Arteriovenous Access for Hemodialysis: A Review.
Reliable arteriovenous (AV) access — an autogenous fistula or a graft — is essential for hemodialysis, and every patient with kidney failure should have an individualized PLAN for access, with generalist clinicians playing a key role in protecting access and recognizing complications.
Background
Hemodialysis requires reliable vascular access to the patient's circulation, most often an autogenous arteriovenous fistula or a nonautogenous arteriovenous graft. This JAMA review addresses the key issues in constructing and maintaining hemodialysis arteriovenous access.
Key findings
Patients should be referred for access when eGFR progressively falls to 15-20 mL/min or when peritoneal dialysis, a transplant, or current access is failing. Autogenous fistulas take 3-6 months to mature, standard grafts can be used 2-4 weeks after creation, and early-cannulation grafts within 24-72 hours. Intimal hyperplasia is the prime lesion behind flow-related complications, causing maturation failure (33%-62% at 6 months) and limited patency (60%-63% at 2 years).
Clinical implications
Nonflow complications include access-related hand ischemia (steal syndrome, 1%-8% of patients) and infection, while an access at high risk of hemorrhaging is a surgical emergency. Patients with CKD should avoid procedures that jeopardize future access (antecubital venipuncture, peripherally inserted central catheters). Generalist clinicians are important for protecting current and future access, identifying complications such as infection, steal syndrome, and high-output cardiac failure, and making timely referrals.
Category
Transplant
Source
JAMA
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