I – Anatomophysiological Recalls:
The anatomy of the veins of the arms is quite variable from one individual to another, but there is, however, four superficial veins used: The cephalic vein, basilic, ulnar and radial. The preliminary study by the surgeon, vessels, is essential to achieving a quality FAV. The assessment will first be clinically by palpation of the pulse examination of veins with and without tourniquet, study of their discharge. It may be necessary to achieve an ultrasound or venography, especially in diabetics. The Allen’s test seems unnecessary.

It is essential to require teams of nurses, to maintain maximum capital of the renal vein, at any stage, by avoiding any aspiration or infusion of these veins.

II – Surgery:
The plexus block by axillary or subclavian is the most used, promoting vasoplegia. Sometimes local anesthesia with or without neuroleptanalgesia may be indicated, general anesthesia is reserved for some special cases, as it almost always accompanied by hypotension embarrassing perception clinic.

The intervention must be economical of veins and arteries, ideally 4 to 5cm, most fistulas eventually be complicated and require further surgery. The vessels should not be pinched, and irrigation serum throughout the intraoperative time may be necessary to prevent drying of tissue and blood vessels. The anastomosis is performed either in latero-lateral or latero-in terminal. Closure in two layers, a very precise way, avoiding areas of necrosis and secondary scarring.

A subcutaneous injection of Xylocaine containing a few drops of nitroglycerin can reduce the spasm and allows a better venous dilation clamping. Similarly, an injection of diltiazem periarterial eliminates arterial spasm during dissection.

Radial fistulas:
It is created near the wrist in the gutter of the pulse, by anastomosis of the radial artery and low dorsal vein of the thumb. If the vein is very close to the artery, it is often preferred a-side anastomosis. The anastomosis may also, depending on the quality of ships, be performed in more proximal position.

Ulnar fistulas:
They are made near the wrist between the ulnar artery and superficial ulnar vein.

III – Time after surgery:
The nurse should monitor the vibration by palpation, and the blast and its intensity with a stethoscope, the lack of bruising or bleeding. The member will be extended or slightly elevated, with a bending prohibited on the operated limb. He will learn during hospitalization, the patient, monitor his daily fistula.

Later, the patient may again use its normal member.

IV – Training of the AVF:
The high blood flow caused by the anastomosis will cause a gradual increase in the size of arterialized veins. Turbulence at the anastomosis are responsible for the perceived thrill to palpation, and received blows to the stethoscope. This must be heard to the elbow. After a few months, the AVF will evolve towards an equilibrium, with the occurrence of stenosis of variable localization. Over time can appear sinuosities arterial and venous induration and localized expansion, including puncture normal.

V – Complications:
A – Thrombosis:
This is the most common complication, often a result of poor venous, or sometimes, a technical foul. In case of unexplained thrombosis (intervention perfectly satisfactory and successful initial operation), it will be done laboratory tests to search for a bleeding disorder.

B – hematoma:
It is not uncommon, but it is unusual for its size leads to a compression requiring surgical evacuation.

C – Hemorrhage:
Early and moderate bleeding is usually due to a lack of hemostasis on a small vein pressurization after fistula creation. Moderate compression, associated with elevation of the limb, often helps to address this situation.

By cons, an early arterial bleeding, often abundant, follows a lack of anastomosis, requiring further surgery in an emergency.

Ischemia may occur, especially in diabetics, variable, ranging from simple hand feel cold to acute ischemia, sometimes requiring, again, an emergency reoperation.

D – stenosis:
She sits in a privileged way near the anastomosis and anatomical peculiarities (valves, bends), but can be consecutive to frequent venipuncture prior to arterialization. Stenosis causes an obstacle to the flow of blood, then the agency seeking to circumvent it by developing collateral circulation could be significant.

Stenosis causes a low throughput, a thrill and a low breath, and difficulty of the puncture, sometimes requiring hemodialysis sessions with tourniquet!

E – Infection:
It may be discreet, limited to redness at the puncture site, or own a clot on an ulcer, or conversely, take the form of an abscess puncture associated with inflammation free, pulsatile hematoma or ulceration sanious. The infection can be extremely serious because it may diffuse away on heart valves in particular.

F – Other complications:
Note also, but had not developed specifically names speak for themselves:

The aneurysm and the lack of development of the AVF.

