Vascular Access for Hemodialysis: 3 Options to Understand

Not all kinds of dialysis accesses are created the same

Fistula First!. Getty Images/Zachary Miller

(This is part 2 of 2-article series. Click here for part 1 which covers the basic differences between the 3 kinds of dialysis accesses- fistula, graft, and catheters) 

PLACING A DIALYSIS ACCESS: TIME IS OF ESSENCE 

A fistula is not something that you could just place and start using right away.  Even after placement, it could take months for a good fistula to be ready for use. This time interval is called the period of maturation.

 A graft might be usable sooner, though. And a catheter can practically be used immediately, making it good for emergency or critical care situations.

DIALYSIS ACCESSES ARE NOT CREATED THE SAME: UNDERSTANDING THE ADVANTAGES AND DISADVANTAGES

An arterio-venous fistula is typically considered the best form of dialysis access.  He has some of the reasons why that is the case:

  • Superior patency
  • Lower long-term health care costs
  • Less risk of infections and hospitalization. This is the highest for catheters.

For the visually oriented, there is a graph.

Some of these points establishing the superiority of fistulas over grafts are still an active area of debate. However, there is little debate that a fistula (and a graft) are way better than having a venous catheter for dialysis. It was because of these reasons that CMS launched the so-called Fistula-First campaign as a breakthrough initiative in July 2003.

WHAT DOES THIS ALL MEAN FOR YOU, THE PATIENT

Now that you're aware of the different kinds of dialysis accesses, and the relative advantages and disadvantages, it is time to make some decisions.

It should be amply clear that catheters are the least preferred option for doing dialysis.  Given a choice, I would not have a single patient initiated or be maintained on hemodialysis via a catheter.

However, they have their place.  The are perhaps the only option for doing dialysis when hemodialysis needs to be initiated in a critical care or in an emergent setting.  To a large extent, and hopefully, this might change with the development of arteriovenous grafts that can be rapidly used, in as little as a day.

However, I cannot overemphasize why because of these very reasons, it is very important to have a timely referral to see a nephrologist with whom you can discuss your options about what kind of dialysis would you want in the first place.  If it is hemodialysis that you would prefer, and if your nephrologist thinks that dialysis might be an impending reality within a short time, it is of great importance to have an arteriovenous fistula placed in a timely manner.  Remember, it could take a few months for a good fistula to even be ready for use.  And that is assuming everything goes as per plan.  They are a decent number of fistulas will not work from the get go, and might need repositioning or replacement.

 In that case, you might be looking at a lag time of over 6 months between deciding on a fistula placement and actually having a fistula ready to use.

The most frustrating things for me as a nephrologist is to see an otherwise healthy patient crash in an ICU needing dialysis and not having a good dialysis access ready-to-go for dialysis.  I typically see this in two kind of situations.  Either the patient has been referred way too late to a nephrologist, or the patient has been in denial about impending dialysis and was putting off getting a proper access. This inevitably leads to more complications and prolonged hospital stay, beside increasing the risk of death significantly. 

So here is what you need to do:

  1. Seek a timely referral to see a nephrologist.  
  2. Make up your mind about what kind of dialysis would you want.  
  3. If you chose hemodialysis, have the nephrologist refer you to a good vascular surgeon and have her/him place a good arterio-venous fistula in a timely manner (unless there are good reasons for you to not receive that). This lifeline will make a big difference to your life expectancy and to your quality-of-life.

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