How are different access options for haemodialysis (hemodialysis) chosen for patients with End-Stage Renal Disease (ESRD)?

Selection of Hemodialysis Access for ESRD Patients

For patients with End-Stage Renal Disease (ESRD) requiring hemodialysis, arteriovenous access (AVF or AVG) should be used over tunneled central venous catheters (CVCs) whenever possible to reduce infection risk and improve mortality outcomes. 1

Hierarchy of Access Options

First-Line Options (Preferred)

• Arteriovenous Fistulae (AVF) should be considered first due to better long-term patency rates and fewer interventions 1
  • Wrist (radiocephalic) primary fistula as first choice 1
  • Elbow (brachiocephalic) primary fistula as second choice 1
  • Transposed brachial basilic vein fistula as third choice 1

Second-Line Options (Acceptable)

• Arteriovenous Grafts (AVG) when fistula placement is not possible 1
  • Forearm loop graft (preferable to straight configuration) 1
  • Upper-arm graft 1
  • Chest wall or "necklace" prosthetic graft or lower-extremity graft (only after exhausting upper-arm sites) 1

Last Resort (Avoid if Possible)

• Tunneled Central Venous Catheters (CVC) 1
  • Should be used only when other options are not available 1
  • Less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters as permanent access 1

Decision-Making Algorithm

Step 1: Patient Assessment

• Evaluate patient's ESRD Life-Plan (expected duration on hemodialysis, transplant candidacy) 1
• Consider patient's vascular anatomy and previous access history 1
• Assess comorbidities that might affect access choice 1

Step 2: Vascular Mapping

• Consider preoperative vascular mapping to increase likelihood of successful AVF creation 2
• Ultrasound should be used to evaluate vessel quality and diameter 1
• Veins ≥2mm in diameter are typically suitable for AVF creation 2

Step 3: Access Location Selection

• Follow distal-to-proximal approach to preserve future access sites 1
• For patients expected to have prolonged duration on hemodialysis, start with distal sites to preserve proximal vessels for future access 1

Step 4: Access Type Selection Based on Patient Factors

• Young patients with good vessels: Prioritize AVF starting with distal sites 1
• Elderly patients with limited life expectancy: May consider more proximal AVF or AVG for faster maturation 1
• Patients with poor vascular anatomy: Consider alternative autogenous options before resorting to AVG 3
• Patients requiring urgent dialysis: Use temporary CVC while AVF matures 1

Special Considerations

For Home/Intensive Hemodialysis

• Arteriovenous access (AVF or AVG) is still preferred over tunneled CVC 1
• If using AVF for intensive home hemodialysis, rope-ladder cannulation is recommended over buttonhole technique unless antimicrobial prophylaxis is used 1
• If buttonhole cannulation is used, mupirocin antibacterial cream should be applied to reduce infection risk 1

For CVC Placement (When Necessary)

• Preferred insertion sites in order of preference 1:
  1. Right internal jugular vein
  2. Right external jugular vein
  3. Left internal and external jugular veins
  4. Femoral veins
  5. Subclavian veins (only when no other upper-extremity or chest-wall options are available)
• Use "closed connector" devices for CVCs in intensive hemodialysis patients 1
• Avoid placing CVC on the same side as a maturing AV access 1

Common Pitfalls and Caveats

• Avoid late referral for access creation: Early planning is essential as AVFs ideally need 3-4 months to mature 1
• Preserve peripheral veins: Avoid venipuncture and IV placement in potential access sites in patients with stage III-V CKD 4
• Don't create bilateral upper arm accesses in young patients: This may limit future access options 1
• Monitor for access dysfunction: Implement surveillance programs to detect problems before thrombosis 1
• Strong patient preference for CVC should not be a barrier: Education about risks and benefits is important, but patient preference should be respected when considering intensive hemodialysis 1

By following this structured approach to hemodialysis access selection, clinicians can optimize access survival, minimize complications, and improve patient outcomes in ESRD management.