110413 Dialysis Access Guidlines Xenos

7/27/2019 110413 Dialysis Access Guidlines Xenos

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HEMODIALYSIS ACCESSKDOQI GUIDELINES

ELEFTHERIOS XENOS, MD, PhD


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Timing of referral to AV access surgeon and timing of

placement of permanent vascular access

Patients with advanced CKD disease (late stage 4, stage 4 CKD (GFR


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Technical remarks

The average maturation time of a new autogenous access is 2

to 4 months

Catheter use at initiation of dialysis is also associated with

higher subsequent mortality

81% of United States ESRD patients initiate dialysis with acatheter, and only 26% have an autogenous or prosthetic AV

access already in place

Mortality is higher among patients who receive dialyses

continuously through a catheter than among those who switch

from a catheter to autogenous or prosthetic permanent access

Referral for initial vascular access placement should ideally

occur approximately 6 months in advance of the anticipated

need for dialysis


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Preoperative evaluation Factors associated with increased difficulty in establishing a functional

AV access : diabetes mellitus, peripheral vascular disease, severecongestive heart failure, advanced age, and female gender

Ultrasound venous mapping is of critical importance in these patients,not only for identifying preferred autogenous access sites but also for

evaluating the depth of venous structures Studies have shown both 1.5 mm and 2.0 mm to be the minimally

acceptable internal arterial diameters for successful autogenous AVaccess, although 2.0 mm seems to be the more commonly accepted limitin adults

The Allen's test confirms a patent palmar arch and is particularlyimportant when an autogenous AV access at the wrist is planned.Bilateral extremity blood pressures should be recorded and found to beequal
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Preoperative evaluation Ultrasound imaging has become the common standard in preparation for

an AV access procedure, ultrasound evaluation increased AV fistula

construction from 14% to 63%

Ultrasound venous mapping, which is performed with and without a

venous pressure tourniquet in place, evaluates vein diameter, patency,

continuity, and distensibility of the planned venous outflow conduit.

Both distensibility and venous diameter have been found to

independently predict autogenous AV access success

Arteriography : individuals with suspected proximal arterial occlusive

lesions where pre-AV access interventional procedures might both

identify and treat the problem site, gaining adequate arterial inflow for

the eventual autogenous AV access


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Operative strategies to optimize the

placement of autogenous

arteriovenous accesses Upper extremity access sites are used first, with the nondominant arm

given preference over the dominant arm only when access opportunities

are equal in both extremities AV accesses are placed as far distally in the upper extremity as possible to

preserve proximal sites for future accesses

When possible, autogenous AV accesses should be considered before

prosthetic arteriovenous accesses are placed. These autogenous access

configurations should include, in order of preference, the use of direct AVanastomosis, venous transpositions, and translocations

Lower extremity and body wall access sites are used only after all upper

extremity access sites have been exhausted


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Autogenous versus prosthetic vascularaccess for hemodialysis: A systematic

review and meta-analysis

M. Hassan Murad, MD, MPH, Mohamed B. Elamin, MBBS, Anton N. Sidawy, MD, MPH, German Malaga, MD,

MSc, Adnan Z. Rizvi, MD, David N. Flynn, BS, Edward T. Casey, MD, Finnian R. McCausland, MD, Martina M.

McGrath, MD, Danny H. Vo, MD, Ziad El-Zoghby, MD, Audra A. Duncan, MD, Michal J. Tracz, MD, Patricia J.

Erwin, MLS and Victor M. Montori, MD, MSc

Journal of Vascular Surgery

Vol 48,page 34-47(November 2008)


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2.1 The order of preference for placement of fistulae in patients with kidney failure

who choose HD as their initial mode of KRT should be (in descending order of

preference):

2.1.1 Preferred: Fistulae. (B)

2.1.1.1 A wrist (radiocephalic) primary fistula. (A)

2.1.1.2 An elbow (brachiocephalic) primary fistula. (A)

2.1.1.3 A transposed brachial basilic vein fistula: (B)

2.1.2 Acceptable: AVG of synthetic or biological material, such as: (B)

2.1.2.1 A forearm loop graft, preferable to a straight configuration.

2.1.2.2 Upper-arm graft.

2.1.2.3 Chest wall or necklace prosthetic graft or lower-extremity fistula or

graft; all upper-arm sites should be exhausted.

