Hemodialysis Access

More than 90% of dialysis patients in the United States rely on chronic hemodialysis (HD) for renal replacement therapy (1,2).  A standard hemodialysis treatment includes the continuous processing of approximately 200-500 mL of blood per minute over a 2-6 hour period and is performed on a 3 times per week basis.  This treatment requires safe and readily available access to the circulatory system.

The primary goal of chronic HD vascular access is to provide repeated access to the circulation with minimal complications (1,3,4). A well-functioning vascular access is essential for patient survival and should have the following characteristics:

  • Safe
    • Well tolerated
    • Few complications
  • Reliable
    • Provide repeated access to circulation
    • Provide continuous blood flow of 400-600 mL/min
    • Long lasting
  • Simple
    • Easy to place
    • Easy to use
  • Acceptable to patient
    • Painless
    • Cosmetically acceptable (5)

A well-functioning arteriovenous fistula (AVF) comes closest to meeting the above characteristics. It is created by the anastomosis (surgical connection) of a vein and artery, typically the radial artery and cephalic vein in the forearm. The AVF is the most reliable form of permanent vascular access, and has the fewest number of complications (1-3).  For this reason, the AVF is considered to be the access of choice. Overview of Arteriovenous Fistula

In addition to the AVF, three other forms of chronic HD vascular access are in use:

  • Prosthetic bridge graft or AV graft (AVG):  A surgical connection of an artery to a vein using a synthetic tube.  They are most commonly placed in the arms or thighs and are another option for permanent hemodialysis access (1,4).  Arteriovenous Graft
  • Central venous catheter (CVC): A catheter is placed through the skin into the jugular, femoral, or subclavian vein. CVC are typically used for temporary access and are not preferred for long-term access due to high rates of infection and thrombus (1-4). Central Venous Catheters
  • AV shunts: A surgically placed external cannulae composed of a U-shaped silastic tube with Teflon tips (eg, Quinton-Scribner or Thomas Shunt) that connect an artery and vein.  Although rarely used today, they were the original “permanent” vascular access for HD (1,6).

Creation and maintenance of a functional AVF will remain one of the greatest challenges in the dialysis field (7-10). Despite the fact that multiple studies have demonstrated the AVF’s overall superiority of clinical outcomes—including lower rates of thrombosis, infection, septicemia (1-3,11)—there is a wide global variation in vascular access utilization. This variance has been attributed in varying degrees to patient characteristics, surgical practice patterns, delivery systems, available technologies, and practitioner and patient bias (8,12). The international renal community is working together to meet these challenges with dedicated and sustained efforts to improve vascular access technology, clinical practice and healthcare policy.

References:

  1. Maya ID, Allon M. Vascular access: core curriculum 2008. Am J Kidney Dis. 2008 Apr;51(4):702-8. http://www.ncbi.nlm.nih.gov/pubmed/18371547
  2. U S Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2011. Available from: http://www.usrds.org/adr.aspx
  3. McCann M, Einarsdóttir H, Van Waeleghem JP, Murphy F, Sedgewick J. Vascular access management 1: an overview. J Ren Care. 2008 Jun;34(2):77-84. http://www.ncbi.nlm.nih.gov/pubmed/18498572
  4. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1).
  5. Sands JJ. Vascular access 2007. Minerva Urol Nefrol. 2007 Sep;59(3):237-49. http://www.ncbi.nlm.nih.gov/pubmed/17912221
  6. Coronel F, Herrero JA, Mateos P, Illescas ML, Torrente J, del Valle MJ. Long-term experience with the Thomas shunt, the forgotten permanent vascular access for haemodialysis. Nephrol Dial Transplant. 2001 Sep;16(9):1845-9. http://www.ncbi.nlm.nih.gov/pubmed/11522868
  7. Ethier J, Mendelssohn DC, Elder SJ, Hasegawa T, Akizawa T, Akiba T, Canaud BJ, Pisoni RL. Vascular access use and outcomes: An international perspective from the dialysis outcomes and practice patterns study. Nephrol Dial Transplant. 2008 Oct;23(10):3219-26. http://www.ncbi.nlm.nih.gov/pubmed/18511606
  8. Wish JB. Vascular access for dialysis in the United States: progress, hurdles, controversies, and the future. Semin Dial. 2010 Nov-Dec;23(6):614-8. http://www.ncbi.nlm.nih.gov/pubmed/21175835
  9. Mid-Atlantic Renal Coalition, Centers for Medicare and Medicaid Services. Fistula First Breakthrough Initiative Annual Report. 2011 Feb [cited 10 Jan 2012]. Available from: http://www.fistulafirst.org/
  10. Kulawik D, Sands JJ, Mayo K, Fenderson M, Hutchinson J, Woodward C, Gore S, Asif A. Focused vascular access education to reduce the use of chronic tunneled hemodialysis catheters: results of a network quality improvement initiative. Semin Dial. 2009 Nov-Dec;22(6):692-7. http://www.ncbi.nlm.nih.gov/pubmed/20017841
  11. Astor BC, Eustace JA, Powe NR, Klag MJ, Sadler JH, Fink NE, Coresh J. Timing of nephrologist referral and arteriovenous access use: the CHOICE Study. Am J Kidney Dis. 2001 Sep;38(3):494-501. http://www.ncbi.nlm.nih.gov/pubmed/11532680
  12. Vachharajani TJ. Hemodialysis vascular access care in the United States: closing gaps in the education of patient care technicians. Semin Dial. 2011 Jan-Feb;24(1):92-6. http://www.ncbi.nlm.nih.gov/pubmed/21338399

P/N 101031-01 2/2009