The hemodialysis access: preferences and concerns of patients, dialysis nurses and technicians, and physicians

The outcome of ultrasound-guided insertion of central hemodialysis catheter

OBJECTIVE

To point out our experience and assess the efficacy and safety of real-time ultrasound-guided central internal jugular vein (IJV) catheterization in the treatment of hemodialysis patients.

METHODS

This retrospective study comprised 150 patients with end-stage renal disease (ESRD) who had real-time ultrasonography (US)-guided IJV HD catheters placed in our hospital between March 2019 and March 2021. Patients were examined for their demographic data, etiology, site of catheter insertion, type (acute or chronic) of renal failure, technical success, operative time, number of needle punctures, and procedure-related complications. Patients who have had multiple catheter insertions, prior catheterization challenges, poor compliance, obesity, bony deformity, and coagulation disorders were considered at high-operative risk.

RESULTS

All patients experienced technical success. In terms of patient clinical features, an insignificant difference was observed between the normal and high-risk groups (p-value > 0.05). Of the 150 catheters, 62 (41.3%) were placed in high-risk patients. The first-attempt success rate was 89.8% for the normal group and 72.5% for the high-risk group (p = 0.006). IJV cannulation took less time in the normal-risk group compared to the highrisk group (21.2 ± 0.09) minutes vs (35.4 ± 0.11) minutes, (p < 0.001). There were no serious complications. During the placing of the catheter in the internal jugular vein, four patients (6.4%) experienced arterial puncture in the high-risk group. Two participants in each group got a small neck hematoma. One patient developed a pneumothorax in the high-risk group, which was managed with an intercostal chest tube insertion.

CONCLUSIONS

Even in the high-risk group, the real-time US-guided placement of a central catheter into the IJV is associated with a low complication rate and a high success rate. Even under US guidance, experience lowers complication rates. Real-time USguided is recommended to be used routinely during central venous catheter insertion.

Adrenal function testing in dialysis patients - a review of the literature

Background

Secondary adrenal insufficiency is a frequent issue in patients with renal replacement therapy. There are concerns about metabolism and clearance for adrenocorticotropic hormone (ACTH) and cortisol in addition to hemoconcentration as confounding factors during hemodialysis (HD). Therefore, ACTH testing is currently performed before or in between HD sessions. This review of the literature aims to evaluate the current evidence for validity of testing for adrenal insufficiency in patients on chronic renal replacement therapy.

Methods

A literature search of PubMed database for interventional and observational clinical trials was performed. Case reports and reviews were excluded. The search included all articles published until July 2020.

Results

Of 218 potentially eligible articles, 16 studies involving 381 participants were included. Seven studies performed an ACTH test before HD or in between HD sessions. There was no data available regarding ACTH testing during HD. But there was evidence of decreased cortisol levels during HD as compared to afterwards. All included 16 studies measured basal cortisol, and seven studies performed an ACTH test. Seven trials had comparable data of baseline cortisol for a quantitative analysis. Standardized mean difference of overall cortisol was 0.18 nmol/l (95%CI − 0.08 to 0.44) in the case group.

Conclusions

In patients undergoing renal replacement therapy, basal serum cortisol values are comparable to healthy volunteers. There is limited data on the validity of stimulated cortisol in these patients, especially during HD.

Trial registration

Registration no. CRD42020199245.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02541-5.

Perceived barriers and attitudes toward arteriovenous fistula creation and use in hemodialysis patients in Palestine

In the dialysis center in Ramallah, we investigated the attitudes and perceived barriers to having arteriovenous fistula (AVF) in 156 patients. The current method of HD access was AVF in 52% and central venous catheter in 47%. Perceived causes of no or delayed AVF were: patient’s refusal of AVF in 54.5%, late referral to a surgical evaluation in 31.3% and too long to surgical appointments in 14.2%. Among those who refused AVF, reasons were: concern about the surgical procedure in 42.5%, poor understanding of disease/access in 23.3%, fear of needles in 15.1%, denial of disease or need for HD in 17.8%, and cosmetic reasons in 1.4%. Forty six percent of patients believed they received education about AVF prior to the creation of HD access, and 73.7% would recommend AVF as the method of access due to the lower risk of infection (96%), easier to care for (16%), easier showering (14%), and better-associated hygiene (3%). In conclusion, the majority would recommend an AVF as the mode of vascular access for HD. The most common barrier to having an AVF was patient’s refusal to undergo AVF creation because of their concern about the surgical procedure. A systematic evaluation of the process that precedes the creation of AVF may allow for better utilization.

Comparison of the pain-reducing effects of EMLA cream and of lidocaine tape during arteriovenous fistula puncture in patients undergoing hemodialysis: A multi-center, open-label, randomized crossover trial

Arteriovenous fistula puncture pain is a serious problem for patients undergoing dialysis and a good indication for topical anesthetics. No previous study has compared lidocaine/prilocaine cream (EMLA) with lidocaine tape for pain relief during arteriovenous fistula puncture in patients undergoing maintenance hemodialysis. To this end, we conducted a multicenter randomized crossover study including 66 patients (mean age, 65.8 years; males, 57.6%) undergoing maintenance hemodialysis thrice/week. Subjects were assigned to Sequence EL (EMLA administration followed by lidocaine, with 1-week wash-out) or Sequence LE (reverse administration, first lidocaine then EMLA). All subjects completed the study. At each puncture site, 1 g EMLA (25 mg lidocaine + 25 mg prilocaine) or one sheet of lidocaine tape (18 mg lidocaine) was applied 1 h or 30 min prior to arteriovenous fistula puncture, respectively. The primary endpoint was puncture pain relief, which was measured using a 100-mm visual analog scale. The secondary endpoints included quality of life, which was measured by SF-36, and safety. EMLA produced a 10.1-mm greater visual analog scale improvement than lidocaine tape (P = 0.00001). However, there was no statistically significant difference in the quality of life between the two groups, and no significant carryover/period effect was observed in any analysis. Further, no drug-related adverse events were observed. Taken together, these results suggest that EMLA cream is superior to lidocaine tape for the relief of arteriovenous fistula puncture pain in patients undergoing maintenance hemodialysis. Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000027885).

Non-randomized safety and performance evaluation of the av-Guardian vascular access system

Introduction:

The ability to successfully cannulate the arteriovenous fistula reliably is a critical step in the delivery of hemodialysis therapy. The av-Guardian vascular access system (Advent Access, Singapore) is designed to overcome the technical barrier to establishing reliable blunt needle access in patients with mature arteriovenous fistula.

Methods:

This was a first-in-man, prospective, non-randomized trial (registered on the Australian New Zealand Clinical Trial Registry (ACTRN12617000501347)) performed to assess the safety and feasibility of achieving repeatable successful cannulation via av-Guardian vascular access system to facilitate blunt needling in patients with mature arteriovenous fistula. The primary endpoints of the study included rate of successful hemodialysis sessions via av-Guardian vascular access system cannulation over 3 months and safety of the implants.

