Most Vital Persistent Problems of Arteriovenous Fistulas for Hemodialysis – FullText – Medical Rules and Follow 2013, Vol. 22, No. 3

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Summary

The purpose of this evaluate was to spotlight crucial issues of arteriovenous fistulas (AVFs) for hemodialysis (HD). The standard of vascular entry for HD ought to be appropriate for repeated puncture and permit a excessive blood circulate price for high-efficiency dialysis with minimal issues. The dialysis employees should be effectively versed in manipulation of the AVF, and there ought to be a minimal want for corrective interventions. Building of an AVF creates circumstances for rising the circulate of blood by the venous system. Achievement of those circumstances reduces the danger of turbulence and endothelium harm, which, in flip, minimizes the potential for stenosis. An AVF is closest to the best mannequin of vascular entry. An important issues of fistulae for HD are lymphedema, an infection, aneurysm, stenosis, congestive coronary heart failure, steal syndrome, ischemic neuropathy and thrombosis. In HD sufferers, the most typical reason for vascular entry failure is neointimal hyperplasia. You will need to achieve details about early scientific signs of AVF dysfunction as a way to stop and adequately deal with potential issues.

© 2012 S. Karger AG, Basel


Introduction

A shift within the remedy of hemodialysis (HD) sufferers occurred when James E. Cimino famous that arteriovenous fistulas (AVFs) brought on by trauma in Korean battle veterans didn’t have important results on their well being. This led to his proposal that AVFs could be a great answer for simple entry to the circulation in sufferers on HD [1,2,3].

For the reason that Facilities for Medicare & Medicaid Companies acknowledged the scientific and financial benefits of AVFs, the Nationwide Kidney Basis’s Kidney Illness Outcomes High quality Initiative (KDOQI) and the Fistula First Initiative have made rising the prevalence of AVFs a precedence [4]. A number of research point out that about 30% of hospitalizations are brought on by the development and issues of vascular entry [5]. The annual price of sustaining vascular entry is round USD 600 for AVFs as much as as a lot as USD 5,000 for arteriovenous grafts (AVGs). Excessive prices of implementation and upkeep of vascular entry could come up from occasional diagnostic procedures, which additional improve the annual prices of USD 1,020 for AVFs and USD 1,610 for AVGs, which signify 14-20% of complete well being care prices for dialysis sufferers [4,5,6,7,8]. However, well timed formation of AVFs diminished the mortality price by 1.72 occasions [6].

The standard of vascular entry for HD ought to be appropriate for repeated puncture and permit a quick blood circulate price for high-efficiency dialysis with minimal issues. Subsequently, a long-term functioning AVF wants a well-trained surgeon to create it and sufficient time allowed for maturation. The dialysis employees should be effectively versed in cannulation of the AVF, and there ought to be a minimal want for corrective interventions. But it should be acknowledged that, beneath the current circumstances, a great strategy actually doesn’t exist [9,10].

European good scientific observe pointers for vascular entry recommend preservation of the venous system and that every one sufferers who’re dedicated to HD remedy have already got a longtime vascular entry in the beginning of dialysis. Early referral of sufferers to a nephrologist is just not solely essential to protect the blood vessels, but additionally has psychological significance within the preparation for dialysis remedy, permits identification of doable choices for dialysis modalities and allows correction of the anemic syndrome, hypertension and metabolic issues. Endurance, belief and compromise between medical doctors, sufferers and the dialysis employees ought to result in profitable placement of vascular entry [11,12,13,14,15]. Most pointers suggest evaluation of sufferers for entry creation on the CKD 4 stage. A fistula ought to be positioned no less than 6 months earlier than the anticipated begin of HD remedies [16].

Is There a Contraindication to the Creation of Vascular Entry?

When AVFs have been launched into routine scientific observe, solely individuals youthful than 40 years with persistent renal failure as a consequence of diabetes mellitus have been thought-about unsuitable for any type of remedy. Nonetheless, these days, along with the aged and diabetics, sufferers affected by congestive coronary heart failure are thought-about to be danger teams for the creation of vascular entry. Absolute contraindications to this are amputation of extremities and superior peripheral artery illness with consecutive necrosis. Nonetheless, the ultimate resolution on the standard of the vasculature is made after a noninvasive coloration Doppler ultrasound examination [3].

