Vascular access for hemodialysis: 2004 and beyond.

PURPOSE OF REVIEW: Developments in vascular access are accruing rapidly. The last systematic Kidney Disease Outcomes Quality Initiative guidelines review took place in 2000. The purpose of this review is to update several major areas in which clear progress has been made. A major 'Fistula First Initiative' in the USA is an attempt to increase markedly the fraction of patients receiving an autologous arteriovenous fistula as opposed to a graft. Preoperative mapping to evaluate veins and artery may permit construction of arteriovenous fistula in up to 70% of all patients, thereby reducing access thrombosis, infection, and perhaps increasing survival of patients. RECENT
FINDINGS: Although a number of different synthetic materials have been tried, none seems to have any definite advantage over plain expanded polytetrafluoroethylene for constructing synthetic bridge grafts. Two developments may influence practice: use of composite self-sealing grafts that can be used within hours may eliminate the need for temporary catheters; and use of nitinol surgical clips may reduce endothelial trauma and improve patency. Large-bore catheters can deliver blood flows of over 400 ml/min initially, but they are prone to progressive occlusion. Optimal means of using a fibrinolytic to preserve flow must be evaluated. Surveillance techniques are undergoing rapid re-evaluation. Finally, a variety of antibiotic lock techniques are being evaluated for their ability to prevent catheter-related infections.
SUMMARY: Greater efforts must be made to establish pre-end-stage renal disease programs to educate and prepare patients for hemodialysis and improve arteriovenous fistula placement rates, and to encourage clinicians to re-examine their current clinical practices and dedicate themselves to improving vascular access outcomes.