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Letters to the Editor cardiac arrest) (4). Although short-term usage was uneventful, the period of functionality of these catheters remains uncertain. Finally, the most difficult decision is how to proceed with the treatment in such cases. PLSVC can be considered and/or maintained as a potential site for a short-term hemodialysis catheter position after excluding the possibility of a coexistent cardiac shunt. Thus, PLSVC can be safely used for a shortterm HD, if the adequacy of hemodialysis is acceptable, but under careful and continuous monitoring of the patient. Physicians who place HD catheters in the left jugular vein should be aware of the existence, diagnosis and complications of PLSVC to prevent misinterpretation of the routine post-procedure chest X-ray, and unnecessary removal or repositioning of appropriately placed dialysis catheters. Conflict of interest: none declared. Financial support: none. Nihad Kukavica,1 Halima Resic,1 and Goce Spasovski2 1 Clinic for Hemodialysis, Clinical Center University of Sarajevo, Bosnia and Herzegovina; and 2University Department of Nephrology, Skopje, Macedonia Email: [email protected] REFERENCES 1. Povoski S, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol 2011;9: 173. 2. Denys BG, Uretsky BF, Reddy S. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external Landmark-Guided Technique. Circulation 1993;87:1557–62. 3. Jang YS, Kim SH, Lee DH, Kim DH, Seo AY. Hemodialysis catheter placement via a persistent left superior vena cava. Clin Nephrol 2009;71:448–50. 4. Stylianou K, Korsavas K, Voloudaki A et al. Can a left internal jugular catheter be used in the hemodialysis of a patient with persistent left superior vena cava? Hemodial Int 2007;11: 42–5.
Ankle Brachial Index in Hemodialysis Patients Dear Editor, We read the article “Ankle-Brachial Index and Cardiovascular Mortality in Nondiabetic Hemodia© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
113
lysis Patients” by Sebastjan Bevc et al. with interest (1). They aimed to determine the impact of the anklebrachial index (ABI) on cardiovascular (CV) mortality in non-diabetic hemodialysis (HD) patients. They demonstrated that low and high ABI were directly associated with higher mortality of non-diabetic HD patients. The ABI is a valuable diagnostic tool for peripheral arterial disease (PAD) (2). A low ABI has been demonstrated as a marker of predicting mortality in decreased renal function patients (3). Previous studies demonstrated an abnormal ABI is not only a marker of PAD but also a predictor of generalized atherosclerosis (2). Previously, the ABI was performed by measuring the systolic blood pressure from both brachial arteries and from both the dorsalis pedis and posterior tibial arteries after the patient has been at rest in the supine position for 10 min (4). ABI measurements were defined as the average systolic pressure of the right and left brachial artery (however, in case of discrepancies of ≥10 mm Hg, the higher reading was used). As nominators, different methods including the highest arterial ankle pressure of each leg, only the systolic pressure of the tibial posterior artery, only the systolic pressure of the dorsalis pedis artery, and the systolic pressure of the tibial posterior artery after exercise can be used in clinical practice. These data have shown that different methods for ABI determination clearly affect the estimation of PAD and mortality in all conditions (5). However, in the present study, the authors did not clearly define the methods of ABI measurement. Furthermore, some medications such as antihypertensive treatments, antiplatelet drug therapy and statins may influence ABI parameters (6). For this reason, the results might be different if the authors had mentioned cardiovascular risk factors in their study. As a conclusion, ABI deterioration is associated with higher mortality of non-diabetic HD patients as presented in the current study. However, one should be keep in mind that although ABI is the easiest, lowest-cost, reliable, noninvasive and most widely available parameter among the tested tools and could help detect the presence of subclinical atherosclerosis, further studies should examine the ABIrelated factors and true measurement methods of ABI. Sevket Balta, Sait Demirkol, Mustafa Demir, Cengiz Ozturk, and Turgay Celik Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey Email: [email protected]
Ther Apher Dial, Vol. 18, No. 1, 2014
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Letters to the Editor REFERENCES
1. Bevc S, Purg D, Turnšek N et al. Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients. Ther Apher Dial 2013;17:373–7. 2. Balta S, Balta I, Demirkol S, Cakar M, Sarlak H, Kurt O. Subclinical peripheral arterial disease and ankle-brachial index. Angiology 2013;64:395–6. 3. Balta S, Demirkol S, Yesil FG, Cakar M, Sarlak H, Celik T. Only ankle-brachial index may not be an accurate information about the prevalence of peripheral arterial disease. Angiology 2013; 64:481–2. 4. Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery. Circulation 2006;113:e463–654. 5. Lange SF, Trampisch H-J, Pittrow D et al. Profound influence of different methods for determination of the ankle brachial index on the prevalence estimate of peripheral arterial disease. BMC Public Health 2007;7:147. 6. Norgren L, Hiatt WR, Dormandy JA et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33(Suppl 1):S1–75.