Results:

A total of six patients (four patients with brachiocephalic and two with radiocephalic arteriovenous fistula) were enrolled in the study. A pair of av-Guardian vascular access system were implanted, one each at the arterial and venous cannulation sites, under local anesthesia. Overall, the rate of successful cannulation through the av-Guardian vascular access system over 3 months in 216 hemodialysis sessions was 98.1% (212/216) at the arterial site and 94.4% (204/216) at the venous site. Significantly, 90% and 85.5% of the cannulations at the arterial and venous site, respectively, were successful at first attempt. Blood flow rates within the arteriovenous fistula were unaffected by the devices.

Conclusion:

The results demonstrated the safety and feasibility of a subcutaneously implanted, extravascular device in achieving repeatable successful cannulation via a constant site, to facilitate blunt needling in matured arteriovenous fistula in limited number of patients.

Attitudes and perceived barriers toward arteriovenous fistula creation and use in hemodialysis patients in Jordan

Current guidelines recommend arteriovenous fistula (AVF) as the preferred method of access for hemodialysis (HD) patients; however, its utilization remains low. The attitudes of Jordanian HD patients and perceived barriers toward AVF are unknown and have not been well studied. In-center HD patients in the Jordan Ministry of Health largest dialysis unit were interviewed, and a questionnaire was administered inquiring about their experiences, attitudes, and perceived barriers toward AVF. Of 104 total patients, 93 met the inclusion criteria. Mean age was 50 ± 16 years, with 44% being female. Average body mass index was 25 ± 5. The cause of end-stage renal disease was diabetes mellitus in 28 (30%), hypertension in 28 (30%), and polycystic kidney disease in three (3%). Patients had an average time on dialysis of 72 months (range 1-240). Current method of HD access was AVF in 45 (48%) and central venous catheter in 30 (32%). The most reported perceived cause of no AVF was delayed referral to surgical evaluation in 19 (40%), refusal to undergo AVF surgical procedure in 16 (33%), and poor understanding of disease in 13 (27%). Of the total studied group, only 29 (31%) indicated that they received sufficient education/information about AVF prior to creation of HD access. Seventy-eight patients (84%) reported that they would recommend AVF as method of access for other HD patients. The reason why majority of patients preferred AVF was reported as: easier to care for 51 (65%), better associated hygiene 26 (33%), and perceived less infection risk 24 (31%). In conclusion, in this sample population from HD patients in Jordan, majority would recommend an AVF as mode of access. Perceived barriers include lack of timely referral for vascular surgical evaluation and poor understanding of disease. A systematic assessment of the process that precedes the creation of AVF, with focus on areas of reported barriers may allow for better utilization of AVF.

Hemodialysis vascular access in the elderly-getting it right

Choosing the optimal hemodialysis vascular access for the elderly patient is best achieved by a patient-centered coordinated multidisciplinary team approach that aligns the patient's end-stage kidney disease Life-Plan, i.e., the individual treatment approach (supportive care, time-limited or long-term kidney replacement therapy, or combination thereof) and selection of dialysis modality (peritoneal dialysis versus hemodialysis) with the most suitable dialysis access. Finding the right balance between the patient's preferences, the likelihood of access function and survival, and potential complications in the context of available resources and limited patient survival can be extremely challenging. The framework for choosing the most appropriate vascular access for the elderly presented in this review considers the individual end-stage kidney disease Life-Plan, the patient life expectancy, the likelihood of access function and survival, the timing of dialysis relative to access placement, prior access history, and patient preference. This complex decision-making process should be dynamic in order to accommodate patients' changing needs and life and health circumstances. Effective and timely communication between the patient, their caregivers, and treating team is key to delivering truly patient-centered care. Delivering this care also requires overcoming the limitations of the currently available evidence that is predominantly based on observational data with its inherent risks of bias. While challenging, future randomized controlled studies exploring the risks, benefits, costs, and timing of placement of available access types in the elderly are required to help us "get it right" for our patients.

Identifying critically important vascular access outcomes for trials in haemodialysis: an international survey with patients, caregivers and health professionals

Background

Vascular access outcomes reported across haemodialysis (HD) trials are numerous, heterogeneous and not always relevant to patients and clinicians. This study aimed to identify critically important vascular access outcomes.

Method

Outcomes derived from a systematic review, multi-disciplinary expert panel and patient input were included in a multilanguage online survey. Participants rated the absolute importance of outcomes using a 9-point Likert scale (7–9 being critically important). The relative importance was determined by a best–worst scale using multinomial logistic regression. Open text responses were analysed thematically.

Results

The survey was completed by 873 participants [224 (26%) patients/caregivers and 649 (74%) health professionals] from 58 countries. Vascular access function was considered the most important outcome (mean score 7.8 for patients and caregivers/8.5 for health professionals, with 85%/95% rating it critically important, and top ranked on best–worst scale), followed by infection (mean 7.4/8.2, 79%/92% rating it critically important, second rank on best–worst scale). Health professionals rated all outcomes of equal or higher importance than patients/caregivers, except for aneurysms. We identified six themes: necessity for HD, applicability across vascular access types, frequency and severity of debilitation, minimizing the risk of hospitalization and death, optimizing technical competence and adherence to best practice and direct impact on appearance and lifestyle.

Conclusions

Vascular access function was the most critically important outcome among patients/caregivers and health professionals. Consistent reporting of this outcome across trials in HD will strengthen their value in supporting vascular access practice and shared decision making in patients requiring HD.

Report of the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop on Establishing a Core Outcome Measure for Hemodialysis Vascular Access

Vascular access outcomes in hemodialysis are critically important for patients and clinicians, but frequently are neither patient relevant nor measured consistently in randomized trials. A Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop was convened to discuss the development of a core outcome measure for vascular access. 13 patients/caregivers and 46 professionals (clinicians, policy makers, industry representatives, and researchers) attended. Participants advocated for vascular access function to be a core outcome based on the broad applicability of function regardless of access type, involvement of a multidisciplinary team in achieving a functioning access, and the impact of access function on quality of life, survival, and other access-related outcomes. A core outcome measure for vascular access required demonstrable feasibility for implementation across different clinical and trial settings. Participants advocated for a practical and flexible outcome measure with a simple actionable definition. Integrating patients' values and preferences was warranted to enhance the relevance of the measure. Proposed outcome measures for function included "uninterrupted use of the access without the need for interventions" and "ability to receive prescribed dialysis," but not "access blood flow," which was deemed too expensive and unreliable. These recommendations will inform the definition and implementation of a core outcome measure for vascular access function in hemodialysis trials.

The Vascular Access Questionnaire: Assessing Patient-Reported Views of Vascular Access

Background

The use of central venous catheters for vascular access in hemodialysis (HD) patients is associated with an increased risk of complications compared to arteriovenous fistulas (AVF). Despite this, catheter use remains high and patient satisfaction may be an important driver of catheter use.

Methods

We developed the Vascular Access Questionnaire (VAQ) to measure patient-reported views of their vascular access. Chronic HD patients at two centers were asked to rate how bothered they were by 17 access-related problems. VAQ symptom scores were compared between patients using catheters and those using fistulas for vascular access.

