Access-Related Hand Dysfunction After Hemodialysis Access Placement

Abstract

Introduction: Patients with chronic kidney disease (CKD) or end-stage kidney disease (ESKD) frequently experience access-related hand dysfunction (ARHD) following hemodialysis access placement, negatively impacting clinical outcomes and quality of life. Despite its prevalence, the mechanisms underlying ARHD remain poorly understood, and its impact on subsequent access maturation failure has not been well-characterized.

Methods: We conducted a longitudinal study of 39 patients with CKD or ESKD undergoing hemodialysis access surgery. Functional assessments, including grip strength, finger pressure, patient-reported hand or arm disability, dexterity, and sensory testing were performed preoperatively and 6 weeks postoperatively. Brachioradialis muscle biopsies were analyzed for morphological changes, mitochondrial function, and transcriptomic profiles. Dialysis access maturation failure was evaluated at 6-month follow-up.

Results: Six weeks after surgery, grip strength declined by 13.5 ± 19.4% (P = 0.0001), finger pressure decreased by 30.6 ± 38.0 mm Hg (P = 0.0008), and patient-reported limb disability scores worsened (P = 0.0213). Dexterity and sensation showed no changes. Histological analysis revealed an approximately 12% reduction in myofiber cross-sectional area (P = 0.0340), which is significantly correlated with grip strength (P = 0.0488). Mitochondrial content increased (P = 0.0683) and was inversely correlated with finger pressure (P = 0.0321), whereas mitochondrial respiration and antioxidant capacity remained unchanged. RNA sequencing revealed alterations in the genes regulating myofiber development. Notably, patients with ARHD had an approximately 20% higher incidence of unassisted maturation failure at 6 months (P = 0.0046).

Conclusion: In patients with CKD or ESKD, hemodialysis access surgery results in ARHD, which is associated with muscle atrophy, altered transcriptomic profiles, and higher incidence of access maturation failure. These findings underscore the need for early identification and targeted interventions to prevent ARHD and improve dialysis-access surgery outcomes.

Keywords: access failure; chronic kidney disease; end-stage kidney disease; hand dysfunction; hemodialysis access; muscle atrophy.

Graphical abstract

Figure 1

Schematic overview of the experimental procedure. BC-AVF, brachiocephalic arteriovenous fistula; RC-AVF, radiocephalic arteriovenous fistula; DASH, Disability of Arm, Shoulder and Hand.

Figure 2

Access-related hand dysfunction emerges as a distinctive manifestation in the early phase of postoperative surgery. (a) Grip strength comparison between nonaccess and access limbs at pre-op and 6 weeks post-op (left 2 panels) and comparison of raw values and percentage delta changes in grip strength for the access limb from pre-op to 6 weeks post-op (right 2 panels). (b) Finger pressure comparison between nonaccess and access limbs at pre-op and 6 weeks post-op (left 2 panels) and comparison of raw values and percentage delta changes in finger pressure for the access limb from pre-op to 6 weeks post-op (right 2 panels). (c) Comparison of calculated DASH scores (left panel) and percentage delta changes in total DASH scores (right panel) between pre-op and 6 weeks post-op. (d) Pegboard score comparison between nonaccess and access limbs at pre-op and 6 weeks post-op (left 2 panels) and comparison of raw values and percentage delta changes in pegboard scores for the access limb from pre-op to 6 weeks post-op (right 2 panels). (e) Comparison of monofilament scores for the first (left) and fifth (right) digits between pre-op and 6 weeks post-op. Data were analyzed using a paired t test, with the scatter dot plot representing both the mean values and individual data points (n = 23–39). DASH, Disability of Arm, Shoulder and Hand; pre-op; preoperation; post-op, postoperation.

Figure 3

Myofiber cross-sectional area is lower 6 weeks following hemodialysis access placement. (a) Representative immunofluorescence images of brachioradialis muscle biopsies, showing labeled fiber types, membrane structures, and capillaries. (b) Cross-sectional areas of total, type i, and type IIa myofibers at pre-op and 6 weeks post-op (n = 19). (c) Representative images of SDH activity. (d) Quantification of capillary density at pre-op and 6 weeks post-op (n = 21). (e) Quantification of SDH activity in muscle sections at pre-op and 6 weeks post-op (n = 20). Data were analyzed using a ratio paired t test, with the scatter dot plot representing both the mean values and individual data points. pre-op; preoperation; post-op, postoperation; SDH, succinate dehydrogenase.

Figure 4

Relationship between primary functional outcomes. (a) Pearson correlations between grip strength and variables, including DASH score, mean cross-sectional area of total and type IIa myofibers, and finger pressure; as well as postoperative delta values between grip strength and finger pressure (n = 22–77). (b) Pearson correlations between finger pressure and variables, including DASH score, citrate synthase activity, maximum JO₂, and capillary density; as well as postoperative delta values between finger pressure and DASH score (n = 21–49). Statistical analyses performed using 2-tailed Pearson correlation coefficient. DASH, Disability of Arm, Shoulder and Hand.

Figure 5

Patients with ARHD had greater access failure rates. Patients with ARHD, defined as a reduction in grip strength of > 10% from the preoperative value, exhibited significantly higher rates of unassisted maturation failure and a nonsignificant trend toward increased assisted maturation failure compared with patients without ARHD (n = 32). Statistical analysis performed using Chi-square test. ARHD, access-related hand dysfunction; post-op, postoperation.