Generic Name/ Trade Name/ Form of Medication

Date Ordered

Classifica -tion

Dosage And Frequenc y 500 units subcutane ous twice a week Peak: 5-24 hrs.

Mechanism Of Action

Indication

Contraindication

Adverse Reaction

Nursing Responsiblity

Epoetin Beta (Recormon)

Haematop oietic drugs

Mimics effect of erythropoietin. Functions as growth factor, enhancing RBC production

Treatment of anemia associated with chronic renal failure on or not on dialysis and malignancy on or not on chemotherapy

-Poorly controlled HTN -Not to be used if the indication is for increasing the yield of autologous blood if mth preceding treatment of patient suffered MI, stroke, unstable angina pectoris, or at risk of DVT,history of thromboembo lic disease.

CNS: Headache, seizures, paresthesia, fatigue, dizziness, asthenia CV: hypertension, edema, increased clotting of arteriovenous grafts EENT: Pharyngitis G.I: Nausea, vomiting, abdominal pain Metabolic: Hyperuricemia, hyperkalimia, hyperphosphate mia

-Before starting
therapy, evaluate patients iron status. Patient should receive adequate iron supplementation beginning no later than when epoetin treatment starts and continuing throughout therapy. Patient also may need vitamin B12 and folic acid -Monitor BP before therapy. Most patients with chronic renal failure have hypertension. BP may Increase, especially when hematocrit increases in the early part of therapy

Respiratory: Cough, shortness of breath Skin : Rash, infection site reactions, urticaria Other: pyrexia

-institute diet restrictions or drug therapy to control BP -monitor hemoglobin level twice weekly until it stabilizes in the target range (10 to 12 g/dl for most patients) and maintenance dose is established, then continue to monitor at regular intervals. Resume twice weekly testing following any dosage adjustments -reduce dosage in patients who have an increase in hemoglobin level of more than 1 g/dl in any 2 week period -monitor blood counts; elevated hematocrit may cause excessive clotting -patient may need additional heparin to prevent clotting treatments

-evaluate patient who experiences a lack or loss of effect for pure red cell aplasia Patient teaching -inform patient that pain or discomfort in limbs (long bones) and pelvis, and coldness and sweating may occur after injection (usually within 2 hours) symptoms may last for 12 hours and then disappear -advise patient to avoid driving or operating heavy machinery at start of therapy. There may be a relationship between too rapid increase hematocrit and seizures -Tell patient to monitor BP at home and adhere dietary restrictions

Nursing Problem: Injury risk for (loss of vascular access)

Assessment Diagnosis
Not applicable; presence of signs and symptoms establishes an actual diagnosis of the shunt Injury risk for (loss of vascular access) related to clotting

Inference
Loss of vascular access is inability to administer therapy or obtaining blood for testing in the vascular system Reference: http://medicaldictionary.thefreedi ctionary.com/vascul ar+access

Planning
After 4 hours of duty patient will be able to maintain patent vascular access

Intervention
Independent Evaluate reports of pain, numbness/tingling ; note extremity swelling distal to access Avoid trauma to shunt: e.g handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood supplies in shunt extremity. Instruct patient not to sleep on side with shunt or carry packages, books, purse of the affected extremity Collaborative: Administer medication

Rationale
May indicate blood supply

Evaluation
Goal met Patient is able to maintain patent vascular access.

Decreases the risk of clotting / disconnecti on

Infused on

as indicated, e.g: Heparin (low dose)

arterial side of filter to prevent clotting in the filter without systemic side effects

HEMODIALYSIS OVERVIEW Dialysis is a treatment for severe kidney failure (also called renal failure, stage 5 chronic kidney disease, and endstage renal disease). When the kidneys are no longer working effectively, waste products and fluid build up in the blood. Dialysis take over a portion of the function of the failing kidneys to remove the fluid and waste. (See "Patient information: Dialysis or kidney transplantation which is right for me?".) Dialysis is typically needed when about 90 percent or more of kidney function is lost. This usually takes many months or years after kidney disease is first discovered. Early in the course of kidney disease, other treatments are used to help preserve kidney function and delay the need for replacement therapy. (See "Patient information: Chronic kidney disease".) WHICH TYPE OF DIALYSIS IS BEST? Once dialysis becomes necessary, you (along with your physicians) should consider the advantages and disadvantages of the two types of dialysis:

Hemodialysis (in-center or at home) Peritoneal dialysis (see "Patient information: Peritoneal dialysis")