Problems throughout and Instantly after Surgical Intervention

Surgical Points

The selection of operative approach for anastomosis has its personal traits and it’s a crucial process as a way to keep away from sure surgical issues. Finish-to-end anastomosis requires a formidable surgical approach, particularly when there’s a discrepancy between the lumen of the arteries and veins. This will result in ischemia of the distal extremities, particularly within the aged and sufferers with diabetes mellitus. Aspect-to-side anastomosis is technically simpler and will be performed if the blood vessels are shut to one another. It should be famous that this kind of anastomosis could result in improvement of venous hypertension. At the moment, essentially the most acceptable choice is end-to-side anastomosis [3,8,11].

AVF building creates circumstances for rising the circulate of blood by the venous system. Earlier than surgical procedure, systemic venous stress is about 20 mm Hg, however instantly afterwards it will increase to between 60 and 120 mm Hg. Subsequently, when making the anastomosis, it is very important keep away from the potential for creating obstacles to blood circulate. One shouldn’t make an acute angle, longitudinally rotate the veins, or change their anatomical place. Achievement of those circumstances reduces the danger of turbulence and endothelium harm, which, in flip, minimizes the potential for stenosis. Surgical issues will be outlined as issues in the course of the intervention as a result of discrepancies between the lumen diameters of the arteries and veins, narrowing of the anastomosis, broken intima media, or interposition of adventitia and the remaining collateral [12].

It’s noteworthy that the routine software of antibiotics is just not acceptable. It’s also necessary to notice that there is no such thing as a consensus on indications for the formulaic software of anticoagulant remedy as a result of surgical errors can’t be corrected by pharmacotherapy [12]. Instantly after surgical procedure, hemorrhage, low venous circulate or hematoma could happen. At a later stage, there could also be issues, equivalent to infections, the event of an aneurysm and/or false aneurysm, fistula vein stenosis, congestive coronary heart failure, steal syndrome, ischemic neuropathy and thrombosis (desk 1).

Desk 1

Medical options and incidence of the most typical issues of AVFs

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Creation and upkeep of vascular entry can’t exclude the incidence of lymphedema.

Infections

An infection accounts for 20% of all AVF issues [17], which is ten occasions decrease than the speed of an infection of AVGs [18,19]. Most AVF infections contain perivascular cellulitis, which manifests as localized erythema and edema and is normally simply handled. Far more severe is an an infection related to anatomical abnormalities, equivalent to aneurysms, hematomas or abscesses, which require surgical excision and drainage [17].

Totally different scientific and microbiological traits could point out AVF an infection. Medical suspicion arises after seen indicators of irritation on the vascular entry puncture website (calor, dolor and rubor) with or with out systemic manifestations. Localized infections occurring after AVF puncture are handled with acceptable antibiotics based mostly on the outcomes of swab and blood cultures. AVF infections are very uncommon and most often reply effectively to antibiotic remedy, lasting 4-6 weeks. A ligature of the AVF is required solely when it turns into a supply of recurrent septic pulmonary embolism [17,19].

Aneurysmal Enlargement of Blood Vessel Partitions

An aneurysm is a pathological enlargement of the blood vessel wall ensuing from repetitive puncture [14]. False aneurysms are hematomas positioned outdoors the vessel wall, fashioned as a result of a leaking gap within the artery, most frequently as a result of iatrogenic trauma – primarily repeated needle punctures [20]. Shade Doppler ultrasound can differentiate false-aneurysm growth from a hematoma, the presence of a thrombotic mass, which allows a choice to be made on doable surgical correction. Surgical intervention is really useful when there’s a danger of perforation and ulceration if there are components of bleeding or if there’s a restricted place for puncture due to the dimensions of the aneurysm [21].

