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• W2075212212 abstract "Fatal vascular access hemorrhage is considered a rare complication of hemodialysis (HD). Ellingson et al. indicate otherwise, and their data suggest that it causes 0.4–1.6% of deaths in US HD patients. It is more common with grafts than fistulas, and many victims have had previous access hemorrhages. The widespread presumption that a fistula is the best, and a cuffed catheter the worst, access for HD patients needs reassessment, particularly in older, sicker patients. Fatal vascular access hemorrhage is considered a rare complication of hemodialysis (HD). Ellingson et al. indicate otherwise, and their data suggest that it causes 0.4–1.6% of deaths in US HD patients. It is more common with grafts than fistulas, and many victims have had previous access hemorrhages. The widespread presumption that a fistula is the best, and a cuffed catheter the worst, access for HD patients needs reassessment, particularly in older, sicker patients. Most nephrologists with any experience of hemodialysis (HD) will have seen cases of severe vascular access hemorrhage requiring urgent surgical intervention, and some will recall fatalities. However, it is likely that most would consider this complication a rare cause of death, and, until now, there has been little in the literature to suggest otherwise. For this reason, the paper by Ellingson et al.1.Ellingson K.D. Palekar R.S. Lucero C.A. et al.Vascular access hemorrhages contribute to deaths among hemodialysis patients.Kidney Int. 2012; 82: 686-692Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar (this issue) is both surprising and important. The investigators from the Centers for Disease Control and Prevention became involved when a cluster of such deaths was noticed in Maryland, Virginia, and the District of Columbia. A regional investigation identified 88 fatal vascular access hemorrhage (FVAH) deaths over a 6–year period and noted that only a quarter of these cases had been identified on Centers for Medicare and Medicaid Services (CMS) death reports. Across the United States, a startling 1654 deaths were identified from CMS data in the same period, accounting for 0.4% of all HD deaths. However, if the same underestimation had occurred nationwide, the true number of HD deaths due to FVAH might be more than 6000, corresponding to at least 1000 annually or 1.6% of all HD deaths. The authors then investigated 88 cases in detail and made important observations. A large majority of the bleeds began in the patient's residence and not in the dialysis unit. More than half involved an arteriovenous graft. The mean age of the patients was only 64 years, and only a very small number of cases appear to have been episodes of ‘self-harm’. Compared with case controls, the victims were more likely to have had grafts and to be long-term HD patients, and, most importantly, they were three times more likely to have had an access-related complication within the previous 6 months, usually an infection or a previous bleed. In a subset of cases in which there had been a medical examiner review, 72% had evidence of access erosion, but no information is provided about the presence of aneurysms, which might have been of interest. What conclusions can be drawn from this important paper? First, FVAH is not a common problem, but we now know it is not rare, and hundreds of patients are dying from it annually in the United States. Second, patients at high risk for FVAH are those who have a graft or fistula that has been infected or has already hemorrhaged, and that may be showing evidence of erosion. Such a situation should now lead to a specific evaluation of the risk of FVAH, and the desirability of ligating the graft or fistula should at least be considered. Survival of the patient is more important than survival of the access. Also, although this complication is rare, HD patients and their families should be regularly educated by HD unit staff on how to deal with acute access hemorrhage. This leads us to consideration of the broader issue of vascular access in the contemporary HD population. The past decade has seen aggressive efforts to increase the use of fistulas and to reverse the growth in the use of cuffed catheters as a form of definitive access for HD patients.2.Vascular Access Work Group Clinical practice guidelines for vascular access.Am J Kidney Dis. 2006; 48: S248-S273PubMed Google Scholar,3.Fistula First National Vascular Access Improvements Initiative. <http://www.fistulafirst.org (accessed 5 March 2012)Google Scholar This strategy is based on a large volume of circumstantial evidence showing a consistent association between use of cuffed catheters and decreased survival on dialysis relative to what is seen with the use of fistulas.4.Xue J.L. Dahl D. Ebben J.P. et al.The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.Am J Kidney Dis. 2003; 42: 1013-1019Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar, 5.Bradbury B.D. Fissell R.B. Albert J.M. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).Clin J Am Soc Nephrol. 2007; 2: 89-99Crossref PubMed Scopus (376) Google Scholar, 6.Moist L.M. Trpeski L. Na Y. et al.Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001-2004.Clin J Am Soc Nephrol. 2008; 3: 1726-1732Crossref PubMed Scopus (116) Google Scholar The presumed major mechanism is increased infection rates, and, in particular, bacteremia and its complications, in patients with catheters. There may, however, be the beginning of a reaction to this approach with concern being expressed as to whether fistulas and grafts really are the best access for all patients.7.James M.T. Manns B.J. Hemmelgarn B.R. et al.What's next after Fistula First: is an arteriovenous graft or central venous catheter preferable when an arteriovenous access is not possible?.Semin Dial. 2009; 22: 539-544Crossref PubMed Scopus (9) Google Scholar,8.Amerling R. Ronco C. Kuhlmann M. et al.Arteriovenous fistula toxicity.Blood Purif. 