Management of high-flow arteriovenous access

Area of Science:

• Nephrology
• Cardiology
• Vascular Surgery

Background:

• Hemodialysis (HD) requires arteriovenous (AV) access, typically connecting an artery to a vein.
• Modern end-stage kidney disease (ESKD) patients are older, often necessitating upper arm AV access.
• Upper arm access is more prone to high-flow, potentially leading to cardiac complications in vulnerable elderly patients.

Purpose of the Study:

• To highlight the increased risk of high-output cardiac failure in elderly ESKD patients due to high-flow HD access.
• To emphasize the importance of evaluating and managing high-flow AV access in this population.
• To inform nephrologists about the clinical implications and management strategies for high-flow HD access.

Main Methods:

• Initial evaluation involves Doppler ultrasound to measure AV access flow volume.
• Flow volumes exceeding 2,000 mL/min warrant further assessment of cardiac output (CO) and recirculation.
• Management strategies include surgical or endovascular interventions to reduce access flow.

Main Results:

• High-flow HD access can lead to high-output cardiac failure, particularly in elderly ESKD patients.
• Many patients with high-flow access remain asymptomatic, underscoring the need for proactive monitoring.
• Interventions to reduce flow are available and effective in managing this complication.

Conclusions:

• Nephrologists must pay increased attention to identifying and managing high-flow HD access in elderly ESKD patients.
• Understanding the risks of high-flow access and its impact on cardiac status is critical.
• Patient education regarding the prognosis of high-flow access and cardiac failure is essential.