Etiology:

• The beta-hemolytic streptococcus group A is most commonly involved.
• Other bacteria: pneumococci, meningococci, staphylococci …, hepatitis viruses

Signs and symptoms:

• Definition of angina, pharyngitis or skin infections: impetigo and scarlet fever within 10 to 15 days earlier
• asthenia,
• headache,
• hyperthermia,
• back pains,
• pain in the kidneys,
• edema, with feeling faces “inflated” sudden onset of diffuse, steep, which may affect the legs, loins, hands, face, abdominal pain with effusion, lung, brain, with weight gain,
• discoloration of urine (red-brown) due to hematuria,
• Hypertension in a person usually normo tense (as a result of GNA)
• oliguria (urine rare), urine “stock sale”
• hyperhydration with overload at heart (as a result of oliguria), which can lead to pulmonary edema.
• anorexia
• pallor

Diagnosis:

• ECBU reveals leucocyturia and significant proteinuria, hematuria and a microphone or even macroscopic cylinder with presence of erythrocytes and erythrocytes deformed.
• blood tests: The ESR is increased (indicating inflammation), leukocytosis. The balance is disturbed kidney with urea and creatinine levels.
• Renal ultrasound: it allows the differential diagnosis between chronic ANG and NG (CNG). When the CNG, will indeed find a kidney size decreased.
• looking for a site of infection, including streptococcal (ENT, stomatology, skin) and search for streptococcal antigens

Treatment:

• Penicillin in cases of post-streptococcal GNA.
• corticosteroids
• cyclophosphamide (Endoxan ®)
• azathioprine (Imurel ®)
• Symptomatic treatment of hypertension, edema and heart failure.
• bed rest 3 to 4 weeks, especially in cases of hypertension, edema or significant increase in serum creatinine (risk of renal failure)
• control pulse / voltage regular, and measuring the weight and temperature
• Monitoring urine with achieving a balance fluid
• monitoring of regular blood levels (urea, creatinine, electrolytes)
• Food: reduced intake of salt, liquid and protein. If hyperkalemia because of renal failure, lower potassium intake (bananas)
• required dialysis.

Prognosis:
Good in most cases.

• Renal failure, if it exists, will disappear in a few days.
• Hypertension was cured in a week.
• The macroscopic hematuria is microscopic in 2 to 3 weeks.
• Proteinuria decreased rapidly.
• Hematuria and proteinuria disappeared after no more than 18 ° month.
• Relapses are exceptional.

Long-term prognosis: no hypertension or renal disease.
Bad in the case of GN of autoimmune origin, with need for dialysis early.
A biopsy should be performed in cases of:

• anuria,
• renal failure for more than 2 weeks
• syndrome during beyond the 2nd week;
• Persistent hypertension after 2 weeks;
• proteinuria> 1g/24 h after 1 month;
• hematuria persisting after 18 months of evolution;
• relapse

Complications:
In the acute phase:

• threatening hypertension with cerebral edema, retinopathy and hypertensive pulmonary edema,
• anuria, which may take several sessions of extra renal treatment, but whose long-term prognosis is as good as the non-anuric forms.
• rapid deterioration of renal function.

Subsequently:

• Chronic renal failure

Chronic glomerulonephritis (CNG)
GN that develops over years, combined with a slowly progressive renal insufficiency. They may be secondary to another disease or looked so primitive.
The glomerular lesions are induced by antigen-antibody complex.

Etiology:

• often unknown
• complication of systemic lupus erythematosus (presence of circulating anti-DNA and antinuclear cell)
• complication of rheumatoid purpura (disease Schonlein-Henoch)
• complication of diabetes
• HIV infection

Signs and symptoms:

• Asymptomatic.
• Small hematuria, proteinuria, sometimes with nephrotic syndrome.
• Over time, appears hypertension, and signs of chronic renal failure.
• Histologically, the glomeruli are normal by light microscopy.

The renal biopsy (PBR) allows to establish the diagnosis, prognosis and treatment
Treatment:
There is no specific treatment. It is to this day on steroids.
Rest, diet low in protein. Symptomatic treatment.

Prognosis:
Rather bad. Patients find themselves inevitably one day in dialysis.

