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Last Updated 02/21/10
 
   

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Hemodialysis requires frequent access to the patient's blood stream (vascular system). Vascular access has been called the "Achilles' Heel" of hemodialysis care. Hemodialysis vascular access procedures and associated costs come to $8,000-10,000 per patient per year. This amount represents approximately 25 percent of total ESRD medical costs. The most common problems are stenosis (narrowing of graft/blood vessel), infection, and thrombosis (clotting).

At present, three types of vascular access are predominant: AV (arteriovenous) fistulas, AV grafts, and catheters. AV fistulas are surgically created by connecting a patient's own artery and vein, usually in the forearm. AV fistulas have the lowest rate of complications, but take from several weeks to several months to mature, heal, and develop in size. Over time, an AV fistula becomes large enough to accommodate the needles required for hemodialysis. AV grafts are also created surgically, but use a synthetic blood vessel to connect the vein and artery. The needles are inserted into this synthetic graft. AV grafts require shorter times (if any) to heal before they can be used, but tend to have more incidents of stenosis and thrombosis than AV fistulas. Catheters are most often used as "bridge" devices, used to bridge the time between from start of dialysis treatments (often an emergency) to when the patient's AV fistula or AV graft has matured and is ready for use. Catheters are generally not used as long-term devices as they tend to have higher rates of infection and thrombosis.

In an effort to reduce vascular access problems, several companies are developing new implantable devices that have self-sealing ports that permit the needles to be inserted in the same place every treatment. This may prove to reduce the complications seen with fistulas, grafts, and catheters and may also make it easier for hemodialysis patients to perform their own dialysis treatments at home.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.

  NEWS AND LATEST ARTICLES
Recall: Medcomp 10F Hemodialysis Catheter Insertion Kits Mislabeled - FDA Enforcement Report for 2/17/10. Scroll down 90-95% of page. - February 17, 2010
Infection of hemodialysis arteriovenous grafts - Abstract from the Journal of Vascular Access. - February 15, 2010
A Phase III, Randomized, Double-Blind, Placebo-Controlled Study of Tenecteplase for Improvement of Hemodialysis Catheter Function: TROPICS 3 - Article from CJASN. - February 4, 2010
Class 1 Recall: Edwards Lifesciences Inc., Aquarius Hemodialysis System - Notice from the FDA web site. Baxter International, Inc. is the U.S. distributor of the Aquarius. - February 3, 2010
Class 1 recalls are the most serious type of recall and involve situations in which there is a reasonable probability that use of these products will cause serious adverse health consequences or death. Earlier this month, Baxter sent an Urgent Device Correction notice (2-page pdf) to peritoneal dialysis clinicians to help reduce or eliminate overfill, also referred to as Increased Intraperitonal Volume (IIPV), associated with HomeChoice/HomeChoice PRO cyclers.
FDA Announces Class I Recall of Certain Infusion Set Needles (Huber) - Notice from the FDA web site concerning Exel/Exelint needles and sets manufactured by Nipro. - February 1, 2010

