PRESENTED BY
SANDIP MITRA

Presentation Summary

Written by Jasna Trbojevic-Stankovic
Reviewed by Sandip Mitra

Home haemodialysis (HHD) has been available as a modality of renal replacement therapy, since the beginning of the era of maintenance haemodialysis, for nearly six decades. The interest in this type of treatment has increased in the past few years because of its proven psychosocial benefits and notable flexibility, offering patients more freedom to pursue their work and lifestyle schedule in the convenience of their homes alongwith improved outcomes and quality of life. There has been a remarkable resurgence in the past decade in a number of countries, specifically in the interest in more frequent or intensive home hemodialysis.
An adequate vascular access (VA) is the cornerstone of efficient HHD. Since HHD patient is not under regular weekly supervision of healthcare staff, VA use and care in HHD is predominantly self-managed, its maintenance remains a key responsibility for the patients themselves. The several steps in VA care in HHD include a) VA choice and its placement, b) patient training for self-cannulation and connection, c) ongoing monitoring and support and d) managing complications. These steps are discussed with reference to practice in a large established HHD program in Manchester, UK.

Vascular access choice and its creation
Experiences from a large single center which has trained 453 patients to date to perform HHD show higher prevalence of arterio-venous fistulas (AVF) as compared to the intermittent hemodialysis (IHD) program [1]. The prevalence of central venous catheters (CVC) range between 10% and 15% during the five-years follow-up period, which is in the midrange compared to the wider international practice data from other countries. (Figure 1)

Figure 1. The prevalence of certain vascular access types during a 5-years follow-up period in the Manchester Home Haemodialysis program [1]

 

The technique of placement of AV fistula or graft should take into account factors to enable self-cannulation such handedness, accessible location in the arm and patient preferences. Ease of access to the VA, choice of the dominant arm for AVF placement and full maturation are key to successful self use. In order to achive this often 2 stage procedures for superficialisation, refashioning and accessory vein ligation may need to be performed to enhance maturation and facilitate self-cannulation. These are some of the dominant access-related issues to consider for HHD patients in the creation phase. Many patients would prefer to avoid self-needling via use of a catheter, but where possible, all patients should be encouraged to consider definite access options for long term HHD. The five-year survival rate in HHD is higher for patients with AVF (95%) than for patients with CVC (78%), notwithstanding the good overall access survival rates in such patients [1].

Patient training and re-training for VA use
Successful patient training for self-cannulation remain the ultimate goal for success in HHD. Experience from a single center shows that total training time correlates with age, but not with access type [1]. Several useful tools, when choosing the best cannulation technique, have been suggested in a recently published study by Faratro et al. [5]. The step-by-step cannulation training approach with an ongoing support has so far provided the best results in the Manchester HHD program [1]. The process of access education and self-cannulation training can be time dependent and variable with a median AVF age at the start of self-cannulation as 5.5 months since full maturation [1]. The most often used cannulation technique is sharp, and about one third of the patients use the buttonhole approach [1]. From the patients’ experience, self-cannulation is an important aspect of gaining control over their treatment, building self-confidence and eventually the norm in HHD. Identification and understanding the barriers encountered by the patient would allow better cooperation between the patient and medical team in order to achieve independence with self-cannulation [6]. Where the final step of self cannulation is not achieved, patients can be considered for self care HD in a limited care centre with access to cannulation support. Several strategies have been described to overcome the possible barriers to fear of self cannulation, such as using the hierarchical approach, exercising patience, using dull needles, peer modeling, measuring anxiety and applying relaxation techniques and topical analgesics [7]. The ongoing debate on the relative merits of buttonhole versus rope ladder cannulation technique still remains a subject of debate. The buttonhole cannulation technique has been associated with higher rates of infection, increased staff support requirements and no reduction in surgical AVF intervention compared to rope ladder in HHD patients, even though many patients personally prefer the former technique for comfort and less pain [7, 8]. Some centers have defined technical criteria for choice of these cannulation techniques in order maximise its advantages but avoid complications, including the risk of infection (Figure 2).

