Frequent Hemodialysis Fistula Infectious Complications

Abstract

Background: Few studies have examined if infectious arteriovenous access complications vary with the cannulation technique and whether this is modified by dialysis frequency. We compared the infection rate between fistulas cannulated using buttonhole versus stepladder techniques for patients treated with short daily (SDH) or nocturnal hemodialysis at home (NHD). We also compared patients receiving conventional intermittent hemodialysis (CIHD) using stepladder cannulation. Methods: Data were prospectively collected from 631 patients dialyzed with a fistula from 2001 to 2010 (Toronto and Ottawa, Canada). We compared the person-time incidence rate of bacteremia and local fistula infections using the exact binomial test. Results: Forty-six (7.3%) patients received SDH (≥5 sessions/week, 2-4 h/session), 128 (20.3%) NHD (≥4 sessions/week, ≥5 h/session) and 457 (72%) CIHD (3 sessions/week, ≤4 h/session). Fifty percent of SDH and 72% of NHD patients used the buttonhole technique. There were 39 buttonhole-related bacteremias (rate: 0.196/1,000 fistula days) and at least 2 local buttonhole site infections. Staphylococcus aureus accounted for 85% of the bacteremias. There were 5 (13%) infection-related hospitalizations and 3 (10%) serious metastatic infections, including fistula loss. In comparison, there was 1 possible fistula-related infection in CIHD during follow-up (rate: 0.002/1,000 fistula days). Conclusions: The rate of buttonhole-related infections was high among patients on frequent hemodialysis and more than 50 times greater than that among patients on CIHD with the stepladder technique. Most bacteremias were due to S. aureus - with serious consequences. The risks and benefits of buttonhole cannulation require individual consideration with careful monitoring, prophylaxis and management.

A Systematic Review of Buttonhole Cannulation Practices and Outcomes

“…Twenty‐two full‐text articles were therefore included in this review . We also identified four ASN conference abstracts published between 2009 and 2011 . Two full‐text articles were separate reports of the same study ; one abstract corresponded to a full‐text publication .…”

“…Bacteremia rates among home dialysis populations ranged between 0.00 and 0.28 per 1000 AVF‐days across 6 studies, which included 416 patients, followed for 1069 patient‐years . Three studies specifically examined the absolute risk of Staphylococcus aureus ( S. aureus ) bacteremia for patients who received home (frequent or long) hemodialysis using buttonhole cannulation, and reported between 0.15 and 0.28 episodes per 1000 patient‐days (Table ) . At least one study reported metastatic complications, including septic arthritis, septic pulmonary emboli, vertebral osteomyelitis, and death .…”

Clinical practice guidelines for the provision of renal service in Hong Kong: Haemodialysis

“…The buttonhole (or constant‐site) technique for AV fistula cannulation has been the routine self‐cannulation method for home HD patients because of less painful and faster in needle placement. Recently, the buttonhole technique is found to have higher risk of local and systemic infection than that of rope‐ladder (or rotating sites) method . The rope‐ladder technique is now the preferred method for home HD patients.…”

Access-Related Infections Involving the Buttonhole Technique

“…This provokes the hesitation to use BH cannulation in routine clinical practice [8,9] . Therefore, whether the BH method will further prevail or no longer be utilized may depend on the results of a search for a measure to prevent access-related infections.…”