2011; 31: 113-120Crossref PubMed Scopus (40) Google Scholar In this regard, there is some evidence that needs to be noted (Figure 1). First, failure rates with fistulas are alarmingly high in contemporary populations. In a US multicenter randomized controlled trial on the effect of clopidogrel, more than 60% of 877 fistulas were not adequate for dialysis.9.Dember L.M. Beck G.J. Allon M. et al.Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis.JAMA. 2008; 299: 2164-2171Crossref PubMed Scopus (613) Google Scholar In a recent Mayo Clinic study, there was a 37% primary failure and a subsequent 11% secondary failure rate, while 21% of patients had significant postoperative complications.10.Schinstock C.A. Albright R.C. Williams A.W. et al.Outcomes of arteriovenous fistula creation after the Fistula First Initiative.Clin J Am Soc Nephrol. 2011; 6: 1996-2002Crossref PubMed Scopus (147) Google Scholar Such failure rates would be unacceptable with most other types of surgery. Second, a sequence of failed fistula construction, repeat attempts that may or may not be successful, difficulty with needling, requirement for salvage procedures, and all the associated pain and inconvenience can be very difficult and unpleasant, especially for patients who may already have an impaired quality of life and multiple comorbidities. All this may not be justifiable in patients with a limited life expectancy. The alternative approach of using a synthetic graft has a higher success rate and facilitates earlier use but also has a higher and perhaps unacceptable requirement for subsequent interventions and probability of eventual failure.7.James M.T. Manns B.J. Hemmelgarn B.R. et al.What's next after Fistula First: is an arteriovenous graft or central venous catheter preferable when an arteriovenous access is not possible?.Semin Dial. 2009; 22: 539-544Crossref PubMed Scopus (9) Google Scholar Furthermore, both fistulas and grafts may also be associated with other problems, such as aggravation of cardiac failure; steal syndromes, including overt hand ischemia; pulmonary hypertension; and, as Ellingson et al. have now shown, FVAH (Figure 1).1.Ellingson K.D. Palekar R.S. Lucero C.A. et al.Vascular access hemorrhages contribute to deaths among hemodialysis patients.Kidney Int. 2012; 82: 686-692Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar,8.Amerling R. Ronco C. Kuhlmann M. et al.Arteriovenous fistula toxicity.Blood Purif. 2011; 31: 113-120Crossref PubMed Scopus (40) Google Scholar Of course, all these risks have to be accepted if those associated with catheter use are clearly greater. Two large US studies have reported that adjusted mortality rates for incident HD patients with catheter access are 1.70 and 1.49, respectively, relative to those with a fistula.4.Xue J.L. Dahl D. Ebben J.P. et al.The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.Am J Kidney Dis. 2003; 42: 1013-1019Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar,5.Bradbury B.D. Fissell R.B. Albert J.M. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).Clin J Am Soc Nephrol. 2007; 2: 89-99Crossref PubMed Scopus (376) Google Scholar Moist et al. report that incident catheter use in Canada is associated with a remarkable sixfold increase in the mortality rate compared with fistula use.6.Moist L.M. Trpeski L. Na Y. et al.Increased hemodialysis catheter use in Canada and associated mortality risk: data from the Canadian Organ Replacement Registry 2001-2004.Clin J Am Soc Nephrol. 2008; 3: 1726-1732Crossref PubMed Scopus (116) Google Scholar These are observational studies, however, and there is always the reservation that adjustment for baseline comorbidity and other characteristics cannot be complete. In an era in which most North American patients initiate HD via a cuffed catheter, the presence of a functioning fistula is surely a marker of a patient's exceptional health and adherence, and so all or even most of the superior outcome may not be related to the fistula itself. Also, catheter use is inevitably associated with acute illness and late presentation for dialysis, factors that are in turn associated with high mortality and that may be difficult to adjust for. In other words, the association of catheters and mortality may not be causal. Studies have not shown all the excess mortality with catheters to be infection-related, and, in any case, there is evidence that, with increased experience and better preventative strategies, catheter-associated bacteremia rates are falling impressively—to as low as one to two every 3 years in a recent trial.11.Solomon L.R. Cheesborough J.S. Ebah L. et al.A randomized controlled trial of tauroliodine-citrate catheter locks for the prevention of bacteremia in patients treated with hemodialysis.Am J Kidney Dis. 2010; 55: 1060-1068Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar Notwithstanding all this, a fistula appears to be the access of choice for younger and healthier HD patients. However, for the large number of older, sicker patients with risk factors for fistula failure and associated complications and with shorter life expectancy, the risk-to-benefit ratio changes and it may be reasonable to use a catheter as definitive access. Perhaps it is to time to discard the dogma that has long dominated this area and to propose a randomized controlled trial of fistulas versus cuffed catheters in the high-risk, older, frailer HD population, which is such a prominent feature of North American HD units. Such a trial would look at not only patient survival but also quality of life and degree of pain; access infections and other complications, including thrombosis and hemorrhage, cardiovascular consequences, and numbers of interventions required; and, not least, cost. The results might be surprising. It would be far from unprecedented for a dogmatic belief about how to care for dialysis patients to be contradicted by a randomized trial." @default.
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