What is the recommended management for a patient's last dialysis access?

From the Guidelines

The recommended management for a patient's last dialysis access involves preserving it at all costs while implementing a comprehensive care approach. This approach is crucial in reducing morbidity, mortality, and improving the quality of life for patients with end-stage renal disease, as highlighted in the 2023 study on acr appropriateness criteria® dialysis fistula malfunction 1. Healthcare providers should strictly avoid venipunctures, blood pressure measurements, or IV placements in the access arm to prevent complications.

Regular monitoring for signs of infection, stenosis, or thrombosis is essential, with prompt intervention for any complications. Patients should perform daily self-examination of their access for thrill, bruit, redness, or swelling. Antiplatelet therapy with aspirin (81-325 mg daily) or clopidogrel (75 mg daily) may be prescribed to reduce thrombosis risk, as suggested by the 2020 kdoqi clinical practice guideline for vascular access: 2019 update 1.

For arteriovenous fistulas or grafts, regular surveillance with ultrasound every 3-6 months helps detect stenosis before thrombosis occurs. Nephrology and vascular surgery consultations should be established for ongoing management. The 2023 study on acr appropriateness criteria® dialysis fistula malfunction 1 emphasizes the importance of multidisciplinary care in achieving optimal patient outcomes.

Key aspects of managing the last dialysis access include:

• Avoiding venipunctures, blood pressure measurements, or IV placements in the access arm
• Regular monitoring for signs of infection, stenosis, or thrombosis
• Patient self-examination for thrill, bruit, redness, or swelling
• Antiplatelet therapy to reduce thrombosis risk
• Regular surveillance with ultrasound for arteriovenous fistulas or grafts
• Nephrology and vascular surgery consultations for ongoing management

This aggressive preservation approach is critical because each successive access typically has shorter functionality, and patients with failed accesses may require central venous catheters, which carry higher infection and mortality risks, as noted in the 2020 kdoqi clinical practice guideline for vascular access: 2019 update 1. Preserving the last access directly impacts patient survival and quality of life on dialysis.

From the Research

Recommended Management for Last Dialysis Access

The management of a patient's last dialysis access is crucial to ensure optimal outcomes. The following points highlight the recommended approaches:

• When an arteriovenous fistula (AVF) is not possible, an arteriovenous graft (AVG) or central venous catheter (CVC) must be selected as an alternate form of vascular access 2.
• The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines prefer surgery for thrombosed AVF when the cause of thrombosis is a stenosis at the site of the anastomosis 3.
• The European Best Practice Guidelines (EBPG) suggest that thrombosed AVF may be preferably treated with endovascular techniques, but when the cause of thrombosis is in the anastomosis, surgery provides better results with re-anastomosis 3.
• In elderly patients, a native fistula can be easily created, and the use of instrumental tests like echo-color Doppler or angiography can help evaluate the vascular bed and find the best position for creating a fistula or graft 4.
• Creating a concomitant new AVF while continuing to use the primary failing aneurysmal AVF can avoid the placement of a temporary hemodialysis catheter (HDC) 5.
• Avoidance of ipsilateral catheters may improve long-term vascular access survival, as cumulative access survival is inferior in patients with prior ipsilateral catheters 6.

Key Considerations

• The type of hemodialysis vascular access employed plays a crucial role in the results of dialysis treatment 4.
• Different complications can affect the vascular access and interfere with the morbidity and mortality of patients 4.
• The ideal vascular access is the Cimino Brescia fistula, followed by graft, while tunnelled central venous catheters should be considered as 'second choice' due to a higher incidence of complications 4.
• Patient selection is important, and even patients of 80 years or older who are considered suitable for surgical placement of access should not be denied an AVF solely because of age 4.