The Optimal Conduit for Hemodialysis Access

  • Frank T. PadbergJr
  • Robert W. Zickler

Case Report

A 42-year-old type 1 diabetic of normal weight has recently progressed to chronic renal disease. Insulin-dependent diabetes mellitus (DM) has been managed by the same primary care physician for the preceding 12 years; glucose control has never been a problem in this cooperative and well-educated individual. The renal failure was initially managed with appropriate adjustments to diet and medications; the presumptive diagnosis is diabetic nephropathy. Recent laboratory tests demonstrate a creatinine of 4.1, a blood urea nitrogen of 94, a potassium of 4.8, mild proteinuria, and a creatinine clearance of 20 mL/min.

Question 1

At this juncture the physician’s most appropriate course of action is:
  1. A.

    Refer the individual to a surgeon for hemoaccess.

  2. B.

    Refer the individual to a nephrologist to refine diagnosis and initiate specialty care. It is not time to initiate dialysis.

  3. C.

    Refer the individual to a nephrologist who will refine diagnosis, and determine if there is a...


  1. 1.
    NKF-K/DOQI Clinical Practice Guidelines for vascular access: update 2000. Am J Kidney Dis. 2001;37:S137–81.Google Scholar
  2. 2.
    Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003;41:310–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Khan IH. Co-morbidity: the major challenge for survival and quality of life in end stage renal disease. Nephrol Dial Transplant. 1998;13:S176–9.Google Scholar
  4. 4.
    Powe NR. Early referral in chronic kidney disease: an enormous opportunity for prevention. Am J Kidney Dis. 2003;41:505–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int. 2002;61:305–16.CrossRefPubMedGoogle Scholar
  6. 6.
    Silva MB, Hobson RW, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg. 1998;27:302–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Sidawy AN. The Society for Vascular Surgery: clinical practice guidelines for surgical placement and maintenence of arteriovenous hemodialysis access. J Vasc Surg. 2008;48:S2–255.CrossRefGoogle Scholar
  8. 8.
    Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int. 1999;56:275–80.CrossRefPubMedGoogle Scholar
  9. 9.
    Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg. 1996;12:207–13.CrossRefPubMedGoogle Scholar
  10. 10.
    Hodges TC, Fillinger MF, Zwolek RM, Walsh DB, Bech F, Cronenwett JL. Longitudinal comparison of dialysis access methods: risk factors for failure. J Vasc Surg. 1997;26:1009–19.CrossRefPubMedGoogle Scholar
  11. 11.
    Kalman PG, Pope M, Bhola C, Richardson R, Sniderman KW. A practical approach to vascular access for hemodialysis and predictors of success. J Vasc Surg. 1999;30:727–33.CrossRefPubMedGoogle Scholar
  12. 12.
    Choi HM, Lal BK, Cerveira JJ, Padberg FT, Hobson RW, Pappas PJ. Durability and cumulative functional patency of transposed and non-transposed arterio-venous fistula. J Vasc Surg. 2003;38(6):1206–12.CrossRefPubMedGoogle Scholar
  13. 13.
    Cerveira JJ, Padberg FT, Pappas PJ, Lal BK. Prevention and management of complications from hemoaccess. In: Pearce W, Yao J, Matsumura J, editors. Trends in vascular surgery. Chicago, IL: Greenwood Academic; 2004.Google Scholar
  14. 14.
    Currier CBJ, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery. 1986;100:25–8.PubMedGoogle Scholar
  15. 15.
    Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jendrisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol. 1991;156:623–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg. 2003;38:1005–11.CrossRefPubMedGoogle Scholar
  17. 17.
    Silva M, Hobson RW, Simonian GT, Haser PB, Jamil Z, Padberg FT, et al. Successful autogenous hemodialysis access placement after prosthetic failure: the impact of non-invasive assessment. Toronto, CA: Poster presentation at SVS/AAVS; 2000.Google Scholar
  18. 18.
    Haser PB, Padberg FT Jr. Ch 33: Complex solutions for hemoaccess. In: Matsumura J, Pearce W, JST Y, editors. Trends in vascular surgery. Evanston, IL: Greenwood Academic; 2003.Google Scholar
  19. 19.
    Puskas JD, Gertler JP. Internal jugular to axillary vein bypass for subclavian vein thrombosis in the setting of brachial arteriovenous fistula. J Vasc Surg. 1994;19:939–42.CrossRefPubMedGoogle Scholar
  20. 20.
    Raju S. PTFE grafts for hemodialysis access. Techniques for insertion and management of complications. Ann Surg. 1987;206:666–73.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Ryan SV, Calligaro KD, Sharff J, Dougherty MJ. Management of infected prosthetic dialysis arteriovenous grafts. J Vasc Surg. 2004;39:7378.CrossRefGoogle Scholar
  22. 22.
    Padberg FT, Lee BC, Curl GR. Hemoaccess site infection. Surg Gynecol Obstet. 1992;174:103–8.PubMedGoogle Scholar
  23. 23.
    Lin PH, Johnson CK, Pullium JK, et al. Transluminal stent graft repair with Wallgraft endoprosthesis in a porcine arteriovenous graft pseudoaneurysm model. J Vasc Surg. 2003;37:175–81.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Vascular Surgery, Department of Surgery, New Jersey Medical SchoolUniversity of Medicine and Dentistry of New JerseyNewarkUSA

Personalised recommendations