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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Current advances in nephrology and similar advances in other areas of medical knowledge mean that nephrologists must develop technical skills that are not provided by traditional training in nephrology&#46; We present a case that illustrates that fact&#46;</p><p class="elsevierStylePara">The patient in question is an 83 year old male in a conventional haemodialysis &#40;HD&#41; programme with chronic kidney disease secondary to diabetic nephropathy&#46; He had a history of type 2 diabetes mellitus with various diabetes-related complications&#44; arterial hypertension and atypical chest pain with no evidence of ischaemic heart disease&#46;</p><p class="elsevierStylePara">The patient started HD via a tunnelled catheter in February 2010&#44; with good haemodynamic tolerance and adaptation&#46; A left humeral-cephalic arteriovenous fistula &#40;AVF&#41; was created one month later&#46; Following a 30-day maturation period&#44; we began venipuncture in the AVF and observed suboptimal maturation&#44; difficult anatomical interpretation&#44; venous collapse&#44; &#180;frequent extravasations and impossibility of reaching a blood flow &#40;Qb&#41; greater than 250ml&#47;min&#46;</p><p class="elsevierStylePara">Given these findings&#44; we examined the vascular access &#40;VA&#41; with a portable vascular ultrasound machine &#40;EcoAVP&#41; in the HD room &#40;Figure 1&#41; and observed no stenosis in the arteriovenous fistula and a dual venous system with a collateral vessel branching off 3cm from the arterial anastomosis with a thickness similar to that of the two veins &#40;diameter&#58; 0&#46;39cm vs 0&#46;36cm&#59; area&#58; 0&#46;12 vs 0&#46;14cm<span class="elsevierStyleSup">2</span>&#41;&#46; We found 2 stenoses in the proximal part of the cephalic vein&#46;</p><p class="elsevierStylePara">The fistulography &#40;Figure 2&#41; confirmed the ultrasound findings&#44; a haemodynamically significant &#40;80&#37;&#41; stenosis at 10cm from the arteriovenous fistula and another smaller one in the proximal third of the cephalic vein&#46; Percutaneous angioplasty was performed on the 2 stenoses with good angiographic results&#46; The identified collateral vessel was not treated in any way&#46;</p><p class="elsevierStylePara">One month later&#44; the AVF had progressed well&#44; allowing for cannulation with no extravasations and an acceptable Qb rate&#46; A second image from the EcoAVP &#40;Figure 3&#41; confirmed the increase in the diameter and the cross-sectional area of the main vein &#40;diameter&#58; 0&#46;5cm&#44; area&#58; 0&#46;24cm<span class="elsevierStyleSup">2</span>&#41; with a decrease in the size of the collateral vessel &#40;diameter&#58; 0&#46;35&#44; area&#58; 0&#46;08cm<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p class="elsevierStylePara">One year later&#44; the AVF was functioning properly&#44; with a Qb of 350ml&#47;min and a normal venous pressure of 140mmHg&#46;</p><p class="elsevierStylePara">Table 1 shows the changes in some clinical parameters and ultrasound images taken after the treatment with percutaneous angioplasty&#46;</p><p class="elsevierStylePara">The use of an EcoAVP is not common in daily practice&#46; However&#44; it is very useful for approaching&#44; monitoring&#44; and diagnosing AVF complications&#46;<span class="elsevierStyleSup">1</span> Ultrasound provides both morphological and functional information in a fast&#44; reliable and non-invasive way&#44; which helps us determine whether percutaneous or surgical treatment is necessary&#46;<span class="elsevierStyleSup">2</span> The EcoAVP enables us to combine B-mode imaging&#44; which estimates vein volume&#44; the presence of haematomas&#44; parietal calcifications&#44; intraluminal thrombi&#44; collateral vessels and stenosis&#44; with the Colour Doppler mode&#44; which estimates blood flow&#44; peak systolic velocity&#44; the presence of turbulences&#44; and the shape of pulse waves with the corresponding resistance indices&#46;<span class="elsevierStyleSup">3</span> Ultrasound results must always be interpreted in conjunction with clinical findings&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">A broader view of the nephrologists&#8217; participation in decision-making would include using ultrasound for arterial and venous mapping&#44; which has been proven to increase success in surgical interventions&#44;<span class="elsevierStyleSup">4&#44;5&#44;6&#44;7</span> and estimated venous elastography as a tool that may predict AVF success &#40;limited evidence at present&#41;&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">At present&#44; guidelines do not set strict criteria for periodical ultrasound assessments of VA or recommend a time to initiate ultrasound monitoring&#46; In some studies&#44; the complications involved in VA failure&#44; which can be detected with a EcoAVP&#44; are present in AVF that still function normally&#46;<span class="elsevierStyleSup">8</span> On the other hand&#44; early dysfunction and primary failure in radiocephalic AVF and the frequent delayed maturation in diabetic patients leads us to recommend using a EcoAVP as a monitoring device for all patients on dialysis&#46;<span class="elsevierStyleSup">4</span> Considering the increased mean age of patients in dialysis units and data on the high number of complications at any level and any type of VA in elderly patients&#44;<span class="elsevierStyleSup">4&#44;9</span> we can state that training in ultrasound examinations should be included in the nephrological curriculum&#46; Active participation of nephrologists in the diagnosis and treatment of VA complications may reduce the number and duration of hospital stays associated with such problems&#44; reduce the use of venous catheters&#44; shorten waiting times for having an AVF&#44; reduce costs derived from diagnostic and therapeutic procedures&#44; and optimise prevention of complications in general&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Despite a certain amount of dependence on specialties such as vascular surgery or interventional radiology in this field&#44; the nephrologist is ultimately responsible for ensuring that the VA works correctly&#46; This responsibility requires strict monitoring and early treatment of VA complications in a multidisciplinary area that encounters frequent administrative obstacles&#46; Proper training in ultrasound examinations will enable professionals to make better treatment decisions in situations in which success depends upon swift action&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11109&#95;16025&#95;26372&#95;en&#95;11109&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11109_16025_26372_en_11109_t1.jpg" alt="Changes in certain study parameters following percutaneous transluminal angioplasty of the arteriovenous fistula"></img></a></p><p class="elsevierStylePara">Table 1&#46; Changes in certain study parameters following percutaneous transluminal angioplasty of the arteriovenous fistula</p><p class="elsevierStylePara"><a href="grande&#47;11109&#95;16025&#95;26374&#95;en&#95;11109&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11109_16025_26374_en_11109_f1.jpg" alt="First B-mode ultrasound image of the vascular access in which we see two veins of similar size"></img></a></p><p class="elsevierStylePara">Figure 1&#46; First B-mode ultrasound image of the vascular access in which we see two veins of similar size</p><p class="elsevierStylePara"><a href="grande&#47;11109&#95;16025&#95;26375&#95;en&#95;11109&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="11109_16025_26375_en_11109_f2.jpg" alt="Fistulography image taken after percutaneous angioplasty to both stenoses"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Fistulography image taken after percutaneous angioplasty to both stenoses</p><p class="elsevierStylePara"><a href="grande&#47;11109&#95;16025&#95;26376&#95;en&#95;11109&#95;f3&#46;jpg" class="elsevierStyleCrossRefs"><img src="11109_16025_26376_en_11109_f3.jpg" alt="Second B-mode ultrasound of the arteriovenous fistula showing an increase in cephalic vein size and decrease in the width of the collateral vessel"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Second B-mode ultrasound of the arteriovenous fistula showing an increase in cephalic vein size and decrease in the width of the collateral vessel</p>"
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