The choice between hemodialysis and peritoneal dialysis is influenced by a number of issues such as availability, convenience, underlying medical problems, home situation, and age. This choice is best made by discussing the risks and benefits of each type of dialysis with a healthcare provider. (See "Patient information: Dialysis or kidney transplantation which is right for me?".) WHEN TO START DIALYSIS You and your doctor will make the decision about when to start dialysis as your kidney disease progresses. Your kidney function (as measured by blood and urine tests), overall health, nutritional status, symptoms, quality of life,

personal preferences, and other factors impact the decision. Healthcare providers recommend that dialysis begin well before kidney disease has advanced to the point where life threatening complications can occur. It is generally possible to be put on a kidney transplant waiting list when kidney function is about 20 percent of normal. Many patients will need to start dialysis when their kidney function is about 8 to 12 percent of normal, although this is variable. In certain situation, dialysis must be started immediately. If blood tests indicate the kidneys are working very poorly or not at all, or if there are symptoms such as confusion or bleeding that is related to kidney disease, dialysis should be started at once. PREPARING FOR HEMODIALYSIS Preparations for hemodialysis should be made at least several months before it will be needed. In particular, you will need to have a procedure to create an "access" (described below) several weeks to months before hemodialysis begins. Vascular access An access creates a way for blood to be removed from the body, circulate through the dialysis machine, and then return to the body at a rate that is higher than can be achieved through a normal vein. There are three major types of access: primary AV fistula, synthetic AV bridge graft, and central venous catheter. Other names for an access include a fistula or shunt. The access should be created before hemodialysis begins because it needs time to heal before it can be used. Discussions about the access should begin even earlier, since you will need to avoid injuring blood vessels that will eventually be used for access. Having an intravenous line (IV) or frequent blood draws in the arm that will be used for access can damage the veins, which could prevent them from being used for a hemodialysis access. The access is usually created in the non-dominant arm; for a right-handed person this would be their left arm. After the access is placed, it is important to monitor and care for it over time. (See 'Caring for the access' below.) Primary AV fistula A primary AV fistula is the preferred type of vascular access. It requires a surgical procedure that creates a direct connection between an artery and a vein (figure 1). This is often done in the lower arm, but can be done in the upper arm as well. Sometimes a vein that would not normally be useful for creating an AV fistula can be moved so that it is more accessible; this is often done in the upper arm.

Regardless of its location or how it is created, the access is located under the skin. During dialysis, two needles are inserted into the access. Blood flows out of the body through one needle, circulates through the dialysis machine, and flows back into the access through the other needle. A primary AV fistula is usually created two to four months before it will be used for dialysis. During this time, the area can heal and fully develop or "mature". Synthetic bridge graft Sometimes, a patient's arm veins are not suitable for creating a fistula. In these cases, a surgeon can use a flexible rubber tube to create a path between an artery and vein (figure 2). This is called a synthetic bridge graft. The graft sits under the skin and is used in much the same way as the fistula except that the needles used for hemodialysis are placed into the graft material rather than the patient's own vein. Grafts heal more quickly than fistulas and can often be used about two weeks after they are created. However, complications such as narrowing of the blood vessels and infection are more common with grafts than with AV fistulas. Central venous catheter A central venous catheter uses a thin flexible tube that is placed into a large vein (usually in the neck) (figure 3). It may be recommended if dialysis must be started immediately and the patient does not have a functioning AV fistula or graft. This type of access is usually used only on a temporary basis. In some cases, however, there can be problems maintaining an AV fistula or graft, and the central venous route is used for long-term access. Catheters have the highest risk of infection and the poorest function compared to other access types; they should be used only if a primary fistula or synthetic bridge graft cannot be maintained. Dietary changes Some patients, especially those who receive dialysis in a center, will need to make changes in their diet before and during hemodialysis treatment. These changes ensure that you do not become overloaded with fluid and that you consume the right balance of protein, calories, vitamins, and minerals. A diet that is low in sodium, potassium, and phosphorus may be recommended, and the amount of fluids (in drinks and foods) may be limited. A dietitian can help you to choose foods that are compatible with hemodialysis treatment.

Complications of Hemodialysis and their management For Nursing

Complications that occur during a hemodialysis session. Common complications: Hypotension - Muscle cramps - Nausea and vomiting - Headache - Chest and back pain Uncommon but serious complications - Disequilibrium syndrome - Dialyzer reactions - Arrhythmias - Cardiac tamporade - Intracranial bleeding - Febrile reactions - First-use syndromes - Prutitus - Cardiopulmonary arrest during dialysis

- Seizures - Hemolysis - Air embolism - Dialysis-associated neuropenia & complement activation - Hypoxemia.