Results

Two hundred and twenty-two patients were eligible for the study. Symptom score was not different between patients using catheters and those using fistulas (p=0.36). However, patients using fistulas were more likely to be at least moderately bothered by pain, bleeding, bruising, swelling, and the appearance of their access than patients using catheters. Elderly patients reported lower symptom scores with catheters than fistulas.

Conclusions

Patients appear to be primarily concerned with the appearance of their access and cannulation-related complications, particularly the elderly. Better education about the risk of adverse events with catheters and the implementation of measures aimed at reducing cannulation-related complications may help to increase fistula rates and improve patient satisfaction with their vascular access.

Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access

This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.

Vascular Access Outcomes Reported in Maintenance Hemodialysis Trials: A Systematic Review

BACKGROUND

Many randomized controlled trials have been performed with the goal of improving outcomes related to hemodialysis vascular access. If the reported outcomes are relevant and measured consistently to allow comparison of interventions across trials, such trials can inform decision making. This study aimed to assess the scope and consistency of vascular access outcomes reported in contemporary hemodialysis trials.

STUDY DESIGN

Systematic review.

SETTING & POPULATION

Adults requiring maintenance hemodialysis.

SELECTION CRITERIA

All randomized controlled trials and trial protocols reporting vascular access outcomes identified from ClinicalTrials.gov, Embase, MEDLINE, and the Cochrane Kidney and Transplant Specialized Register from January 2011 to June 2016.

INTERVENTIONS

Any hemodialysis-related intervention.

OUTCOMES

The frequency and characteristics of vascular access outcome measures were analyzed and classified.

RESULTS

From 168 relevant trials, 1,426 access-related outcome measures were extracted and classified into 23 different outcomes. The 3 most common outcomes were function (136 [81%] trials), infection (63 [38%]), and maturation (31 [18%]). Function was measured in 489 different ways, but most frequently reported as "mean access blood flow (mL/min)" (37 [27%] trials) and "number of thromboses" (30 [22%]). Infection was assessed in 136 different ways, with "number of access-related infections" being the most common measure. Maturation was assessed in 44 different ways at 15 different time points and most commonly characterized by vein diameter and blood flow. Patient-reported outcomes, including pain (19 [11%]) and quality of life (5 [3%]), were reported infrequently. Only a minority of trials used previously standardized outcome definitions.

LIMITATIONS

Restricted sampling frame for feasibility and focus on contemporary trials.

CONCLUSIONS

The reporting of access outcomes in hemodialysis trials is very heterogeneous, with limited patient-reported outcomes and infrequent use of standardized outcome measures. Efforts to standardize outcome reporting for vascular access are critical to optimizing the comparability, reliability, and value of trial evidence to improve outcomes for patients requiring hemodialysis.

Ability to Work among Patients with ESKD: Relevance of Quality Care Metrics

Enabling patient ability to work was a key rationale for enacting the United States (US) Medicare program that provides financial entitlement to renal replacement therapy for persons with end-stage kidney disease (ESKD). However, fewer than half of working-age individuals in the US report the ability to work after starting maintenance hemodialysis (HD). Quality improvement is a well-established objective in oversight of the dialysis program, but a more patient-centered quality assessment approach is increasingly advocated. The ESKD Quality Incentive Program (QIP) initiated in 2012 emphasizes clinical performance indicators, but a newly-added measure requires the monitoring of patient depression—an issue that is important for work ability and employment. We investigated depression scores and four dialysis-specific QIP measures in relation to work ability reported by a multi-clinic cohort of 528 working-age maintenance HD patients. The prevalence of elevated depression scores was substantially higher among patients who said they were not able to work, while only one of the four dialysis-specific clinical measures differed for patients able/not able to work. Ability to work may be among patients’ top priorities. As the parameters of quality assessment continue to evolve, increased attention to patient priorities might facilitate work ability and employment outcomes.

Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access Care

The vascular access is the lifeline for the hemodialysis patient. In the United States, the Fistula First Breakthrough Initiative (FFBI) has been influential in improving use of arteriovenous fistulas (AVF) in prevalent hemodialysis patients. Currently, prevalent AVF rates are near the goal of 66% set forth by the original FFBI. However, central venous catheter (CVC) rates remain very high in the United States in patients initiating hemodialysis, nearly exceeding 80%. A new direction of the of the FFBI has focused on strategies to reduce CVC use, and subsequently the FFBI has now been renamed the "Fistula First-Catheter Last Initiative". However, an AVF may not be the best vascular access in all hemodialysis patients, and arteriovenous grafts (AVG) and CVCs may be appropriate and the best access for a subset of hemodialysis patients. Unfortunately, there still remains very little emphasis within vascular access initiatives and guidelines directed towards evaluation of the individual patient context, specifically patients with poor long-term prognoses and short life expectancies, patients with multiple comorbidities, patients who are more likely to die than reach end stage renal disease (ESRD), and patients of elderly age with impaired physical and cognitive function. Given the complexity of medical and social issues in advanced CKD and ESRD patients, planning, selection, and placement of the most appropriate vascular access are ideally managed within a multidisciplinary setting and requires consideration of several factors including national vascular access guidelines. Thus, the evolution of the FFBI should underscore the need for multidisciplinary health teams with a major emphasis placed on "the right access for the right patient" and improving the patient's overall quality of life.

Factors Affecting Hemodialysis Adequacy in Cohort of Iranian Patient with End Stage Renal Disease

BACKGROUND

There are many factors that can affect dialysis adequacy; such as the type of vascular access, filter type, device used, and the dose, and rout of erythropoietin stimulation agents (ESA) used. The aim of this study was investigating factors affecting Hemodialysis adequacy in cohort of Iranian patient with end stage renal disease (ESRD).

METHODS

This is a cross-sectional study conducted on 133 Hemodialysis patients referred to two dialysis units in Sistan-Baluchistan province in the cities of Zabol and Iranshahr, Iran. We have looked at, (the effects of the type of vascular access, the filter type, the device used, and the dose, route of delivery, and the type of ESA used) on Hemodialysis adequacy. Dialysis adequacy was calculated using kt/v formula, two-part information questionnaire including demographic data which also including access type, filter type, device used for hemodialysis (HD), type of Eprex injection, route of administration, blood groups and hemoglobin response to ESA were utilized. The data was analyzed using the SPSS v16 statistical software. Descriptive statistical methods, Mann-Whitney statistical test, and multiple regressions were used when applicable.

RESULTS

The range of calculated dialysis adequacy is 0.28 to 2.39 (units of adequacy of dialysis). 76.7% of patients are being dialyzed via AVF and 23.3% of patients used central venous catheters (CVC). There was no statistical significant difference between dialysis adequacy, vascular access type, device used for HD (Fresenius and B. Braun), and the filter used for HD (p> 0.05). However, a significant difference was observed between the adequacy of dialysis and Eprex injection and patients' time of dialysis (p <0.05).