TEP Project Overview from the Centers for Medicare and Medicaid Services - Nominations for this TEP are now being accepted through February 17. - February 2010
The six measures are:
• Anemia Management (Target value for Serum Ferritin, Target value for Transferrin Saturation)
• Mineral Metabolism (Target value for Calcium, Target value for Phosphorus)
• Vascular Access Infection Rate (Catheter Infection Rate)
• Pediatric Adequacy (Hemodialysis [HD], Peritoneal Dialysis [PD])
• Pediatric Anemia (Anemia Management)
• Fluid Weight Management
Editor's Note: Where are the quality-of-life measures?
CMS Program Transmittal on Dialysis Adequacy, Infection and Vascular Access Reporting - 46-page pdf. - February 2010
New quality data will be required on ALL ESRD claims with dates of service on or after July 1, 2010
Audio Samples from Fistula First
• Patients: Listen to your AV Fistula
• Professionals: Listen for the Bruit (near bottom of page)
Patient-centric analysis of dialysis access outcomes - Abstract from The Journal of Vascular Access. - January 29, 2010
Article in Press Abstracts from the Journal of Vascular Access
• Liposuction over a Shielded AF Fistula for Hemodialysis Access Maturation
• Patient-centric Analysis of Dialysis Access Outcomes
• Hemodynamic Impact of Anastomosis Size and Angle in Side-to-end AV Fistulae: a Computer Analysis
MLN Matters: Dialysis Adequacy, Infection and Vascular Access Reporting - 5-page pdf on claim submission changes going into effect on July 1, 2010. - January 29, 2010
Long-term Effects of Arteriovenous Fistula Closure on Echocardiographic Functional and Structural Findings in Hemodialysis Patients: A Prospective Study - Article from the American Journal of Kidney Disease. - January 20, 2010
Effect of Catheter-Lock Solutions on Catheter-Related Infection and Inflammatory Syndrome in Hemodialysis Patients: Heparin versus Citrate 46% versus Heparin/Gentamicin - Abstract from Blood Purification. - January 12, 2010
Validation of QB stress test as a useful tool in the detection of native arteriovenous fistula stenosis: results after 22 months of follow-up - Advance access abstract from NDT. - January 11, 2010
Interventions for preventing infectious complications in haemodialysis patients with central venous catheters - Abstract from the Cochrane Library. - January 2010
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  WEB RESOURCES
Latest Scientific Journal Articles on Vascular Access - list compiled by RenalWEB's Journal Watch
Latest issue of the Journal of Vascular Surgery
AV Access information page and Please be careful with my veins - An information page to be given to nurses or phlebotomist who are about to start an IV or draw blood on dialysis patients (1998). All information from the Nephron Information Center web site.
Buttonhole Techniques from the Home Dialysis Central web site
Using the Buttonhole Technique for Your AV Fistula (pdf format requires Adobe Acrobat reader) from the Northwest Renal Network web site
Example Central Venous Catheter Insertion Form from the CDC Division of Healthcare Quality Promotion (DHQP)
Cannulation of the Arteriovenous Fistula (AVF) video from the Fistula First web site
Caring For & Developing Your New Fistula (pdf) from the Northwest Renal Network web site

'Change Concepts' from Fistula First

•Routine CQI review of vascular access
•Timely referral to nephrologist
•Early referral to surgeon for "AVF only" evaluation and timely placement
•Surgeon selection based on best outcomes, willingness, and ability to provide access services
•Full range of appropriate surgical approaches to AVF evaluation and placement
•Secondary AVF placement in patients with AV grafts
•AVF placement in patients with catheters where indicated
•Cannulation training for AV fistulas
•Monitoring and maintenance to ensure adequate access function
•Education for caregivers and patients
•Outcomes feedback to guide practice
•Modify hospital systems to detect CKD and promote AV fistula planning and placement
•Support patient efforts to live the best possible quality of life through self-management