2.1.3 Avoid if possible: Long-term catheters. (B)

2.1.3.1 Short-term catheters should be used for acute dialysis and for a

limited duration in hospitalized patients. Noncuffed femoral catheters should

be used in bed-bound patients only. (B)

2.1.3.2 Long-term catheters or dialysis port catheter systems should be usedin conjunction with a plan for permanent access. Catheters capable of rapid

flow rates are preferred. Catheter choice should be based on local experience,

goals for use, and cost. (B)

2.1.3.3 Long-term catheters should not be placed on the same side as a

maturing AV access, if possible. (B)

Special attent ion sh ou ld be paid to considerat ion of avoidin g femo ral catheteraccess in HD pat ients w ho are current or futu re kidney transplant candid ates.


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Brescia-Cimino AVF


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Choice of arteriovenous access when a

patient is not a suitable candidate for

forearm autogenous access

Two studies compared the autogenous upper arm access with a

prosthetic lower arm access (prosthetic looped forearm access).

Placement of autogenous access in the upper arm is associatedwith a significantly lower rate of infections (RR, 0.23; 95% CI, 0.07-

0.83) and nonsignificant trends for better 12-month primary (RR,

0.88; 95% CI, 0.72-1.07) and secondary (RR, 0.81; 95% CI, 0.54-

1.20) patency.

Patency at 24 months was similar between the two accesses. Bothstudies reported the upper arm placement of autogenous access

to be associated with fewer complications and to require fewer

interventions to maintain patency.


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Choice of arteriovenous access when a

patient is not a suitable candidate for

forearm autogenous access For patients who have exhausted all forearm veins on both sides and, according to

vein availability the surgeon should offer both alternatives to patients

Although the upper arm autogenous access may fare better compared with a

forearm prosthetic access, using these two accesses sequentially may lead to

additive benefit: This practice may help to preserve upper arm veins for future

placement of autogenous access, may help to increase the caliber of these veins

and maximize the success of future upper arm autogenous access, and may provide

patients with an additional 1 to 3 years of functional hemodialysis access .

For patients at risk for ischemia, such as when the brachial or lower extremity

arteries are used for inflow, a tapered graft should be considered for use with the

smaller end of the graft placed at the arterial end


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ACCESS CONFIGURATIONS

Upper arm autogenous accesses Autogenous brachial (or proximal radial)cephalic upper arm

direct access

Autogenous brachial (or proximal radial)basilic upper armtransposition

Autogenous brachial (or proximal radial artery)brachial vein

upper arm transposition

Autogenous brachial (proximal radial) arteryaxillary veinupper arm indirect greater saphenous translocation


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Configurations of prosthetic AV accesses

Prosthetic radialantecubital forearm straight

access

Prosthetic brachialantecubital forearm

looped access

Prosthetic brachialaxillary (vein) upper arm

access


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Configurations of prosthetic AV accesses Prosthetic femoral arteryfemoral vein lower

extremity looped access

Prosthetic axillaryaxillary (vein) chest access(necklace prosthetic access)

Prosthetic axillaryinternal jugular chest loop

access Prosthetic axillaryfemoral (vein) body wall

access


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The role of monitoring and surveillance in

arteriovenous access management

Monitoring :physical examination indicators such as observation,

palpation, and auscultation of the access,

Surveillance :tests to assess access function.

Clinical monitoring by skilled personnel was shown to have adequatediagnostic accuracy; clinical monitoring has been reported to have

positive predictive value of70% to 90% in prosthetic accesses and a

specificity of90% and a sensitivity of93% in autogenous accesses

Lower incidence of thrombosis may translate into a reduction in access-

related costs and hospitalizations Flow surveillance produced a 32.5% reduction in the overall cost of

access care


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Surveillance of arteriovenous

hemodialysis access: A systematic

review and meta-analysis

Edward T. Casey, DO, M. Hassan Murad, MD, MPH, Adnan Z. Rizvi, MD, Anton N.