CONCLUSION

Subcutaneous ESA (Eprex) injection and dialysis shift (being dialyzed in the morning) can have positive impact on dialysis adequacy. Patients should be educated on the facts that the type of device used for HD and the vascular access used has no significant effects on dialysis adequacy.

Hemodialysis patients' satisfaction and perspectives on complications associated with vascular access related interventions: are we listening?

PURPOSE

To understand the patient's perspective on complications associated with vascular access-related interventions.

METHODS

A multi-stage comprehensive questionnaire of over 150 items was administered to 140 in-center hemodialysis patients in a large, Toronto-based academic-based facility from May 1, 2011 until July 1, 2014. The questionnaire was divided into three domains: physical complications, disruption to routine, and infection. For each of the 12 prespecified vascular access interventions, there were 9 items about the associated complications. The level of bother associated with complications was measured using a 5-point Likert scale.

RESULTS

The mean Likert value (5 = extremely bothered) for the physical complications domain was highest for grafts at 1.92, followed closely by fistulas at 1.87, and catheters at 1.56. The mean Likert value for the "disruption of routine" domain was highest for catheters at 1.44, followed by grafts at 1.37, and fistulas at 1.33. For infectious complications of all vascular access-related interventions the mean Likert value was highest at 1.76 for catheters as compared to fistulas at 1.23 and grafts at 1.22.

CONCLUSIONS

For hemodialysis patients, the physical complications associated with needle cannulation of fistulas and grafts are a major source of dissatisfaction, while infectious complications, including catheter-related infections, are not a significant source of their concerns. Future research should focus on developing methods to effectively: (i) reduce the fear and pain associated with cannulation and (ii) educate patients about the risks associated with vascular access-related infection.

Prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent hemodialysis: a systematic review

OBJECTIVES

Understanding the epidemiology of pain in patients on hemodialysis (HD) is crucial for further improvement in managing pain. The aim of this study was to systematically review available evidence on the prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent HD.

MATERIALS AND METHODS

We carried out a systematic review of the literature and developed a comprehensive search strategy based on search terms on pain and HD. We searched the databases MEDLINE, Scopus, PsycINFO, and CINAHL from the earliest date of each database to July 24, 2014. Manuscripts in all languages were taken into consideration. Two authors performed each step independently, and all disagreements were resolved after discussion with the third author. The quality of studies was estimated using the STROBE checklist and Cochrane risk-of-bias tool.

RESULTS

We included 52 studies with 6,917 participants. The prevalence of acute and chronic pain in HD patients was up to 82% and 92%, respectively. A considerable number of patients suffered from severe pain. Various locations and causes of pain were described, with most of the studies reporting pain in general, pain related to arteriovenous access, headache, and musculoskeletal pain.

CONCLUSION

The findings of this systematic review indicate high prevalence of pain in HD patients and considerable gaps and limitations in the available evidence. Pain in this population should be recognized as a considerable health concern, and the nephrology community should promote pain management in HD patients as a clinical and research priority to improve patients' quality of life and pain-related disability.

Frequent hemodialysis fistula infectious complications

Background

Few studies have examined if infectious arteriovenous access complications vary with the cannulation technique and whether this is modified by dialysis frequency. We compared the infection rate between fistulas cannulated using buttonhole versus stepladder techniques for patients treated with short daily (SDH) or nocturnal hemodialysis at home (NHD). We also compared patients receiving conventional intermittent hemodialysis (CIHD) using stepladder cannulation.

Methods

Data were prospectively collected from 631 patients dialyzed with a fistula from 2001 to 2010 (Toronto and Ottawa, Canada). We compared the person-time incidence rate of bacteremia and local fistula infections using the exact binomial test.

Results

Forty-six (7.3%) patients received SDH (≥5 sessions/week, 2-4 h/session), 128 (20.3%) NHD (≥4 sessions/week, ≥5 h/session) and 457 (72%) CIHD (3 sessions/week, ≤4 h/session). Fifty percent of SDH and 72% of NHD patients used the buttonhole technique. There were 39 buttonhole-related bacteremias (rate: 0.196/1,000 fistula days) and at least 2 local buttonhole site infections. Staphylococcus aureus accounted for 85% of the bacteremias. There were 5 (13%) infection-related hospitalizations and 3 (10%) serious metastatic infections, including fistula loss. In comparison, there was 1 possible fistula-related infection in CIHD during follow-up (rate: 0.002/1,000 fistula days).

Conclusions

The rate of buttonhole-related infections was high among patients on frequent hemodialysis and more than 50 times greater than that among patients on CIHD with the stepladder technique. Most bacteremias were due to S. aureus – with serious consequences. The risks and benefits of buttonhole cannulation require individual consideration with careful monitoring, prophylaxis and management.

Patients' perspectives on hemodialysis vascular access: a systematic review of qualitative studies

BACKGROUND

Delayed creation of vascular access may be due in part to patient refusal and is associated with adverse outcomes. Concerns about vascular access are prevailing treatment-related stressors for patients on hemodialysis therapy. This study aims to describe patients' perspectives on vascular access initiation and maintenance in hemodialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies.

SETTING & POPULATION

Patients with chronic kidney disease who express opinions about vascular access for hemodialysis.

SEARCH STRATEGY & SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched to October 2013.

ANALYTICAL APPROACH

Thematic synthesis was used to analyze the findings.

RESULTS

From 46 studies involving 1,034 patients, we identified 6 themes: heightened vulnerability (bodily intrusion, fear of cannulation, threat of complications and failure, unpreparedness, dependence on a lifeline, and wary of unfamiliar providers), disfigurement (preserving normal appearance, visual reminder of disease, and avoiding stigma), mechanization of the body (bonded to a machine, internal abnormality, and constant maintenance), impinging on way of life (physical incapacitation, instigating family tension, wasting time, and added expense), self-preservation and ownership (task-focused control, advocating for protection, and acceptance), and confronting decisions and consequences (imminence of dialysis therapy and existential thoughts).

LIMITATIONS

Non-English articles were excluded.

CONCLUSIONS

Vascular access is more than a surgical intervention. Initiation of vascular access signifies kidney failure and imminent dialysis, which is emotionally confronting. Patients strive to preserve their vascular access for survival, but at the same time describe it as an agonizing reminder of their body's failings and "abnormality" of being amalgamated with a machine disrupting their identity and lifestyle. Timely education and counseling about vascular access and building patients' trust in health care providers may improve the quality of dialysis and lead to better outcomes for patients with chronic kidney disease requiring hemodialysis.