Stenosis

Thrombosis is an important reason for lack of operate of an AVF. It normally happens close to a stenosis within the space of anastomosis or fistula vein. Uremic components equivalent to homocysteine or endogenous inhibitors of NO synthase (uneven dimethylarginine) could possibly be straight poisonous to the vascular endothelium [22]. In sufferers with end-stage renal illness, along with the impaired vasodilatation of capacitance vessels as a result of endothelial dysfunction, diminished venous distensibility happens [23]. Vein wall distensibility is managed by collagen, elastin and easy muscle. Wali et al. [24 ]demonstrated accumulation of collagen fibers rather than easy muscle cells in preaccess cephalic veins, inflicting a lower within the elasticity of the vein wall. This course of reduces the useful properties of forearm blood vessels, and thus interferes with the correct maturation of the AVF. The danger of thrombosis will increase with the diploma of stenosis. KDOQI pointers outline important stenosis of the vessel lumen as a discount by greater than 50%. Medical suspicion of stenosis is confirmed by the presence of a number of components: diminished high quality of dialysis, issues with puncture, equivalent to extended bleeding after AVF puncture, ache within the space of the fistula or elevated venous stress. Recirculation is a vital situation because it seems to be a major reason for insufficient HD. The commonest trigger is the presence of high-grade venous stenosis, which hinder venous outflow, resulting in backflow into the arterial needle. Recirculation is identified when dialyzed blood returning by the venous aspect reenters the dialyzer by the arterial needle somewhat than returning to the systemic circulation, and in consequence, the effectivity of HD is diminished [14]. It should be identified that stenosis could also be as a result of extraluminal compression by an abscess, hematoma or seroma. The height systolic velocity in Doppler ultrasound is used to find out the existence of stenosis. Values higher than 400 cm/s point out the presence of stenosis; a month-to-month decline in circulate by 20-25% can also be thought-about important for this kind of complication. Angiography is a dependable approach for figuring out stenosis however is dearer and technically demanding. Remedy entails balloon dilatation of the stenosis, stent implantation or surgical revision [12,20]. Percutaneous transluminal angioplasty (PTA) within the remedy of vascular entry stenosis improves fistula operate and prolongs fistula survival in sufferers with shorter lesions (<1 cm), however restenosis stays the most important downside. Though percutaneous interventions are much less invasive than surgical revision for preserving vascular entry, long-lasting PTA outcomes haven't been demonstrated to be helpful. Concerted efforts of nephrologists, interventional radiologists and surgeons are key to sustaining and prolonging operate of the vascular entry [12,25,26,27].

Impression of AVFs in Coronary heart Failure

Some authors consider that cardiac decompensation in sufferers with AVFs happens solely in people with beforehand persistent coronary heart illness. Preliminary knowledge present a development in the direction of left ventricular hypertrophy (LVH) in sufferers with an AVF [28] circulate exceeding 2,000 ml, however there aren’t any pointers about doable interventions within the AVF to forestall the incidence of coronary heart failure [29]. Cardiovascular issues are the main reason for demise in sufferers on HD, and LVH is the most typical cardiac change in sufferers with end-stage renal failure, which is noticed in 74% of sufferers in the beginning of HD remedy, in all probability on account of adaptation to the hemodynamic adjustments after shunt creation [30,31]. Improvement and development of LVH in HD sufferers is advanced and sometimes multifactorial; pathogenetic components embody quantity overload, creation of an AVF, anemia and stress overload. LVH is an adaptive response to elevated cardiac workload that has short-term helpful results on cardiac operate however long-term detrimental penalties [31,32].

The mechanisms of hemodynamic compensation in HD sufferers are very advanced and contain, amongst different issues, diminished vascular resistance and arterial dilatation on account of elevated blood circulate and the formation of collaterals. Though AVFs have a detrimental impact on cardiac operate, the precise function of the vascular entry is just not sufficiently clear. It’s assumed that the development of an AVF will increase cardiac output by 15% and end-diastolic ventricular stress by 4% [30].

There aren’t any important research that might point out the incidence of LVH after AVF creation. Particular person leads to small cohorts of sufferers point out that the speed of LVH is between 12.2 and 17% [33,34]. In a state of affairs when coronary heart failure is just not etiologically clear sufficient, stimulation of natriuretic peptide synthesis by the AVF will increase intravascular quantity, which can be a predictive parameter of mortality in these sufferers. Earlier research confirmed that plasma ranges of B-type natriuretic peptide (as a marker of quantity overload/left ventricle distension) elevated in LVH after creation of an AVF [35] and within the short-term [36]. Sadly, there is no such thing as a legitimate proof that closing fistulas reduces cardiovascular danger as a result of this could require numerous respondents. Accessible knowledge recommend that after ligation of the AVF, adjustments within the architectonics of the left ventricle don’t present the anticipated helpful impact [30].