Sidawy, MD, MPH, Martina M. McGrath, MD, Mohamed B. Elamin, MBBS, David N.Flynn, BS, Finnian R. McCausland, MD, Danny H. Vo, MD, Ziad El-Zoghby, MD, Audra

A. Duncan, MD, Michal J. Tracz, MD, Patricia J. Erwin, MLS and Victor M. Montori,

MD, MSc

Journal of Vascular SurgeryVol 48, 2008


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The role of monitoring and

surveillance in arteriovenous accessmanagement

We recommend regular clinical monitoring (inspection,

palpation, auscultation, and monitoring for prolongedbleeding after needle withdrawal) to detect access

dysfunction

We suggest access flow monitoring or static dialysis venous

pressures for routine surveillance We suggest performing a Duplex ultrasound (DU) study or

contrast imaging study in accesses that display clinical signs

of dysfunction or abnormal routine surveillance


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Four most useful surveillance methods: (1) serial access flow

measurement, (2) serial measurement of static dialysis venous pressure,

(3) prepump arterial pressure, and (4) DU scanning

The KDOQI Guidelines recommend monthly measurement of access

flow. It requires specialized equipment and a trained technician.

Access blood flow measurements. Access blood flow is the best

determinant of access function. As an access develops progressivestenosis, access blood flow falls. Prosthetic access blood flow rate of

25% from the previous

baseline, has a high predictive value for significant stenosis (87% to

100%).


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Static venous dialysis pressure. The greatest value is in prosthetic accesses, but is of little orno value as a surveillance tool for autogenous.

Prepump arterial dialysis pressure: New autogenous accesses, which have a high incidence

of failure to mature, almost always have an access flow problem that is on the arterial side

of the venous needle and therefore will be identified by an excessively negative arterial

dialysis pressure (ADP). In addition, most of the flow-restricting lesions in dysfunctionalradialcephalic as well as some other autogenous accesses, are likewise present on the

arterial side of the venous needle and are often identified by increasingly negative ADPs.

Therefore, routinely checking the ADP at every dialysis session is critically important in

evaluating function in autogenous accesses, especially new ones.

Duplex ultrasound imaging. DU imaging can assess the access for both anatomic as well as

flow abnormalities that may represent significant stenosis. This test requires measuring the

peak systolic velocity (PSV) at the graft venous anastomosis and at any other area of visual

stenosis. A ratio ofPSV 2.0 at the stenotic site compared with the PSV immediately

upstream is used to diagnose stenosis, with a positive predictive value of 80% for

significant graft stenosis


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Autogenous access :The best, most feasible tools for

identifying dysfunction in autogenous access include (1)

physical examination (monitoring), (2) routine measurementof prepump ADP at every dialysis session, and (3) serial

access blood flow measurements

Prosthetic access function is best and most feasibly followedup by (1) a physical examination (monitoring), (2) serial

access blood flow measurements, and (3) serial static VDP

measurements.


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Management of nonfunctional

arteriovenous access Access too deep

Nonligated side branches

Insufficient arterial inflow:Stenosis at the arterial anastomosis is the

most common reason for inadequate arterial inflow. Arterial anastomoticstenosis usually occurs as a result of a technical error or neointimal hyperplasia.

The next most common location for arterial stenosis is an orificial stenosis of the

subclavian artery

Poor venous outflow :Poor venous outflow can also be caused by early

anastomotic stenoses, which are technical errors, usually manifest as earlythrombosis, but they can also lead to nonfunctionality or failure to mature in

autogenous accesses.


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Management of failed

arteriovenous access Prosthetic accesses have a much higher incidence of

thrombosis and the access-specific stenotic lesion is more

predictably found at the prosthetic venous anastomosis

In autogenous access the stenosis can be located anywhere

along the access vein used for needle puncture, and multiple

stenoses are often present(need for complete access

evaluation)

Prosthetic and autogenous accesses can both have stenoses

along the venous outflow tract, including central veins on

the same side.


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f f i l


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Management of nonfunctional or

failed arteriovenous access It is important to note that once access occlusion occurs,

prolonged patency is unusual

In >90% of cases, prosthetic accesses failure is due to

stenosis of the venous anastomosis, draining vein, or central

vein

Histologic analysis of the venous anastomotic lesion

demonstrates that it is identical to restenotic lesions that

occur in the coronary arteries after coronary angioplasty or

artery-to-artery bypass. The pathophysiology of prostheticaccess failure is largely that of neointimal hyperplasia at the

venous anastomosis.


