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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 651-656

Brachiobasili carteriovenous fistula: a primary angioaccess for regular hemodialysis


1 Department of Vascular Surgery, Menoufia University, Menoufia, Egypt
2 Department of Vascular Surgery, Gamal Abdel Naser Hospital, Alexandria, Egypt

Date of Submission12-Feb-2015
Date of Acceptance11-Apr-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Ehab Kandeel
Behira, Kafr el-dawar, 22783
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198749

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  Abstract 

Objective
The aim of  the present study was to examine the use of brachiobasilic arteriovenous fistula (BBAVF) as a primary angioaccess for regular hemodialysis in patients having metabolic syndrome in comparison with distal forearm radiocephalic arteriovenous fistula (RCAVF).
Patients and methods
Sixty patients recently diagnosed with end-stage renal disease fulfilling the inclusion criteria for this study were selected from a total of 638 patients referred from the nephrologists clinic to the vascular clinic at Gamal Abdel-Nasser Hospital and Shebin El-Koum Hospital. The patients were randomly divided into two groups, the RCAVF group, which included 30 patients, and the BBAVF group, which also included 30 patients. All patients suffered from metabolic syndrome. Metabolic syndrome was defined as the presence of three or more of the following: blood pressure greater than 130/90 mmHg; triglycerides greater than 150 mg/dl; high-density lipoprotein less than 50 mg/dl for women and less than 40 mg/dl for men; BMI greater than 30 kg/m 2 ; or fasting blood glucose greater than 110 mg/dl.
Results
The patency rate after 1 year in BBAVF group was 27 (90.0%), and nine (30.0%) in the RCAVF group. Primary access failure in the BBAVF group was 6.7%, and 3.3% in the RCAVF group. Moreover, secondary access failure in the BBAVF group was 10%, and 70% in the RCAVF group. The number of metabolic syndrome criteria and incidence of angioaccess failure showed significantly low patency of RCAVF in patients fulfilling the fourth and fifth criteria for the metabolic syndrome.
Conclusion
BBAVF was found to have higher patency in comparison with RCAVF in metabolic syndrome patients with end-stage renal disease. However, establishing BBAVF as the first choice in metabolic syndrome patients needs further studies in the future.

Keywords: brachiobasilic arteriovenous fistula, metabolic syndrome, radiocephalic arteriovenous fistula


How to cite this article:
Elazeem Saleh HA, Hossny A, Kandeel E. Brachiobasili carteriovenous fistula: a primary angioaccess for regular hemodialysis. Menoufia Med J 2016;29:651-6

How to cite this URL:
Elazeem Saleh HA, Hossny A, Kandeel E. Brachiobasili carteriovenous fistula: a primary angioaccess for regular hemodialysis. Menoufia Med J [serial online] 2016 [cited 2020 Feb 17];29:651-6. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/651/198749


  Introduction Top


Renal failure occurs when the functioning renal mass is reduced sufficiently so that the kidney is no longer able to carry out the excretory function, and can be divided into acute renal failure and chronic renal failure [1] . Since the development of hemodialysis in 1944 there has been a dramatic increase in both the availability of hemodialysis and long-term survival of patients with chronic renal failure. Because of this extended life expectancy, secondary and tertiary access is needed [2] .

Metabolic syndrome is prevalent among patients undergoing hemodialysis access placement. It is defined as the presence of three or more of the following five criteria: hypertension (systolic blood pressure 140 mmHg or diastolic pressure 90 mmHg on three occasions during a 6-month period), reduced high-density lipoprotein (HDL) cholesterol (40 mg/dl for men, 50 mg/dl for women), elevated triglycerides (150 mg/dl), impaired glucose control (110 mg/dl fasting serum glucose), and a BMI 30.0 kg/m 2 [3] .