Vascular Entry-Induced Ischemia

A developed AVF may cause diminished blood circulate distal to the arteriovenous anastomosis, which ends up in hypoxia, ischemia and necrosis. The danger of ischemia and the emergence of this syndrome, recognized within the literature because the steal syndrome, are particularly excessive in diabetics and aged individuals. Medical indicators embody diminished motion of the wrist with a way of coldness within the hand and a coloration change to pale yellow, or purple, ache at relaxation and through train and peripheral necrosis [37]. Low resistance within the system of fistula veins and retrograde circulate within the space of the palmar arch jeopardize satisfactory perfusion of the fingers. There’s proof that the steal syndrome in danger teams could happen in 75-90% of sufferers after creation of an AVF. This phenomenon stays clinically asymptomatic till the second when compensatory mechanisms for perfusion by peripheral arteries are exhausted [38].

Usually, an AVF doesn’t compromise perfusion of the hand [39]. Nonetheless, 1.6-8% of sufferers develop unilateral ischemia of the hand [40]. On the whole, for the incidence of ischemia within the hand with a fistula, sure circumstances are required: primarily, diminished blood circulate by the arterial system as a result of arterial occlusive illness proximal or distal from the arteriovenous anastomosis. The steal syndrome could come up from extreme blood circulate by a dilated blood vessel along with inadequate vascular adaptation and diminished collateral perfusion. This ischemia is usually gentle, however extreme long-term hypoperfusion results in tissue necrosis requiring amputation of fingers and/or forearm in 1% of sufferers [39]. Pathophysiological mechanisms of vascular access-induced distal ischemia are advanced and never well-known. Signs of arterial blood diversion are extra widespread in sufferers with diabetes mellitus and people who smoke [41,42]. Vascular access-induced hand ischemia is a standard scientific symptom, maybe 1 in 500 instances, almost definitely because of the wealthy collateral vascular community and small muscle mass. Knowledge within the literature recommend that symptomatic ischemia develops in 10-25% of sufferers with brachiocephalic and brachiobasilic vascular entry, 4-6% on the degree of the forearm and 1-2% on the radiocephalic degree [43]. Because of the rising age of sufferers on HD in addition to a rising variety of comorbidities, the incidence of hand ischemia is considerably rising. It’s assumed that sooner or later, the frequency of those ischemias will rise as a result of popularization of vascular entry within the proximal area of the elbow, in addition to the rising variety of aged individuals on HD [43]. Remedy of this situation is tough and the danger of amputation of fingers and the forearm is nice. Subsequently, consideration should be targeted on prevention, which incorporates satisfactory preoperative evaluation, use of Doppler ultrasound, and a exact surgical approach that entails arteriotomy no higher than 7 mm in addition to being throughout the vary of a 90-180° angle of anastomosis. Failure to make use of these exact surgical methods could result in elevated resistance and diminished blood circulate [40,43]. To this point, there are 5 recognized therapeutic choices for the remedy of distal arm ischemia brought on by vascular entry. One necessary operational approach is named distal revascularization interval ligation (DRIL), a process launched in 1983 as a remedy choice for distal ischemia brought on by vascular entry. The essence of this operation is stopping retrograde diastolic influx into the fistula because the pathophysiologic precept of the steal syndrome [44]. Nonetheless, the strategic software of a remedy relies on the severity of signs, comorbidities and the talent of the surgical staff. In milder instances, we monitor the event of signs, and a radical strategy is just not required. Percutaneous transluminal angioplasty with doable stent implantation within the case of a stenotic lesion is carried out as part of diagnostic arteriography and could also be a therapeutic choice for a 3rd of instances [40,45].

Ischemic Polyneuropathy

Ischemic neuropathy is most typical in diabetic sufferers with extreme types of peripheral arterial illness, particularly when the brachial artery is used for creation of vascular entry. It’s manifested by weak arms, within the instant preoperative interval, extreme ache, and paresthesia. Neurological examination exhibits weak point in distal muscle teams within the space of sensory innervation by a faulty median nerve [30]. The frequency of such issues varies between 1 and 10%. The syndrome develops rapidly (sometimes inside hours) of AVF creation [46,47].

Thrombosis

The primary function of the endothelium in hemostasis is its antithrombotic operate. A traditional hemostatic response is initiated by harm to blood vessel partitions, exposing the subendothelial buildings to blood circulate, ensuing within the formation of a thrombus [48]. Fibrinogen and fibrin D dimer are unbiased danger components for thrombosis of vascular entry in sufferers on HD and are related to intra- and extravascular activation of the coagulation system [49,50].