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Complications of arteriovenous

hemodialysis access: Recognition and

management

Dysfunctional hemostasis

Infection

Noninfectious fluid collections

Pseudo aneurysm

Venous hypertension

Arterial steal syndrome High-output cardiac failure

Neuropathy


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Platelet dysfunction in uremia is common ,the hazard rate

for bleeding in ESRD patients is 0.55 per annum, the hazard

rate increased with antiplatelet therapy to 0.99 per annum

Management of acute bleeding is best treated with 1-

deamino-8-d-arginine vasopressin (DDAVP). Cryoprecipitate

may play an adjunctive role

Bleeding time in von Willebrand disease is often corrected

during pregnancy, and randomized, placebo-controlled trials

have confirmed that estrogen administration shortens the

bleeding time in uremic patients, both women and men



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Evidence from randomized, prospective clinical trials shows

no role for clopidogrel or warfarin as an adjunct to patency

of prosthetic or autogenous AV access

Prosthetic access thrombosis was not reduced by 75 mg of

clopidogrel plus 325 mg of acetylsalicylic acid

low dose warfarin (international normalized ratio, 1.4-1.9)

reported no improvement in prosthetic graft function and an

increase in major bleeding events with warfarin

Clopidogrel (75 mg) demonstrated no benefit for autogenousaccess


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Venous hypertension

Flow in the radial artery increases from 30 to 300 mL/min afterconstruction of a radiocephalic AV access, Mean flow using ultrasound-

detected indicator dilution is 645 mL/min for radiocephalic and 1336

mL/min for brachiocephalic autogenous AV accesses.

The most frequent cause of upper extremity venous thrombosis is now

central venous catheters or cardiac devices; the most powerful predictoris the presence of these devices, with an odds ratio of7.3

Approximately 50% of dialysis patients had a history of subclavian

catheterization, and 50% of those exposed had stenoses that were

considered significant

10-year review of pacemaker insertions at one institution found a 71%incidence of significant subclavian vein stenosis; ligation of an ipsilateral

AV access was required in 10 of 14 dialysis patients

defibrillator lead placements found 14 of 30 had >50% subclavian

stenosis


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Venous hypertension

Endovascular options offer a minimally invasive approach

with relatively low risk

durability is only mediocre

repeated intervention is frequently necessary to maintain

the result

Surgical management options include a direct approach to

the site of obstruction, bypass of the obstruction,

construction of the access in another extremity, and

conversion to peritoneal dialysis.


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Infection An increasing international body of data implicates catheter

access as the leading source of these bloodstream infections

81% of United States ESRD patients initiate dialysis with a

catheter, and only 26% have an autogenous or prosthetic AV

access already in place

CDC, recruited 109 centers in 30 states to form the Dialysis

Surveillance Network in the United States. Overall, there

were 3.22 access-related infections per month, of which 1.78

per month were bacteremias. As expected, the rate ratios foraccess-related bacteremia were less with autogenous AV

access (0.48 [95% CI, 0.35-0.65]), or prosthetic graft (1.0

[reference]) than with a cuffed catheter (9.2 [95% CI, 7.7-

10.8]).


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Infection Staphylococcus spp constitute 32% to 53%

Enterococci and coagulase-negative Staphylococcus spp, 20%

to 32

Polymicrobial infections with gram-negative bacteria, 10% to

18

Staphylococcus and Pseudomonas spp may both be highly

destructive and likely to incur anastomotic disruption

0.56% to 5% per year for autogenous AV access

4% to 20% per year for prosthetic AV grafts


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Infection

Total or subtotal AV access excision

Segmental access excision:94% success rate

when 17 patients were treated withsegmental graft excision

Complete AV access preservation


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Noninfectious fluid collections

Most of these complications may be managed with limited

intervention, but each has the potential to result in loss of

access

Hematoma Seroma: Seromas are sterile fluid collections that can

develop around prosthetic AV grafts and almost never

involve autogenous AV accesses

Lymphocele-lymphorrhea


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Pseudo aneurysm

Puncture site pseudoaneurysm

Anastomotic pseudoaneurysm

Diffuse enlargement of an autogenous AVaccess : a unique feature that may develop in

an autogenous AVF


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Steal

Clinical condition caused by arterial

insufficiency distal to a hemodialysis access

Usually associated with reversal of distal flow

Incidence around 3-5%

Can progress to irreversible neuropathy , loss

of function (claw hand), gangrene, digit loss,

limb loss


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Steal

Hand pain

Diminished/altered sensation

Pale, cold hand

Diminished/absent pulses

Weakness

Ischemic monomelic neuropathy


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IMN

The pathognomic feature of ischemic monomelic

neuropathy is the presence of diffuse neurologic

dysfunction usually in the absence of significant

clinical ischemia The hand is usually warm and often a palpable

radial pulse or audible Doppler signal is present.