Metabolic syndrome is associated with several proinflammatory and prothrombotic factors, which contribute to arteriovenous fistula (AVF) dysfunction. It results in a state of platelet dysfunction, endothelial dysfunction, and a prothrombotic environment. Several inflammatory markers are increased in the metabolic syndrome: monocyte chemotactant protein-1 (MCP-1), tumor necrosis factor, interleukin-6 (IL-6), IL-8, and plasminogen activator inhibitor (PAI) type-1. Before the conception of the metabolic syndrome, De Marchi et al. [4] found that patients who presented with fistula dysfunction postoperatively had elevated levels of IL-6, MCP-1, PAI-1, protein C, and protein S compared with the patients without fistula dysfunction. Not surprisingly, these patients also had elevated cholesterol and triglyceride levels and lower HDL levels. This is because IL-6, MCP-1, PAI-1, and dyslipidemia are hallmark characteristics of metabolic syndrome [4] .

Patients with metabolic syndrome have unfavorable perioperative outcomes for cardiovascular and peripheral vascular interventions, as well as for nonvascular operations. The metabolic syndrome increases the risk for postoperative saphenous vein graft occlusion and the development of a significant lesion after coronary artery bypass grafting. Furthermore, patients with lipid abnormalities and diabetes mellitus (DM) have been identified as having greater rates of access dysfunction [5] .

Patients undergoing hemodialysis access placement in the presence of metabolic syndrome experience greater mortality and decreased secondary patency rates. Patients with metabolic syndrome form a high-risk group that needs intensive surveillance protocols [6] .


  Patients and methods Top


Sixty  patients recently diagnosed with end-stage renal disease (ESRD) fulfilling the inclusion criteria for this study were selected from 638 patients referred from the nephrologists clinic to the vascular clinic at Gamal Abd El-Nasser Hospital and Shebin El-Koum Hospital in the period between October 2011 and October 2013.

The inclusion criteria included patients suffering from metabolic syndrome, which is as the presence of three or more of the following five criteria:

  • Hypertension (systolic blood pressure 140 mmHg or diastolic pressure 90 mmHg on three occasions during a 6-month period)
  • Reduced HDL cholesterol (40 mg/dl for men, 50 mg/dl for women)
  • Elevated triglycerides (150 mg/dl)
  • Impaired glucose control (110 mg/dl fasting serum glucose)
  • BMI 30.0 kg/m 2 .


Moreover, patients with no previous angioaccess were included.

Patients suitable for both distal radiocephalic arteriovenous fistula (RCAVF) and proximal brachiobasilic arteriovenous fistula (BBAVF) by clinical examination and duplex study were also included in the study.

Patients were randomly divided into two group, the RCAVF group, which included 30 patients, and the BBAVF group, which also included 30 patients.

RCAVF was created under local anesthesia with a technique similar to that described by Brescia.

BBAVF was created under interscalene nerve block or general anesthesia with a technique similar to that described by Dagher with immediate transposition.

All patients received broad spectrum prophylactic antibiotic. Aspirin was not used postoperatively. Access to hemodialysis was denied until at least 6 weeks after surgery, to allow the fistula to mature.

Patency was determined by the ability to access the fistula for hemodialysis and by the presence of propagating thrill.

Patency also was evaluated through ultrasound examination (fistula considered to be adequately developed if the ultrasound measurements revealed vein diameter >4 mm, blood flow >500 ml/min, and perpendicular distance from the skin <5 mm).

Primary failure for AVF means fistula never used for dialysis (early thrombosis within 12 weeks of its creation or failed to mature).

Secondary failure for AVF means fistula failed after being used successfully for dialysis.

Operative ligation was classified as failure; death with functioning fistula was considered as lost to follow-up when the cause of death was not related to the fistula.

Complications data related to functioning fistulas were obtained from frequent examinations in the dialysis unit and from the nephrologists and dialysis nurses.

All patients were followed up for at least 12 month after operation.


  Results Top


[Table 1] shows age, sex, BMI, hypertension, and DM in the two studied groups. In the BBAVF group, age ranged from 62 to 70 years with a mean age of 66.2 ± 2.98 years, and in the RCAVF group, age ranged from 60 to 71 years with a mean age of 65.4 ± 3.68 years.
Table 1 Show age, sex, body mass index, hypertension, diabetes mellitus in the two studied group


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There were 10 (33.3%) male patients in the BBAVF group and 12 (40%) in the RCAVF group, whereas there were 20 (66.7%) female patients, respectively.