Common clinical problems during a HD session The common complications that occur during a hemodialysis sessions are: 1) Hypotension (20-30% of dialysis), 5) Chest pain (2-5%), and back pain (2-5%), 6) Febrile reactions 2) Muscle cramps (5-20%), 7) Itching (5%), 3) Nausea and vomiting (5-15%), Fever and chills (<1%), 4) Headache (5%), 9) Cardiopulmonary arrest. 1) Hypotension The cause of hypotension, which can be classified into common and uncommon. Common causes 1.Related to excessive decreases in blood volume a. Fluctuations in the ultra filtration rate b. High ultra filtration rate (to treat a large interdialysis weight gain) c.Target dry weight set too low d. dialysis solution sodium level too low 2. Related to lack of vasoconstriction a. Acetate-containing dialysis solution

b. Food ingestion (splanchnic vasodilatation) c. Tissue ischemia (adenosine-mediated, aggravated by low hematocrit) d. Autonomic neuropathy (e.g., diabetic) e. Dialysis solution that is relatively too warm f. Antihypertensive medications 3. Related to cardiac factors a. Cardiac output unusually dependant on cardiac filling: Diastolic dysfunction due to left ventricular hypertrophy, schemic heart disease, or other conditions b. Failure to increase cardiac rate (I) Ingestion of beta-blockers (ii) Uremic autonomic neuropathy (iii) Aging c. Inability to increase cardiac output for other reasons: Poor myocardial contractility due to age, hypertension, atherosclerosis, myocardial calcification, valve disease, amyloidosis, etc. ..

uncommon causes 1.Pericardial tamponade 2.Myocardial infarction 3.Occult hemorrhage 4.Septicemia 5.Arrhythmia 6.Dialyzer reaction 7.Hemolysis 8.Air embolism Detection of Hypotension: Most patients will complain of feeling dizzy, light-headed, or nauseated when hypotension occurs. Some experience muscle cramps. Other may experience no symptoms whatsoever until the blood pressure falls to extremely low (and dangerous) levels. Thus, blood pressure must be monitored on a regular basis in all patients throughout the hemodialysis session. Management of hypotension a) Fluid administration: Management of the acute hypotensive episode is straightforward. The patient should be placed in the trendelenburg position (if respiratory status allows this). A bolus of 0.9% saline (100 ml or more, as necessary) should be rapidly administered through the venous blood line. The ultra filtration rate should be reduced to as near zero as possible. Ultra filtration can be resumed (at a slower rate, initially) oncevital signs have stabilized. As an alternative to 0.9% saline, hypertonic saline, glucose, mannitol, or albumin solutions can be used to treat the

hypotensive episode. Unless cramps are also present, use of hypertonic solutions appears to offer no benefit over 0.9% saline. Nasal oxygen administration may also be of benefit by virtue of helping to improve or maintain myocardial performance. b) Slowing the blood flow rate: In the past, part of initial therapy for dialysis hypotension was to slow the blood flow rate, a practice developed at a time when plate dialyzers and acetate dialysis solution were being used. There are four potential reasons to lower the blood flow rate to treat hypotension: I) when plate dialyzers are used, reduction of the blood flow rate reduces pressure in the blood compartment of the dialyzer. The plates come closer together, reducing the total volume of the extracorporeal circuit. ii) When acetate dialysis solution is used, reduction of blood flow rate reduces transfer of acetate to the patient. iii) When an ultra filtration controller is not used, slowing the blood flow rate makes it easier to limit the amount of ultra filtration. iv) At very rapid blood flow rates and at a low cardiac output, there may be a steal effect by the extracorporeal circuit, with diversion of blood from systemic tissue beds. Prevention of hypotension: A useful strategy to help prevent hypotension during dialysis is: 1-Use a dialysis machine with an ultra filtration controller whenever possible. 2-Counsel patient to limit weight gain to < 1 kg/day. 3-Do not ultra filter a patient to below his or her dry weight. 4-Keep dialysis solution sodium level at or above the plasma level.

5-Give daily dose of antihypertensive medications after, not before, dialysis. 6-Use bicarbonate-containing dialysis solution when high blood flow rate or high-efficiency dialyzers are used. 7-In selected patients, try lowering the dialysis solution temperature to 34-36C. 8-Ensure that hematocrit is > 25-30% pre-dialysis. 9-Do not give food or glucose orally during dialysis to hypotensive-prone patients. Muscle cramps The pathogenesis of muscle cramps during dialysis is unknown. The three most important predisposing factors are hypotension, the patient being below dry weight, and/or use of sodium-poor dialysis solution. Management: When hypotension and muscle cramps occur concomitantly, the hypotension may respond to treatment with 0.9% saline, but the muscle cramps may persist. Muscle-bed blood vessels can be dilated by hypertonic solutions. Perhaps for this reasons, administration of hypertonic saline or glucose is very effective in the acute management of muscle cramps. Prevention of cramps: Prevention of hypotensive episodes will eliminate the majority of episodes of cramping. Increasing the dialysis solution sodium level to 145 mmol/liter or higher may also be of benefit. Strategies of decreasing sodium dialysis sometimes can be useful to treat patients with refectory intradialytic cramps. Start out with a sodium level of 150-155 and program in a linear fashion, decrees to 135-140 mmol/liter by the end of treatment. Carnitine supplementation of dialysis patients might result in fewer muscle cramps during dialysis. Other strategies are to administer orally quinine sulfate 260 mg, or oxazepam 5-10 mg, 2 hours prior to dialysis. A program of stretching exercises targeted at the affected muscle groups may also be useful. Nausea and vomiting