Disparities in arteriovenous fistula placement in older hemodialysis patients

The benefits of an arteriovenous fistula (AVF) as the preferred vascular access for hemodialysis have been clearly demonstrated. However, only about 20% of patients in the United States initiate hemodialysis with an AVF. In this study, we assessed whether disparities exist in the type of first hemodialysis access placed prior to dialysis start (rather than that used at dialysis initiation), to detect whether certain disadvantaged groups might have lower likelihood of AVF placement. Study cohort of 118,767 incident hemodialysis patients ≥67 years of age (1/2005-12/2008) derived from the United States Renal Data System was linked with Medicare claims data to identify the type of initial access placed predialysis. We used logistic regression model with outcome being the initial predialysis placement of an AVF as opposed to an arteriovenous graft or a central venous catheter. Increasing age, female sex, black race, lower body mass index, urban location, certain comorbidities, and shorter pre-end-stage renal disease nephrology care are all associated with a significantly lower likelihood of AVF placement as initial access predialysis. Our study suggests the presence of significant disparities in the placement of an AVF as initial hemodialysis vascular access. We suggest that additional attention should be paid to these patient groups to improve disparities by patient education, earlier referral, and close follow-up.

The flow field near a venous needle in hemodialysis: a computational study

The vascular access used in hemodialysis can suffer from numerous complications, which may lead to failure of the access, patient morbidity, and significant costs. The flow field in the region of the venous needle may be a source of damaging hemodynamics and hence adverse effects on the fistula. In this study, the venous needle flow has been considered, using three-dimensional computational methods. Four scenarios where the venous needle flow could potentially influence dialysis treatment outcome were identified and examined: Variation of the needle placement angle (10°, 20°, 30°), variation of the blood flow rate settings (200, 300, 400 mL/min), variation of the needle depth (top, middle, bottom), and the inclusion of a back eye in the needle design. The presence of the needle has significant effect on the flow field, with different scenarios having varying influence. In general, wall shear stresses were elevated above normal physiological values, and increased presence of areas of low velocity and recirculation-indicating increased likelihood of intimal hyperplasia development-were found. Computational results showed that the presence of the venous needle in a hemodialysis fistula leads to abnormal and potentially damaging flow conditions and that optimization of needle parameters could aid in the reduction of vascular access complications. Results indicate shallow needle angles and lower blood flow rates may minimize vessel damage.

Education in vascular access

The successful creation and use of an arteriovenous vascular access (VA) requires a coordinated, educated multidisciplinary team to ensure an optimal VA for each patient. Patient education programs on VA are associated with increased arteriovenous VA use at dialysis initiation. Education should be tailored to patient goals and preferences with the understanding that experiential education from patient to patient is far more influential than that provided by the healthcare professional. VA education for the nephrologist should focus on addressing the systematic and patient-level barriers in achieving a functional VA, with specific components relating to VA creation, maturation, and cannulation that consider patient goals and preferences. A deficit in nursing skills in the area of assessment and cannulation can have devastating consequences for hemodialysis patients. Delivery of an integrated education program increases nurses' knowledge of VA and development of simulation programs or constructs to assist in cannulation of the VA will greatly facilitate the much needed skill transfer. Adequate VA surgical training and experience are critical to the creation and outcomes of VA. Simulations can benefit nephrologists, dialysis nurses surgeons, and interventionalists though aiding in surgical creation, understanding of the physiology and anatomy of a dysfunctional VA, and practicing cannulation techniques. All future educational initiatives must emphasize the importance of multidisciplinary care to attain successful VA outcomes.

Optimal hemodialysis vascular access in the elderly patient

The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2 years, primary patency rates range from 43% to 74% and from 29% to 67%, respectively. Secondary patency rates at 1 and 2 years range from 56% to 82% and 44% to 67%, respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared with a catheter; however, catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes. The framework for choice of vascular access presented in this article considers: (1) likelihood of disease progression before death, (2) patient life expectancy, (3) risks and benefits by vascular access type, and (4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients' preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient.

Placement of hemodialysis catheters with a technical, functional, and anatomical viewpoint

Aims. Vascular access is of prime importance for hemodialysis patients. We aimed to study early complications of hemodialysis catheters placed in different central veins in patients with acute or chronic renal failure with or without ultrasound (US ) guidance. Material and Methods. Patients who were admitted to our unit between March 2008 and December 2010 with need for vascular access have been included. 908 patients were examined for their demographic parameters, primary renal disease, and indication for catheterization, type and location of the catheter, implantation technique, and acute complications. Results. The mean age of the patients was 60.6 ± 16.0 years. 643 (70.8 %) of the catheters were temporary while 265 (29.2%) were permanent. 684 catheters were inserted to internal jugular veins, 213 to femoral, and 11 to subclavian veins. Arterial puncture occurred in 88 (9.7%) among which 13 had resultant subcutaneous hematoma. No patient had lung trauma and there had been no need for removal of the catheter or a surgical intervention for complications. US guidance in jugular vein and experience of operator decreased arterial puncture rate. Conclusion. US-guided replacement of catheter to internal jugular vein would decrease complication rate. Referral to invasive nephrologists may decrease use of subclavian vein. Experience improves complication rates even under US guidance.

Impact of hemodialysis catheter dysfunction on dialysis and other medical services: an observational cohort study

Practice guidelines define hemodialysis catheter dysfunction as blood flow rate (BFR) <300 mL/min. We conducted a study using data from DaVita and the United States Renal Data System to evaluate the impact of catheter dysfunction on dialysis and other medical services. Patients were included if they had ≥8 consecutive weeks of catheter dialysis between 8/2004 and 12/2006. Actual BFR <300 mL/min despite planned BFR ≥300 mL/min was used to define catheter dysfunction during each dialysis session. Among 9,707 patients, the average age was 62,53% were female, and 40% were black. The median duration of catheter dialysis was 190 days, and the cohort accounted for 1,075,701 catheter dialysis sessions. There were 70,361 sessions with catheter dysfunction, and 6,33 1 (65.2%) patients had at least one session with catheter dysfunction. In multivariate repeated measures analysis, catheter dysfunction was associated with increased odds of missing a dialysis session due to access problems (Odds ratio [OR] 2.50; P < 0.001), having an access-related procedure (OR 2.10; P < 0.001), and being hospitalized (OR 1.10; P = 0.001). Catheter dysfunction defined according to NKF vascular access guidelines results in disruptions of dialysis treatment and increased use of other medical services.

Preservation of vascular access for hemodialysis in acute care settings

A vascular access for hemodialysis is the client's lifeline. It must be protected and used only for hemodialysis. Clients are knowledgeable about their vascular access and need to be listened to about its care. These clients' greatest fear is that their vascular access will be damaged and rendered nonfunctional. All health care personnel who come in contact with the vascular access and the client need to properly care for the vascular access with the goal of preserving its function. The purpose of this article is to explain the different types of vascular access for hemodialysis and how nurses can preserve and care for them. The vascular access and adjacent body areas need to be assessed regularly for circulatory, neurological, and muscular functions. Adequate perfusion helps to preserve the vascular access. Clients with end-stage renal disease will undergo many invasive procedures to establish and maintain a vascular access. Therefore, it is important to preserve the integrity of the existing vascular access as well as the surrounding vessels for future accesses. Nurses in acute care settings can assist to reduce the human and economic burden of vascular access.

