Chapter 48: Hemodialysis Access

INTRODUCTION

Patients with acute and chronic renal failure require dependable access for dialysis. Dialysis access failure has been reported to be one of the most frequent causes of hospitalization among patients with end-stage renal disease (ESRD).¹ With our ability to treat ESRD, improving the longevity of our patient population has been steadily increasing.

The Kidney Dialysis Outcomes Quality Initiative (DOQI),² as published by the National Kidney Foundation, sets forth recommendations as part of a national consensus that parishioners avoid percutaneous-catheter based arteriovenous (AV) hemodialysis access in favor of autogenous access (AA), followed by prosthetic access (PA), as a second preference. With vascular access (VA) complications accounting for 15% of hospital admissions among hemodialysis patients,^3,4 and Medicare costs approximating $182 million in 2003,⁴ the population of patients requiring hemodialysis access is expected to increase by 10% per year from a group which exceeded 345 000 patients in 2000.⁵

The current DOQI recommendations for practice patterns are the insertion of an AA in 50% of long-term access patients. However, some centers have had trouble achieving this goal as a result of vein mapping results or availability of forearm basilic vein.⁶ The DOQI guidelines-recommended surgical referral pattern should begin when a patient exhibits a creatinine clearance of less than 25 mL/min or a serum creatinine greater than 4 mg/dL or when AV access is anticipated within 1 year.²

The introduction of hemodialysis as routine treatment of ESRD made it necessary to find a simple form of repeated access to the vascular system. It was only after the introduction of external silastic cannulae by Quinton and Scribner⁷ in 1960 that extracorporeal treatment could be established. Several years later, Brescia and Cimino⁸ devised the AV fistula, which overcame the limitations of frequent infections and thrombosis. In the 1970s the implantation of grafts was introduced,^9,10,11 which permitted renal replacement therapy in patients devoid of venous vessels.

Currently, complications of VA (i.e., dysfunction, thrombosis, or infection) are a major cause of hospital admission. They affect the quality of life. For this there are objective reasons (they make it difficult to administer sufficient dose of dialysis) and subjective ones (anxiety because of uncertainty about correct functioning).¹² Furthermore, they give rise to frustration in health care personnel.^13,14,15 Recently, repeated VA failure has been identified as a risk factor for mortality.¹⁶ Finally, VA failure causes high economic costs, accounting for up to one-third of ESRD expenditure.¹⁷

The radiocephalic AV fistula is the preferred VA because of its low complication rates, its long survival, and its ease of puncture once it has matured.^18,19,20 Nevertheless, its establishment on the wrist or in the anatomical snuffbox of the nondominant arm is potentially inconvenient for two reasons: (1) Four to eight weeks ...