Etiology: Nausea or vomiting occurs in up to 10% of routine dialysis treatments. The etiology is multifactorial. Most episodes in stable patients are probably related to hypotension. Nausea or vomiting can also be early manifestation of the so-called disequilibrium syndrome. Management: The first step is to treat any associated hypotension. If nausea persists, an antiemtic can be administered. Prevention: Avoidance of hypotension during dialysis is of prime importance. In some patients, reduction of the blood flow rate by 30% during the initial hour of dialysis may be of benefit. A change to bicarbonate dialysis can be helpful. Headache Etiology: Headache is a common symptom during dialysis, the cause of which is largely unknown. It may be a subtle manifestation of the disequilibrium syndrome or may be related to use of acetate-containing dialysis solution. In patients who are coffee drinkers, headache may be a manifestation of caffeine withdrawal as the blood caffeine concentration is acutely reduced during the dialysis treatment. Management: Acetaminophen can be given during dialysis. Prevention: As for nausea and vomiting, a reduction in the blood flow rate during the early part of the dialysis treatment can be tried. A change to bicarbonate-containing dialysis solution is sometimes beneficial. Chest and back pain Chest pain (often associated with back pain) occurs in 1-4% of dialysis treatment. The cause is unknown but may be related to complement activation. There is no specific management or prevention strategy other than switching to a synthetic or substituted cellulose membrane.

The occurrence of angina during dialysis is common, and this as well as the numerous other potential cause of chest pain (e.g., hemolysis) must be considered in the differential diagnosis. Immediate treatment: The treatment of symptoms is supportive, with nasal oxygen and antihistamines. Usually the symptoms are not severe and abate within an hour, and the dialysis treatment can be completed. Prevention: This syndrome may be prevented by using a more biocompatible membrane or enrolling the patient in a reuse program using preprocessed new dialyzers. Febrile reactions In general, febrile episodes should be aggressively evaluated with appropriate wound and blood cultures. The suspicion of infection should be particularly high in patients with right atrial dialysis catheters. Fistula or graft infections may be subtle, and empirical treatment with antibiotics may become necessary in many cases. Pathophysiology: Febrile reactions during the course of treatment may be related to exposure to endotoxins originating from the dialyzer or dialysate. Such events may be associated with chills, nausea, and more rarely, hypotension. Febrile reactions occurring shortly after treatment are characteristic of systemic infections. Immediate treatment: Treatment of endotoxin related fever is generally supportive with antipyretics. In most cases the dialysis treatment can be completed. Infection-related fever is treated with antibiotics administrated at the end of the treatment.

Prevention: Prevention of endotoxin-related fevers requires effective cleaning and disinfection of dialysis equipment with particular attention to the water-treatment system. In general, the source of such endotoxins will be from contaminated water used for dialyzer reprocessing or for preparing dialysate. However, endotoxin exposure may occur from new dialyzers as well. Clusters of pyrogenic reactions should prompt a thorough review of the procedures for water disinfection and monitoring. Water used in the dialysis unit should have a bacterial content of less than 200 CFU/ml and be free of endotoxin as judged by the limulus amebocyte lysate test. Bicarbonate dialysate should be prepared fresh daily, and if it is prepared in quantity, the holding tank should be relatively small with constant recirculation. First-use syndromes The term first-use syndrome refers to two clinical conditions: an immediate hypersensitivity reaction and a symptom complex of nonspecific chest and back pain. The immediate hypersensitivity reaction is particularly noted with cuprophane membranes. Pathophysiology: In many cases an immediate hypersensitivity response may related to IgE-mediated reaction to ethylene oxide used in the sterilization of new dialyzers. Recently, similar reactions have been observed in patients taking angiotensin-converting enzyme (ACE) inhibitors. The symptoms include anxiety, dyspnea, uricaria, and pruitus that may manifest in a wide spectrum of severities, ranging from mild discomfort to true anaphylaxis. Immediate treatment: Immediate treatment involves stopping dialysis, clamping the dialysis lines, and discarding the blood and dialyzer. Symptoms are treated supportively with oxygen, antihistamines, bronchodilators, epinephrine, and steroids as required. Dialysis may be resumed with a new dialyzer, preferably of different membrane composition. Prevention: Prevention involves adequate dialyzer rinsing before commencing dialysis and, rarely, the use of dialyzers sterilized by other means. Pruritus

