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Vascular access for hemodialysis.

Article Excerpt
Patients with chronic kidney disease (CKD) Stage 5 or end stage renal disease (ESRD) who require maintenance hemodialysis therapy must have a permanent means of access to their bloodstream by which this life-sustaining therapy can adequately be delivered.

It is the position of ANNA that:

* CKD teaching related to creation and maintenance of the hemodialysis vascular access should be made available to CKD patients and their families as soon as the diagnosis of impending progression into Stage 5 and need for kidney replacement therapy has been determined. It is recommended that this is done in Stages 3 to 5 of CKD.

* Vein preservation of both peripheral and central vessels should be incorporated into patient teaching and care. Blood draws and IV placement will be from/in the dorsum of the hands whenever possible, regardless of arm dominance. Forearm and upper-arm veins suitable for future vascular access should not be used for venipuncture or for placement of IV catheters or subclavian catheters or peripherally inserted central catheter lines (PICCs) to avoid potential for ipsilateral peripheral access due to the risks of central vein stenosis and occlusion.

* Optimally, all patients requiring maintenance hemodialysis therapy should have a functioning permanent vascular access in place before initiating hemodialysis. It is recommended that access placement be carried out in Stage 4 of CKD.

* ANNA endorses the recommendations of the NKF KDOQI Vascular Access Guidelines regarding the order of preference for the placement of fistulae as the preferred choice. Acceptable choice when an A-V fistula is not possible or viable is AV graft of synthetic or biological material. Avoid if possible the long-term use of hemodialysis catheters.

* Detailed, focused history and physical examination, as well as vessel mapping, is the expected standard of care and should be performed on each new CKD patient to determine the type of vascular access...

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