Dialysis Access in Patients with Systemic Lupus Erythematosus: A Single Institution Experience with a Challenging Patient Population
Eric B. Trestman, M.D., John Phair, M.D., Karan Garg, M.D., Evan C. Lipsitz, M.D., Larry A. Scher, M.D..
Montefiore Medical Center, Bronx, NY, USA.
To review our experience with dialysis access in patients with systemic lupus erythematosus (SLE) and chronic kidney disease (CKD) or end stage renal disease (ESRD) who required hemodialysis.
We performed a retrospective review of our prospectively collected institutional database for consecutive patients with SLE who underwent arteriovenous fistula(AVF) creation or arteriovenous graft (AVG) placement from 2009 through 2015. Only the initial index procedure was considered for review. Procedure and conduit choice was determined by surgeon preference and anatomic suitability. Primary endpoint was functional patency of the access which was defined as 3 successful dialysis cannulations.
Fifty-three patients with SLE and CKD or ESRD underwent access surgery and required hemodialysis. Mean age was 44.9 years and 45 (84.9%) were female. Thirty-eight (72.8%) patients had autologous access and 15 (27.2%) had AVG as their index procedure. Thirty-one (81.6%) of the autologous accesses were radiocephalic or brachiocephalic fistulae and 7 (18.4%) were basilic vein transpositions. Of the 13 AVG, 10 (76.9%) were performed with ePTFE and 3 (23.1%) with biologic conduits including bovine carotid and bovine mesenteric vein. In 41 patients (77.8%), the AVF or AVG was the initial access and 12 (22.2%) had prior dialysis access surgery outside of the study period. Forty-two (79.3%) patients initiated hemodialysis with a temporary or tunneled dialysis catheter. Three patients (5.6%) had prior peritoneal dialysis. Thirty-eight (71.7%) patients were on chronic corticosteroids at the time of index access procedure. Of the 38 AVF, 23 (60.5%) achieved functional patency with or without secondary intervention. Twelve of the thirteen (92.3%) grafts including all three biologic grafts were successfully used for hemodialysis. Seventeen (32.1%) of the overall patients went on to renal transplantation.
SLE is a relatively rare cause of CKD or ESRD. Patients with ESRD secondary to lupus nephritis are typically younger, have longer life expectancy and longer duration of dialysis. These patients can present a unique challenge in access surgery due to their chronic corticosteroid use, smaller native conduit caliber and overall low maturation rate. Despite the challenges of long term access in this patient population there remains a relatively low transplantation rate.
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