By Peter Laird, MD
The lifeline of a patient on chronic hemodialysis is his access for blood. The Brecia-Cimino fistula which is constructed side to side anastamosis of the forearm vein and artery is the most common native vessel hemodialysis access. Fistula placement and function remains one of the most important survival strategies for dialysis patients. However, the ability of a surgeon to construct a function fistula is greatly hindered by excessive blood sampling and IV line placement, especially those that are central lines into the great vessels.
Ultimately, however, our ability to create functional fistulas is critically dependent on the availability and condition of the patient’s peripheral veins. Frequent venipuncture and the indiscriminate use of peripherally inserted central catheters (PICCs) or central venous catheters can damage veins and jeopardize future fistula construction. Therefore, it is of paramount importance that patients who have or are at risk for renal failure are identified and their venous access be restricted to preserve peripheral veins for future vascular access construction. This important concept has been emphasized in editorials by Trerotola related to the publication of the original DOQI vascular access guidelines (4,5), and more recently in updated NKF-K/DOQI guidelines (6).
Many nephrologists fail to adhere to these simple guidelines. I am aware of practices where home hemodialysis patients are sent to infusion centers every few weeks in some case for iron supplementation. In addition, some home hemodialysis patients do peripheral venopunctures before the beginning of dialysis and after the session is completed each month for the required labs. Both of these approaches are short sighted in my opinion and can be prevented by simple procedures. I draw all of my own blood samples and I bought a centrifuge to spin the lab samples as required for accuracy of the tests. It is simply one more task to learn as a home hemodialysis patient. Since I refuse peripheral venopunctures for my iron supplementation, I obtain those medications by going back to dialyze in-center on very infrequent occasions.
Vascular damage is part of the constellation of physiologic changes of renal disease. One of the first and foremost tasks that dialysis patients must undertake is to become their own advocate for protecting any future access sites. In addition, I am very protective of my left upper arm fistula. Avoid wearing tight clothing or sleeping on the access is only the beginning of protecting our access. Several studies suggest that Aggrenox (25mg Aspirin/200mg extended-release dipyridamole) twice daily help prevents clotting during early fistula creation. There are also suggestions in studies that Aggrenox can prevent stenosis (narrowing) of existing fistulas. Extending the life of your fistula is very much a survival strategy given the consequences of creating new access sites or having to have a catheter for dialysis access.
Patients must be the captains of their own health care in many instances and simply refuse venopunctures unless their is no alternative. Since starting dialysis, I have only had one IV in five years and not a single peripheral venopuncture. The IV was unavoidable due to the need to remove an early melanoma from my back one month after starting dialysis. Even so, the vein that the nurse used was damaged and I likely won't be able to use it a second time. Fortunately, it was on the back of hand and away from any potential future fistula sites. Patients should be able to identify their cephalic vein on their forearm and instruct health care personnel to avoid that specific vein especially. The back of the dominant hand is the first place to look for an IV insertion site or blood draw. Patients have the right to ask for the most experienced nurse or tech to perform these procedures. Once a vein is damaged and scarred, it cannot be used for dialysis access.
Being a proactive patient and your own advocate is one of the tasks we need to learn to survive. No health care professional can perform any procedure without your express permission. Reminding them of this obligation is your right. It is your life, and your access. Treat it with respect and a well constructed fistula can last for decades. After all, the goal is to live longer than the average patient and to avoid hospitalizations and complications. Much is within your control. Please, simply demand that your health care team practice these basic precautions. After all, you are the captain of your own health.