Pathophysiology: The pathophysiologic basis for uremic pruitus remains to be elucidated. Many dialysis patients have bothersome itching, some of whom experience an exacerbation during or soon after dialysis. Among the many reported etiologic factors is dryness of the skin, secondary hyperparathyroidism, abnormal skin levels of calcium, magnesium, and phosphorus, abnormalities in plasma histamine concentration, or mast cell proliferation. Immediate treatment: Treatment has remained largely empirical and includes general measures such as skin lotions and tepid baths as well as antihistamines, oral charcoal, ultraviolet phototherapy or cholestyramine. Prevention: Efforts should be made optimize serum calcium and phosphorous concentrations, maintain parathyroid hormone levels within normal limits, and ensure adequate quantities of dialysis. Cardiopulmonary arrest during dialysis Catastrophic cardiorespiratory collapse may occur rarely during a dialysis treatment. Decisions must be made quickly as to whether the collapse is due to an intrinsic disease alone or whether technical errors have occurred. Major technical problems include air embolism, unsafe dialysate composition, over-heated dialysate or line disconnection. Air in the dialysate lines, grossly translucent hemolyzed blood, and hemorrhage due to a line disconnection may be immediately apparent. If the arrest occurs immediately upon initiation of treatment and the cause is unknown, blood should not be returned to the patient. An anaphylactic reaction to the dialyzer membrane or infusion of formaldehyde from an inadequately rinsed reused dialyzer could present as a cardiorespiratory arrest during this initial period. The dialyzer should be checked as to its use number and composition. Formaldehyde infusion is associated with complaints of burning at the access site and, unless the patient had been unable to communicate, should be apparent.

If the event occurs intra-dialytically and there is no reason to suspect problems with dialysate composition, blood should be returned to the patient promptly. A sample of the dialysate should be sent for immediate electrolyte analysis along with the first patient blood samples. The dialyzer and blood lines should be saved for later analysis. The above assessment is performed simultaneously with removal of the patient from the dialysis chair and placement of the floor, where procedures for cardiopulmonary resuscitation are immediately implemental. Access lines should remain in place to provide a route for administration of saline and medications. After any cardiopulmonary arrest, the dialysis machine should be replaced until all its safety features have been thoroughly evaluated for possible malfunction.

Types of Dialysis Surgery & FAQ's Creating an Arteriovenous Fistula Arteriovenous fistula The best way to establish long-term hemodialysis access is to construct an arteriovenous (AV) fistula. An AV fistula is a surgically placed "shunt" whereby an artery is directly sutured to a vein. An artery is a high-pressure tube that carries blood away from the heart and delivers nutrients and oxygen to the tissues. A vein is a lowpressure system that returns blood back to the heart to begin the process all over again. When an artery and a vein are sewn together, the high-pressure blood does not reach the tissues but is diverted instead into the vein and back to the heart. Over time the vein will dilate, which is often called maturation. At maturation, nurses can easily access the vein with needles for dialysis therapy. AV Fistula Surgery A surgeon usually performs the procedure in the operating room. The patient receives a local anesthetic (numbing medicine) at the proposed site along with sedation. Surgeons can create an AV fistula in the wrist, forearm, inner elbow or upper arm. Discomfort is minimal and the patient may even fall asleep during the procedure, which can take from one to two hours. The surgical incision is usually only two to four inches long. Generally patients are able to return home later that same day. The fistula usually requires from eight to 12 weeks for the veins to dilate prior to initial use. When properly constructed, and with satisfactory maturation, an AV fistula can function for many years. What is an Arteriovenous Graft?

One kind of AV graft. An arteriovenous graft is another form of dialysis access, which can be used when people do not have satisfactory veins for an AV fistula. In this procedure, surgeons connect an artery and a large vein in the elbow or armpit using a graft made of synthetic fabric that is woven to create a watertight tube. Frequently used to repair blood vessels or perform blood vessel bypass when blockages occur in the legs or abdomen, this tube/graft also works very well to establish dialysis access.

