JOURNAL READING

AKSES VASKULAR PADA PASIEN

TRANSPLANTASI GINJAL

dr. Liber Siahaan

M.S. Karim, P. Aryal, A. Gardezi, et al., Vascular access in kidney transplant recipients, Transplantation Reviews, https:// doi.org/10.1016/j.trre.2020.100544
PENDAHULUAN
PENDAHULUAN
11–13% Dari populasi dunia menderita Penyakit Ginjal Kronik (PGK)
1
;

PGK  Berkembang menjadi GGK ( St. V) Terapi transplantasi ginjal

Pasien GGK akan membutuhkan akses vaskular :

Kateter dialysis peritonial, AV Akses, Kateter Vena Sentral

Pasien GGK Membutuhkan transplantasi atau dialysis

 Sangat penting untuk bisa menjaga pembuluh darah untuk akses vaskular
Transplantationuntuk kedepanya.
 preferred means of RRT
Jurnal ini akan
**kidney menjelaskan
function may nottentang
improveakses
to avaskualr
non-CKD prosedur danindestructible
state, not komplikasi yang
terjadi pada pasien translpantasi ginjal

1. Hill NR, Fatoba ST, Oke JL, et al. Global prevalence of chronic kidney disease - a systematic review and meta-analysis. PLoS One 2016;11:e0158765.
2. Saran R, Li Y, Robinson B, et al. US renal data system 2015 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis 2016;67:S1–305 Svii.
AKSES VASKULAR
Vascular Access
Pasien dengan transplantasi membutuhkan IV Akses

SE IV access:
Akses Vaskular untuk bagi
 phlebitis, pasienstenosis,
sclerosis, yang dirawat di
Rumah Sakit :
or thrombosis

Lead to loss of the vessel

Akses Vena
perifer Kateter Tunneling Pemasanga
Akses IV dengan Vena Kateter n alats
Vena Perifer kateter Sentral Vena ecara
sentral temporer Sentral implan
Perlu pembatasan akses vascular Making
(PICC) future venous access or
untuk menjaga pembuluh darah AV fistula or graft creation
difficult

1. Urbanetto Jde S, Peixoto CG, May TA. Incidence of phlebitis associated with the use of peripheral IV catheter and following catheter removal. Rev Lat Am Enfermagem 2016;24:e2746.
2. [Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a practical review for 2009. Can Fam Physician 2009;55:494–6.
Vascular Access
Akses IV Jenis Akses Vaskular yang banyak digunakan
Vena
Perifer

Menurut NKF (National Kidney Foundation) : Harus dipasang

pada bagian dorsum tangan dominan

Keuntunganya : Lengan non Pemasangan di mulai dari bagian

dominan dapat dipakai untuk dorsum tangan lalu bagian
pemasangan fistula atau graft di proksimal. Sehingga vena lengan
masa depan atas tetap terjaga.

1. NKF KDOQI GUIDELINES. Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Updates. http://kidneyfoundation.cachefly.net/professionals/ KDOQI/guideline_upHD_PD_VA/index.htm; 2006. Accessed 056/01/2019
2019.
Vascular Access
Dapat menyebabkan cedera pada site
Akses Vena perifer pemasangan
5–7 French Catheter inserted into a peripheral vein in the arm
-- karena pemasangan hingga ke Vena Cava
dengan kateter Superior
sentral Basilic or Cephalic vein in the upper arm

(PICC) Cedera tomenyebabkan

Extends stenosis, sclerosis,
the central vasculature
thrombosis atau infeksi

Dapat Ease to
merusak obtaining darah
pembuluh a PICCdan
line tidak dapat
Limited immediate risks (pneumothorax, large vessels injuries)
dilakukan pembuatan akses Kembali.

The access of choice among patients with limited access

Patients who
Jikaneed to be discharged
memungkinkan, withpemasangan
maka long-term IV access
akses
dengan PICC bagi pasien transplantasi ginjal,
sebaiknya dihindari.
1. [Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a practical review for 2009. Can Fam Physician 2009;55:494–6.
Vascular Access
Temporary SE: ass. arterial puncture,
Central lines  obtained in
central internal jugular, subclavian,
catheter malposition,
pneumothorax, thrombosis,
or femoral vein
venous infection

catheter
Placement site depend on Subclavian vein cannulation
 operator proficiency, bedside  lowest risk of infection, but
USG, patient's condition, highest risk of central venous
urgency stenosis  should avoid

Central venous stenosis Renal transplant

 inability to create access  preferred internal jugular /
in the upper arm femoral veins

