HemoDoc, From Doctor to Patient

Preserving Venous Access Sites: Avoid Unnecessary Venopunctures

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.

Venous Access for Patients with Chronic Kidney Disease

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.

America Still Struggles to Accept Fistula First Initiative

By Peter Laird, MD

CJASN has a recent article calling for more studies on fistula vs grafts before adopting further measures of the Fistula First initiative.  Fistulas once matured have a much lower incidence of complications than grafts or catheters, yet America has been a long time outlier on fistula usage compared to the rest of the developed world. At the start of hemodialysis in America, only 52% of patients have a functioning fistula. On the other hand, Belgium and Italy have 100% fistula rate at onset of dialysis with Japan right behind them at 99%.  Previous studies from DOPPS have shown that our lack of attention to fistula creation during vascular surgery training plays a role in these disparities.

Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients: 

Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training. CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

One of the differences between what is considered mature fistulas in Europe and America is the difference in clinical practice for dialysis blood flow rates which are significantly higher in America fixated on rapid, "efficient" dialysis sessions predicated on our business model of dialysis care. Many fistulas deemed inadequate in America would work well in the European model of dialysis care with lower blood flow rates.  I cannot agree with the authors call in the CJASN article that there is equipoise between grafts and fistulas justifying randomized and controlled trials on their use since this is a uniquely America difficulty based on both our clinical practice patterns and our lack of training compared to all other developed nations.

Perhaps instead of calling for further studies between grafts vs fistulas, America might actually learn from those nations with a 100% fistula rate what we are doing wrong here only in America before blaming the procedure itself for our own failings.  It is time for American dialysis practitioners to look beyond our own egocentric views of dialysis practice and join the rest of the world with more optimal outcomes in all aspects of dialysis care.

NBC Report on Dialysis Reveals Continued Media and Nephrology Bias

By Peter Laird, MD

NBC did several background videos on dialysis to accompany their  recent ProPublica feature report which  in my opinion continues the false impression that dialysis is a horrible treatment and renal transplant is our only hope. They correctly pointed out the need for a fistula to avoid complications of catheters, patients fear of needles, risks of infection and reduced clearances, but the primary focus was that of renal transplant implying that renal transplant is the only true hope.  This report based on the ProPublica series returns to the sad bias, in my opinion, now also by NBC of the only hope for patients with CKD-5 is to avoid dialysis and get on the transplant list early.

Visit msnbc.com for breaking news, world news, and news about the economy

Visit msnbc.com for breaking news, world news, and news about the economy

Visit msnbc.com for breaking news, world news, and news about the economy

I would hope that one day, a true and unbiased report on all renal replacement options, including optimal dialysis strategies would be headline news on a national network. Unfortunately, even noting the ProPublica report as the first part of the NBC nightly news that accompanies these videos gives the very biased viewpoint that dialysis is dangerous and that the only hope is renal transplant. Yet, for those that are not part of the 15,000 or so that get a renal transplant in the US each year, we must continue with dialysis as our mainline treatment option.  Yes, for many, renal transplant transforms their life, but so likewise does daily, nocturnal dialysis which is equal in survival to cadaveric transplant, and you don't have to wait to survive 5-8 years to get that survival benefit.  

While I applaud the attention that NBC focused on the ProPublica Dialysis series, it did so in my opinion, by continuing the myth of the gift of life only from renal transplant.  In such, their report will only bring continued death and destruction to hundreds of thousands of dialysis patients because NBC chose to completely ignore optimal dialysis in these 4 segments.  What a failed opportunity.

The dialysis  industry spin continues and people continue to die needlessly because home dialysis options are overlooked at the hands of our nephrologists who fail to inform.  Dr. Barbara Murphy of Mount Sinai Medical Center, in my opinion, is simply the latest biased nephrologist failing American dialysis patients by lack of informed consent of all renal replacement options, even more so on a national news program.  Perhaps she did speak of optimal dialysis, and NBC chose to exclude that discussion in her three segments, I will give her the benefit of the doubt on that issue, but certainly NBC could have chosen to truly educate but did not do so in 4 separate dialysis segments.

You may wish to contact Dr. Murphy at the link above and inform her of your opinion on optimal dialysis issues as I plan to do myself since she failed to make mention of anything outside of in-center dialysis other than renal transplant in three news segments focussed on dialysis especially in light of the recent FHN results.  I will be more than willing to run a full rebuttal by NBC or Dr. Murphy on my blog as well, should they choose to do so.

Not surprisingly, Dr. Barbara Murphy's specialty is renal transplant medicine.  Why would NBC choose a transplant specialist to tell us about dialysis?  Why not a dialysis specialist such as Dr. Chris Blagg, Dr. Robert Lockridge or Dr. John Agar? I can only state that the bias against optimal dialysis appears to run deep in my opinion, even at NBC nightly news. After all, these 4 segments were featuring dialysis, not renal transplant.  Shall the truth ever be told? This is simply my own opinion and my own personal impression of the 4 NBC nightly news segments on Dialysis.

Ultrasound Improves Fistula Patency

By Peter Laird, MD

Fistula First, the initiative to improve placement of arteriovenous fistulas for dialysis access reached 57.1% in October of 2010, yet this still falls short of nations such as Japan with over 90% of patients utilizing fistulas for dialysis access.  A recent randomized study on the use of preoperative vascular ultrasound may improve the success rate of fistula placement:

Routine Preoperative Vascular Ultrasound Improves Patency and Use of Arteriovenous Fistulas for Hemodialysis: A Randomized Trial

Results: AVFs were made in 208 of 218 randomized patients. Clinical and ultrasound groups were similar in terms of patient characteristics, allocation to individual surgeons, and proportion of forearm AVFs. The ultrasound group had a significantly lower rate of immediate failure (4% versus 11%, P = 0.028) and, among failed AVFs, less thrombosis (38% versus 67%, P = 0.029). Primary AVF survival at 1 year was not statistically different (ultrasound = 65%, clinical = 56%,P = 0.081). Assisted primary AVF survival at 1 year was significantly better for the ultrasound group (80% versus 65%, P = 0.012). The number of patients requiring preoperative ultrasound to prevent one AVF failure was 12.

Conclusions: Routine preoperative vascular ultrasound in addition to clinical assessment improves AVF outcomes in terms of patency and use for dialysis. National Research Register, United Kingdom, trial number N0046131432.

Previous studies also show that the number of fistulas placed in training by vascular surgeons corresponds to better rates of success as well.  For those that perfom less than 25 fistula procedures in training, they have poor rates of patency.

Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients: Results From the Dialysis Outcomes and Practice Patterns Study. 

Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training.

CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

Microscopic surgical techniques more widely used in pediatric cases is also a promising adjunct to increased cases in training and vascular ultrasound.  Perhaps the best indicator of success with fistula placement is the size and condition of the veins in the arm.  All patients with CKD who may be at risk of developing the need for renal replacement therapy need to preserve these veins by avoiding blood draws and BP checks.  Using the distal veins in the hands is the preferred site for blood draws.  Exercises to improve circulation in the arms is highly recommend as well.  A concerted effort to improve dialysis access is a proven method of reducing dialysis related complications.  Use of the vascular ultrasound is a step in the right direction.