Most research paradoxically point out disturbances of platelet adhesion, thus explaining the tendency to elevated bleeding. Thus, a query arises concerning the circumstances resulting in frequent coagulation on the vascular entry. It’s believed that HD platelets are activated by adhesion to the extracellular circulatory system and the turbulence in blood circulate generated by the vascular entry. Fibrinogen, which has an elevated focus in sufferers on persistent HD [49], prompts platelets and will increase additional platelet deposition. Adherent platelets launch platelet-derived development issue to provoke intimal hyperplasia, thereby lowering blood circulate. This creates circumstances for the deposition of activated and inactivated platelets, which, regardless of a bent to bleeding, favors thrombosis of the vascular entry [50]. Important research point out that clopidrogel diminished the frequency of early thrombosis of latest AVFs, and didn’t improve bleeding occasions throughout a 6-week administration interval. Upkeep of patency is important for fistula maturation, which implies that prevention of early thrombosis could be related to the next price of fistula maturation. A helpful impact of clopidogrel on fistula patency however not on suitability is necessary to the evolving understanding of the pathophysiology of fistula maturation and failure, and means that early patency is important however not ample for fistula maturation. The discrepancy between the results of clopidogrel on fistula patency and fistula suitability signifies that thrombosis could also be a manifestation somewhat than a reason for maturation failure [51].

An necessary reason for issues in HD sufferers is an elevated thrombotic tendency, inflicting many fatalities involving ischemic coronary heart illness or stroke, however in 17-25% of instances the explanation for hospitalization is AVF thrombosis [52,53]. The commonest reason for vascular entry thrombosis is venous neointimal proliferation. This causes vascular stenosis, resulting in fistula thrombosis [53]. Neointimal hyperplasia is characterised by the proliferation of easy muscle cells beneath the affect of fundamental fibroblast- and platelet-derived development components. The sleek muscle cell layer penetrates by the inner elastic lamina, migrates into the intima, and secretes matrix proliferous substances, equivalent to collagen, elastin and proteoglycans. Throughout migration of easy muscle cells into the intima, they’re reworked from a contractile right into a secretory kind that produces a fundamental substance inflicting intimal fibrosis [54]. Parallel scientific research have been carried out on the correlation of dysfunction of vascular entry for HD and coronary artery stenosis as a result of it’s assumed that the vascular entry for HD is a perfect mannequin for figuring out the therapeutic protocol for vascular stenosis [55].

The vascular endothelial cell is a dynamic medium positioned between the wall and lumen of vessels. Its core features are upkeep of vascular tone and blood circulate, prevention of vascular irritation and proliferation of easy muscle cells, in addition to fibrinolytic, anti-inflammatory, anticoagulant and antiplatelet features [56].

Nonetheless, the altered hemodynamic circumstances ensuing from arteriovenous anastomosis induce mechanisms of vascular transforming, contributing to the emergence and improvement of endothelial dysfunction. This, along with elevated oxidative stress, is a vital promoter of inflammatory processes. Endothelial vasodilator exercise (nitric oxide, prostacyclin and bradykinin) is considerably diminished, whereas the synthesis of highly effective vasoconstrictors (endothelin, angiotensin II and free oxygen radicals) is elevated. Restenosis is without doubt one of the necessary pathophysiological occasions within the endothelium of blood vessels; it might happen after percutaneous transluminal strategies of angioplasty. One other necessary course of that results in renarrowing of blood vessels is neointimal hyperplasia with proliferation of easy muscle cells and endothelial cells [57,58].

The kinetics of the proliferation response, which was demonstrated in animal fashions, indicated an necessary function for sure glycoproteins (vβ3 integrins) as a stimulus for platelet-derived development issue, proliferation of easy muscle cells [59], pro-inflammatory brokers (MCP-1, PAI-1, ET-1) [60], interleukin-1 [61] and early adjustments in venous wall contractility [62]. However, latest analysis in people indicated that about 90% is dominated by proliferation and neovascularization of the subendothelial layer, with macrophage infiltration of monocyto-intimal endothelial cells [63].