AV Graft Surgery Creating an AV graft is a surgical procedure, which requires a small incision at the proposed site. The graft is sewn to an artery and tunneled, just under the skin, creating a loop back to the starting incision where it is then sewn to a vein. The long loop gives the dialysis nurses space to access the graft. AV grafts can be safely used in about two weeks, as no maturation of the vessels is required. Grafts have a lifespan of approximately two to three years but can often last longer. However, AV grafts can be more troublesome than AV fistulas. Blood is more likely to clot in grafts because they are made of prosthetic (foreign) material. When this happens, interventional procedures can remove the clot and restore blood flow for dialysis Dialysis Access Center Dialysis access Coordinator The Dialysis center was developed under the guidance of Dr Kirksey in a collaborative effort with talented nephrologists. Our goal is to provide prompt, state-of-the-art care to patients who need to have a dialysis access created or repaired before undergoing or continuing hemodialysis or peritoneal dialysis. There are several ways to establish dialysis access. The patients nephrologist (kidney doctor) and surgeon decide which type of access will provide the best long-term dialysis function for each individual. Transplant surgeons specialize in all types of dialysis access surgery, including: * placement of arteriovenous (AV) fistulae and grafts, types of vascular access for hemodialysis that involve connecting arteries to veins, sometimes with foreign (prosthetic) graft materia l * placement of tunneled central venous dialysis catheters (permanent catheters that are tunneled under the skin to enter the venous system for hemodialysis) * catheter placement (tunneling a long silicone tube into the abdomen) for peritoneal dialysis In addition to access services for patients new to dialysis, surgeons also are available for immediate repair for patients who experience urgent problems such as blood clots, infection or pseudoaneursyms (a bulge in a graft wall). Frequently Asked Questions About Dialysis Access What is dialysis access surgery?

Dialysis, either hemodialysis or peritoneal dialysis, is a life-saving procedure that replaces kidney function when the organs fail. In order to be treated with dialysis, physicians must establish a connection between the dialysis equipment and the patients bloodstream. Dialysis access surgery creates the vascular opening so a needle can be inserted for hemodialysis or an abdominal catheter inserted for peritoneal dialysis. There are several ways to establish dialysis access. The patients nephrologist (kidney doctor) and surgeon work with the patient to decide which type of access will provide the best long-term dialysis function for each individual. Who performs the dialysis access procedure? Establishing dialysis access is an invasive (surgical) procedure that can be performed by nephrologists, interventional radiologists and surgeons. A team effort helps ensure excellent patient service, care and long-term results. Our center is staffed with leading vascular surgeon, vascular interventional specialist and nephrologists in the community. The team also consists of nurse practitioners and social workers. All of these individuals meet regularly to ensure that patients receive the best that each specialty has to offer. What type of dialysis access procedure is necessary for hemodialysis? Hemodialysis circulates blood through a machine outside of the body to remove toxins and excess fluid and to correct electrolytes like potassium, sodium, phosphate and calcium, to name a few. The machine then pumps the cleansed blood back into the body. The blood leaves and returns to the body through a catheter, a long piece of silicone tubing placed in the neck, chest or leg. A catheter is used to establish quick vascular (bloodstream) access, when an individual needs to begin dialysis therapy immediately. Or bloodstream access can also be accomplished by placing two needles into a fistula or a graft that has been previously constructed for this purpose. How are catheters placed? Catheters come in two varieties, temporary and permanent. Temporary catheters penetrate the skin and directly enter the venous system. Permanent catheters also penetrate the skin, but are then tunneled under the skin for several inches before they finally enter the venous system. Tunneling the catheter reduces the risk of infection. Any medical professional can place a temporary catheter with minor discomfort, using a local anesthetic and minimal sedation. However a surgeon in the operating room, or an interventional radiologist in the interventional suite, must place permanent catheters. During the procedure, physicians use fluoroscopy (continuous X-rays) to be sure the catheter is positioned correctly. Permanent catheters require a minor procedure for removal whereas temporary catheters can simply be pulled out.

Are catheters safe for long-term use? Prolonged catheter access can lead to multiple complications, the most common of which is infection. Even with excellent placement technique, bacteria can enter the bloodstream directly through the catheter during dialysis. Bacteria from the skin can also move down the catheter and enter the bloodstream. With catheter infection people develop high fevers and chills and need prompt treatment. Generally physicians must remove the catheter so the body can fight the infection. Another possible complication from long-term catheter use is damage to the main chest vessels, which can lead to stenosis (narrowing) or thrombosis (clotting) of the veins. This type of damage is usually permanent and the vessel as well as the arm on the side of the vessel may no longer be useable for dialysis access. Because of these potential complications, physicians make every effort to avoid prolonged catheter use. What is an AV fistula? The best way to establish long-term hemodialysis access is to construct an arteriovenous (AV) fistula. An AV fistula is a surgically placed "shunt" whereby an artery is directly sutured to a vein. An artery is a high-pressure tube that carries blood away from the heart and delivers nutrients and oxygen to the tissues. A vein is a low-pressure system that returns blood back to the heart to begin the process all over again. When an artery and a vein are sewn together, the high-pressure blood does not reach the tissues but is diverted instead into the vein and back to the heart. Over time the vein will dilate, which is often called maturation. At maturation, nurses can easily access the vein with needles for dialysis therapy. Where are AV fistulas located and how long do they last? Surgeons can create an AV fistula in the wrist, forearm, inner elbow or upper arm. When properly constructed, and with satisfactory maturation, an AV fistula can function for many years. How is the AV fistula procedure performed? A surgeon usually performs the procedure in the operating room. The patient receives a local anesthetic (numbing medicine) at the proposed site along with sedation. Discomfort is minimal and the patient may even fall asleep during the procedure, which can take from one to two hours. The surgical incision is usually only two to four inches long. Generally patients are able to return home later that same day. The fistula usually requires from eight to 12 weeks for the veins to dilate prior to initial use. Despite excellent technique, some patients may suffer complications from the AV fistula procedure. Infection, bleeding, arm swelling and/or tingling in the fingers may occur postoperatively. An unusual, but serious, complication