The number of patients with normal weight in the BBAVF group was 10 (33.3%), and 11 (36.7%) in the RCAVF group, whereas the number of obese patients (BMI >30) in the BBAVF fistula group was 20 (66.7%), and 20 (66.7%) in the RCAVF group.

Regarding the clinical data, there were 21 (70%) hypertension patients in the BBAVF group, and 20 (66.7%) in the RCAVF group.

There were 15 (50%) hyperlipidemia patients in the BBAVF group, and 16 (53.3%) in the RCAVF group.

In addition, there were 11 (36.7%) diabetics in the BBAVF group, and 10 (33.3%) in the RCAVF group.

There was no statistical significant difference regarding demographic and clinical data of the studied patients (P > 0.05).

[Table 2] shows, there were eight (26.7%) patients fulfilling three criteria for metabolic syndrome diagnosis in the BBAVF group, and nine (30%) in the RCAVF group, with no statistically significant difference between them.
Table 2 Comparison between the two studied groups regarding the number of metabolic syndrome criteria in patients with end-stage renal disease


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  • And the number of patients fulfilling four criteria for metabolic syndrome diagnosis in the BBAVF group was 15 (50%), and in the RCAVF group it was 16 (53.3%), with no statistically significant difference between them
  • The number of patients fulfilling five criteria for metabolic syndrome diagnosis in BBAVF group was seven (23.3%), and in the RCAVF group was five (16.7%), with no statistically significant difference between them.


[Table 3] shows the incidence of complication of angioaccess. Bleeding was found in three (10%) patients in the BBAVF group, and in one (3.3%) patient in the RCAVF group.
Table 3 Incidence of complication in the two studied group


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Infection was found in two (6.7%) patients in the BBAVF group and in no patients in the RCAVF group. Aneurysm was found in two (6.7%) patients in the BBAVF group and in one (3.3%) patient in the RCAVF group.

Limb swelling (venous hypertension) was observed in four (13.3%) patients in the BBAVF group and in two (6.7%) patients in the RCAVF group. Steal syndrome was found in one (3.3%) patient in the BBAVF group and in no patient (0%) in the RCAVF group.

[Table 4] shows the relationship between the number of metabolic syndrome criteria and the incidence of complication with significant increase in the number of complications in the BBAVF group with five criteria for metabolic syndrome (100%); it was 80% in the RCAVF group.
Table 4 Incidence of complication in relation to number of criteria of metabolic syndrome in the two group


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[Table 5] shows the number of cases with primary access failure and secondary access failure in the two studied groups with significant number of secondary failure in the RCAVF group (70%) in comparison with 10% in the BBAVF group.
Table 5 Comparison between the two studied groups regarding primary and secondary failure incidence


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[Table 6] shows the relationship between the number of metabolic syndrome criteria and the incidence of angioaccess failure and shows significant low patency of RCAVF in patients fulfilling four criteria and five criteria for metabolic syndrome (100%) in comparison with patients related to BBAVF group fulfilling four criteria and five criteria was (0 and 28.6%, respectively).
Table 6 Failure of arteriovenous fistula in relation to numbers metabolic syndrome criteria in the two studied group


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[Table 7] and [Figure 1] show patency rate of angioaccess. Patency rate after 1 year in the BBAVF group was 27 (90.0%) and in the RCAVF group it was nine (30.0%). There was a statistically significant difference regarding patency rate of angioaccess (P < 0.05), as shown in [Figure 1].
Table 7 Show patency of arteriovenous fistula in the two studied group over 1 year


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Figure 1: Patency rate of angioaccess in the two group over 1 year (life table analysis). BBAVF, brachiobasilic arteriovenous fistula; RCAVF, radiocephalic arteriovenous fistula.

