TYPES AND CHOICE OF HOME HEMODIALYSIS VASCULAR ACCESS
Hemodialysis (HD) is the dialysis modality for approximately 63% of all prevalent end-stage kidney disease (ESKD) patients in the United States, with only 2% of all HD patients dialyzing at home as of December 31, 2016.1 The number of prevalent patients on home therapies (including 7% of patients utilizing peritoneal dialysis [PD]) is difficult to reconcile with the desired goal of 80% of incident patients starting with either home dialysis therapy or transplantation by year 2025 as proclaimed by the American Kidney Health Initiative executive order in July 2019.
HD remains the dialysis modality of choice around the world. It is well known that an arteriovenous fistula (AVF) or an arteriovenous graft (AVG) is superior to a tunneled dialysis catheter (TDC) in terms of outcomes. Despite various initiatives to improve AVF use, approximately 80% of incident patients start HD with a catheter in the United States and nearly 20% of the prevalent patients still use a TDC. Thus, all types of dialysis access, including AVF, AVG, and TDC, will need to be considered for home hemodialysis (HHD) in both incident and prevalent patients.
[For more information, see Chapter 14.]
Characteristics of Vascular Access for Home Hemodialysis
A vascular access that can be cannulated or accessed by the patient (or care partner) with consistency at home is the key to success in enabling the patient to “go home.” HHD also presents a unique challenge as, in most instances, the responsibility of the vascular access connection to the dialysis machine is placed upon the patient or a care partner, who is most frequently a family member. Moreover, an access may be used more frequently (four to six times a week compared to only thrice-weekly in in-center HD). Failure to have an easily accessible and stable vascular access is perhaps one of the most significant barriers to HHD initiation and maintenance and can lead to patient and care partner fatigue with subsequent technique failure. Therefore, it is crucial for a successful HHD program to establish an excellent vascular access management program for home.
Access Preparation for Home Hemodialysis
Due to the rather tumultuous and at times chaotic clinical, social, and psychological environment surrounding dialysis initiation, the process of access creation is often poorly organized or deferred. Vascular access management should start before renal replacement therapy (RRT) and a patient, starting on HHD should consider both an arteriovenous (AV) access and a TDC depending upon their ESKD life plan. Establishing a step-wise approach can ensure vessel mapping and scheduling for AV access creation in most cases, although a TDC can remain as a final access for a minority of select individuals. Similarly, in a more stable prevalent patient, it is optimal to proceed with AV access creation, although it should not delay the transition ...