can occur when the arterial blood that is supposed to reach the hand is redirected through the fistula. Sometimes the fistula functions so well that not enough blood reaches the hand causing ischemia (lack of oxygen). This condition is called "steal" and usually requires surgical intervention and establishing a new access at a different site. Can anyone have an AV fistula? Unfortunately not every patient is suitable for an AV fistula. Numerous needlesticks for IV fluids, blood work and/or medicines can damage veins over time, creating scar tissue, which can make creation of an AV fistula impossible. If the veins are damaged or too small, the AV fistula will not mature, or worse yet, clot. In this situation, the dialysis access team recommends other options that may include another fistula at a different site, catheter placement or an arteriovenous graft. What is an arteriovenous graft? An arteriovenous graft is another form of dialysis access, which can be used when people do not have satisfactory veins for an AV fistula. In this procedure, surgeons connect an artery and a large vein in the elbow or armpit using a graft made of synthetic fabric that is woven to create a watertight tube. Frequently used to repair blood vessels or perform blood vessel bypass when blockages occur in the legs or abdomen, this tube/graft also works very well to establish dialysis access. How is the AV graft created? Creating an AV graft is a surgical procedure, which requires a small incision at the proposed site. The graft is sewn to an artery and tunneled, just under the skin, creating a loop back to the starting incision where it is then sewn to a vein. The long loop gives the dialysis nurses space to access the graft. AV grafts can be safely used in about two weeks, as no maturation of the vessels is required. Grafts have a lifespan of approximately two to three years but can often last longer. However, AV grafts can be more troublesome than AV fistulas. Blood is more likely to clot in grafts because they are made of prosthetic (foreign) material. When this happens, interventional procedures can remove the clot and restore blood flow for dialysis. Complications related to AV grafts are similar to those with AV fistulas: bleeding, thrombosis (clotting), steal and because of the prosthetic nature of the graft, infection. Infected grafts must be removed immediately and a new access site developed once the infection clears. What type of dialysis access procedure is necessary for peritoneal dialysis? A Tenckhoff catheter, a long silicone-based tube, must be placed into the abdomen before peritoneal dialysis can begin. The surgeon in the operating room positions the tube using a local anesthetic and sedation. Making a small

incision in the abdomen, the surgeon advances the tube deep into the lower part of the peritoneal cavity, tunnels the tube under the skin for several inches, brings the tube up through the skin at a different location, and then surgically closes the initial incision. A sterile dressing covers the catheter that remains outside of the body. Tunneling the catheter reduces the likelihood of infection in the peritoneal cavity. Patients are allowed to go home the same day of surgery. Once the incisions heal, anywhere from two to four weeks, peritoneal dialysis can begin. What types of complications are possible from the Tenckhoff catheter? Complications related to catheter placement may include bleeding and damage to large or small intestines or abdominal blood vessels. Although usual, these issues could require additional corrective surgery. Once peritoneal dialysis begins, complications related to repeated use of the catheter include peritonitis, which is an infection of the peritoneal cavity. Peritonitis, which can be quite serious, is usually associated with abdominal pain, fevers and cloudy peritoneal dialysis solution. If the infection does not respond to antibiotic treatment, then it may be necessary to remove the catheter. When should dialysis access surgery take place? The best approach is to undergo dialysis access surgery well before dialysis therapy needs to begin, which will give the access site time to mature and avoid the use of temporary catheters. Sometimes patients need a temporary catheter while they are waiting for their permanent AV fistula or AV graft to heal. How does the dialysis access team evaluate individuals for long-term success? The team, which includes a vascular surgeon, vascular interventional specialists and nephrologist, perform an extensive physical exam to identify satisfactory vessels to construct the AV fistula or graft. The team may request additional studies such as ultrasounds or even dye studies of the blood vessels in the extremities. After the team decides on the appropriate type of access, then location is the next selection. Typically surgeons construct hemodialysis access in the forearm of the non-dominant hand. If this site is not suitable then the team may choose to use the forearm of the dominant hand or the upper arm of the non-dominant hand, above the elbow. What is Dialysis Access? When kidneys fail, kidney replacement therapyeither dialysis or renal transplantationmust begin. There are two forms of dialysis: hemodialysis and peritoneal dialysis .

