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When Will You Need To Consider An Access?

Nearly a half million Americans are undergoing hemodialysis to treat end stage renal disease (ESRD), with over 62% of these cases caused by diabetes and high blood pressure. When you are informed you require hemodialysis to survive, it can be a scary, tumultuous time. Consulting with specialists, finding a convenient, comfortable dialysis location and making the physical transition to dialysis can be confusing at best.

You can have a smooth transition to hemodialysis when needed. Careful monitoring, early intervention, and a timely referral to a vascular surgeon for permanent access creation, education and management will ease your changeover and help improve your  quality of life.

    You are at risk for developing kidney problems requiring hemodialysis if you are experiencing:
• Diabetes
• High blood pressure
• Autoimmune disease
• Nephrotic syndrome
(when there is too much protein in the urine, low levels of protein in blood, high levels of fat and cholesterol in bloodstream or edema in the legs, feet, ankles or hands)
• Chronic urinary tract infections or problems

You should be screened at each health appointment. Ask about your Glomerular Filtration Rate (GFR), or how much blood passes each minute through the glomeruli, the tiny membranes in the kidneys that filter waste from the blood, allowing the blood cells and protein to remain in the bloodstream.

    Ask for a referral to a vascular surgeon when your GFR is 30 to 40, Stage 3 Kidney Disease. 

When your vascular surgeon can place the arteriovenous fistula (AVF) or arteriovenous graft (AVG) at least 6 months before hemodialysis is required, that allows ample time for the access to mature and be ready for use. This timely referral also allows adequate time for proper education and relationship- and trust-building between the vascular surgeon and yourself. Because your vascular surgeon will become a significant and constant healthcare provider, this time to establish trust is vital for a successful working relationship. A prompt referral also drastically reduces the risk of a catheter insertion, which is rife with complications and problems.

An access is always needed to perform hemodialysis. Because your kidneys no longer function to eliminate wastes from the blood stream and body, an “artificial kidney” or dialyser is used to perform this task. The fistula or graft is accessed in two spots; the first is used to carry blood to the dialyser and the second is used to return clean blood back to you. The tubes carry blood into the machine, to a bundle of hollow fibers forming a membrane to filter out the wastes. Blood is diffused with a saline solution, dialysate, and then the dialysate is diffused with blood, cleaning the blood. When this process is finished, cleansed blood is returned via the access. Hemodialysis lasts about 3 to 5 hours and is required 3 times each week.

The health of your vascular system is the determining factor in the choice of an access. Either a fistula or a graft will be created, increasing the blood flow and strengthening the vein to allow an even greater flow, making dialysis efficient and effective.

   A fistula is the preferred choice for an access, if at all possible.A fistula can be created during a minor, outpatient procedure. A fistula is created from the body’s own tissues, joining a vein to an artery, usually at the elbow or wrist. Fistulas tend to be more durable, longer lasting, and are much less inclined to infection and complications.

When veins are not large enough to create a fistula, a graft is a good option. A graft is an artificial tube that is used to join artery to vein. This is also done in a minor, outpatient procedure. When dialysis needs to begin quickly, a graft can be used within 2 weeks.

After surgery, you will be encouraged to strengthen the veins by squeezing a stress ball. Proper care of the access is vital to its long term health.

Complications can include:
• “Steal”, when the fistula causes too much blood to flow away from the hand
• Clotting
• Infection
• Narrowing
• Bleeding
• Formation of an aneurysm in the access

When you see any changes near the access or in the arm, contact your vascular surgeon immediately.Signs of access failure, infection or other complications include:
• Unusual skin color
• Swelling, redness or red streaks
• Increased pain
• Blood or pus at the access site
• Numbness
• Fever

When physicians wait until your GFR dips near or below 15 to recommend a vascular surgeon, you will be in acute kidney failure or acute renal failure, when 85-90% of kidney function has been destroyed. At this point, a catheter may be the only option for access.

Catheter access should only be used in emergent situations, or as a last resortwhen neither fistula nor graft can be placed. Catheters are recommended only while a fistula or graft is maturing or there is no other option for permanent access.

A catheter is inserted under the skin at the neck, with the tubes sitting outside of your body. Because of this outside positioning, catheters are very prone to infections. When a catheter is in place, you cannot shower or take a bath, also increasing the risk of infection from bacteria on the skin.

Catheters dramatically increase the risk of superior vena cava syndrome (SVCS), a serious complication. SVCS occurs when the superior vena cava, a major vein carrying blood from the head, neck, upper chest and arms back to the heart, becomes clogged, obstructing blood flow. Symptoms include shortness of breath, swelling in the eyes, face, neck and upper chest, a blue tinge to the skin, a cough, chest pain and hoarseness.

When a catheter is placed on a temporary basis in an emergent situation, you may be very resistant to a permanent fistula or graft placement due to the emotional and physical pain you have already endured. This can have tragic results as studies show a significantly higher mortality rate for those with catheters; 26% of patients will die within 12 months of catheter insertion, compared with just 11-16% of those who started hemodialysis with an AVF or AVG.

    Asking for a referral to a vascular surgeon for access placement as soon as possible will help avoid these complications. 

Your vascular surgeon should monitor the health and viability of a dialysis access regularly, beyond the checks that are made prior to each dialysis treatment. You’ll make an appointment with your vascular surgeon every 3 months.

Adequate time for thorough patient education and relationship building, placement and proper maturation of the access and ample training in the care of the access will help your retain as much quality of life as possible, and keep you as healthy as possible throughout their dialysis experience.

Central-venous-catheter-2 AV-graft-1 Dialysis_Access_01_Base-1 NKDEP_Hemodialysis_Dialyzer_Illustration_P2

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