In case of severe weakness or absence of kidney function, it is necessary to regularly perform dialysis using a dialysis fistula at a dialysis center, so that the metabolic products and harmful substances transported by the kidneys into the patient’s bloodstream can be removed from the blood.
Reasons for dialysis sessions
Several causes of kidney damage make it possible to connect an artificial dialysis machine, such as chronic renal failure (end-stage renal failure) in addition to long-term diabetes mellitus, chronic kidney disease, cystic kidney as well as medications, diseases of the immune system (glomerulonephritis), high blood pressure, or in rare cases, kidney tissue damage due to other causes.
Symptoms for dialysis patients
With chronic kidney failure, there is an increase in the amount of urine at first and then a decrease. Water retention, also known as edema, forms in the body, for example, in the legs and lungs. In the long term, hormone issues cause high blood pressure, lack of red blood cells (anemia), and osteoporosis. Since the toxins can no longer be adequately eliminated, further organ damage may occur. Yellow skin discoloration is often noticeable. In the advanced stage (stage IV, terminal kidney failure, uremic intoxication), there is nausea, vomiting, bad breath, and disorders of the brain, nerves, and other organs.
Diagnosing the need for hemodialysis
First, the patient is questioned and physically examined at the dialysis center. Blood, urine, and ultrasound examination of the kidneys will be done.
Differential diagnosis
End-stage renal failure requiring dialysis is usually clearly diagnosed through medical history and tests.
Treatment
Within the dialysis unit in hospitals, the dialysis machine is connected to the bloodstream, where blood is transported from the patient to the dialysis machine, where it reaches a semi-permeable membrane. This filters out toxins, metabolic waste, and excess fluid from the blood, which then flows back into the patient’s body in a purified state.
Dialysis sessions included other forms, such as peritoneal dialysis, which uses the peritoneum (the layer lining the abdominal cavity) as a membrane.
There must be access to a blood vessel to connect a dialysis machine. When dialysis is needed, a catheter is inserted into a large vein, for example, in the neck or the collarbone.
Surgery
Creating a dialysis fistula for the first time
Superficial veins that are punctured for hemodialysis become clogged with blood clots (thrombi) after a short while, and the blood flow becomes insufficient. Therefore, a connection is created from this vein to the nearby artery, and this is then referred to as an arteriovenous shunt or arteriovenous fistula.
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The operation to create a dialysis fistula can be performed under local or regional anesthesia (anesthesia of a larger area of the body). General anesthesia is also possible, but kidney patients do not typically require it for such procedures.
A new dialysis fistula is usually made on the forearm; however, the procedure can also be performed on veins in the upper arm, in the elbow, or on the leg. If the forearm is used, the end of the vein that runs from the thumb to the arm is sewn into the neighboring artery (Semeno shunt). It is preferable to use the left arm for right-handed people and the right arm for left-handed people to access the dialysis fistula.
If there is an artery in the desired area but no suitable vein, a vein can be removed from the patient’s own body, usually from the leg, and transplanted, or a plastic vascular prosthesis (graft) can be inserted. To ensure a larger vascular path for subsequent repeated punctures, the fistula can be placed in a zigzag path.
The condition of the new blood vessels after creating the dialysis fistula can be examined and evaluated by X-ray examination with the injection of a contrast agent.
Surgical interventions on a pre-existing dialysis fistula
A blood clot (thrombus) that has formed inside the dialysis fistula can block it and must be removed by surgery. For this purpose, the fistula is opened, and a catheter with a balloon mechanism that can be filled and inflated is inserted behind the clot. The thrombus and catheter can then be pulled into the open area and easily removed there. Here, too, an X-ray contrast agent scan can be performed for evaluation. After the clot has been successfully removed, the dialysis fistula is sutured, often with the insertion of a strip (graft) made of plastic or a vein taken from another part of the body, usually from the leg.
If there is not enough blood for dialysis in the dialysis fistula, the fistula connection can be moved to another area, for example, in the upper arm or in the bend of the elbow. If the fistula vessel is no longer in good condition or a bulge (aneurysm) forms, it can be replaced with a vein from your body or a plastic replica of a blood vessel (graft).
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If too much blood enters the shunt, the connection must be made tighter on the one hand to protect the heart, which has to do extra work, and on the other hand to ensure that the blood reaches the arm or leg.
Dialysis fistula removal
When kidney function is again ensured in affected people, for example, after a kidney transplant, or when another functioning shunt is applied, the vascular connection can be tied with a suture. The vein often remains open due to other flows and can be shunted again later if necessary.
Possible additional procedures for the process
If unexpected or more extensive results, pathological changes, or other complications are detected during the procedure, additional or different measures may be necessary. These include dilating narrowed blood vessels with balloon dilation, dissolving blood clots with specific active ingredients (dissolving), or inserting an endothelial stent (STENT).
Complications of dialysis fistula surgery
Minor discomfort and pain usually go away in a short time. Injuries to neighboring structures can occur. If the blood vessels are damaged or the thread is opened, bleeding, secondary bleeding, and hematomas (bruises) can occur. On the other hand, blood clots can accumulate in the shunt and can break off and block other blood vessels. Shunt bulging (aneurysm) may also occur. Nerve damage can lead to numbness and paralysis. There is a risk of developing infection, inflammation, wound healing disorders, and scarring. Infection in the shunt area can lead to life-threatening bacteremia (the infection spreads through the bloodstream). Another complication is allergies.
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Prognosis after dialysis shunt
The newly created shunt (arteriovenous fistula) becomes thicker over time, and the vessel wall generally becomes stronger. After several weeks, the first dialysis puncture can be performed through this shunt. The shunt often lasts for several years, sometimes 10 years or more. However, it may stop working at an early stage.
Despite medical advances, the life expectancy of patients on dialysis is lower than that of patients with healthy kidneys. The ten-year survival rate in dialysis patients is more than 50%. The prognosis depends on comorbidities and the age of the patient. Kidney transplantation may be considered.
People with end-stage kidney disease (kidney failure) need to remove waste products from the bloodstream by connecting a dialysis machine to the patient’s bloodstream (hospital dialysis) or a kidney transplant as a treatment for kidney disease to stay alive.
Before dialysis fistula surgery
If necessary, medications that inhibit blood clotting, such as Marcumar® or Aspirin®, should be discontinued in consultation with your doctor. Medications with the active ingredient metformin used in diabetes mellitus (diabetes) may also be omitted before contrast agent screening.
After dialysis fistula surgery
If the procedure for creating a dialysis fistula is performed on an outpatient basis, a chaperone must be present to pick up the patient, as the patient is not allowed to drive for 24 hours.
The position of the arm or leg with the dialysis fistula should initially be shifted high and not pressed. There are hardly any restrictions later on; only injuries should be avoided, as they can lead to more profuse bleeding.
Adequate skin hygiene must be observed in the area of the dialysis fistula. The fistula center should also be checked repeatedly by patients; for example, blood flow can be felt. If there are any abnormalities, the doctor should be contacted, or hospitalization may be required.
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