Hemodialysis Access

More than 90% of dialysis patients in the United States rely on chronic hemodialysis (HD) for renal replacement therapy1,2. A standard hemodialysis treatment includes the continuous processing of approximately 200-600 mL of blood per minute over a 3-4 hours period and is performed on a 3 times per week basis3.  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 complications1,4,5. A well-functioning vascular access is essential for patient survival and should have the following characteristics6:

  • Safe
    • 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

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 complications1,4,5. For this reason, the AVF is considered to be the access of choice.

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 1,6
  • 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 1,6.
  • AV shunts: A surgically placed external cannula 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 HD1,7.

Creation and maintenance of a functional AVF will remain one of the greatest challenges in the dialysis field7–9. Despite the fact that multiple studies have demonstrated the AVF’s overall superiority of clinical outcomes—including lower rates of thrombosis, infection, septicemia1,4,5,10 —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 bias8,11. 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;51(4):702-708. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18371547.
  2. United States Renal Data System. 2019 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2019. Available from: https://www.usrds.org/annual-data-report/.
  3. Singh A, Kari J. Management of CKD Stages 4 and 5: Preparation for Transplantation, Dialysis, or Conservative Care. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 5th ed. Walters Kluwer Health; 2015:22-31.
  4. McCann M, Einarsdóttir H, Van Waeleghem J-P, Murphy F, Sedgewick J. Vascular access management 1: an overview. J Ren Care. 2008;34(2):77-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18498572.
  5. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4):S1-S164. Available from: https://pubmed.ncbi.nlm.nih.gov/32778223/.
  6. Sands J. Vascular access 2007. Minerva Urol e Nefrol. 2007;59((3)):237-249.
  7. Ethier J, Mendelssohn DC, Elder SJ, et al. Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study. Nephrol Dial Transplant. 2008;23(10):3219-3226. Available from: https://pubmed.ncbi.nlm.nih.gov/18511606/.
  8. Wish JB. Vascular access for dialysis in the United States: progress, hurdles, controversies, and the future. Semin Dial. 2010;23(6):614-618. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21175835.
  9. Kulawik D, Sands JJ, Mayo K, et al. Focused vascular access education to reduce the use of chronic tunneled hemodialysis catheters: results of a network quality improvement initiative. Semin Dial. 2009;22(6):692-697. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20017841.
  10. Astor BC, Eustace JA, Powe NR, et al. Timing of nephrologist referral and arteriovenous access use: the CHOICE Study. Am J Kidney Dis. 2001;38(3):494-501. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11532680.
  11. Vachharajani TJ. Hemodialysis Vascular Access Care in the United States: Closing Gaps in the Education of Patient Care Technicians. Semin Dial. 2011;24(1):92-96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21338399.

P/N 101031-01 Rev A 02/2021

Overview of Arteriovenous Fistula

Overview of Arteriovenous Grafts

Overview of Central Venous Catheters

Vascular Access Monitoring and Surveillance