Taking care of the dialysis fistulas for renal failure
patients
#dialysis #vascularsurgeonpune #fistula
Dr. Nupur
Sarkar
Vascular
and Endovascular surgeon
MBBS
(CMC Vellore), MS (Gen Surg – CMC Vellore)
MCh
(Vascular Surgery – MMC Chennai)
FIVS
(Fellowship in vascular and endovascular surgery, Austria)
Patients who have been diagnosed with chronic renal failure (CRF) are usually
started on renal replacement therapy (RRT) while evaluation towards a possible
renal transplantation (RTx) is started. However, in a developing country like
India, due to shortage of eligible voluntary donors / cadaver donors and
restricted financial resources, more often than not patients need to be on
chronic haemodialysis / peritoneal
dialysis.
A nephrologist is the best person to judge
which modality of dialysis is best suited for a particular patient keeping in
mind his/her age, comorbidities, reason for kidney failure and financial
condition. For many patients, haemodialysis is chosen as the most
cost-effective option. For haemodialysis, a ready “access” to the blood vessel is required which should be able to be
used for months and even years. Often patients have a long catheter inserted
into their neck or chest (dialysis catheters) which can be connected to the
dialysis machine. This is one of the easiest and fastest ways to start a
patient on dialysis. However, it may be uncomfortable for some patients and
also puts the patient at risk for infections. Moreover, prolonged use of these
catheters can cause some narrowing of the blood vessel which can make it
difficult later to create a successful “fistula”
in the upper limb on that side.
One of the most cost-effective options for
access for haemodialysis is “fistula”. The correct medical term for this is “Autogenous Arteriovenous Fistula”.
However in common language it is often referred to as “fistula” or “shunt” for
dialysis. Fistula establishes a connection
between vein and artery and is usually done in the forearm or at the level of
the wrist by a surgeon in an operation room usually under local anesthesia. This procedure can take about 45
minutes. Sutures can be removed after a
week. It does not create any problems with movements of the wrist but still the
non-dominant hand is given preference to avoid any inconvenience to the patient
while performing daily activities. Even children with renal failure with weight
as low as 15kg can be offered a “fistula” for dialysis. The fistula takes
atleast 6 weeks to “mature” – to
become ready for use for dialysis. It may take upto 2-3 months in children to
“mature”. Early cannulation or use for dialysis of these fistulas should be
avoided as it can cause problems and often the fistula then fails. Despite best
measures, a small percentage5- 10% of these fistulas never mature enough to be
used for successful dialysis and for these patients, a second surgery may be
required. In some patients with vasculitis / SLE causing renal failure, often
the fistulas fail multiple times. However, a well-created and functioning
fistula especially at the wrist level can be kept active and useful for as many
as 10 years or more, thus significantly decreasing costs and economic burden to
the patients. That is why these natural fistulas should be offered to each and
every patient with renal failure.
Sometimes, some patients do not have any
suitable veins for a successful fistula surgery or multiple attempts to create
a fistula have failed. These patients should be offered a synthetic “graft” or “shunt”.
This is placed surgically in the forearm, arm, thigh or chest wall. The
currently available grafts can be used for dialysis as early as 24-36 hours
after surgery. So it is also useful in
patients who need to start dialysis early and cannot wait for 6 weeks for a
natural fistula to mature. However, these “grafts” do have their limitations –
they often do not work longer than 6 months, they may require multiple
procedures to keep it functional, they are expensive and they are at risk of
infections. Therefore, they are not advised as first choice to patients. The
last option is “permanent tunneled
catheters” when all other options at fistulas/grafts have been exhausted.
These again have the limitations of failure and infection.
Precautions to be
followed by patients diagnosed with kidney disease or renal failure:
1. 1. Avoid use of the vein seen on
the thumb side of the hand till the elbow (the cephalic vein) for giving blood for investigations or for IV
cannula placement. Please inform the doctor/nurse that you have renal failure
and that this vein needs to be preserved for a future fistula surgery.
2. 2. If you need emergency dialysis,
request for a catheter to be placed on the right side of the neck or chest or
in the legs. Avoid the left side of the neck.
3. 3. Consult a specialist fistula
surgeon early for advice regarding timing of fistula surgery. Earlier the
better. In fact, medical literature has now proven that the best time to have
this surgery is 3-6 months in advance before weekly dialysis becomes necessary.
This requires careful co-ordination between the nephrologist, the fistula
specialist surgeon and the patient.
Surgical specialties who can do fistula surgery:
1. 1. Vascular surgeon –
Worldwide, it has been accepted that the best results of fistula surgery are
from vascular surgeons. They are the best qualified for any blood vessel
surgery and can often offer multiple options especially for patients with
failing/failed attempts at fistulas. However, in India, there are only around
250 qualified vascular surgeons. Therefore, often our colleagues from other
surgical specialties have to help out with the patient burden.
2. 2. Cardiothoracic surgeon with
special interest in fistula surgery
3. 3. Plastic surgeon with special
interest in fistula surgery
4. 4. Urosurgeon with special
interest in fistula surgery
5. 5. General surgeon with special
interest in fistula surgery
Precautions for patients after a fistula surgery:
1. 1. Avoid dehydration and sudden drop in blood pressure. Consult your
nephrologist / surgeon on how much fluids can be taken safely per day. Also
please adjust your medicines for blood pressure in consultation with your
doctor so that there is no sudden drop in blood pressure.
2. 2. Avoid pressure on the fistula site.
3. 3.While sleeping, do not place the fistula hand under your head or
pillow.
4. 4. Keep your fistula hand elevated over a pillow while sleeping.
5. 5. Buy a rubber ball and keep exercising your fistula hand.
6. 6. If you feel the sound “machinery
thrill” of the fistula has decreased or stopped, consult your surgeon
early. Most of the times, these fistulas can be saved if you come for treatment
early.
7. 7. Make sure that blood pressure and blood tests are not taken on the
fistula arm.
8. 8. Make sure that IV fluids or drips are not started on the fistula
arm.
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