title: Exhausting multiple hemodialysis access failures.
abstract: BACKGROUND
  Vascular access is often considered the Achilles heel the of hemodialysis because of its impact on morbidity, all cause mortality and finally costs of these patients. The most common complication of permanent hemodialysis (HD) vascular access is thrombosis, with some cases being related to hypercoagulability states. Antiphospholipid antibody syndrome (APAS) is a cause of increased thrombotic tendency, and this may complicate the management of such patients on HD.
  
  
  METHODS
  We describe a 41-year-old woman with end stage renal disease (ESRD) from Adult Polycystic Kidney Disease who was referred to our tertiary care center for treatment and selection of renal replacement therapy form. It was thought to initiate with peritoneal dialysis considering her actual conditions. She was putted on hemodialysis for several sessions, and a subclavian cathether was her first vascular access. The surgeon created an arterio-venous fistula which did not mature. After the implantation of the peritoneal cathether she started peritoneal dialysis and continued living with that for 2 years. She felt exhausted and because of a grave peritonitis episode accompanied with procedure failure and a long hospitalization she was transferred to hemodialysis. Renal transplantation was not possible because she didn't have a kidney donation. She was maintained on regular HD, but her dialysis care was complicated by recurrent vascular access failures. She had multiple interventions for arterio-venous fistulas and grafts but almost all of them failed due to thrombosis to the extent that only one access site was available for her routine renal replacement treatment. A thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies. A diagnosis of APAS was made and she was anticoagulated with warfarin. The AVG made in this last available site is still working from 18 months. If it fails we have no answers and solutions for her.
  
  
  CONCLUSIONS
  The presence of APAS can complicate HD management by causing recurrent vascular access thrombosis and failure, and nephrologist must remain alert to this possibility. Checking and treating as soon as possible it's our future challenge.
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Erjola
authors.initials: E
authors.lastname: Bolleke
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Saimir
authors.initials: S
authors.lastname: Seferi
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Merita
authors.initials: M
authors.lastname: Rroji
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Alma
authors.initials: A
authors.lastname: Idrizi
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Myftar
authors.initials: M
authors.lastname: Barbullushi
authors.affiliation: Nephrology and Dialysis Unit, UHC Mother Theresa, Tirana, Albania.
authors.forename: Nestor
authors.initials: N
authors.lastname: Thereska
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use*; D002408:Catheters, Indwelling / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy*; D006435:Renal Dialysis / Q000379:methods*; D013927:Thrombosis / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology*; D016896:Treatment Outcome; D014859:Warfarin
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: access failure; antiphospholipid antibody syndrome (APAS); hemodialysis; recurrent thrombosis