Access Options

(Topic from archives: Originally posted 17:13:59 09/10/2001)

My father has had 2 fistulas, both of which have failed due to infection. We are going to the doctor on Friday but before then I am trying to educate myself on alternative access options. His doctor mentioned a "tube" that can be implanted that joins the artery and vein with lower infection risk. Does anyone know about this? I've searched the internet for information but it is hard to understand. What happens if a successful access cannot be obtained? He's using a catheter now. Thanks for any support.

Lori, there are 3 main ways to gain access to the blood for hemodialysis. The first is a fistula: a direct surgical connection between the patient's own artery & vein. The vein is closer to the surface of the skin (easier to reach) and the artery has a strong, fast blood supply. Fistulas are the "gold standard" for dialysis access because they are much *less* likely to become infected or clotted, although, clearly, it does happen. The needle holes seal up after each use, and a good fistula can last for decades. The experience of the surgeon creating the access can be important to the success of the fistula or graft. If possible, the fistula surgery should be done by a vascular surgeon who has done many dialysis access surgeries.

It sounds as if the doctor is talking about the second form of access: a GRAFT, which is a piece of artificial vein used to connect the patient's own artery and vein. Grafts are much *more* prone to infection and clotting, and the needle holes do not seal by themselves after use. For these reasons, grafts do not usually last as long as a good fistula. Ask the doctor why he believes a graft would be less likely to be infected in your father's case.

The third form of access--almost always temporary--is a catheter, a tube that enters a central vein, but remains outside the body. New types of catheters that can be implanted beneath the skin where they are less likely to become infected (e.g., VasCa's "Lifesite") can also be used.

Did your father's fistulas become infected during surgery, or when needles were placed for dialysis? Careful technique may prevent either of these cases from happening again. Some patients learn to place needles in their own accesses, to protect their "dialysis lifeline" as much as possible.

It sounds as if your dad still has access possibilities for hemodialysis. If he cannot obtain a successful access, then peritoneal dialsyis (PD), which uses the lining of the sac surrounding the abdominal organs to filter the blood, may be an alternative for him, if he is physically suited for it.

Please let us know what happens with your dad! We wish him luck and a safe dialysis journey. He's lucky to have a daughter like you to look out for him.

I have done both hemo and PD and I would say that if one can do PD by using a cycler (machine that you hook up to by night) you should!

It is the best as far as I am concerned. Am willing to give you more info.

Joel-

How do you deal with travel when you have a night-time PD cycling machine?

In particular, if I wanted to spend a night or two on a private sailboat, is there some way I could deal with this, do you think?

It seems like all the PD supplies would be burdensome when traveling. I find myself wondering whether one could switch to Center Hemodialysis when traveling if one had both types of access. But I'm sure that must be very non-standard and it would be hard to get cooperation from the medical
community, I'd think.

Another question, how noisy is the machine? I'm afraid it would
disturb my husband's sleep.

Thanks,
Julie
(not yet on dialysis)

Depending on where people plan to go, whether they're traveling by car or public transportation, availability of space and electricity at the destination, etc. some people choose to take the PD cycler with them while others choose to do daily exchanges manually (CAPD). It is usually easier to arrange for PD supply delivery or to take supplies with you for peritoneal dialysis than it is to arrange to do hemodialysis in a center. A few centers in tourist areas seem to cater to traveling dialysis patients, but most have limited space making it necessary for people to plan at least 1-3 months ahead and require them to be flexible on days and times of dialysis.

Ask your dialysis clinic, your local National Kidney Foundation affiliate ([url]http://www.kidney.org[url]), or your local American Association of Kidney Patients chapter (http://www.aakp.org) if there is someone you can talk with who uses the cycler. The NKF has People Like Us, Live! classes for people in some NKF affiliates to help people approaching kidney failure understand their options. If you have an opportunity to talk with someone on the cycler, ask about how to set it up, what it feels like to dialyze using it, whether their sleep (or their spouse's sleep) has been disturbed, how they travel, etc. People on a particular treatment are great resources and generally enjoy doing what they can to help new people.

There is a new alternative available for access called "Lifesite" the web site is: http://vasca.org

It's a great device, my friend is starting the process to learn more about it and possibly have one put in.

[Beth Witten MSW ACSW]

There are three types of hemodialysis access. National Kidney Foundation practice guidelines on hemodialysis access recommend these types of accesses in this order:
1st: fistula
2nd: graft
3rd: catheter

Patients who use the Vasca LifeSite (and other catheters) are reported to have a higher rate of infection than those who have either fistulas or grafts.

You can read more about options for vascular access in Module 8 of Kidney School (www.kidneyschool.org).

[Angie1973]

I found this forum through searching as I have an appointment in the morning for a fistula and I am scared. I have a catheter right now. I wish I still was on Peritoneal Dialysis but after 4 good years I got Peritonitis. Now I have been on hemo since the summer (6 months now) using the catheter but the nurses are pushing for me to get a fistula. I am scared and don't want to be pushed or rushed.

Anyway, the kidneyschool site has given me some info so I feel a bit better but am still nervous. Thx for everything. Without all this info I would be solely dependent on the doctors and they are just too busy to really give me all the info I am in need of. Thank you.

[Beth Witten MSW ACSW]

I can imagine that it's scary to think about having the surgery and it may be scary for you to think about having needle sticks. However, the nurses may be pushing you to get a fistula because catheters can get infected or clot easily and lead people to need to be hospitalized or even die. You may think that this is not possible, but if you learn to do your own needle sticks, from what I've heard, it gives patients so much more control over dialysis that you will be amazed. Even those with needle fear have overcome it and learned how to do it.

Check out the Home Dialysis Central website (www.homedialysis.org). As someone who has done PD, it probably wouldn't be too much of a stretch for you to learn how to do home hemodialysis. Read about the different options and visit the message board for home hemo patients. It's very active.

[Angie1973]

I will check it out when I get back from Hemo today. I can't ever imagine sticking myself. Too scary as I hate needles even though I don't get grossed out by them. It took me the longest time to learn to be able just to give myself my eprex (epo in US) subcutaneous injections as it is. There isn't home hemo yet in my area but I am in a clinic called 'Self Care' where I have already learned how to calculate my numbers (fluid weight to be taken off) and putting on the blue and red connectors to the filter thingy. I am still learning but it is true. The more I do myself the more control I feel I have.

I saw the surgoen today and he said there should not be any problems for me to get a successful fistula. I have a lot of knots in my veins but he found a good spot on my arm. It will be in my left arm since I am right handed.