Reply to Letter to the Editor Dear Editor, We thank Dr Sevket Balta et al. for their comments on our manuscript entitled “Ankle-Brachial Index and Cardiovascular Mortality in Nondiabetic Hemodialysis Patients” (1). We totally agree that clinicians should be aware that different methods for Ankle-Brachial Index (ABI) determination clearly affect the estimation of peripheral arterial disease and mortality in all conditions. Moreover, we also agree that some medications such as antihypertensive treatment, antiplatelet drug therapy and statins may influence ABI parameters. However, we would like to stress again that our study was performed on well-defined population of patients with end-stage renal disease. Furthermore, the measurements of ABI were done concerning
Ther Apher Dial, Vol. 18, No. 1, 2014
previously published and available studies on hemodialysis population at the time we started our study (2). Therefore, as we clearly discussed in our manuscript, before we started with our study, there were no standard protocols for ABI measurement. The American Heart Association released their recommendations for the use of ABI in scientific reports after our study was already concluded (3). Additionally, also vascular access should be kept in mind when deciding where to measure ABI in hemodialysis population. Despite some limitation of ABI measurement, the conclusions of our study cannot be simply overlooked. We suggest to measure the ABI in all hemodialysis patients for a better risk estimation in this high-risk population and to commence preventive treatment of other modifiable risk factors to increase these patients’ survival and quality of life. Finally, some new ABI devices, like automated ankle-brachial index measuring device (ABPI MD) based on oscillometric method, could help us to have a more simple, accurate and objective screening tool for the diagnosis of peripheral arterial disease. Sebastjan Bevc, Robert Ekart, and Radovan Hojs Clinic for Internal Medicine, Departments of Nephrology and Dialysis, University Medical Center Maribor, Maribor, Slovenia Email: [email protected] REFERENCES 1. Bevc S, Purg D, Turnsek N et al. Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients. Ther Apher Dial 2013;17:373–7. 2. Su HM, Chang JM, Lin FH et al. Influence of different measurement time points on brachial-ankle pulse wave velocity and ankle-brachial index in hemodialysis patients. Hypertens Res 2007;30:965–70. 3. Aboyans V, Criqui MH, Abraham P et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012;126: 2890–909.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Letters to the Editor cardiac arrest) (4). Although short-term usage was uneventful, the period of functionality of these catheters remains uncertain. Finally, the most difficult decision is how to proceed with the treatment in such cases. PLSVC can be considered and/or maintained as a potential site for a short-term hemodialysis catheter position after excluding the possibility of a coexistent cardiac shunt. Thus, PLSVC can be safely used for a shortterm HD, if the adequacy of hemodialysis is acceptable, but under careful and continuous monitoring of the patient. Physicians who place HD catheters in the left jugular vein should be aware of the existence, diagnosis and complications of PLSVC to prevent misinterpretation of the routine post-procedure chest X-ray, and unnecessary removal or repositioning of appropriately placed dialysis catheters. Conflict of interest: none declared. Financial support: none. Nihad Kukavica,1 Halima Resic,1 and Goce Spasovski2 1 Clinic for Hemodialysis, Clinical Center University of Sarajevo, Bosnia and Herzegovina; and 2University Department of Nephrology, Skopje, Macedonia Email: [email protected] REFERENCES 1. Povoski S, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol 2011;9: 173. 2. Denys BG, Uretsky BF, Reddy S. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external Landmark-Guided Technique. Circulation 1993;87:1557–62. 3. Jang YS, Kim SH, Lee DH, Kim DH, Seo AY. Hemodialysis catheter placement via a persistent left superior vena cava. Clin Nephrol 2009;71:448–50. 4. Stylianou K, Korsavas K, Voloudaki A et al. Can a left internal jugular catheter be used in the hemodialysis of a patient with persistent left superior vena cava? Hemodial Int 2007;11: 42–5.