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  Discussion Top


Progressive rise in the number of patients accepted for renal replacement therapy has been reported worldwide. Permanent vascular access is the life-line for the majority of these patients, when hemodialysis is the treatment of choice. Thus, the successful creation of permanent vascular access and the appropriate management to decrease the complications is mandatory. A well functional access is also vital to deliver adequate hemodialysis therapy in ESRD [7] .

Few would argue that the radial artery-cephalic vein arteriovenous fistula described in 1966 by Brescia et al. [8] should be attempted first, as this clearly is the access procedure of choice followed by other potential options.

However, when this access site is unavailable or has been failed, unfortunately obese patients, those with poor or exhausted superficial venous system of the forearm due to repeated venipuncture, and patients who had lost their primary fistulas are in need for alternative methods for surgical angioaccess [9] .

Metabolic syndrome is associated with several proinflammatory and prothrombotic factors, which contribute to AVF dysfunction. Patients undergoing hemodialysis access placement in the presence of metabolic syndrome need intensive surveillance protocols [6] .

Patients with metabolic syndrome have unfavorable perioperative outcomes for cardiovascular and peripheral vascular interventions, as well as for nonvascular operations. Moreover, patients with lipid abnormalities and DM have higher rates of access dysfunction [5] .

Sixty patients suffering from the metabolic syndrome participated in the study and were divided into the BBAVF group and the RCAVF group with no statistically significant difference regarding the demographic and clinical data (age, sex, BMI, hypertension, hyperlipidemia, and DM) of the studied patients (P > 0.05).

In the early period following AVF formation, there may be a need for hospitalization or surgical revision due to local complications, such as thrombosis, hematoma, hemorrhage, and infection. The most common complication, early and later on, is the thrombosis of the fistula (3.0-14.5%). Complications other than early thrombosis, such as revisions due to hyperemia, aneurismal dilatation, hematoma, infection, and hemorrhage at the incision site, were also occasionally observed [10] .

In the present study, the incidence of complication of angioaccess in the BBAVF group was 12 cases in comparison with four cases in the RCAVF group with significant complication number in group of BBAVF and RCAVF with five criteria for the metabolic syndrome.

Failure to mature is an inability to use the fistula for hemodialysis at 6 weeks. Logistic regression analysis showed that age over 60 years was associated with failure to mature and lower patency rates [11] .

Early failure of AVF may result from nonmaturation or thrombosis. Early failure was reported to be from 40 [9] to 55% [10] from 145 dialysis units in the American series and about 7 [11] to 10% [12] from 101 units in five European countries (France, Germany, Italy, Spain, and the UK) in the European series. Few recent studies have been published about the predictors of failure of AVF. Some have shown that advanced age, female sex, diabetes, and forearm fistula were significantly correlated with failure. Hypotension and overweight were other significant risk factors for failure in some studies. The use of large-sized arteries and veins was associated with high success rate [11] .

Allon et al. [12] stated that unfortunately, because of a lack of adequate distal veins, it may not be possible to create a primary distal AVF in all patients. This problem is seen particularly in women, African Americans, obese individuals, elderly patients, and patients who have peripheral vascular disease. These factors have been used in the past to justify the marked differences in the incidence and prevalence rates of AVF in the USA and in Europe/Japan [12] .

In the present study, we found a number of cases with primary access failure and secondary access failure in the two studied group, with significant number of secondary failure in the RCAVF group.

Several clinical studies have reported a lower prevalence of fistulas among obese hemodialysis patients, as compared with nonobese ones. Increasing the prevalence of fistulas requires increasing fistula placement, adequate maturation of new fistulas, and successful long-term cannulation of the fistulas by the dialysis staff. Thus, there are several potential explanations for the lower fistula prevalence among obese patients. First, it is possible that fistulas are less likely to be placed in obese patients. Second, fistulas placed in obese patients may be more likely to have a primary failure (never be usable for dialysis). In addition, patients with lipid abnormalities and DM have been identified as having greater rates of access dysfunction [13] .

