Vascular Access Considerations in Home Hemodialysis

Abstract

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Figure 1

Vascular access options in HHD. Differing characteristics between access methods are described for (A) AVF, (B) AVG, and (C) CVC. AV, arteriovenous; AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC, central venous catheter; HHD, home hemodialysis.

Figure 2

Rope ladder and buttonhole cannulation in the AVF. Contrasting cannulation techniques are demonstrated in two separate patients using (A) rope ladder and (B) buttonhole. Photographs published with patient consent.