Within the first 7 days after implantation of vein grafts in animals, there’s degeneration and lack of cell wall storage with simultaneous infiltration of mononuclear cells within the adventitia. Later, mononuclear cells infiltrate the adventitia and the blood vessel partitions. Thickening of the venous wall begins within the first week. At 16 weeks, the thickness of the venous wall has elevated by 18 occasions, considerably lowering the lumen of the vein. It’s assumed that mechanical stress has a decisive function within the elevated gene expression of adhesion molecules, development components, cytokines and matrix proteins that set off the irritation course of, along with the emergence and subsequent proliferation of neointimal atheromatosis lesions. It’s believed that mechanical stress on the vein wall is a robust impetus for the transformation and proliferation of easy muscle cells, resulting in diminished circulate and termination of AVF operate [64].

New Methods within the Remedy of Vascular Entry Dysfunction

Endovascular interventional methods (desk 2) [65,66,67,68,69] proved to achieve success in treating stenotic lesions throughout the entry utilizing PTA to deal with focal stenoses and coil embolization and ligation to remove competing department veins [69,70,71,72,73,74,75,76]. Nassar et al. [75] used balloon angioplasty of focal stenoses and coil embolization of accent veins to salvage 83% of nonmaturing fistulas however concluded that 16.8% of the fistulas have been unsalvageable as a result of full occlusion of the outflow tract or the venous outflow tract being prohibitively deep, tortuous, or strictured. Turmel-Rodrigues et al. [77 ]not too long ago facilitated maturation in 96% of sufferers with failing Brescia-Cimino fistulas, who underwent long-segment arterial angioplasty of the radial artery to 4 mm in diameter to assist the circulate charges obligatory to advertise maturation.

Desk 2

Remedy of stenosed HD AVFs

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With a view to stop consecutive hemodynamic adjustments manifesting as decreased blood circulate by the AVF, elevated venous stress and extended bleeding after HD, early identification of neointimal hyperplasia is essential. There are particular limiting components, which have an effect on remedy, equivalent to the shortcoming to attain efficient native concentrations of particular antiproliferative brokers with out inflicting systemic toxicity. It’s believed that radiation can inhibit easy muscle cell proliferation of endothelial cells and macrophages on account of DNA harm. Newly fashioned blood vessels are notably delicate to the results of radiation. Intracoronary gamma radiation of restenosis confirmed optimistic findings in 42% of instances. Related outcomes have been obtained after software of beta radiation. Inhibition of intimal endothelial hyperplasia by gene switch was achieved in an experimental mannequin involving induction of nitric oxide synthase, inhibitors of cyclin-dependent kinases and retinoblastoma protein. Using such remedy in human medication remains to be in its infancy. Stents coated with an antiproliferative agent signify essentially the most important advance within the remedy of venous neointimal hyperplasia. The outcomes of a European multicenter examine point out virtually full absence of stenosis in sufferers with coronary angioplasty utilizing sacrolimus-treated stents, however whether or not or not using such stents will probably be an efficient methodology within the regulation of vascular entry dysfunction is just not but recognized [78].

Protocols and procedures of therapeutic technique encompass suppression of circumstances that may result in proliferation of easy muscle cells, which is very necessary for sufferers with heart problems. Methotrexate, paclitaxel [79] and sirolimus [80] can have a major impact on the event of venous neointimal proliferation. The outcomes of some research point out that hypercholesterolemia and hyperglycemia improve the danger of emergence of intimal hyperplasia. There are preliminary optimistic outcomes in regards to the software of infrared radiation for inhibition of intimal hyperplasia [81].

Conclusions

A useful AVF is a significant determinant of profitable HD; nonetheless, AVFs could also be a danger issue for hospitalization in dialysis sufferers. Information concerning the potential issues of AVFs ought to contribute to their well timed detection and permit measures to be taken that may stop deleterious penalties that vary from lack of vascular entry to severe morbidity, and will finally be deadly. Subsequently, AVF care ought to be a precedence not just for sufferers but additionally for your complete skilled staff concerned within the remedy of dialysis sufferers.

Acknowledgements

This work was supported by the Ministry of Training and Science of Serbia, Grants III41010, and by the Medical College of Pristina/Ok.Mitrovica, Serbia, junior challenge quantity 07/09.

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Writer Contacts

Prof. Radojica Stolic

College of Medication

Anri Dinan bb

RS-38220 Kosovska Mitrovica (Serbia)

E-Mail [email protected]


Article / Publication Particulars

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Abstract of Review

Acquired: April 10, 2012
Accepted: September 17, 2012
Revealed on-line: November 02, 2012
Situation launch date: March 2013

Variety of Print Pages: 9
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ISSN: 1011-7571 (Print)
eISSN: 1423-0151 (On-line)

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