Dialysis access is the surgical process of establishing a connection between the patients bloodstream and an artificial kidney (dialysis machine). Surgeons perform dialysis access surgery for patients who need dialysis replacement therapy because their kidneys have failed. With hemodialysis, nurses connect the patient to the dialysis machine via a needle and tubing, and blood is continuously passed through the machines artificial membrane to remove toxins and excess fluid. Hemodialysis requires four to five hours per treatment, and is generally performed three days each week. In peritoneal dialysis, patients put several gallons of a special fluid into their abdomen through a surgically placed tube. Toxins and extra fluid leak into the abdominal (peritoneal) cavity and are removed when the fluid is drained from the abdomen. Peritoneal dialysis requires several exchanges of fluid per day, but people may do this at home or at work. No matter which type of dialysis is chosen, dialysis access surgery is always necessary to establish a connection to the bloodstream or the abdominal cavity. Dialysis Access Surgery and Possible Complications: Access Surgery as Soon as Possible The best possible approach for people who must begin renal replacement therapy is to undergo dialysis access surgery well before dialysis therapy needs to begin, to give the access site time to mature and to avoid the use of temporary catheters. Sometimes patients need a temporary catheter while they are waiting for their permanent AV fistula or AV graft to heal. Access for Hemodialysis The physician team, which includes a nephrologist, interventional radiologist and surgeon, perform an extensive physical exam to identify satisfactory vessels to construct the AV fistula or graft. The team may request additional studies such as ultrasounds or even dye studies of the blood vessels in the extremities. After the team decides with the patient about the appropriate type of access, then location is the next selection. In the operating room, while the patient is sedated, surgeons typically construct hemodialysis access in the forearm of the non-dominant hand. If this site is not suitable then the team may choose to use the forearm of the dominant hand or the upper arm of the nondominant hand, above the elbow. Access for Peritoneal Dialysis A surgeon must place a Tenckhoff catheter, a long silicone-based tube, into the abdomen before peritoneal dialysis can begin. Tunneling the catheter reduces the likelihood of infection in the peritoneal cavity.

Access-Related Complications: Infection Prolonged catheter access can lead to multiple complications, the most common of which is infection. Even with excellent placement technique, bacteria can enter the bloodstream directly through the catheter during dialysis. Bacteria from the skin can also move down the catheter and enter the bloodstream. With catheter infection people develop high fevers and chills and need prompt treatment. Generally physicians must remove the catheter so the body can fight the infection. Stenosis and Thrombosis Another possible complication from long-term catheter use is damage to the main chest vessels, which can lead to stenosis (narrowing) or thrombosis (clotting) of the veins. This type of damage is usually permanent and the vessel as well as the arm on the side of the vesselmay no longer be useable for dialysis access. Because of these potential complications, physicians make every effort to avoid prolonged catheter use. AV Fistula Issues An AV fistula is a surgically placed "shunt" whereby an artery is directly sutured to a vein. Over time the vein will dilate, which allows easy access with needles for hemodialysis therapy. Blood flow through the surgically-created fistula is not as smooth as through normal blood vessels. This turbulence (not unlike water passing over stones and rocks) can be felt through the skin as a buzzing sensation, or "thrill," which also creates a noise, or "bruit," which physicians can hear with a stethoscope. If there is no thrill or buzz, it may mean the fistula is blocked or not working for other reasons and patients should seek immediate medical attention. Despite excellent technique, some patients may suffer post-operative complications from the AV fistula procedure: infection, bleeding, arm swelling and/or tingling in the fingers. In addition, an unusual, but serious, complication can occur when the arterial blood that is supposed to reach the hand is redirected through the fistula. Sometimes the fistula functions so well that not enough blood reaches the hand causing ischemia (lack of oxygen). This condition is called "steal" and usually requires surgical intervention and establishing a new access at a different site. Patients should always report any changes they notice in their fistula to the BIDMC dialysis access nurse coordinator who will alert the transplant surgeons and schedule immediate repair for serious complications. Tenckhoff Catheter Complications

Complications related to Tenckhoff catheter placement for peritoneal dialysis may include bleeding and damage to large or small intestines or abdominal blood vessels. Although usual, these issues could require additional corrective surgery. Once peritoneal dialysis begins, complications related to repeated use of the catheter include peritonitis, which is an infection of the peritoneal cavity. Peritonitis, which can be quite serious, is usually associated with abdominal pain, fevers and cloudy peritoneal dialysis solution. If the infection does not respond to antibiotic treatment, then it may be necessary to remove the catheter.