Background: Stenosis represents the main cause of hemodialysis fistula malfunction. The ultrasound-guided angioplasty with ecographic contrast (CEUS) could provide further advantages to the classical ultrasound guided method improving the morphological characterization of the stenosis and providing quantitative data with the creation of time intensity curves (TIC) collecting functional data comparable between pre and post procedure. Methods: A total of 10 CEUS-guided angioplasties were performed on malfunctioning fistulas. The sonographic contrast medium was injected into the vascular tree trough the introducer. Morphological and functional data nature were collected. Were generated TIC curves, obtained by positioning a ROI in correspondence with the post-stenotic tract of the efferent vein. The data collected, regarding the peak intensity reached by the signal (PI) and the time to reach the peak signal intensity (TTP), were compared in the pre and post-procedural phase with flow of vascular access (Qa) and resistance indices (RI). Results: Statistically significant correlation ( p < 0.05) was observed between Qa and TTP ( r = 0.77; p = 0.009), RI and TTP ( r = 0.71; p = 0.02), Qa and PI ( r = 0.86; p = 0.0012), and between RI and PI ( r = 0.88; p < 0.001). Conclusion: In addition to the advantages associated with the use of ultrasound contrast medium in improving the visualization and characterization of the stenosis by facilitating the PTA procedure, the functional data deriving from the quantitative analysis provide new parameters for evaluating the success of the procedure which could also be used as predictive markers of stenosis recurrence together with the classical ones.

The first-choice vascular access for starting dialysis is autogenous distal forearm arteriovenous-fistula (AVF); the increasing demand to create more fistulas may lead to their creation in borderline vessels and, in this setting, the early failure (EF) and failure of maturation (FTM) remain the main issues. The size of vessels or preexisting stenotic lesions of artery or vein are no longer considered absolute exclusion criteria for the creation of distal AVF, but huge arterial calcification still represents an indication to create upper arm AVF. A novel approach to treat arterial calcifications is represented by intravascular lithotripsy (IVL). This technique could represent a valid option to save failed to mature AVF due to extended calcified artery. We describe a case of a male patient, 43 years old with middle forearm AVF failed to mature with a completely calcified radial artery, low brachial flow (Qa) and small efferent vein. We treated the patient AVF with less invasive, percutaneous, endovascular, eco-guided IVL on the entire radial artery. After the procedure was observed a rapid increase of Qa, with reduction of calcification in the arterial wall, increase of arterial caliper and flow. This procedure could represent a valid alternative to surgical upper-arm AVF creation in patient with functioning but failed to mature fistula due to spread artery calcification, with a rapid, less invasive procedure.

BACKGROUND AND AIMS SARS-CoV-2 pandemic is pressuring healthcare systems worldwide. Disease outcomes in certain subgroups of patients, such as nephropathic patients, are still scarce. Patients with chronic kidney disease (CKD) and on haemodialysis (HD) are at risk of a more severe disease course and worst outcomes. Here, we aimed to describe the characteristics and outcomes of CKD and HD patients with SARS-CoV-2 infection, admitted to the Covid Nephrology Unit in the first three pandemic waves, analysing mortality rate and risk factors for mortality in this subgroup of patients. METHOD A Covid Nephrology Unit was organized in March 2020 to manage the high number of CKD and HD patients with SARS-CoV-2 infection. Several ‘spoke’ units were also set to manage HD asymptomatic patients (Hi Hotel and ‘Villa Luce’ Dialysis Center) or with mild symptoms (‘Miulli Hospital’-Acquaviva delle Fonti and ‘Fallacara Hospital’—Triggiano). Clinical and laboratory data in several timepoints were collected using electronic medical records. Primary outcome was to assess the mortality rate. Moreover, we analysed the trend of inflammatory markers in the first 7 days after hospital admission between survivors and non-survivors; finally, risk factors for mortality were analysed by logistic regression. RESULTS From March 2020 to May 2021, a total of 221 patients were admitted to the Covid Nephrology Unit; among these, 112 patients on chronic haemodialysis, 21 with acute kidney injury (AKI), 58 with CKD, 24 kidney transplant recipients and 6 patients on peritoneal dialysis (PD). Median age was 71 years (IQR 62.5–80), while male gender predominated (61.5%). Main comorbidities were arterial hypertension (81%), diabetes mellitus (41.8%) and cardiovascular disease (CVD, 60.6%). At admission, 13.2% of patients required non-invasive ventilatory (NIV) support (CPAP, BiPAP) and about 60% presented interstitial pneumonia at CT scan. A total of 80 patients (36.1%) died during hospital stay with a medium length of stay of 15.8 days. In the first 7 days, 29 patients presented respiratory failure requiring transfer to ICU. Conversely, 100 patients were discharged at home, while 48 patients were transferred to the spoke units (39 patients at Miulli and Fallacara Hospitals, 9 patients at Hi Hotel). Compared to survivors, patients who died were older (median age 75.5 versus 66 years, P &lt; .001), characterized by more comorbidities (diabetes mellitus 54.5% versus 35.2%, P = .01; CVD 81.1% versus 51.4%, P &lt; .001; chronic obstructive pulmonary disease (COPD, 41.5% versus 19%, P = .01; peripheral vasculopathy 58.4% versus 34.2%, P = .01) and more severe respiratory compromission at hospital admission (patients in NIV, 22.6% versus 8.1%, P = .005). As shown in Table 1, in the first 7 days of hospital stay, a significant increase in WBC (8.29 versus 12.6 × 106P &lt; .001) was described in the non-survivor group; similarly, inflammatory markers such as CRP and IL-6 did not improve in the non-survivors at day 7 (CRP 81.8 versus 85.7 mg/L, P = .62; IL-6 63.1 versus 79.4 pg/mL, P = .84), while they significantly improved in survivors (median CRP 42.5 versus 10.1 mg/L, P &lt; .001; median IL-6 32.3 versus 13.7 pg/mL, P = .01). In a multivariate logistic regression model, age (OR 1.062, 95% CI 1.007–1.119, P = .025), history of CVD (OR 8.308, 95%CI 1.704–40.499, P = .009) and dyspnoea at hospital admission (OR 9.465, 95%CI 1.231–72.79, P = .031) were associated with risk of mortality in this population. CONCLUSION To our knowledge, this is the largest study analyzing characteristics and outcomes of CKD and hemodialysis patients to date. A wide heterogeneity of severity of disease has been documented in our cohort; we documented a higher mortality rate in this cohort of patients compared to general population. The presence of several comorbidities, a more severe disease at hospital admission and the persistence of elevated inflammatory markers during hospital stay are risk factors for mortality.