Diagnosis and salvage of an immature fistula

A 45-year-old-white woman with chronic kidney disease stage V received a left radial-cephalic fistula in preparation for renal replacement therapy. Her past medical history was remarkable for hypertension, hypercholesterolemia, and anemia. The social history was unremarkable. Her medications included alteplase (5mg/day), amlodipine (10mg/day), atorvastatin (10mg/day), doxecalciferol ( 0.25 mg), and erythropoietin alpha (20000U subcutaneously every other week). Laboratory data are shown in Table 1. Three months later the patient required renal replacement therapy. Because the fistula was not considered adequate for cannulation by the dialysis staff, she received a right internal jugular-tunneled hemodialysis catheter to receive dialysis therapy ( 3 h three times a week with a blood flow rate of 360ml/min). Six weeks later, the patient was hospitalized with a febrile illness. Tunneled hemodialysis catheter was removed and the patient fully recovered with antibiotic therapy. She was discharged with a new catheter. Two months later, the patient was referred for difficulties during dialysis because of progressively decreasing blood flow. Thrombolytic treatments failed to correct the problem. Obliteration of the fibro-epithelial sheath with catheter exchange was performed to provide dialysis. At this point, the patient was referred to the surgeon for arteriovenous fistula evaluation. Six weeks later the patient was seen during rounds receiving hemodialysis successfully through a right forearm brachial-basilic loop graft. The arteriovenous fistula had been abandoned.