[Access for starting kidney replacement therapy: vascular and peritoneal temporal access in pre-dialysis]

C R Rodríguez, E Bardón Otero, M L Vila Paz
Nefrología: Publicación Oficial de la Sociedad Española Nefrologia 2008, 28 Suppl 3: 105-12

UNLABELLED: PATIENT EVALUATION AND PREPARATION PRIOR TO VASCULAR ACCESS (VA) PLACEMENT: 1. Early referral of patients with advanced chronic kidney disease (ACKD: GFR <or= 30 ml/min: CKD stage 4) is necessary so that they are educated about the different modalities of kidney replacement therapy (KRT) and there is sufficient time to perform a permanent functioning VA before the initiation of HD (Strength of Recommendation C). 2. Preservation of the venous network of the upper extremities (UE): - Venipuntures and catheterizations in the UE should be avoided to reduce the incidence of venous occlusions and stenosis (Strength of Recommendation B). - If venipuncture or catheterization of veins of the UE is necessary, the dorsum of the hand should be the site of choice used and puncture sites should be rotated (Strength of Recommendation C). 3. Preoperative evaluation: Patient evaluation prior to VA placement should include: - A patient history and physical examination directed to evaluation of the existence and quality of the arterial and venous vessels of the UE (Strength of Recommendation B). - When necessary, a complementary examination by Doppler ultrasound (Strength of Recommendation B) or phlebography may be performed. Recommended when there is a history or central venous catheters (CVC) or pacemakers. 4. Timing of VA placement: - A vascular access should be placed starting from a GFR < 20 ml/min (Strength of Recommendation B). - The VA should be placed at least 6 months before the start of HD in the case of native AV fistulae and 3-6 weeks before in the case of synthetic VA (Strength of Recommendation B). SELECTION OF TYPE OF PERMANENT VA AND ITS LOCATION: 1. Type of VA: - A native AV fistula is the VA of choice. When a native AV fistula cannot be established, a synthetic AV graft is the second option (Strength of Recommendation A). - A CVC is the last choice after the previous two options. 2. LOCATION of the VA: In general, the order of preference for the type and location of the VA is: - A wrist (radial-cephalic) primary AV fistula (Strength of Recommendation A). - An elbow (brachial-cephalic) primary AV fistula (Strength of Recommendation B). - A transposed brachial basilic vein fistula (Strength of Recommendation B). - Synthetic or biological grafts; in order of preference, antecubital straight or looped graft, in the arm, and lastly in the chest wall or lower extremity once all options in upper extremities have been discarded (Strength of Recommendation B). CARE OF VA IN PREDIALYSIS: 1. Maturation: - A native AV fistula should not be used in the first month and 6-8 weeks (minimum 4) should be waited before use (Strength of Recommendation C). - A synthetic AV fistula should not be used for puncture for at least 2 weeks after placement and up to 4 weeks may be desirable (Strength of Recommendation C). 2. Prevention of thrombosis: Antiaggregation/Anticoagulation: 1. Systematic use of platelet antiaggregants or anticoagulants in VA to prevent thrombosis or increase their survival has not been established by the evidence and also is associated with a greater risk of bleeding. Their use can be considered in certain situations after careful assessment of the risk-benefit balance (Strength of Recommendation C). CENTRAL VENOUS CATHETERS (CVC): 1.

INDICATIONS: They should not be the first option for a permanent VA and should be considered for temporary use only whenever possible. Their main indications are: - Need for urgent HD in patients without permanent VA, patients with a maturing VA or that cannot be cannulated (Strength of Recommendation A). - Inability or difficulty to establish an adequate VA due to either a poor arterial bed or lack of venous development (Strength of Recommendation B). - Hemodialysis for short periods while waiting for a living donor kidney transplant (Strength of Recommendation C). - Patients with special circumstances: very severe comorbidities that imply a life expectancy of less than 1 year, cardiovascular status contraindicating placement of VA, PD patients temporarily on HD, etc. (Strength of Recommendation C). 2. Types of CVC: Selection of the type of catheter should be based on local experience, the patient's individual circumstances and the requirements for its use. - Nontunneled CVC should be reserved for stays < 3 weeks due to their higher rate of complications (Strength of Recommendation B). - Intravascular lengths of 15 cm are recommended in the right jugular vein, 20 cm in the left jugular vein, and 20-25 cm in the femoral veins (Strength of Recommendation B). 3.

LOCATION: - The first choice is the right internal jugular vein, followed by the left internal jugular vein, the external jugular vein and the femoral veins. The subclavian veins should only be used exceptionally (Strength of Recommendation A). - Placement of a CVC ipsilateral to a maturing AV fistula should be avoided (Strength of Recommendation B). The use of femoral catheters should be limited to hospitalized (bedridden) patients (Strength of Recommendation B) because they are associated with higher infection and dislodgement rates. - The tip of the CVC should be placed at the entry of the right atrium for nontunneled catheters and within the right atrium for tunneled catheters (Strength of Recommendation B). Placement of CVC in the jugular and subclavian vein should be confirmed radiologically (Strength of Recommendation A). TYPES OF CATHETER AND IMPLANTATION TECHNIQUES: - The implantation team (nephrologist, surgeon, nurse) is more important for results than the technique of implantation used (Strength of Recommendation A). - No catheter has been demonstrated to be superior to others (Strength of Recommendation A). - Surgical, laparoscopic or percutaneous technique show similar results (Strength of Recommendation A). TIMING OF CATHETER IMPLANTATION: - Between catheter insertion and the start of peritoneal dialysis (PD) at least two weeks should be allowed to avoid early leaks (Strength of Recommendation C). - Antibiotic prophylaxis should be performed prior to the implantation procedure (preferably a 1st generation cephalosporin) (Strength of Recommendation A). EARLY COMPLICATIONS AND THEIR TREATMENT: - Prevention of exit site infections: It is mandatory to identify Staphylococcus aureus nasal carriers and treat them with mupirocin ointment either intranasal or pericatheter, or gentamycin pericatheter, to reduce the incidence of infections by this germ (Strength of Recommendation A). - Treatment of exit site infections: Treatment should conform to the PD guidelines published by the SEN. Withdrawal of the catheter due to exit site infection should be considered when there is concurrent peritonitis by the same germ (except coagulase-negative staphylococcus) or treatment-refractory or recurrent infections by the same germ (Strength of Recommendation C). - Mechanical complications: If leakage of peritoneal fluid occurs and dialysis is necessary, the patient should be temporarily transferred to HD or started on automatic peritoneal dialysis (APD) with low volumes and in a decubitus position.

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