Ankle Brachial Index in Hemodialysis Patients Dear Editor, We read the article “Ankle-Brachial Index and Cardiovascular Mortality in Nondiabetic Hemodia© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
113
lysis Patients” by Sebastjan Bevc et al. with interest (1). They aimed to determine the impact of the anklebrachial index (ABI) on cardiovascular (CV) mortality in non-diabetic hemodialysis (HD) patients. They demonstrated that low and high ABI were directly associated with higher mortality of non-diabetic HD patients. The ABI is a valuable diagnostic tool for peripheral arterial disease (PAD) (2). A low ABI has been demonstrated as a marker of predicting mortality in decreased renal function patients (3). Previous studies demonstrated an abnormal ABI is not only a marker of PAD but also a predictor of generalized atherosclerosis (2). Previously, the ABI was performed by measuring the systolic blood pressure from both brachial arteries and from both the dorsalis pedis and posterior tibial arteries after the patient has been at rest in the supine position for 10 min (4). ABI measurements were defined as the average systolic pressure of the right and left brachial artery (however, in case of discrepancies of ≥10 mm Hg, the higher reading was used). As nominators, different methods including the highest arterial ankle pressure of each leg, only the systolic pressure of the tibial posterior artery, only the systolic pressure of the dorsalis pedis artery, and the systolic pressure of the tibial posterior artery after exercise can be used in clinical practice. These data have shown that different methods for ABI determination clearly affect the estimation of PAD and mortality in all conditions (5). However, in the present study, the authors did not clearly define the methods of ABI measurement. Furthermore, some medications such as antihypertensive treatments, antiplatelet drug therapy and statins may influence ABI parameters (6). For this reason, the results might be different if the authors had mentioned cardiovascular risk factors in their study. As a conclusion, ABI deterioration is associated with higher mortality of non-diabetic HD patients as presented in the current study. However, one should be keep in mind that although ABI is the easiest, lowest-cost, reliable, noninvasive and most widely available parameter among the tested tools and could help detect the presence of subclinical atherosclerosis, further studies should examine the ABIrelated factors and true measurement methods of ABI. Sevket Balta, Sait Demirkol, Mustafa Demir, Cengiz Ozturk, and Turgay Celik Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey Email: [email protected]
Ther Apher Dial, Vol. 18, No. 1, 2014
bs_bs_banner
114
Letters to the Editor REFERENCES
1. Bevc S, Purg D, Turnšek N et al. Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients. Ther Apher Dial 2013;17:373–7. 2. Balta S, Balta I, Demirkol S, Cakar M, Sarlak H, Kurt O. Subclinical peripheral arterial disease and ankle-brachial index. Angiology 2013;64:395–6. 3. Balta S, Demirkol S, Yesil FG, Cakar M, Sarlak H, Celik T. Only ankle-brachial index may not be an accurate information about the prevalence of peripheral arterial disease. Angiology 2013; 64:481–2. 4. Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery. Circulation 2006;113:e463–654. 5. Lange SF, Trampisch H-J, Pittrow D et al. Profound influence of different methods for determination of the ankle brachial index on the prevalence estimate of peripheral arterial disease. BMC Public Health 2007;7:147. 6. Norgren L, Hiatt WR, Dormandy JA et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33(Suppl 1):S1–75.
Reply to Letter to the Editor Dear Editor, We thank Dr Sevket Balta et al. for their comments on our manuscript entitled “Ankle-Brachial Index and Cardiovascular Mortality in Nondiabetic Hemodialysis Patients” (1). We totally agree that clinicians should be aware that different methods for Ankle-Brachial Index (ABI) determination clearly affect the estimation of peripheral arterial disease and mortality in all conditions. Moreover, we also agree that some medications such as antihypertensive treatment, antiplatelet drug therapy and statins may influence ABI parameters. However, we would like to stress again that our study was performed on well-defined population of patients with end-stage renal disease. Furthermore, the measurements of ABI were done concerning
Ther Apher Dial, Vol. 18, No. 1, 2014
previously published and available studies on hemodialysis population at the time we started our study (2). Therefore, as we clearly discussed in our manuscript, before we started with our study, there were no standard protocols for ABI measurement. The American Heart Association released their recommendations for the use of ABI in scientific reports after our study was already concluded (3). Additionally, also vascular access should be kept in mind when deciding where to measure ABI in hemodialysis population. Despite some limitation of ABI measurement, the conclusions of our study cannot be simply overlooked. We suggest to measure the ABI in all hemodialysis patients for a better risk estimation in this high-risk population and to commence preventive treatment of other modifiable risk factors to increase these patients’ survival and quality of life. Finally, some new ABI devices, like automated ankle-brachial index measuring device (ABPI MD) based on oscillometric method, could help us to have a more simple, accurate and objective screening tool for the diagnosis of peripheral arterial disease. Sebastjan Bevc, Robert Ekart, and Radovan Hojs Clinic for Internal Medicine, Departments of Nephrology and Dialysis, University Medical Center Maribor, Maribor, Slovenia Email: [email protected] REFERENCES 1. Bevc S, Purg D, Turnsek N et al. Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients. Ther Apher Dial 2013;17:373–7. 2. Su HM, Chang JM, Lin FH et al. Influence of different measurement time points on brachial-ankle pulse wave velocity and ankle-brachial index in hemodialysis patients. Hypertens Res 2007;30:965–70. 3. Aboyans V, Criqui MH, Abraham P et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012;126: 2890–909.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
