Steal syndrome is a feared complication of dialysis vascular access in a population becoming older and frailer. The aim of this study was to determine the predictor factors of steal syndrome. All proximal arteriovenous fistulas (AVFs), patent at day 30, inserted between January 2008 and December 2009 were studied. Data on age, gender, diabetes mellitus (DM) status, presence of coronary or peripheral artery disease, date of initiation of renal replacement therapy, date of access construction, localization, type of anastomosis, previous interventions, and outcome for AVF and patients were analyzed. There were 324 AVFs placed into 309 individual patients. The mean age was 66.7 ± 15.3 years, and the majority (53.7%) of the patients was male. Mean follow-up of all 324 fistulas was 18.6 ± 8.5 months. During follow-up, steal syndrome occurred in 26 (8%) of the AVFs. Univariate analysis revealed correlations between steal syndrome and DM (P = 0.002), brachiomedian fistulas (P = 0.016), and side-to-side (STS) anastomosis (P = 0.003). However, in multivariate analysis, the presence of DM, STS anastomosis, and female gender were found to be the independent risk factors. The strongest predictive factor was DM (odds ratio: 6.7; 95% confidence interval: 2.5-17.9). Being diabetic is the factor most predictive of having steal syndrome. In diabetic women, with a proximal access, it seems preferable to construct fistulas with end-to-side anastomosis to minimize the risk.

Classical familial amyloid polyneuropathy may have a course with progressive renal impairment. We studied 62 patients (24 males, 38 females) with FAP, transthyretin variant V30M, and end-stage renal disease (ESRD) treated with hemodialysis, all referred to a single center over a period of 11 years. Clinical course, morbidity and survival after dialysis were analyzed. Patient's mean age at first dialysis was 51.5 +/- 10.7 years, and mean duration of neuropathy was 10.2 +/- 3.8 years. The most frequent form of presentation of FAP nephropathy was nephrotic proteinuria with renal dysfunction. In the year prior to dialysis, renal function declined rapidly, and fluid overload was the main indication to initiate treatment. The presence of decubitus ulcers, significant disability, venous catheter for definitive vascular access for long-term treatment, and permanent bladder catheter, were related to death during the first year of dialysis. The mean duration of renal replacement therapy was 21 months, with a 54.5% one year, and 38.4% two year treatment survival. However, when the duration of neurological symptoms at first dialysis exceeded 10 years, survival was significantly lower. Infections, (41% were decubitus ulcers with sepsis) were the cause of early, as well as late mortality. Early creation of vascular access for hemodialysis, surveillance of skin wounds, and intervention on neurogenic bladder are essential to improve the prognosis of ESRD in FAP.

C ARDIOVASCULAR disease (CVD) is a major cause of morbidity and mortality after renal transplantation (RT). 1,2 The excess risk of CVD in RT is due in part to a higher prevalence of established atherosclerotic risk factors, including hypertension, dyslipidemia, diabetes, obesity, and physical inactivity. 1,2 However, some renal-related risk factors like immunosuppressive medication and residual renal insufficiency also contribute to this excess CVD risk and may complicate the management of dyslipidemia and hypertension in this population. 1,2 Accordingly, there is a compelling need to identify and safely manage other putative CVD risk factors among RT patients. Elevated plasma homocysteine is emerging as an important risk factor for cardiovascular disease in general populations. 3,4 Some studies have demonstrated that hyperhomocysteinemia is present in patients with impaired renal function and is associated with CVD. 5-7 Only a small number of studies are available on the prevalence and determinants of hyperhomocysteinemia in renal transplant recipients. 8 -15 We undertook this study to 1. estimate the prevalence of hyperhomocysteinemia in renal transplant recipients; 2. examine the relationships between plasma total homocysteine (tHcy) and its metabolic determinants vitamin B 6 , vitamin B 12 , and folic acid; and 3. identify other determinants of tHcy. MATERIALS AND METHODSA cross-sectional study was conducted in 202 stable RT recipients (113 male, 89 female), selected from 633 RT patients with functioning allografts of our Renal Transplant Unit. All recipients received grafts from cadaver donors. The eligibility criteria were: age over 18 years, first renal allograft, time since RT of at least 6 months, and stable plasma creatinine values during 3 months prior to study. Patients with diagnosis of any kind of cancer, clinical or analytical evidence of liver disease, and chronic alcoholism were also excluded. None of the selected RT recipients were taking B vitamin.The mean age was 44 Ϯ 11 years (range, 21 to 71; median, 43). The mean duration after renal transplantation was 58.5 Ϯ 37.2 months (range, 17 to 192; median, 50.6). Patients had been on dialysis for an average of 42.7 Ϯ 37.5 months (range, 0 to 221; median, 30.5) before transplantation. Mean serum creatinine value was 1.5 Ϯ 0.6 mg/dL (range, 0.6 to 4.7; median, 1.4) at the time blood was drawn for this study. Immunosuppression protocol of the 202 RT patients is described on Table 1.The Ethics Committee of Santo Antonio Hospital approved the study protocol, and all participants provided written informed consent. Biochemical DeterminationsOvernight fasting blood samples were collected from each participant. Total fasting homocysteine levels were determined by polarized immunofluorescence on an automated Abbott IMx analyzer. Hyperhomocysteinemia was considered if plasma levels of fasting tHcy were higher than 15 mol/L. Plasma pyridoxal 5Ј-phosphate was determined by high performance liquid chromatography with fluorescence detection. Plasma vitamin B 12...

We concluded that low-dose simvastatin and fish oil are both effective and safe in correcting post-RT hyperlipidaemia. Further prospective studies with larger follow-up are needed to clarify whether this therapy has an impact on cardiovascular morbidity and mortality in RT patients.

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