Hemodialysis access

Posted by e-Medical PPT Saturday, March 3, 2012
The number of patients with end-stage renal disease (ESRD) in the United States has increased steadily.
2030: 2.24 million patients with ESRD.
The creation and maintenance of functioning vascular access, along with the associated complications, constitute the most common cause of morbidity, hospitalization, and cost in patients with end-stage renal disease.

Vascular Access via Percutaneous Catheters
useful method of gaining immediate access to the circulation.
associated with higher risks.
the use-life of this type of access is shorter than that of AVFs.
Noncuffed catheters
Short term: <3 weeks Cuffed catheters Patients who will require long-term access should have a tunneled catheter placed. allow so-called no-needle dialysis with high flow rates eliminate the problem of vascular steal placed in a subcutaneous tunnel under fluoroscopic guidance The Dacron cuff allows tissue ingrowth that helps reduce the risk of infection when compared with noncuffed catheters. Hemodialysis access: complications Complications can be divided into those that occur secondary to catheter placement and those that occur later. The early complications of subclavian or internal jugular placement include pneumothorax, arterial injury, thoracic duct injury, air embolus, inability to pass the catheter, bleeding, nerve injury, and great vessel injury. A chest radiograph must be taken after catheter placement to rule out pneumothorax and injury to the great vessels and to check for position of the catheter. The incidence of pneumothorax is 1% to 4%,the incidence of injury to the great vessels is less than 1%. Thrombotic complications occur in 4% to 10% of patients Infection may occur soon after placement (3 to 5 days) or late in the life of the catheter and may be at the exit site or the cause of catheter-related sepsis. Rate of infection between 0.5 and 3.9 episodes per 1000 catheter-days. Catheter thrombosis increases the incidence of catheter sepsis. Vascular Access via Arteriovenous Fistulas The ideal vascular access permits a flow rate that is adequate for the dialysis prescription (³ 300 ml/min), can be used for extended periods, and has a low complication rate. The native AVF remains the gold standard Arteriovenous fistulas The standard by which all other fistulas are measured, is the Brescia-Cimino fistula. (2 year patency: 55% to 89%) Arteriovenous fistulas: Complications Failure to mature Stenosis at the proximal venous limb (48%). Thrombosis (9%) Aneurysms (7%) Heart failure The arterial steal syndrome and its ensuing ischemia occur in about 1.6%: pain, weakness, paresthesia, muscle atrophy, and, if left untreated, gangrene Venous hypertension distal to the fistula : distal tissue swelling, hyperpigmentation, skin induration, and eventual skin ulceration.

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