Exploring the impact of a decision support intervention on vascular access decisions in chronic hemodialysis patients: study protocol

BACKGROUND

In patients with Stage 5 Chronic Kidney Disease who require renal replacement therapy a major decision concerns modality choice. However, many patients defer the decision about modality choice or they have an urgent or emergent need of RRT, which results in them starting hemodialysis with a Central Venous Catheter. Thereafter, efforts to help patients make more timely decisions about access choices utilizing education and resource allocation strategies met with limited success resulting in a high prevalent CVC use in Canada. Providing decision support tailored to meet patients' decision making needs may improve this situation. The Registered Nurses Association of Ontario has developed a clinical practice guideline to guide decision support for adults living with Chronic Kidney Disease (Decision Support for Adults with Chronic Kidney Disease.) The purpose of this study is to determine the impact of implementing selected recommendations this guideline on priority provincial targets for hemodialysis access in patients with Stage 5 CKD who currently use Central Venous Catheters for vascular access.

METHODS/DESIGN

A non-experimental intervention study with repeated measures will be conducted at St. Michaels Hospital in Toronto, Canada. Decisional conflict about dialysis access choice will be measured using the validated SURE tool, an instrument used to identify decisional conflict. Thereafter a tailored decision support intervention will be implemented. Decisional conflict will be re-measured and compared with baseline scores. Patients and staff will be interviewed to gain an understanding of how useful this intervention was for them and whether it would be feasible to implement more widely. Quantitative data will be analyzed using descriptive and inferential statistics. Statistical significance of difference between means over time for aggregated SURE scores (pre/post) will be assessed using a paired t-test. Qualitative analysis with content coding and identification of themes will be conducted for the focus group and patient interview data.

DISCUSSION

Coupling the SURE tool with a decision support system structured so that a positive test result triggers providers to help patients through the decision-making process and/or refer patients to appropriate resources could benefit patients and ensure they have the opportunity to make informed HD access choices.

Who should be referred for a fistula? A survey of nephrologists

BACKGROUND

There is marked variation in the use of the arteriovenous fistula (AVF) across programmes, regions and countries not explained by differences in patient demographics or comorbidities. The lack of clear criteria of who should or should not get a fistula may contribute to this, as well as barriers to creating AVFs.

METHODS

We conducted a survey of Canadian and American nephrologists to assess the patient variables considered to determine the timing and type of access requested. Perceived barriers and absolute contraindications to access were also collected.

RESULTS

An immediate referral for a fistula was more highly preferred when patients are <65 years old, have minimal comorbidities or have no history of failed accesses. In older patients, and in those with increased comorbidities or a previously failed fistula, US nephrologists selected arteriovenous grafts as an alternative to the fistula, while Canadian nephrologists selected primarily catheters. Referral for vascular mapping was more common in the USA than in Canada. Gender did not influence the timing or the type of access. Perceived barriers to establishing a mature fistula included patient refusal for creation (77%) or cannulation (58%), delay in decision regarding dialysis modality (71%), wait time for surgical creation (55%) and high failure-to-mature rate (52%). We found that 27% of Canadian and 43% of American nephrologists indicated no absolute contraindications for permanent vascular access.

CONCLUSIONS

This study demonstrated marked variability in timing and criteria used to select patients for referral for a vascular access between nephrologists practicing within Canada and the USA. Establishing minimal eligibility criteria for fistulae is an important area of future research.

A systematic review of factors influencing decision-making in adults living with chronic kidney disease

OBJECTIVE

To identify factors influencing patient involvement in decision-making in the context of chronic kidney disease (CKD) and effective interventions to support their decision-making needs.

METHODS

A systematic review included studies and decision support tools that involved: (1) adults with CKD, (2) studies published from 1998-2008; and (3) a focus on patient decision-making needs, and/or barriers and facilitators to shared decision-making. Studies were quality appraised.

RESULTS

Forty studies were appraised. These studies mainly focused on the decisions patients with CKD faced around the choice of renal replacement therapy and withholding/withdrawing dialysis. Moreover, studies typically focused on health care professional's provision of information about the decision rather than identifying decisional conflict and supporting patients in decision-making. No studies were found that identified the patient's point of view about factors that might influence or inhibit quality decision-making. Factors influencing CKD patient's participation in decision included: (1) interpersonal relationships; (2) preservation of current well being, normality and quality of life; (3) need for control; and (4) personal importance on benefits and risks. Of the four patient decision aids identified, none had been evaluated for effectiveness.

CONCLUSION

Patients with CKD face decisions that are likely to cause decisional conflict. Most studies focused on information needs related to renal replacement therapy and withdrawing or withholding dialysis. There was less focus on other decision-making needs in the context of those choices and across the trajectory of CKD. Although patient decision aids and implementation of shared decision-making have been evaluated in patients with other medical conditions, little is known about interventions to support patients with CKD making quality decisions.

PRACTICE IMPLICATIONS

Patients with CKD have decision-making needs across the trajectory of their illness. Although little is known about supporting patients with CKD decision-making, support could be provided with protocols and tools that have been developed for other chronic illness situations. Development of CKD-specific clinical practice guidelines that include decision support best practices could benefit CKD patients. Research priorities include development and evaluation of CKD focused decision support tools and processes.

Research into pain perception with arteriovenous fistula (avf) cannulation

Patients with end-stage renal failure (ESRF) undergoing haemodialysis (HD) are repeatedly exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula (AVF). Repeated AVF punctures lead to a considerable degree of pain, due to the calibre and length of the bevel of fistula needles. Pain is a sensitive, emotional and subjective experience. The objective of this study was to measure pain associated with AVF needling. The analogue visual scale (AVS) divided into 10 equal parts (0 indicating lack of pain, and 10 unbearable pain) was used. Patients(7) perceptions were measured in three different HD sessions. Pain was considered mild during AVF needling. The buttonhole technique caused a mean degree of pain of 2.4 (+/-1.7), compared to 3.1 (+/-2.3) using the conventional ropeladder technique. Although without reaching a statistically significant difference, diminished pain was associated with the buttonhole technique.

Clinical surveillance and monitoring of arteriovenous access for hemodialysis

Clinical surveillance and monitoring of arteriovenous access for hemodialysis can best ensure long term access function. The failing access can be identified and referred for intervention prior to complete access failure. This article reviews the basic science of access function and the various techniques for detecting the failing access. These techniques are utilized by the dialysis unit staff and by the physician, often the interventionalist, who takes primary care of the access. A combination of various techniques to detect dysfunction and trend analysis of various parameters is most likely to identify in a timely manner, those patients who need intervention.

Effect of online haemodialysis vascular access flow evaluation and pre-emptive intervention on the frequency of access thrombosis

Introduction. Guidelines advocate surveillance of vascular access to reduce incidences of thrombosis. However, the value of online vascular access flow monitoring is still under debate.

Methods. Through a systematic literature search, the effect of online access flow surveillance combined with pre-emptive intervention on thrombosis frequency is reviewed.

Results. Due to methodological differences, adequate comparison of the individual study results is not possible. Moreover, the methodological quality of most of the included studies is not suitable for an adequate statistical analysis of the results.