Diameters of the arteries and veins used to create the fistulas were similar between the obese and nonobese patient groups, whether one examined forearm or upper-arm fistulas. Primary fistula failure occurred at a similar rate in the two groups. However, among those patients whose fistulas were successfully used for dialysis for at least 1 month, the secondary fistula survival was substantially lower in obese patients, as compared with their nonobese controls [14] .

Twenty-three patients underwent more than one surgical intervention due to early AVF thrombosis or failure. Early AVF failure occurred more often in females (60.8%) than in males (39.2%). Complications were observed in a total of 11.4% patients. Mechanical dilatation of the artery and vein, before starting the anastomosis, as well as the use of vasodilatory agents, could decrease early thrombosis of the fistula, and this method has very high early patency [15] .

The present study showed relationship between the number of metabolic syndrome criteria and the incidence of angioaccess failure, and also showed significant failure incidence in the patients of the RCAVF group fulfilling fourth and fifth criteria for the metabolic syndrome with 100% incidence of failure to AVF in the patient from RCAVF group with fourth and fifth criteria of metabolic syndrome.

Metabolic syndrome has been shown to contribute to AVF dysfunction. Patients undergoing hemodialysis access placement in the presence of metabolic syndrome experience greater mortality and decreased patency rates. The metabolic syndrome has been shown to have unfavorable perioperative outcomes for cardiovascular and peripheral vascular interventions, as well as for nonvascular operations [6] .

Protack et al. [16] stated that 30-day primary patency rate was 93.1% for the metabolic syndrome patients with AVF. The median time until failure of primary patency was 0.460 years (95% confidence interval, 0.37-0.58 years). The median time to primary patency failure was 0.436 years for metabolic syndrome patients and 0.555 years for nonmetabolic syndrome patients. The 6-, 12-, and 24-month freedom from primary patency failure was 43, 19, and 9%, respectively, for metabolic syndrome and 54, 29, and 5%, respectively, for nonmetabolic syndrome (P = 0.255). Most of the access failures occurred in the venous outflow (91%), with 18% of failures having an arterial lesion and 9% having an arterial and a venous lesion; there was no difference between patients with and without metabolic syndrome [16] .

Protack et al. [16] stated that 30-day secondary patency rate was 94.7% for metabolic syndrome patients with AVF. The median time until failure of secondary patency was 1.180 years (95% confidence interval, 0.73-1.86 years). Metabolic syndrome patients demonstrated failure of secondary patency at 0.720 years versus 1.940 years for nonmetabolic syndrome patients (P = 0.024). The 6-, 12-, and 24-month freedom from secondary patency failure was 61, 41, and 33%, respectively, for metabolic syndrome, and 79, 68, and 47%, respectively, for nonmetabolic syndrome patients (P = 0.024).

Although Horimi H and Kusano [15] reported that AVF patency rates were significantly lower for diabetic patients, both Protack CD [16] found that diabetes had no effect on AVF patency rates. Feldman HI et al. [7] reported that fistula survival rates in nondiabetic patients were higher than in patients with diabetes, but this difference was not significant.

However, Erkut et al. [17] also reported that DM was one of the factors affecting the primary patency of AVF.

DM and essential hypertension are major challenges among individuals worldwide. They are a major threat to public health, rapidly reaching an epidemic scale, with the biggest impact on adults of working age in developing countries [18] .

Components of metabolic syndrome and the metabolic syndrome itself are also associated with measures of inflammation, such as increased concentrations of C-reactive protein and decreased anti-inflammatory molecule, adiponectin. This low-grade inflammation, which has been associated with an increased risk for atherosclerotic disease and diabetes, may provide a mechanism for the increased risk of these conditions experienced by individuals who have the metabolic syndrome [18] .


  Conclusion Top


The present study showed that the patency rate of angioaccess after 1 year in the BBAVF group was 27 (90.0%) and nine (30%) in the RCAVF group. There was a statistically significant difference regarding the patency rate of angioaccess (P < 0.05).

