Vascular Access Vulnerability in Intensive Hemodialysis: A Significant Achilles' Heel?

Abstract

Background: Frequent hemodialysis (HD) may be associated with an increased risk of vascular access complications. Studies addressing vascular access outcomes in frequent HD show conflicting results. Methods: We searched Medline for trials looking at vascular access outcomes in frequent HD. Results: Nineteen studies met the inclusion criteria; only studies with a control group were included for analysis (n = 15). The vascular access event rate was higher in intensive HD as compared to conventional HD (difference of 6.7 events per 100 patient-years, p = 0.009). Overall event rates were not significantly different between conventional and intensive HD when stratified for access type, but were notably higher in the arteriovenous grafts and catheter group as compared to the arteriovenous fistula (AVF) group. Conclusion: Intensive HD is associated with an increased risk of vascular access complications. Overall reported event rates were lower in the AVF group. Further controlled studies should investigate whether a ‘fistula first' strategy may be recommended also for intensive HD.

Survival comparisons of intensive vs. conventional hemodialysis: Pitfalls and lessons

“…Patients on intensive HD have been shown to have a more expedited loss of residual renal function than their CHD counterparts, a factor associated with increased mortality in earlier PD literature . Additionally, more frequent dialytic therapy may result in increased vascular access complications including vascular damage and infections due to more frequent cannulation of fistulas and access of catheters . Finally, patients may experience middle/large molecule accumulation in short daily dialysis, or malnutrition from loss of water soluble vitamins and minerals in nocturnal/extended hour HD .…”

“…Increased vascular access complications have been observed with intensive therapy as demonstrated in a systematic review in 2014. This review consisted of 19 studies, all but 2 of which had 5 or greater dialysis sessions per week …”

“…15 Additionally, more frequent dialytic therapy may result in increased vascular access complications including vascular damage and infections due to more frequent cannulation of fistulas and access of catheters. 5,16 Finally, patients may experience middle/large molecule accumulation in short daily dialysis, 17 or malnutrition from loss of water soluble vitamins and minerals in nocturnal/extended hour HD. 18 These factors and their presumed influence on patient survival are summarized in Figure 1.…”

“…This review consisted of 19 studies, all but 2 of which had 5 or greater dialysis sessions per week. 16…”

Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis

“…These events included access dysfunction, access-related hospital admission, access failure, and access-related infection. 62 The predominant cannulation method of arteriovenous fistulas and grafts is the rope-ladder technique. Buttonhole (constant-site) cannulation is an alternative technique whereby needles are inserted each time at exactly the same spot using the same insertion angle and the same depth of penetration for each dialysis session.…”