Clinical Algorithms on Vascular Access for Hemodialysis from the Vascular Access Society web site
Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America - full-text article from Clinical Infectious Diseases. - July 1, 2009
Creating AV Fistulas in All Eligible Hemodialysis Patients from the University of Oklahoma College of Medicine web site
Dialysis Surveillance Network is a voluntary national surveillance system monitoring bloodstream and vascular infections, was initiated by the Centers for Disease Control and Prevention in August 1999
ESRD National Vascular Access Improvement Initiative (NVAII) - Fistula First Project from the ESRD Network of Texas, Inc web site
Fistula First web site and Patient Section
Fistula First Inservice Module (pdf format requires Adobe Acrobat reader) from the ESRD Mid-Atlantic Renal Coalition web site
Fistula First Project news summary from RenalWEB
Frequently Asked Questions about the ArterioVenous Fistula (pdf) and Fístula Arteria Venosa En Español (pdf) from the Northwest Renal Network web site
Guidelines for the Prevention of Intravascular Catheter Related Infections from Morbidity and Mortality Weekly Report
web site - August 2002
Helping the Patient Make Healthy Fistula Choices - educational Web-EX Series from The Renal Network, Inc. - June 29, 2009
Just the Facts: Vascular Access and Información esencial: Acceso vascular (pdf format requires Adobe Acrobat Reader) from the Life Options web site
Keeping Your Access Uncovered - (2-page pdf) from the Northwest Renal Network
National Surveillance of Dialysis-Associated Diseases in the United States, 2002 (pdf format requires Adobe Acrobat reader) from The Centers for Disease Control and Prevention (CDC)
Preparing the Vascular Access for Cannulation (pdf format requires Adobe Acrobat reader) from the Northwest Renal Network web site
Prevent Dangerous Hemodialysis Catheter Disconnections article from FDA's Center for Medical Devices
Protocol for the Referral and Placement of Permanent Vascular Access (pdf format requires Adobe Acrobat reader) from the ESRD Network 11 web site
Revised European Best Practice Guidelines for Hemodialysis - Vascular Access Part I (pdf) and Revised European Best Practice Guidelines for Hemodialysis - Vascular Access Part II (pdf) - guidelines endorsed by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)
Example Self-Cannulation of Vascular Access Procedure (requires Microsoft Word™) from the National Vascular Access Improvement Initiative (NVAII) Tools and Resources Sub-committee
Understanding Your Hemodialysis Access Options - 16-page brochure outlines the various access devices available for patients on hemodialysis from the American Association of Kidney Patients web site.
Vascular Access quality improvement from The Renal Network (ESRD Network 9/10) web page
Vascular Access - A Lifeline for Dialysis - new module at the KidneySchool™.
Vascular Access: Before During & After - education tool from Network 8 web site
Vascular Access Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
Vascular Access for Hemodialysis from the NIDDK Publications Online for Kidney Disease
Vascular Access for Hemodialysis (pdf) from the Northwest Renal Network web site
Vascular Access for Hemodialysis power point presentation from the American Nephrology Nurses’ Association
Vascular Access Patient Education "Electronic Notebook" (pdf format requires Adobe Acrobat reader) from the ESRD Network # 14 web site
Venous Needle Dislodgement - How To Minimize the Risks - (pdf) poster from the EDTNA/ERCA
Videos in Clinical Medicine: Placement of an Arterial Line from The New England Journal of Medicine (NEJM)
What's your ACCESS-ability? (pdf) from the Northwest Renal Network web site
Your Role in AV Fistula Cannulation (pdf) from the Northwest Renal Network web site
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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
vascular access and hemodialysis articles   Continually Updated!
catheter AND hemodialysis articles   Continually Updated!
Lifesite™ AND hemodialysis articles   Continually Updated!
anticoagulants AND catheter AND hemodialysis articles   Continually Updated!
graft survival AND hemodialysis articles   Continually Updated!
cost AND access AND dialysis Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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K/DOQI™ -  Kidney Disease Outcomes Quality Initiative ( pronounced "kay DOE key" )

Clinical Practice Guidelines for Vascular Access 2006 Updates

I. Clinical Practice Guidelines for Vascular Access

Guideline 1. Patient Preparation for Permanent Hemodialysis Access
Guideline 2. Selection and Placement of Hemodialysis Access
Guideline 3. Cannulation of Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems
Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Guideline 5. Treatment of Fistula Complications
Guideline 6. Treatment of Arteriovenous Graft Complications
Guideline 7. Prevention and Treatment of Catheter and Port Complications
Guideline 8. Clinical Outcome Goals

II. Clinical Practice Recommendations for Vascular Access

Clinical Practice Recommendations for Guideline 1: Patient Preparation for Permanent Hemodialysis Access
Clinical Practice Recommendations for Guideline 2: Selection and Placement of Hemodialysis Access
Clinical Practice Recommendations for Guideline 3: Cannulation of Fistulae and Grafts and Accession of Dialysis Catheters and Ports
Clinical Practice Recommendations for Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Clinical Practice Recommendations for Guideline 5: Treatment of Fistula Complications
Clinical Practice Recommendations for Guideline 7: Prevention and Treatment of Catheter and Port Complications
Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients

 

K/DOQI™ Home Page from the National Kidney Foundation web site
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  DISCUSSION FORUM
Vascular Access Issues on RenalWEB
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  PRODUCTS
CathSling - available as part of For Patients, Inc.'s customized Dressing Change Kit
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  UPCOMING EVENTS
Listing of Vascular Access Society meetings and events
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Vascular Access Topic
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