1. Agarwal AK. Central vein stenosis: current concepts. Adv Chronic Kidney Dis 2009; 16:360–70.
2. McGee DC, GouldMK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123–33.
3. Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med 2015;373:1220–9.
Vascular Access
Tunneled External portion of
the catheter placed in
Extends from insertion
(neck) to 4–5 in.
Tunneling a catheter
reduces the risk of
central a subcutaneous
tunnel
subcutaneously on the
anterior chest
infection
venous
catheters Femoral-tunneled catheters
Subclavian tunneled catheters
 last resort and have a
higher rate of venous
substantially shorter primary
thrombosis
patency

Placing in internal jugular vein

 reduces risk of central venous stenosis
 recommended access in patients with a functional kidney
transplant who need IV access for prolonged periods
1. Ash SR. Advances in tunneled central venous catheters for dialysis: design and performance. Semin Dial 2008;21:504–15.
2. Funaki B. Tunneled central venous catheter insertion. Semin Intervent Radiol 2008; 25:432–6.
3. Timsit JF, Sebille V, Farkas JC, et al. Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study. JAMA 1996;276:1416–20.
4. Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology
2000;217: 89–93.
Vascular Access
Such as subcutaneous ports

Implanted Placed subcutaneously, connected to central circulation  inserted

devices in internal jugular / subclavian vein

A port is completely beneath the skin  cosmetically discreet,

not require catheter care, low risk of infection

Risk of thrombosis and central venous stenosis  similar to

tunneled central catheters

Study it had lower complications, higher patient satisfaction and

better QoL compared to PICC lines or temporary central catheters

An implanted port  should be considered for long term access in

patients with a kidney transplant
1. ] Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a practical review for 2009. Can Fam Physician 2009;55:494–6.
PEMILIHAN AKSES VASKULAR
Selection of vascular access

NKF guidelines:

Upper extremity IV, venipuncture, PICC,

subclavian vein central line
 avoided to persevere future vasculature
Short term IV access (<1week) for dialysis access sites
 peripheral IVs in the dorsum of
the hands  should be considered

1. NKF KDOQI GUIDELINES. Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Updates. http://kidneyfoundation.cachefly.net/professionals/ KDOQI/guideline_upHD_PD_VA/index.htm; 2006. Accessed
056/01/2019 2019.
MANAGEMENT AKSES DIALISIS PADA
PASIEN TRANSPLANTASI
Management of dialysis access in a patient with functional transplant

AV fistulae & grafts

 the best forms of access for
HD

Risk: inadequate flow (arterial &

anastomotic stenosis),
complications in the outflow
tract (venous stenosis),
thrombosis

1. Smith GE, Gohil R, Chetter IC. Factors affecting the patency of arteriovenous fistulas for dialysis access. J Vasc Surg 2012;55:849–55.
Management of dialysis access in a patient with functional transplant

Patients with functional access - Once a patient undergoes a KT

chronic HD and has a functional graft “How should the fistula or graft be
managed in a patient with a
 surveillance program  early  no further need for dialysis  functional KT ?”
access issues detection  referral accesses are no longer monitored.
for timely intervention.

Several cohort studies

Ideally KT have low risk of
rejection & renal graft loss
Benefit of ligation
 significant cardiac burden of a
 unclear due to limited data functional fistula & improvement of
 no need for a fistula or a graft
cardiac dimensions after fistula
 could potentially be ligated
ligation among successful KT

1. Smith GE, Gohil R, Chetter IC. Factors affecting the patency of arteriovenous fistulas for dialysis access. J Vasc Surg 2012;55:849–55.
Management of dialysis access in a patient with functional transplant

Lack of randomized trials not possible to make any definitive conclusion & recommendations

Conflicting findings of AVF closure  decision to ligate a fistula must undertaken great caution.

Vjadic et al. Weekers et al. Fraser et al. Unger et al.

• Outcomes of KT at 1 • Retrospective study • 28/ 30 functional • A prospective

year in patients with • Closure of an AVF or kidney allograft echocardiographic trial
functioning VS nonfunctional AVF maintained normal of 8 KT
nonfunctional fistula among KT recipients allograft function after • Decrease in left
• Functional fistula   associated with an fistula removal ventricular mass, left
lower eGFR, future accelerated decline in • 2 / 30 who went on the ventricular
risk of allograft failure. graft function over 12 dialysis following hypertrophy, and left
• 70/72 nonfunctional months post closure excision of AVF had ventricular end-
fistula access  suboptimal kidney graft diastolic diameter, but
spontaneously closed function to begin with an increase in diastolic
arterial blood pressure
1. Vajdic B, Arnol M, Ponikvar R, Kandus A, Buturovic-Ponikvar J. Functional status of hemodialysis arteriovenous fistula in kidney transplant recipients as a predictor of allograft function and survival. Transplant Proc 2010;42:4006–9.
2. Weekers L, Vanderweckene P, Pottel H, et al. The closure of arteriovenous fistula in kidney transplant recipients is associatedwith an acceleration ofkidney function decline. Nephrol Dial Transplant 2017;32:196–200.
3. Fraser 3rd CD, Grimm JC, Liu RH, et al. Removal ofnoninfected arteriovenous fistulae after kidney transplantation is a safe and beneficialmanagement strategy for unused dialysis access. Ann Vasc Surg 2018;53:128–32.
4. Unger P, Velez-Roa S, Wissing KM, Hoang AD, van de Borne P. Regression of left ventricular hypertrophy after arteriovenous fistula closure in renal transplant recipients: a long-term follow-up. Am J Transplant 2004;4:2038–44.
PERAWATAN AKSES VASKULAR
Maintenance of arteriovenous access