Dysfunction of multiple upper extremity peripheral

nerves-potential for long term disability


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Revision Using Distal Inflow: A Novel

Approach to Dialysis-associated Steal

syndrome

David J. Minion, MD, Erin Moore, MD, and Eric

Endean, MD, Lexington, Kentucky

Ann Vasc Surg 2005; 19: 625-628


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Venous hypertension


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Venous hypertension

Flow in the radial artery increases from 30 to 300 mL/min after construction of aradiocephalic AV access, Mean flow using ultrasound-detected indicator dilution is

645 mL/min for radiocephalic and 1336 mL/min for brachiocephalic autogenous

AV accesses.

The most frequent cause of upper extremity venous thrombosis is now central

venous catheters or cardiac devices; the most powerful predictor is the presence

of these devices, with an odds ratio of 7.3

Approximately 50% of dialysis patients had a history of subclavian catheterization,

and 50% of those exposed had stenoses that were considered significant

10-year review of pacemaker insertions at one institution found a 71% incidence

of significant subclavian vein obstruction; ligation of an ipsilateral AV access was

required in 10 of 14 dialysis patients

defibrillator lead placements found 14 of 30 had >50% subclavian stenosis

First choice is forearm autogenous


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First choice is forearm autogenous

arteriovenous access Compared with prosthetic access, the autogenous access is associated with a lower incidence

of death and access infection and with a higher primary and secondary patency at 12 and 36

months

Benefit of autogenous access compared with prosthetic access in terms of lowering the

incidence of the three complications of steal, aneurysm, and hematoma is significantly more

in the case of lower arm autogenous access compared with upper arm autogenous access

Gentle flushing of the distal end of the vein with heparinized saline allows for evaluation ofthe caliber and extent of the vein and identification of side branches for ligation through stab

incisions after performing the anastomosis. This encourages flow in the main venous

segment, allowing for faster maturation. Ligation or endovascular coiling of side branches can

also be delayed to a later date and performed only if the autogenous access does not mature

in a timely basis


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A mature autogenous access requires three components: (1) an adequate diameter to permit safecannulation with dialysis needles without infiltration, (2) an adequate access flow rate to permit

achieving an access blood flow of 500 mL/min and (3) it must be sufficiently superficial to permit

recognition of landmarks and accurate, safe cannulation. The access blood flow increases dramatically

within 24 hours of autogenous access placement and reaches most of its maximum flow within 3 to 6

weeks. Similarly, most of the increase in access diameter is achieved within 4 to 8 weeks of autogenous

access placement.

If upon clinical evaluation at 4 to 6 weeks the autogenous access is not clearly maturing adequately,

further investigation is warranted to identify potentially remediable anatomic lesions. These may

include a venous or arterial stenosis, competing veins, large patent branches, or excessive depth from

the skin.27 The assessment may be performed either by DU scanning or by an imaging study. Several

studies have demonstrated that at least 80% of immature autogenous accesses can be salvaged after

correcting one or more underlying lesions

When the vein diameter is 4 mm and the access blood flow is 500 mL/min, there is a 95% likelihood

that the autogenous access will be usable for dialysis. If the vein diameter is


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Conversion of a prosthetic AV access to a

secondary autogenous AV access

Plan and protocol for eventual conversion of forearm

prosthetic access to a secondary autogenous AV access

should be put in place at the presence of any sign of failing

forearm prosthetic AV access, or after the first failure Conversion of the prosthetic access mature outflow vein to

an autogenous access

Identifying a new, remote site for autogenous access

construction in a patient where the prosthetic accessoutflow vein is not deemed suitable

Conversion of prosthetic AV access


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Conversion of prosthetic AV access

outflow vein to an autogenous

access

Forearm AV prosthetic

The outflow vein candidates in the arm are

the cephalic, basilic, and brachial veins

Autogenous alternative that is durable and

usually usable immediately


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Documents

110413 Dialysis Access Guidlines Xenos