BBAVF had a higher patency compared with RCAVF in metabolic syndrome patients with ESRD. However, establishing BBAVF as the first choice in metabolic syndrome patients needs further studies in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wyngaarden JB, Smith LD, Bennets JC. Cecil textbook of medicine. 19 th ed. Philadelphia, PA, London, Toronto, Montreal, Sydney: saunders Company; 1992. 447-545.  Back to cited text no. 1
    
2.
Murphy GJ, White SA, Knight AJ, Doughman T, Nicholson ML. Long-term results of arteriovenous fistulas using transposed autologous basilic vein. Br J Surg 2000; 87 :819-823.  Back to cited text no. 2
    
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Vykoukal D, Davies MG. Vascular biology of metabolic syndrome. J Vasc Surg 2011; 54 :819-831.  Back to cited text no. 3
    
4.
De Marchi S, Falleti E, Giacomello R, Stel G, Cecchin E, Sepiacci G. Risk factors for vascular disease and arteriovenous fistula dysfunction in hemodialysis patients. J Am Soc Nephrol 1996; 7 :1169-1177.  Back to cited text no. 4
    
5.
Kalman PG, Pope M, Bhola C, Richardson R, Sniderman KW. A practical approach to vascular access for hemodialysis and predictors of success. J Vasc Surg 1999; 30 :727-733.  Back to cited text no. 5
    
6.
Snyder DC, Clericuzio CP, Stringer A, May W. Comparison of out-comes of arteriovenous grafts and fistulas at a single veterans' affairs medical center. Am J Surg 2008; 196 :641-646.  Back to cited text no. 6
    
7.
Feldman HI, Kobrin S, Wasserstein A. Hemodialysis vascular access morbidity. J Am Soc Nephrol 1996; 7 :523-535.  Back to cited text no. 7
    
8.
Brescia MJ, Cimino JE, Appel K. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966; 275 :1089-1092.  Back to cited text no. 8
    
9.
Miller CD, Robbin ML, Allon M. Gender differences in outcomes of arteriovenous fistulas in hemodialysis patients. Kidney Int 2003; 63 :346-352.  Back to cited text no. 9
    
10.
Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistula for vascular access. Eur J Vasc Endovasc Surg 2000; 19 :70-76.  Back to cited text no. 10
    
11.
Rao RK, Azin GD, Hood DB, Rowe VL, Kohl RD, Katz SG. Basilic vein transposition fistula: a good option for maintaining hemodialysis access site options? J Vasc Surg 2004; 39 :1043-1047.  Back to cited text no. 11
    
12.
Allon M, Ornt D, Schwab S. Factors associated with the prevalence of A-V fistulas in hemodialysis patients in the HEMO Study. Kidney Int 2000; 58 :2178-2185.  Back to cited text no. 12
    
13.
Stehman CO, Sherrard DJ, Gillen D, Caps M. Determinants of type and timing of initial permanent hemodialysis vascular access. Kidney Int 2000; 57 :639-645.  Back to cited text no. 13
    
14.
Allon M, Lockhart ME, Lilly RZ. Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int 2001; 60 :2013-2020.  Back to cited text no. 14
    
15.
Horimi H, Kusano E, Hasegawa T, Fuse K, Asano Y. Clinical experience with an anatomic snuff box arteriovenous fistula in hemodialysis patients. ASAIO J 1996; 42 :177-180.  Back to cited text no. 15
    
16.
Protack CD, Bakken AM, Xu J, Saad WA, Lumsden AB, Davies MG. Metabolic syndrome: a predictor of adverse outcomes after carotid revascularization. J Vasc Surg 2008; 49 :1172-1180.  Back to cited text no. 16
    
17.
17. Erkut B, Unlü Y, Ceviz M. Primary arteriovenous fistulas in the forearm for hemodialysis: effect of miscellaneous factors in fistula patency. Ren Fail 2006; 28 :275-281.  Back to cited text no. 17
    
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18. Ghanayema NM, Abdel Azizb WF, El-Sattar El-Ghobashia YA, El-Shazlya RMA, El-Din Wahba AMS. Endogenous secretory receptor of advanced glycated end products of type II diabetic and hypertension. Menoufia Med J 2014; 27 :395-400.  Back to cited text no. 18
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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