No guidelines on Any change in the exams

Patients on dialysis via an
usually prompts referral for
management of AV AVF or graft are monitored
angiogram & intervention
fistulas in patients with a by physical exam and
early to prevent loss of an
functional RT. access flows.
access.

At our practice we care for access in patients with a functional

This is not possible in transplant in the following way:
patients with a RT, as they • Monitoring
only see their providers on • Evaluation
a limited basis. • Angiogram

1. Smith GE, Gohil R, Chetter IC. Factors affecting the patency of arteriovenous fistulas for dialysis access. J Vasc Surg 2012;55:849–55.
Maintenance of arteriovenous access

Monitoring

• After KT monitor signs of access issues (pain, swelling, ↑ fistula size, aneurysms, change of palpable thrill.
• Any change should prompt contact with their transplant coordinator or nephrologist.

Evaluation

• Concern for access impairment evaluation should be performed.

• KT are off dialysis their renal function may still be abnormal, and the aim is to avoid any further insults.
• Initial test by ultrasound doppler noninvasive, does not need contrast, can identify area needs intervention
• Patient can then be referred for definitive diagnosis and treatment with an angiogram.

Angiogram

• Pre-procedure volume replacement: (ACR recommendation)

 3 ml/kg fluids (isotonic) for 1 hour prior and 1 ml/kg/h for 3 hours procedure.
 Diuretics can be held on the day of the procedure to limit hypovolemia.
• Minimize contrast usage: (to avoid kidney injury)
 CO2 injected into the fistula & images are obtained by fluoroscopy.
 CO2 is rapidly metabolized & not cause an air embolism.
 Once the lesion is determined, a small amount of contrast used to confirm lesion & result of angioplasty

1. Manual on Contrast Media. https://www.acr.org/-/media/ACR/Files/ClinicalResources/Contrast_Media.pdf;2018.

AKSES VASKULAR UNTUK PASIEN
GAGAL GRAFT
Vascular access for the patient with a failing graft

>30% of KT recipients return Kidney allograft failure In a transplant naïve ESRD patient
to dialysis within 5 years of  4th leading cause of  dialysis catheters associated with worse
transplantation. ESRD in US. prognosis than AV access

Laham et al. Among 34 previous KT recipients with failed

 KT recipients with failed graft who initiated allograft who needed vascular access for
dialysis through catheter, 6x increased risk of dialysis
mortality compared to AVF or graft  only 4 (11.7%) started hemodialysis with AVF

Among 683 KT recipients with failed allograft, who also needed

vascular access for HD 16,728 patients with a failed KT
 16% had AV access creation within 12 months before starting HD  2/3 started dialysis using a
venous catheter
 47% had AV access creation within 2 years of being on dialysis

1. LahamG, Pujol GS, Vilches A, Cusumano A, Diaz C. Nonprogrammed vascular access is associated with greater mortality in patients who return to hemodialysis with a failing renal graft. Transplantation 2017;101:2606–11.
2. [29] Sellares J, de Freitas DG, Mengel M, et al. Understanding the causes of kidney transplant failure: the dominant role of antibody-mediated rejection and nonadherence. Am J Transplant 2012;12:388–99.
3. [30] Lorenzo V, Martn M, Rufino M, Hernandez D, Torres A, Ayus JC. Predialysis nephrologic care and a functioning arteriovenous fistula at entry are associated with better survival in incident hemodialysis patients: an observational
cohort study. Am J Kidney Dis 2004;43:999–1007.
KESIMPULAN
Summary

Transplant
centers should
Peripheral IV establish a
Vascular Maintenance of
placement in culture of Only through a
access is an preexisting AV PICC lines
the Basilic and vascular combined effort
important access and have increased
Cephalic veins preservation can the goal of
element in the vessels for in the USA,
and PICC lines that involves vascular
overall care possible future >million PICCs
can damage education of preservation be
provided to KT access is placed annually
vessels for patient, achieved.
recipients. important
future access. transplant
team, and
hospital staff.
MATUR SUKSMA