As a background to this podcast in 2021 there were 15 200 Australians with kidney failure receiving dialysis, a doubling of the number receiving dialysis from 2000 with a male-to-female ratio of approximately 2 to 1.
82% of these patients were receiving chronic haemodialysis all of whom required an arterio venous vascular shunt for access. A small proportion (18%) were being managed by peritoneal dialysis and in that year, there were 857 functioning kidney transplants. Of the haemodialysis patients 25% were being dialysed in hospital, 65 % in satellite centres and 9 % at home. Indigenous Australians representing 2.5 % of the population comprised 9% of patients commencing renal replacement therapy highlighting a very significant health burden for first nations people. The main indications for patients receiving dialysis included having severe renal failure with a GFR less than 15ml/min/1.75m2 accompanied by complications such as metabolic acidosis, hyperkalaemia, pericarditis, encephalopathy, intractable volume overload, anorexia with weight loss and lethargy, peripheral neuropathy, intractable gastrointestinal symptoms or having an e GFR of 5-9 ml/min or less despite being asymptomatic.
Vascular access for haemodialysis is accomplished by the creation of an arteriovenous fistula or use of a prosthetic graft with catheters providing temporary access only. As normal veins are not strong enough to cope with the high pump pressures and the rapid blood flow from a dialysis machine a native fistula joining vein to artery, normally in the forearm is created. As the fistula matures over 6 to 8 weeks the vein adapts and thickens leading to a stable fistula ready for use. Both immediate, early and late complications are described including infection, aneurysm, thrombosis and staphylococcal infection. Despite expert surgery up to 30% of fistulas are unusable. The Kidney Disease Outcome Quality Initiative (KDOGI) describes the Rule of 6 for fistulas comprising being: Ready for use 6 weeks or more after being formed, having a blood flow through the fistula of 600 ml/ min, a diameter of 6 mm accessible for 6 cm and at 6 mm depth.
To learn more about arteriovenous fistulas as well as the Do’s and Don’ts of fistula care in primary practice we welcome back Dr Ming Yii. Ming is a well-recognised expert in vascular surgery and is the director of vascular and transplant surgery at Monash Health and adjunct Senior lecturer with Monash University. Ming is also part of the Monash transplant team in kidney and pancreas transplantation and brings a wealth of knowledge and experience as well as an effusive personality to accompany his skills. In this episode he discusses his approach to fistula formation and for their ongoing management and care.
References:
Dr Ming Yii. mingyiivascular.com.au or admin@yiivascular surgery.com.au
Webster AC et al. Chronic Kidney Disease. Lancet .2017Mar 25;389 (10075):1238-52.
National Kidney Foundation: kidney.org