Vascular access for hemodialysis.

Dr. Steve J. Schwab (Vice-Chairman, Department of Medicine, Duke University Medical Center, and Professor of Medicine, Duke University School of Medicine, Durham, North Carolina, USA): This case exemplifies the current state of the art for the management of vascular access for hemodialysis. The predominant form of vascular access currently in the United States is the polytetrafluoroethylene (PTFE) graft, constituting some 70% of CASE PRESENTATION the total permanent access. Primary arteriovenous fistulas, although generally preferred, are used less often A 62-year-old black woman with end-stage renal disease secondary to type-II diabetes mellitus began hemodialysis 2 because of late referral of patients to nephrologists, and years ago. She presented to the Nephrology Service at Duke because an aging and diabetic population with a limited University Medical Center with a serum creatinine of 8.6 mg/ number of suitable sites for the formation of primary dl; vascular access for hemodialysis was achieved via an internal AV fistulas limits their formation. They currently constijugular, cuffed, Silastic catheter. A brachiocephalic, primary arteriovenous (AV) fistula was attempted but failed to mature. tute less than 20% of the prevalent hemodialysis access A left upper arm PTFE graft was subsequently placed. Hemodiin the United States. This case also provides me an opalysis proceeded uneventfully, and she entered into a hemodialportunity to discuss the current role of the tunneled ysis vascular access monitoring protocol with dynamic venous cuffed catheter in hemodialysis vascular access. pressure testing. On two later occasions, she underwent percuComplications of vascular access are not only a major taneous transluminal angioplasty of a stenotic lesion 2 cm superior to the vein/graft anastomosis. In both instances, venous cause of morbidity in hemodialysis patients, but a major dialysis pressure above the monitor threshold indicated the cost for the end-stage renal disease program. In its latest presence of the lesion. Four months ago, venous dialysis presreport, the United States Renal Data System (USRDS) sure monitoring was changed to monitoring with ultrasound estimated that the costs for access morbidity approach dilution access flow. Her access flow rates continued to decrease on monthly readings, from 1020 ml/min to 750 ml/min over a $8000/patient/year at risk [1]. Remarkably, conservative 4-month period. Fistulography showed recurrence of the same estimates suggest that this figure represents 17% of the stenotic lesion. Angioplasty was attempted, but the lumen was total spending for hemodialysis patients. Feldman [2, not successfully reconstituted. She was offered elective surgical 3] and others [4–6] have reported that access-related revision but declined. One month later, her access flow had morbidity accounts for almost 25% of all hospital stays decreased to 680 ml/min, and she presented with a thrombosed arteriovenous graft. Pulse spray thrombolysis revealed a residfor ESRD patients and may contribute to as much as ual 95% outflow stenosis. The patient then elected surgical 50% of all hospitalization costs [2–7]. Using the prospectively collected data from the Dialysis Outcome Practice Patterns Study (DOPPS), Held has confirmed Feldman’s Presentation of this Forum is made possible by grants from Merck and observations [6]. Indeed, managed care organizations Co., Incorporated; Astra Pharmaceuticals; Hoechst Marion Roussel, Incorporated; Dialysis Clinic, Incorporated; and R & D Laboratories, planning for a capitated payment environment estimate Incorporated. that as much as one-quarter of the total cost of endstage renal disease is spent on the maintenance of vascu