Aetiology and predisposing factors:
Gallstone formation is favored by the hyper-concentration in the urine of some mineral components, such as oxalate and calcium phosphate. A supersaturated urine allows the formation of a nidus homogeneous or heterogeneous matrix used in the formation of a small crystal. This will increase volume and give rise to a large stone or may aggregate with other crystals to form an identical crystal aggregation.
The etiology is unknown in 60% cases, followed by:

• Hypercalciuria idiopathic, autosomal dominant, with urinary leakage or increased intestinal absorption of calcium;
• by hypercalciuria hyperparathyroidism
• hypercalciuria Intoxication with vitamin D, A
• hypercalciuria associated with neoplasia, Kahler disease, Paget
• abnormal metabolism of uric acid
• hyperoxaluira primitive or family
  syndrome ureteropelvic junction.

However, whatever the etiology, it is noted that nutritional factors play a decisive role, particularly those rich in salts, sugars and animal protein.

Symptoms:
Clinically, the sudden blockage of the urinary tract resulting in:

• pain associated with hypertension, may develop into the break called colic, very painful position without analgesic
• anuria / oligosurie
• sometimes hematuria
• urinary stasis favoring infection
• destructive pyelonephritis kidney




• pyonephrosis calculous (complication consisting destruction by renal hypertension and accumulation of a purulent collection upstream of the obstacle) and sepsis
• Radiologically, there was 90% radiopaque stones (calcium salts) (Fig. 1) and 10% of radiolucent stones (uric acid, cystine …)

The ASP allows direct visualization of stones in 90% of cases, and assert its position and size
Ultrasound can assess the importance of expansion of the urinary tract;
The IVU (intravenous urography) can target a much more accurate, especially in cases of radiolucent stones
Differential Diagnosis: it will on other possible causes of compression, namely tumor of the urinary tract, blood clot, tuberculosis sequelae.

Treatment:
The most recent, lithotripsy, and is currently used in more than 90% of cases: using the resonance property of materials to destroy gallstones in him by converging ultrasonic waves. These waves cause cracking each pulse, thus, subsequently, excretion by natural means.
In case of failure of lithotripsy treatment, calculations of size> 2cm in, of stasis important infected conventional surgical treatment is preferred. Having proper CNA training class is important to offer your services in this industry.

• Disinfection and urinary acidification (beneficial bacteria on urease)
• Systematic screening of urine

Conventional surgery:

• pyelotomie + nephrotomie nephrectomy and kidney if destroyed
• surgical percutaneous puncture

Medical surveillance will focus on disinfection of urine, hyperdiurese and urinary acidification.

• in cases of calcium urolithiasis, diet:
  • Diuresis than 2l/24h
  • Avoid oxalate (chocolate, sorrel, rhubarb, asparagus, white wine …)
  • Avoid animal protein
  • Plan moderately desode
  • Consumption between 600mg and 1g of Ca + +, by 24 hours, taking care not to over reduce calcium intake, increasing intake of oxalates.
• if uric lithiasis:
  • Medical treatment by alkalinization of urine (urinary control pH> 7)
  • Alkaline water: Water from Vichy
  • Urinary alkalinization (Foncitril: 2 to 3 sachets per day)
  • Prophylaxis of recurrences by Allopurinol (Zyloric) whether hyperuricemia and urate.

• rigidity of the corpora cavernosa of the penis
• without turgidity of spongy body and glans
• several hours
• painful
• without sexual desire

Etiology:

• Idiopathic: some patients have no known cause in the onset of priapism.
• Hematologic: leukemia, sickle cell disease.
• Neoplastic: lymphoma or metastasis of the corpora cavernosa.
• Neurological: multiple sclerosis, paraplegia.
• Iatrogenic: the most frequent. It is injected intra-cavernous overdose during treatment of impotence.

Complication:
If no treatment is implemented, the priapism may resolve spontaneously but extensive fibrosis cavernosal appears responsible for a final secondary impotence.
Treatment:

• exercise
• Intra-cavernous injection of 6mg etilefrine, repeated once after 30 minutes if ineffective. Surgical treatment then if still ineffective
• puncture of the corpora cavernosa,




• incision of the corpora cavernosa.
• anastomoses caverno-surgical sponge

The speed with which the injection etilefrine then, if necessary, the venous drainage of cavernous bodies are implemented remains an important success factor.