Vascular Access and Intradialytic Complications in Hemodialysis

Vascular Access Complications

• Pseudoaneurysm of dialysis grafts requires surgical resection and interposition graft placement when rapidly expanding, exceeds twice the graft diameter, threatens overlying skin viability, or is infected, according to the American Journal of Kidney Diseases 1
• Needle insertion into pseudoaneurysm areas must be avoided due to hemorrhage risk, as recommended by the American Journal of Kidney Diseases 1
• For infected pseudoaneurysms with skin erosion or active hemorrhage, prompt recognition and definitive management are required, as stated by the Journal of the American College of Radiology 2
• Aneurysms of primary AV fistulae require surgical intervention only when involving the arterial anastomosis, and venipuncture should avoid the aneurysm, according to the American Journal of Kidney Diseases 1
• Catheter-associated bacteremia with tunnel tract involvement mandates catheter removal, as recommended by the American Journal of Kidney Diseases 1
• Three weeks of systemic antibiotic therapy are required to treat catheter-associated bacteremia, according to the American Journal of Kidney Diseases 1
• New permanent access should not be placed until cultures have been negative for at least 48 hours after cessation of antibiotic therapy, as stated by the American Journal of Kidney Diseases 1
• Exit site infections can be reduced by using dry gauze dressing with povidone iodine and mupirocin ointment, particularly in patients with nasal carriage of Staphylococcus aureus, as recommended by the American Journal of Kidney Diseases 3
• Patients and staff should wear surgical masks during all catheter procedures that access the bloodstream to reduce infectious droplet transmission, according to the American Journal of Kidney Diseases 3

Intradialytic Complications

• Any symptomatic BP decrease or nadir intradialytic systolic BP <90 mm Hg should prompt immediate reassessment of BP management, including ultrafiltration rate, dialysis treatment time, interdialytic weight gain, dry-weight estimation, and antihypertensive medication use, as recommended by Kidney International 4
• Intradialytic hypotension occurs in 15-50% of HD treatments and is associated with vascular access thrombosis, inadequate dialysis dose, and mortality, according to Kidney International 4
• Avoiding excessive ultrafiltration, slowing ultrafiltration rate, increasing dialysate sodium concentration, and switching to bicarbonate-buffered dialysate are management strategies for intradialytic hypotension, as recommended by the American Journal of Kidney Diseases 5
• SBP increase >10 mm Hg into hypertensive range in at least 4 of 6 consecutive treatments should prompt extensive evaluation of BP and volume management, including out-of-unit BP measurements and critical dry weight assessment, according to Kidney International 4
• Cramps are a leading cause of treatment discomfort and premature termination, and management includes avoiding excessive ultrafiltration, slowing ultrafiltration rate, increasing dialysate sodium concentration, and switching to bicarbonate-buffered dialysate, as recommended by the American Journal of Kidney Diseases 5

Prevention and Surveillance

• Systematic monitoring programs must be instituted to detect vascular accesses at risk and establish quality assurance programs tracking access complication rates and outcomes, as recommended by the American Journal of Kidney Diseases 1
• Avoidance of intradialytic hypotension should not come at the expense of maintaining euvolemia or ensuring adequate dialysis time, according to Kidney International 4
• Targeting excessively low BP thresholds may heighten cardiovascular risk, and an individualized approach focusing on avoiding overly low BPs is necessary, as stated by Kidney International 4

Vascular Access and Systemic Complications in Dialysis

Vascular Access Complications

• The American College of Radiology recommends that stenosis be identified early through systematic monitoring, as it is the primary precipitator of vascular access failure 6, 7
• Stenosis ≥50% of lumen diameter requires intervention when associated with previous thrombosis, elevated venous dialysis pressure, abnormal recirculation measurements, unexplained decrease in dialysis dose, or decreasing access flow rates 8
• Physical examination detects 90% of clinically significant access problems through changes in access thrill or bruit, prolonged bleeding after decannulation, arm swelling, and difficulty achieving prescribed blood flow rates 6, 7, 8, 9
• Percutaneous transluminal angioplasty is first-line treatment for stenosis, with surgical revision reserved for patients requiring angioplasty more than twice within 3 months 8
• Access thrombosis is the primary cause of vascular access loss and directly increases healthcare costs while compromising quality of life 6, 7

Intradialytic and Systemic Complications

• Left ventricular hypertrophy affects approximately 75% of patients by dialysis initiation, having developed progressively during earlier stages of chronic kidney disease 10
• Peripheral vascular disease in dialysis patients should not automatically result in amputation—revascularization is the preferred treatment in selected patients who are ambulatory or use the affected extremity for weight bearing 11, 12
• Primary amputation is indicated only for extensive tissue necrosis in non-weight-bearing limbs, preoperative infection, or chronically bedridden patients 11, 12

Uremic Symptom Burden and Management

• Regular assessment of uremic symptoms using validated tools is necessary, as symptoms are often underreported and under-recognized by providers 13, 9
• Bone pain affects many hemodialysis patients, yet only half receive analgesia 13
• Sleep disturbance is common, but less than a quarter receive appropriate treatment 13
• Clinicians must assess symptoms most important to individual patients and prioritize based on patient perceptions of impact on their ability to live the life they want 13
• Extended or more frequent dialysis sessions should be considered for patients with persistent uremic symptoms 9

Systematic Surveillance and Prevention

• Regular physical examination of vascular access at every dialysis session to detect early dysfunction 6, 7, 9
• Periodic surveillance using noninvasive methods to assess access blood flow rate, recirculation, and venous pressure 6, 7
• Diagnostic imaging upon detection or suspicion of access abnormality 6, 7
• Regular interdisciplinary team meetings to address all aspects of dialysis care 9
• Systematic assessment and documentation of complications during routine visits 9
• Development of individualized care plans addressing each element of potential complications 9
• Patient education and engagement in self-management is essential for early complication recognition 9