American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate
participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per
article at their own pace.
This month’s feature article is titled: “Dialysis-Associated Steal Syndrome.”
Accreditation and Designation Statement
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical
Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American
Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians.
Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians
should only claim credit commensurate with the extent of their participation in the activity.
Statement of Need
Dialysis-associated steal syndrome (DASS) is a serious complication of arteriovenous fistulae (AVF), which is commonly used for hemodialysis
in patients with end-stage renal disease (ESRD), both prior to transplantation and after graft failure. Early recognition of the clinical signs and
symptoms of DASS is critical as delayed diagnosis can lead to significant complications. If DASS is diagnosed and treated in a timely manner,
tissue will be preserved, leading to markedly improved care of ESRD patients.
Purpose of Activity
The purpose of this activity is to recognize the clinical manifestations, natural history and treatment of DASS to allow for timely resolution of this
condition and minimize morbidity for ESRD patients.
Identification of Practice Gap
Recognition of the clinical presentation and potential dermatologic manifestations of DASS are paramount in the successful diagnosis and management
of patients with AVF. Dermatologic manifestations of DASS are not commonly recognized as manifestations of DASS by health professionals and can
be easily misdiagnosed. Other classical symptoms of DASS, including digital pain and paresthesias, are nonspecific and may be incorrectly attributed
to diabetic neuropathy, especially since diabetes is a known risk factor for DASS.
Learning Objectives
Upon completion of this educational activity, participants will be able to:
• Recognize the clinical manifestations and cutaneous findings in DASS.
• Understand the pathophysiology, risk factors and mechanisms of DASS.
• Determine the underlying mechanisms of the secondary complications of DASS.
• Explain the treatment modalities for DASS and the critical need for prompt diagnosis and intervention.
Target Audience
This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation.
Disclosures
No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed
all disclosures and resolved or managed all identified conflicts of interest, as applicable.
Editor-in-Chief
Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose.
Editors
Sandy Feng, MD, PhD, discloses stock and/or equity interest in Abbott, Amgen, Charles River Labs, Eli Lily, Glaxo-Smith-Klein, Hospira, Johnson
& Johnson, Express Scripts, Medco, Merck, Pfizer, and Stryker; research support from Cumberland and Quark; and research support and consulting
work for Novartis.
Douglas W. Hanto, MD, PhD, has no relevant financial relationships to disclose.
Authors
Nika Cyrus, MD, Changhyun Kim, Antonios Arvelakis, MD, and Oscar R. Colegio, MD, PhD, have no relevant financial relationships to disclose.
ASTS Staff
Mina Behari, Director of Education, has no relevant financial relationships to disclose.
This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal
of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of
Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal
peer review.
Instructions on Receiving CME Credit
This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the
activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and
potentially updated and extended for an additional twelve months.
Follow these steps to participate, answer the questions and claim your CME credit:
• Log on to https://www.wileyhealthlearning.com/ajt
• Read the learning objectives, target audience, and activity disclosures.
• Read the article in print or online format.
• Reflect on the article.
• Access the CME Exam, and choose the best answer to each question.
• Complete the required evaluation and print your CME certificate.

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 Continuing Medical Education

Dialysis-Associated Steal Syndrome

A 50-year-old kidney transplant recipient presented to transplant dermatology in April 2008 with a three-month history
of questionable onychomycosis involving the right fingernails. He had undergone a kidney transplant in 1989, secondary
to diabetic renal disease. Subsequent graft failure had necessitated the creation of a radial artery to cephalic vein arterio-
venous fistula (AVF) in the right forearm in December 2005 for hemodialysis. He had received hemodialysis exclusively
from this AVF since his left arm arteriovenous graft was removed in August 2007. Since then, he complained of resting
right hand pain and paresthesias exacerbated by activity. There was reduced return of blood during hemolysis. Doppler
ultrasound in November 2007 had demonstrated severe stenosis at the anastomosis with no dominant draining vein and
reversal of flow in the distal radial artery. A procedure had been done at that time (Figure 1). The patient had no known
vascular disease.
On physical examination in April 2008, the right hand was cool, pale, and noncyanotic. There was reduced sensation in
the digits, intact strength, and weaker radial and ulnar pulses in the right hand. The AVF had a thrill and bruit, and was
pulsatile. There was proximal shedding of three fingernails and an index finger ulcer on the right hand (Figure 2A). KOH
preparation of subungual debris was negative for fungus.
In May 2008, the AVF was ligated and his symptoms rapidly resolved. In June, the patient underwent a second kidney
transplant. By March 2009, the fingernails had regrown and the ulcer had healed (Figure 2B).

N. Cyrus1, C. Kim1, A. Arvelakis2 and O. R. Colegio1,2,*

1Yale Transplant Dermatology Clinic, 2Yale-New Haven Transplantation Center,
Yale University School of Medicine, New Haven CT
*Corresponding author: Oscar R. Colegio, oscar.colegio@yale.edu

Figure 1: A Side-to-side fistula between cephalic vein and radial artery with
stenosis at the anastomosis, catheter tip in the radial artery. Before dilation.
B. The same fistula after balloon dilation, catheter tip in the cephalic vein.

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Figure 2. A. Patient’s right hand fingers on initial presentation to transplant dermatology in April 2008. Onychomadesis of
three fingernails and an index finger ulcer is seen. B. Patient’s right hand at follow up in March 2009. Fingernails have regrown
and the ulcer has healed.

Questions
1. The physical findings, Doppler ultrasound and angiogram are consistent with what diagnosis?
a. Thrombosed AVF
b. Venous outflow stenosis
c. Dialysis-associated steal syndrome (DASS)
d. Arterial inflow stenosis
e. Diabetic neuropathy

2. Onychomadesis is characterized by:

a. Distal shedding of fingernails
b. Proximal shedding of fingernails
c. Nail pitting
d. Whitening of the nail

3. What is the underlying mechanism of the steal syndrome in this patient?

a. Inadequate blood flow secondary to reduced cardiac output
b. Poor arterial blood flow secondary to proximal arterial stricture
c. Reduced blood flow to the hand from arterial/anastomotic stricture
d. Excess blood flow through the AVF
e. Lack of arterial adaptation to increased flow through AVF

4. The clinical sequelae of dialysis-associated steal syndrome, when left untreated, include:
a. Finger necrosis and gangrene
b. Onychomycosis
c. Aneurysm formation in the AVF
d. Thrombosis of the AVF
e. Development of collaterals with spontaneous resolution

5. Initial treatment goal in this patient should be:

a. No treatment is necessary as spontaneous resolution takes place in a majority of patients
b. Create a new AVF on the other arm for hemodialysis
c. Correct distal hypoperfusion in the affected arm while preserving the hemodialysis access site
d. Prevent thrombosis by heparin infusion followed by lifelong warfarin
e. Stop hemodialysis, as hemodialysis is the root cause of hand ischemia

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt

2770 American Journal of Transplantation 2013; 13: 2768–2770