Oclusión de Injerto Vascular/diagnóstico , Examen Físico/normas , Diálisis Renal/métodos , Diagnóstico Diferencial , Humanos , Fallo Renal Crónico/terapia , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
BACKGROUND AND OBJECTIVES: Physical examination has been highlighted to detect vascular access stenosis; however, its accuracy in the identification of stenoses when compared with the gold standard (angiography) has not been validated in a systematic manner. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective study was conducted of 142 consecutive patients who were referred for an arteriovenous fistula dysfunction to examine the accuracy of physical examination in the detection of stenotic lesions when compared with angiography. The findings of a preprocedure physical examination and diagnosis were recorded and secured in a sealed envelope. Angiography from the feeding artery to the right atrium was then performed. The images were reviewed by an independent interventionalist who had expertise in endovascular dialysis access procedures and was blinded to the physical examination, and the diagnosis was rendered. Cohen's kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. RESULTS: There was strong agreement between physical examination and angiography in the diagnosis of outflow (agreement 89.4%, kappa = 0.78) and inflow stenosis (agreement 79.6%, kappa = 0.55). The sensitivity and specificity for the outflow and inflow stenosis were 92 and 86% and 85 and 71%, respectively. There was strong agreement beyond chance regarding the diagnosis of coexisting inflow-outflow lesions between physical examination and angiography (agreement 79%, kappa = 0.54). CONCLUSIONS: The findings of this study demonstrate that physical examination can accurately detect and localize stenoses in a great majority of arteriovenous fistulas.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/efectos adversos , Examen Físico , Angiografía , Constricción Patológica/diagnóstico , Humanos , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Bowel perforation is an uncommon but serious complication of peritoneoscopic peritoneal dialysis (PD) catheter insertion. The approach to diagnosis of bowel perforation utilizing this technique has not been previously published. The authors report their experience with the diagnosis and management of bowel perforation in the context of peritoneoscopic placement of PD catheters. METHODS: The authors retrospectively reviewed the records of 750 PD catheters inserted over a 12-year period (January 1991 to May 2003) utilizing peritoneoscopic technique. RESULTS: Six (0.8%) patients experienced bowel perforation during the procedure. The diagnosis was made immediately during the procedure in 5 (83%) of the 6 patients. Of these 5, peritoneoscopy confirmed intrabowel position of the cannula by visualizing bowel mucosa (n = 3) and hard stool (n = 1). The fifth patient showed extrusion of fecal matter upon trocar withdrawal before peritoneoscopy. All 5 had emanation of foul-smelling gas through the cannula. Bowel rest and broad-spectrum intravenous antibiotics were initiated. Of the 5, 1 required surgery, whereas the others were discharged home after 3 days. The sixth patient had fever, severe peritoneal irritation, and polymicrobial peritonitis the morning after the procedure. In this patient, no evidence of bowel injury was noted during the procedure except for brief emanation of foul-smelling gas. He required surgical intervention. CONCLUSION: Bowel perforation can be diagnosed immediately in most patients undergoing peritoneoscopic PD catheter insertion. A majority of these patients can be treated medically. The surgical team should be consulted if the patient shows clinical deterioration or has signs of peritoneal irritation.
Asunto(s)
Cateterismo/efectos adversos , Perforación Intestinal/etiología , Laparoscopía/efectos adversos , Diálisis Peritoneal/instrumentación , Abdomen Agudo/etiología , Adulto , Anciano , Antibacterianos , Terapia Combinada , Nefropatías Diabéticas/complicaciones , Quimioterapia Combinada/uso terapéutico , Heces , Femenino , Gases , Humanos , Inmunosupresores/efectos adversos , Perforación Intestinal/diagnóstico , Perforación Intestinal/cirugía , Perforación Intestinal/terapia , Fallo Renal Crónico/inducido químicamente , Fallo Renal Crónico/terapia , Trasplante de Pulmón , Masculino , Persona de Mediana Edad , Peritonitis/tratamiento farmacológico , Peritonitis/etiología , Peritonitis/cirugía , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Instrumentos Quirúrgicos , Tacrolimus/efectos adversosAsunto(s)
Derivación Arteriovenosa Quirúrgica , Nefrología , Factores de Edad , Anciano , Derivación Arteriovenosa Quirúrgica/efectos adversos , Derivación Arteriovenosa Quirúrgica/estadística & datos numéricos , Complicaciones de la Diabetes , Europa (Continente) , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Diálisis Renal/métodos , Resultado del Tratamiento , Estados UnidosRESUMEN
A 76-year-old man had biopsy-proven acute tubular necrosis (ATN) after intravenous administration of 3 doses of 60 mg of pamidronate (Aredia) over a 2-week period. Pamidronate was given to treat hypercalcemia of unknown etiology. Other potential causes of acute renal failure were excluded with appropriate investigations. The patient's preexisting renal impairment in the context of high-doses of pamidronate might have been a potentiating factor for nephrotoxicity. The ATN encountered in this patient resolved; however, short-term hemodialysis was needed. To the best of our knowledge, this is the first reported case of short-term, high-dose pamidronate-induced ATN in the absence of concomitant nephrotoxins. Although necrotic and apoptotic cell death after bisphosphonate administration has been seen in a variety of cells, the exact mechanism of nephrotoxicity is unknown. This report presents a case of pamidronate-induced ATN and discusses the potential mechanisms of bisphosphonate-induced nephrotoxicity.