GUIDELINES [ back to index ]
1. Starting management of vascular access
*1 Vein preservation of both arms:
• Veins must be preserved in all patients with declining renal function 1 2 and those undergoing renal replacement therapy with haemodialysis, peritoneal dialysis and renal transplantation:
• Avoid i.v. infusion or venipuncture in forearm and upper arm veins of both arms whenever possible.
• Whenever a central venous catheter is needed, the placement of a subclavian vein catheter must be avoided, as it is usually complicated by subclavian vein stenosis, which has serious implications for future vascular access of HD patients 3. Catheterisation of the internal jugular or femoral vein is always preferred, although any dialysis catheter can cause central vein stenosis and should be avoided if possible.
• The patient’s vessels should be examined early in the course of chronic renal failure and the best vein for an A/V fistula indicated to the patient so that he/she can prevent use of that vein by healthcare professionals.
• If the patient is hospitalised: Place sign “no venipuncture” over his or her bed.
• Consider handing out a “Medic Alert bracelet or card” to the patient.
• Preferred site for venipuncture are the dorsal veins of both hands .
• Educational programmes alerting physicians, nurses and patients of the importance of vein preservation and training in patients with chronic renal failure should be implemented. The programmes should be primarily focused on the patients themselves, who they can contact in the renal outpatient clinic and through their patients' associations. However, these programmes should also address renal physicians and nurses, and staff in the emergency and intensive care units.
• Some believe in vein training although there is no evidence that it is of benefit. For those who do believe in it, vein training can be included into this educational programme. A blood pressure cuff or tourniquet is inflated around the upper arm proximally to the prospective access site, and venous congestion maintained for two or three minutes . This exercise should be repeated several times within a 15 minute period, and the exercise performed three or four times a day. There is no data in the literature on the effect of vein training on vessel diameters and immediate patency rates of newly constructed fistulae. Vein training, however, is believed to further alert the patient on the importance of vein preservation and hence some renal healthcare professionals recommend it.
*2 Patient education on modality choice options
• Haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation all have their place in renal replacement therapy as an integrated therapy approach for ESRD patients. Early patient education should cover all these treatment modalities. There is increasing evidence that early transplantation prolongs life of patients in renal failure and pre-emptive live donor transplantation should be encouraged.
• Early referral to nephrologists may help in decreasing the rate of progression of renal insufficiency and also offers the possibility of timely A/V fistula placement, when needed.
• Educational programmes should involve the entire nephrological team including physicians, surgeons, transplant co-ordinators, nurses, dieticians and social workers, and be supported by educational materials such as booklets, flip charts and videos.
• Talking with other patients or visiting haemodialysis or peritoneal dialysis units can help patients prepare and choose the most appropriate modality of treatment.
• In patients who are able and motivated to perform PD, this modality may be the first-line therapy of an integrated therapy approach. In one publication, patients who initially started on PD and were later transferred to HD showed a better survival compared to those started directly on HD 4. In addition, vascular access sites can be preserved for a later stage in the life of the patient.
• Jungers et al.. reported that patients who obtained education over six months prior to initiating dialysis had a significantly shorter length of hospital stay (4.8 + 3.3 days versus 29.7 + 15.8 days), lower three month mortality (1.6% versus 7.1%) and a higher prevalence of home or self care dialysis (40.8% versus 20.1%) than patients referred less than 15 days prior to initiation of dialysis therapy 5.
*3 GFR < 25 to 20 mL/min
• When GFR has fallen to below 25 to 20 ml/min the patient, supported by the nephrological team, should decide about the best modality. Irrespectively of the choice of dialysis modality, the forearm and upper arm veins should be preserved for future vascular access surgery. Patients with a GFR 10-15 ml/min and who have chosen haemodialysis as renal replacement therapy should be seen by a surgeon well-trained in vascular access surgery, within 6 to 12 months of anticipated need for dialysis. Timely consultation with such a vascular access surgeon may markedly reduce the placement of acute catheters for the start of dialysis in favour of fistulas and grafts 1 6.
*4 No vascular access placement in PD and kidney transplanted patients
• Pre-emptive vascular access placement for patients in peritoneal dialysis or renal transplantation is not indicated as the vascular access may never be needed (in more than 90% of cases) and will destroy veins . Moreover, the back-up vascular access often occludes before HD becomes necessary 7.
*5 Adequacy of PD
• In PD patients dialysis dose (weekly Kt/V and creatinine clearance) and fluid management should be regularly monitored and adjusted, if necessary, according to the current recommendations of dose, of hydration and cardiovascular status of the patient, respectively 8. If dialysis dose or ultrafiltration adjustments impose problems a timely planned transfer to HD is recommended. This integrated approach has been shown to improve the patient’s survival 4.