Bolleke Erjola, Seferi Saimir, Rroji Merita, Idrizi Alma, Barbullushi Myftar, Thereska Nestor
Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
Med Arch. 2014 Oct;68(5):361-3. doi: 10.5455/medarh.2014.68.361-363. Epub 2014 Oct 15.
Vascular access is often considered the Achilles heel the of hemodialysis because of its impact on morbidity, all cause mortality and finally costs of these patients. The most common complication of permanent hemodialysis (HD) vascular access is thrombosis, with some cases being related to hypercoagulability states. Antiphospholipid antibody syndrome (APAS) is a cause of increased thrombotic tendency, and this may complicate the management of such patients on HD.
We describe a 41-year-old woman with end stage renal disease (ESRD) from Adult Polycystic Kidney Disease who was referred to our tertiary care center for treatment and selection of renal replacement therapy form. It was thought to initiate with peritoneal dialysis considering her actual conditions. She was putted on hemodialysis for several sessions, and a subclavian cathether was her first vascular access. The surgeon created an arterio-venous fistula which did not mature. After the implantation of the peritoneal cathether she started peritoneal dialysis and continued living with that for 2 years. She felt exhausted and because of a grave peritonitis episode accompanied with procedure failure and a long hospitalization she was transferred to hemodialysis. Renal transplantation was not possible because she didn't have a kidney donation. She was maintained on regular HD, but her dialysis care was complicated by recurrent vascular access failures. She had multiple interventions for arterio-venous fistulas and grafts but almost all of them failed due to thrombosis to the extent that only one access site was available for her routine renal replacement treatment. A thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies. A diagnosis of APAS was made and she was anticoagulated with warfarin. The AVG made in this last available site is still working from 18 months. If it fails we have no answers and solutions for her.
The presence of APAS can complicate HD management by causing recurrent vascular access thrombosis and failure, and nephrologist must remain alert to this possibility. Checking and treating as soon as possible it's our future challenge.
血管通路常被视为血液透析的薄弱环节，因为它会影响这些患者的发病率、全因死亡率以及最终成本。永久性血液透析（HD）血管通路最常见的并发症是血栓形成，部分病例与高凝状态有关。抗磷脂抗体综合征（APAS）是血栓形成倾向增加的一个原因，这可能使此类HD患者的管理复杂化。
我们描述了一名41岁患有成人多囊肾病导致终末期肾病（ESRD）的女性，她被转诊至我们的三级护理中心接受治疗并选择肾脏替代治疗方式。考虑到她的实际情况，最初认为应采用腹膜透析。她接受了几次血液透析，首次血管通路是锁骨下导管。外科医生建立了一个动静脉内瘘，但未成熟。植入腹膜导管后，她开始进行腹膜透析，并持续了2年。她感到疲惫不堪，由于一次严重的腹膜炎发作，伴有操作失败和长时间住院，她被转至血液透析。由于她没有肾源，无法进行肾移植。她维持定期HD治疗，但透析护理因反复出现的血管通路失败而复杂化。她对动静脉内瘘和移植物进行了多次干预，但几乎所有干预都因血栓形成而失败，以至于她常规肾脏替代治疗仅剩下一个可用的通路部位。全面的血栓形成倾向筛查证实存在抗磷脂抗体。诊断为APAS，并给予她华法林抗凝治疗。在最后这个可用部位建立的动静脉移植物已经使用了18个月，目前仍在发挥作用。如果它失败了，我们对她将无计可施。
APAS的存在可因导致反复的血管通路血栓形成和失败而使HD管理复杂化，肾病学家必须对此可能性保持警惕。尽早检查和治疗是我们未来的挑战。