Conclusion. Until now, there is no conclusive evidence that online access flow evaluation has a significant effect on the rate of thrombosis. Future large-scale studies with adequate study design, adequate surveillance and intervention protocols and, possibly, better pre-emptive intervention alternative(s) are necessary.

Neointimal hyperplasia associated with synthetic hemodialysis grafts

Stenosis is a major cause of failure of hemodialysis vascular grafts and is primarily caused by neointimal hyperplasia (NH) at the anastomoses. The objective of this article is to provide a scientific review of the biology underlying this disorder and a critical review of the state-of-the-art investigational preventive strategies in order to stimulate further research in this exciting area. The histology of the NH shows myofibroblasts (that are probably derived from adventitial fibroblasts), extracellular matrices, pro-inflammatory cells including foreign-body giant cells, a variety of growth factors and cytokines, and neovasculature. The contributing factors of the pathogenesis of NH include surgical trauma, bioincompatibility of the synthetic graft, and the various mechanical stresses that result from luminal hypertension and compliance mismatch between the vessel wall and graft. These mechanical stimuli are focal in nature and may have a significant influence on the preferential localization of the NH. Novel mechanical graft designs and local drug delivery strategies show promise in animal models in preventing graft NH development. Successful prevention of graft stenosis would provide a superior alternative to the native fistula as hemodialysis vascular access.

Association of initial hemodialysis vascular access with patient-reported health status and quality of life

BACKGROUND

Although the arteriovenous fistula (AVF) is the recommended form of vascular access for patients with ESRD, its impact on patient perception of health status, quality of life (QOL), or satisfaction is unknown.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This study compared patient-reported health status and QOL scores and vascular access type among a national random sample of 1563 patients at dialysis initiation and day 60 of ESRD during 1996 to 1997. Patients were stratified into five categories: AVF at first dialysis and day 60 of ESRD, arteriovenous graft (AVG) at first dialysis and day 60, central venous catheter (CVC) at first dialysis and AVF at day 60, CVC at first dialysis and AVG at day 60, and CVC at first dialysis and day 60.

RESULTS

Ten percent (n = 154) of patients had an AVF, 21% (n = 326) had an AVG, and 69% (n = 1083) had a CVC at dialysis initiation; those who were most likely to use an AVF were white and male. After statistical adjustment, patients with persistent AVF use reported greater physical activity and energy, better emotional and social well-being, fewer symptoms, less effect of dialysis and burden of kidney disease, and better sleep compared with patients with persistent CVC use, whereas measures such as cognitive and sexual function did not differ by access type.

CONCLUSIONS

Compared with persistent CVC use, early persistent AVF use is associated with the perception of improved health status and QOL among patients with ESRD. Future longitudinal studies may help to clarify further the association between QOL and vascular access.

Effects of venous needle turbulence during ex vivo hemodialysis on endothelial morphology and nitric oxide formation

Arteriovenous grafts used for hemodialysis frequently develop intimal hyperplasia (IH), which ultimately leads to graft failure. Although the turbulent jet from the dialysis needle may contribute to vessel wall injury, its role in the pathogenesis of IH is relatively unexplored. In the current study, using bovine aortic endothelial cells (BAEC) cultured on the inner surface of a compliant tube, we evaluated the effects of simulated hemodialysis conditions on morphology and nitric oxide (NO) production. The flows via the graft and needle were 500 ml/min (Reynolds number=819) and 100ml/min (Reynolds number=954), respectively. In the presence of the needle jet for 6h, 19.3% (+/-1.53%) of BAEC were sheared off, whereas no loss of BAEC was observed in the presence of graft flow alone (P<0.05). In the presence of graft flow alone, assessment of cell orientation by the Saltykov method revealed that BAEC were oriented along the flow direction. This alignment, however, was lost in the presence of needle flow. Finally, NO production was also significantly decreased in the presence of the needle flow compared to the presence of graft flow alone (16+/-3.1 vs 34.7+/-1.9 nmol/10(6)cells/h, P<0.05). NO is a key player in vascular homeostasis mechanisms modulating vasomotor tone, inhibiting inflammation and smooth muscle cell proliferation. Thus, the loss of NO signaling and the loss of endothelial integrity caused by needle jet turbulence may contribute to the cascade of events leading to IH formation during hemodialysis.

Routine Surveillance in Vascular Access for Hemodialysis

There is increasing evidence that surveillance of AV access for haemodialysis prevents access thrombosis and improves the quality of care. This article reviews the evidence for surveillance and the various strategies and techniques available for detection of the failing access.

Stenosis in hemodialysis arteriovenous fistula: evaluation and treatment

Vascular access complications are one of the main causes associated with an increase in morbidity and mortality in stage 5 chronic kidney disease patients. The arteriovenous fistula is regarded as the vascular access of choice for hemodialysis (HD) because of its superior patency and lower complication rates. Stenosis is considered the major cause of dysfunction of arteriovenous fistula. Despite the relatively low thrombosis rates of arteriovenous fistula, surveillance programs are necessary for detection of stenosis. We report a case of a HD patient who had never achieved an adequate Kt/V since the start of maintenance HD. During the investigation, abnormal findings were found on physical examination of the fistula, in addition to an alteration in intra-access pressure (IAP) measurements. A venous stenosis was diagnosed by Doppler ultrasound and then promptly treated with percutaneous transluminal angioplasty. The purpose of the discussion is to highlight the peculiarities of arteriovenous fistulae, methods of surveillance, including physical examination, IAP, recirculation, and measurements of blood flow, and the importance of the correction procedures for the stenosis.

Access Monitoring Is Worthwhile and Valuable

During the past several years, a limited number of small clinical trials have questioned the role of surveillance in the management of vascular accesses, since the prolongation of access longevity until replacement was not altered. Although prolongation of access life span is an important endpoint, it is not the only one. Reduction in thrombotic events reduces the risks to the patient resulting from loss of access patency. The body of evidence suggests that the detection of stenosis and prevention of thrombosis are valuable. When a test indicates the likely presence of a stenosis, venography or fistulography should be used to definitely establish the presence and the degree of the stenosis. In most cases, angioplasty should be performed if the stenosis is greater than 50% by diameter. The value of routine use of any surveillance technique for detecting anatomic stenosis alone without concomitant functional assessment by measurement of access flow, venous pressure, recirculation, or other physiologic parameter has not been established. Stenotic lesions should not be repaired merely because they are present. If such correction is performed, then intra-procedural studies of access flow or intra-access pressure prior to and following percutaneous transluminal angioplasty should be conducted to demonstrate a functional improvement with a 'successful' percutaneous transluminal angioplasty.

Vein wall dissection: a rare puncture-related complication of brachiocephalic fistula. Gray-scale and color Doppler sonographic findings

We describe a case of brachiocephalic fistula vein wall dissection (VWD) occurring in a 36-year-old female hemodialysis patient. Unlike subcutaneous or subfascial infiltrations for which the mechanism is blood extravasation, VWD seems to be due to disruption of the fistula vein layers caused by misplacement of the outflow (venous) needle bevel. In this setting, the pressure of the dialysis blood pump acts as the driving force of the dissecting column, extending it proximally. Gray-scale and color Doppler sonography proved to be very useful in the differential diagnosis of VWD, particularly with thrombosis of the fistula. Sonography also helped us decide when to resume cannulations.

