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Last Updated 04/13/08
 
   

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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
Comparison of Early versus Late Use of Antibiotic Locks in the Treatment of Catheter-Related Bacteremia - abstract from the Clinical Journal of the American Society of Nephrology - April 9, 2008
Obesity as a Predictor of Vascular Access Outcomes: Analysis of the USRDS DMMS Wave II Study - abstract from Seminars in Dialysis - April 6, 2008
Thrombosis with Erythropoietic Stimulating Agents—Does Iron-Deficient Erythropoiesis Play a Role? - abstract from Seminars in Dialysis - April 6, 2008
Occlusion of the fistula in a dialysis patient—is it always a common reason? - full-text NephroQuiz from NDT Plus - April 2008
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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 Access
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
The Buttonhole Technique for Arteriovenous Fistula Cannulation (pdf) article from the Nephrology Nursing Journal
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) from the Fistula First web site
Clinical Algorithms on Vascular Access for Hemodialysis from the Vascular Access Society web site
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
Four Training Videos from Medisystems: Introduction to Cannulation Video, The Native AV Fistula Video, The AV Graft Video, Accidental Needlesticks - Issues and Prevention Strategies for Healthcare Workers. Contact information for Medisystems.
Guidelines for the Prevention of Intravascular Catheter Related Infections from Morbidity and Mortality Weekly Report
web site - August 2002
Improving Arteriovenous Fistula Cannulation Skills (pdf format requires Adobe Acrobat reader) article from the Nephrology Nursing Journal - November-December 2005
Just the Facts: Vascular Access and Información esencial: Acceso vascular (pdf format requires Adobe Acrobat Reader) from the Life Options web site
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 Devices and Radiological Health (CDRH)
Protocol for the Referral and Placement of Permanent Vascular Access (pdf format requires Adobe Acrobat reader) from the ESRD Network 11 web site
Example Self-Cannulation of Vascular Access Procedure (requires Microsoft Word™) from the National Vascular Access Improvement Initiative (NVAII) Tools and Resources Sub-committee
The “Touch Cannulation” Technique for Hemodialysis - article from Nephrology Nursing Journal - January/February 2008
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 Patient Education "Electronic Notebook" (pdf format requires Adobe Acrobat reader) from the ESRD Network # 14 web site
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
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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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