Figure 2. Indications for and against buttonhole cannulation technique [1, 8]

 

AVF interventions and complications
The rate of interventions for HHD AVF seems to be higher than for in-center AVFs. This has been also noted amongst in-centre short daily dialysis patients in the FHN study. However, prospectively collected longitudinal data from the Manchester program demonstrate that even though there is a higher incidence of AVF access interventions, when indexed per patient this incidence is lower than for in-center HD, suggesting that particular patients with difficult and complicated accesses may skew the results [1].

Access-related infection is an important adverse event which jeopardizes access and patient survival. The main reason for lower survival rate of patients with CVC is perhaps the infectious complications, thus designating CVCs as clinically less favorable VA, even though they may be preferred by HHD patients to avoid self-cannulation [2, 3]. Patients on nocturnal HHD specifically have a shorter duration to first CVC infection, technique failure, than those with AVFs [4]. Several preventive measures have been suggested in the literature, but there is still a lack of prospective studies to validate their efficiency. Furthermore, there is an ongoing challenge of adherence to the best practice in access care during HD at home. A recently published study emphasized the association between the errors in VA self-cannulation or manipulation technique and higher risk of infection [9]. These results indicate the need for a structured program of surveillance and re-training of VA use in order to prevent deviation from best practice and care, and thereby reduce complications and prolong patency.

In conclusion, despite the limitations in the current data, HHD patients demonstrate better clinical outcomes compared to in-center HD patients [10]. An adequate vascular access contributes to improved outcomes in HHD. However, future work is needed to address ease of cannulation, reduction of VA related infection and hospitalization rates, and reduce treatment burden in self-managed VA. Improved outcomes and survival of VA in the home use setting can help drive and sustain a growth in prevalence of HHD.

References

1. Mitra S. Vascular access in HHD: the Achilles tendon? Presented at the 56th European Renal Association – European Dialysis and Transplantation Association congress, Budapest, Hungary, 2019. Available on Virtual Meeting

2. Perl J, Nessim SJ, Moist LM, et al. Vascular Access Type and Patient and Technique Survival in Home Hemodialysis Patients: The Canadian Organ Replacement Register. Am J Kidney Dis. 2016;67(2):251-9. doi: 10.1053/j.ajkd.2015.07.032.

3. Poon CK, Chan CT. Home hemodialysis associated infection-The “Achilles’ Heel” of intensive hemodialysis. Hemodial Int. 2017;21(2):155-160. doi: 10.1111/hdi.12508.

4. Hayes WN, Tennankore K, Battistella M, Chan CT. Vascular access-related infection in nocturnal home hemodialysis. Hemodial Int. 2014;18(2):481-7. doi: 10.1111/hdi.12140.

5. Faratro R, Jeffries J, Nesrallah GE, MacRae JM. The care and keeping of vascular access for home hemodialysis patients. Hemodial Int. 2015;19 Suppl 1:S80-92. doi: 10.1111/hdi.12242.

6. Ward FL, Faratro R, McQuillan RF. Self-cannulation of the vascular access in home hemodialysis: Overcoming patient-level barriers. Semin Dial. 2018;31(5):449-454. doi: 10.1111/sdi.12708.

7. Muir CA, Kotwal SS, Hawley CM, et al. Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review. Clin J Am Soc Nephrol. 2014;9(1):110-9. doi: 10.2215/CJN.03930413.

8. Faratro R, Jeffries J, Nesrallah GE, MacRae JM. The care and keeping of vascular access for home hemodialysis patients. Hemodial Int. 2015;19 Suppl 1:S80-92. doi: 10.1111/hdi.12242.

9. Rousseau-Gagnon M, Faratro R, D’Gama C, Fung S, Wong E, Chan CT. The use of vascular access audit and infections in home hemodialysis.
Hemodial Int. 2016;20(2):298-305. doi: 10.1111/hdi.12372

10. Miller BW, Himmele R, Sawin DA, Kim J, Kossmann RJ. Choosing Home Hemodialysis: A Critical Review of Patient Outcomes. Blood Purif. 2018;45(1-3):224-229. doi: 10.1159/000485159.

NDT-E Summary Articles