Conversion of tunneled hemodialysis catheter–consigned patients to arteriovenous fistula

OBJECTIVE

Despite their high incidence of complications, costs, morbidity, and mortality, nearly 27% of the chronic hemodialysis (HD) patients are receiving treatment via a tunneled hemodialysis catheter (TDC).

METHODS

In this prospective analysis, an interventional nephrology team employed an organized program consisting of vascular access (VA) education and vascular mapping (VM) to TDC-consigned patients. A full range of surgical approaches for arteriovenous fistula (AVF) creation, including vein transpositions, was exercised. Physical examination was performed every 1 to 2 weeks after surgery to assess the development of the AVF. Fistulas that failed to develop adequately to support HD (early failure) underwent salvage [percutaneous transluminal angioplasty (PTA), accessory vein obliteration (AVL)] procedures.

RESULTS

One hundred twenty-one TDC-consigned patients received VA education. Eighty-six (71%) agreed to undergo VM. Two groups were identified. Group I (N= 66; using TDC for 7.2 +/- 1.8 SD months) had never had an arteriovenous access; group II (N= 20; using TDC for 12.3 +/- 4.0 months) had a history of one or more previously failed arteriovenous accesses. Upon VM, 64/66 (97%) in group I and 18/20 (90%) in group II were found to have adequate veins for AVF creation. Seven patients (11%) in group I and 3 (17%) in group II refused surgery. In group I, 57 (89%) received an arteriovenous access (radiocephalic AVF = 15, brachiocephalic AVF = 35, transposed brachiobasilic AVF = 3, brachiobasilic AVG = 4). In group II, 15 (83%) received a transposed AVF (radiobasilic = 2, brachiobasilic = 13). Sixteen fistulas (30%) in group I and 8 (53%) in group II had early failure. All except for one fistula in each group were salvaged using PTA and/or AVL. All 70 accesses (AVF = 66, AVG = 4) remain functional, with a mean follow-up of 8.5 +/- 3.6 months.

CONCLUSION

These results demonstrate that an organized approach based upon a comprehensive program utilizing VA counseling, VM, application of full range of surgical techniques, and salvage procedures can be very successful in providing optimum vascular access to the catheter-dependent patient.

Overcoming barriers to arteriovenous fistula creation and use

National guidelines advocate the placement of arteriovenous fistulas (AVFs) as the preferred vascular access for hemodialysis (HD) patients because of their low complication rate, lower costs, and prolonged patency, once matured. The current Dialysis Outcomes Quality Initiative (DOQI) guidelines aim for an AVF incidence of 50% and a 40% prevalence in the United States. Although patients currently starting dialysis do so at an increasingly older age and with more comorbidity, they should be given every opportunity to receive an AVF. Meeting this challenge is facilitated by a multidisciplinary approach with early referral to the nephrologist in the predialysis period for access planning. Key components of a vascular access program may include the coordination by a dedicated access coordinator and outcome tracking via a prospective database. Preoperative vessel evaluation and careful selection of an appropriate surgical site, along with an experienced surgeon, improve surgical outcomes. Transposed brachiobasilic or other tertiary fistulas should be offered to patients who cannot receive a native radiocephalic or brachiocephalic fistula. The ability to routinely monitor and salvage failing AVFs is important to achieving successful AVF outcomes. Standardized definitions of AVF outcomes are important to allow individual centers and continuous quality assurance (CQA) programs to track and benchmark their outcomes against local and national standards to help them meet recommended targets.

Improving quality of vascular access care for hemodialysis patients

BACKGROUND

Because quality of care for patients with end-stage renal disease (ESRD) has improved, they require long-term vascular access for hemodialysis. Construction of a native vein arteriovenous fistula (AVF) on the arm is considered best practice; a prosthetic graft (PG) AVF on the arm is a good alternative, although insertion of a central venous catheter (CVC), the third choice, is sometimes necessary. A quality improvement project was initiated at the dialysis unit of Rijnland Hospital (The Netherlands) to improve quality of vascular access care.

METHODS

Seventy-four patients were treated from January 2001 through June 2002. The list of preferred access operations was adapted from evidence-based guidelines. The percentages of CVCs and PGs were chosen as quality indicators.

RESULTS

Twelve of 19 patients (34%) appeared to be using CVCs unnecessarily. Actions were taken, and the CVC indicator decreased by 11%. The PG indicator decreased gradually from 24% to 8%.

DISCUSSION

Reductions in the use of CVCs and PGs suggest that the vascular access improvement project resulted in improvement of long-term vascular access for hemodialysis patients. A considerable decrease in the use of PGs and CVCs was achieved in 2001. However, a decrease of CVCs to < 20% has still not been realized, perhaps because new hemodialysis patients referred to the dialysis unit have already had CVCs inserted.

SUMMARY AND CONCLUSION

Considerable improvement, as reflected in the number of hemodialysis patients with CVCs or PGs, can be achieved with a minimum of costs.

Hemodialysis vascular access preferences and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Synthetic grafts have generally been found to exhibit lower survival rates and higher complication rates than native arteriovenous fistulae. We investigated whether survival of grafts relative to fistulae was better in facilities with a preference for grafts, hypothesizing that such facilities may place more grafts because grafts produced superior outcomes.

METHODS

The study was based on a national U.S. sample of 133 hemodialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS), a prospective, observational study of dialysis treatment practices and outcomes. Vascular access preferences were ascertained from medical directors, nurse managers, and actual practice within each facility (% graft use among prevalent patients). Logistic regression was used to model the odds ratio (OR) of graft placement (vs. fistula) and Cox regression was used to model time from access creation to initial failure.

RESULTS

Grafts were preferred by 21% of medical directors and 40% of nurse managers. Patients in facilities in which the medical director or nurse manager expressed a preference for grafts were more than twice as likely to have a graft than a fistula (AOR = 2.3, P < 0.01; reference group = facilities that did not prefer grafts), suggesting that facility preferences influence the type of access created. Overall, grafts were more prevalent than fistulae in dialysis facilities, but displayed a higher relative risk of failure (RR 1.33, P < 0.0001). However, the risk of graft versus fistula failure did not vary by expressed preference of the medical director: the relative risk of graft versus fistula failure was 1.39 in facilities in which the medical director preferred grafts and 1.39 in facilities in which the medical director preferred fistulae. Moreover, the relative risk of graft versus fistula failure was 1.57 in facilities that used more than the median percentage of grafts and 1.19 in facilities that used less than the median percentage of grafts.

CONCLUSIONS

No evidence was found that graft outcomes are superior in facilities that prefer grafts to fistulae. The observed variation in vascular access practice patterns suggests opportunities for quality improvement if optimal practices can be defined.