From the Guidelines
Management of a patient with a dialysis graft presenting with edema should prioritize prompt evaluation and treatment to preserve graft function, with a focus on determining the cause of edema, which commonly results from venous outflow obstruction or graft stenosis, as highlighted in clinical practice guidelines for vascular access 1. The initial step in managing edema in a patient with a dialysis graft involves determining the underlying cause, which could be due to venous outflow obstruction or graft stenosis, among other reasons.
- Key considerations include:
- Urgent referral to vascular surgery or interventional nephrology for evaluation and possible intervention.
- While awaiting definitive treatment, limb elevation above heart level and gentle compression (if not contraindicated) may provide symptomatic relief.
- Avoiding tight bandages or blood pressure measurements on the affected limb is crucial to prevent further complications. Diagnostic evaluation typically includes:
- Duplex ultrasound to assess graft patency and identify stenosis or thrombosis, as recommended by guidelines to monitor and surveil dialysis grafts for early detection of hemodynamically significant stenosis 1. Depending on the findings, interventions may include:
- Angioplasty,
- Stent placement,
- Thrombectomy, or
- Surgical revision, with the goal of reducing the thrombosis rate to a maximum of 0.5 thrombosis/year for AVGs, as suggested by the guidelines 1. Additionally, managing fluid overload with diuretics like furosemide 20-80mg daily may be necessary if present, but addressing the underlying graft issue is paramount to prevent more serious complications like thrombosis or complete graft failure.
- Patient education on monitoring for worsening symptoms such as increased pain, warmth, or redness, which could indicate infection requiring prompt antibiotic therapy, is also essential. Preserving graft function is critical as it represents a lifeline for dialysis access, and early intervention for edema can prevent more serious complications, highlighting the importance of surveillance and monitoring as outlined in the clinical practice guidelines for vascular access 1.
From the Research
Patient Presentation
- The patient presents with a dialysis graft and edema
- The patient's history and physical examination should be directed to evaluate the existence and quality of the arterial and venous vessels of the upper extremities 2
Management
- A native AV fistula is the vascular access of choice, but when a native AV fistula cannot be established, a synthetic AV graft is the second option 2
- For patients with edema, evaluation of the graft for stenosis or thrombosis is necessary 3, 4
- Fistulogram after arteriovenous dialysis graft thrombectomy should be mandatory to reveal underlying lesions that need correction 4
- Cutting balloon angioplasty can be used for undilatable venous stenoses causing dialysis graft failure 5
Long-Term Dialysis Access
- For patients with unique conditions such as left ventricular assist devices, a right brachio-brachial arterio-venous graft (AVG) placement can be a convenient and durable option 6
- The use of AVG can facilitate early cannulation and expediting freedom from indwelling catheters, thus improving quality of life 6
SOAP Note
- S: The patient presents with a dialysis graft and edema
- O: Evaluation of the graft for stenosis or thrombosis is necessary
- A: The patient may require fistulogram, cutting balloon angioplasty, or AVG placement
- P: The treatment plan should include regular follow-up to monitor the graft's function and adjust the treatment as necessary 2, 3, 4, 5, 6