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Thread: port vs fistula

  1. #1
    Anonymous Guest

    Default port vs fistula

    :?: I'm new to dialysis. Everyone at the center (tech, doctor etc) keep saying to get a fistula. Right now I have a port. Since I've been in the center the people who have fistulas seem to have problems with bleeding after dialysis. I've be told this happens because of blood thinners, blood pressure etc. I'm looking to do home hemo, the last thing I would want is a bleeding problem. I've heard all the stories about the problems with ports, but it seems like fistulas are not problem free. What is the general consensus here?

    bob

  2. #2
    Join Date
    08-17-04
    Posts
    2,125

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    Hi Bob,

    Welcome to Home Dialysis Central. I'm glad to hear that you're considering home hemo--you can learn a lot on this site about why you might feel better, have a less rigid diet, more control over your schedule, a better quality of life--and perhaps even live longer with home dialysis.

    You asked:
    I've heard all the stories about the problems with ports, but it seems like fistulas are not problem free. What is the general consensus here?
    Rather than a general consensus, I'd prefer to share a study with you:

    Kidney Int. 2001 Oct;60(4):1443-51.
    Type of vascular access and mortality in U.S. hemodialysis patients.
    Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK.

    BACKGROUND: Vascular access (VA) complications account for 16 to 25% of hospital admissions. This study tested the hypothesis that the type of VA in use is correlated with overall mortality and cause-specific mortality. METHODS: Data were analyzed from the U.S. Renal Data System Dialysis Morbidity and Mortality Study Wave 1, a random sample of 5507 patients, prevalent on hemodialysis as of December 31, 1993. The relative mortality risk during a two-year observation was analyzed by Cox-regression methods with adjustments for demographic and comorbid conditions. Using similar methods, cause-specific analyses also were performed for death caused by infection and cardiac causes. RESULTS: In diabetic mellitus (DM) patients with end-stage renal disease, the associated relative mortality risk was higher for those with arteriovenous graft (AVG; RR = 1.41, P < 0.003) and central venous catheter (CVC; RR = 1.54, P < 0.002) as compared with arteriovenous fistula (AVF). In non-DM patients, those with CVC had a higher associated mortality (RR = 1.70, P < 0.001), as did to a lesser degree those with AVG (RR = 1.08, P = 0.35) when compared with AVF. Cause-specific analyses found higher infection-related deaths for CVC (RR = 2.30, P < 0.06) and AVG (RR = 2.47, P < 0.02) compared with AVF in DM; in non-DM, risk was higher also for CVC (RR = 1.83, P < 0.04) and AVG (RR = 1.27, P < 0.33). In contrast to our hypothesis that AV shunting increases cardiac risk, deaths caused by cardiac causes were higher in CVC than AVF for both DM (RR = 1.47, P < 0.05) and non-DM (RR = 1.34, P < 0.05) patients. CONCLUSION: This case-mix adjusted analysis suggests that CVC and AVG are correlated with increased mortality risk when compared with AVF, both overall and by major causes of death.

    ---------------------------

    Simply stated, in a large study, non-diabetic people who had catheters were more than 70% more likely to die than people with fistulas.

    Now, I would never try to tell you that fistulas are trouble-free. Folks here who have one will surely say otherwise. But catheters are so prone to causing infection (sepsis--life-threatening blood poisoning) that you truly are risking your life by having one any longer than you absolutely have to.

    The fistula is the gold standard for dialysis access because:
    -- It's entirely your own tissue, so it's less prone to inflammation and infection
    -- Natural blood vessels have a smooth lining that makes them less likely to clot (grafts and catheters are more likely to clot)
    -- Blood flows for dialysis are typically better
    -- Natural blood vessels self-heal after each needle stick
    -- A good fistula can last for decades (grafts probably shouldn't be used for more than 2-5 years--they become too hole-y; and catheters often need to be changed several times a year)

    Does this info help?

  3. #3
    Join Date
    03-06-05
    Location
    Ottawa, Canada
    Posts
    864

    Default

    Hang around dialysis centres a little longer. It won't take too long to see who the sicker people are: the ones without a fistula. They get frequent infections, clotting, etc. and the frequent hospitalizations that go along with that. They have to run their dialysis at a slower pump speed than fistula patients because their access can only provide so much blood flow. Slower pump speeds are fine for daily hemodialysis, but for conventional hemo 3 times per week, it seriously affects the adequacy of the dialysis. This is because conventional hemo is barely adequate as it is. The slower the pump, the less blood goes through the dialyzer each treatment, unless they lengthen the treatment (which they usually don't do, and which the patient doesn't want anyway). People on conventional hemodialysis without a fistula get the least adequate treatment among all dialysis patients.

    The bleeding you mention is not serious bleeding. It's just something that happens occasionally when the blood breaks through the initial scabbing and bandage after having held the needle site. Sometimes it's because the site hasn't been held long enough (some people take longer to coagulate than others), or, heparin needs to be stopped a few minutes earlier before the end of the treatment. All it takes to stop this bleeding is to put your finger on it, since it's just the tiny little needle hole. It usually happens when the person first stands to measure standing blood pressure or while walking to or from the scale. It has happened to me a few times - I think about 3 times during the 2-1/2 years I was at the dialysis centre.

    A fistula heals naturally, because it's just an enlarged vein covered by your own skin, and so it's least prone to infection. It's not absolutely trouble-free. The absolutely trouble-free access for dialysis hasn't been invented yet. But it is the best we have. Where I come from, every hemodialysis patient gets a fistula - even those who don't have adequate veins. In those cases, it's so advantageous to have a fistula that they give it a try anyway.

    Pierre

  4. #4
    Join Date
    06-16-05
    Location
    Saratoga, California
    Posts
    113

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    I strongly suspect that one of the unstated benefits of home dialysis is that it greatly reduces the risk of infection with central venous catheters. In fact, I believe a case can be made that CVCs may be preferable for nocturnal dialysis. At home the catheter is managed by one person carefully following exactly the same procedure every day with a strong vested personal interest in avoiding infection -- in stark contrast to the highly variable care received in centers and where all of the studies of access comparisons have been made. Properly secured using apparently little-known and seldom-followed techniques catheters avoid the problems often associated with needles while sleeping. My belief is also reinforced by 3-1/2 years of nocturnal dialysis experience with catheters.

    While it is not my intention to disuade anyone from attempting to establish an effective fistula I believe that home patients who fail to do so for one reason or another need not be frightened or discouraged of undertaking dialysis with a catheter.

    Mel

  5. #5
    Anonymous Guest

    Default Experience

    Mel, I don't have any medical education but our nocturnal program started out insisting everyone have a catheter for safety reasons. They have switched to the fistula first because of catheter infections. I was quite lucky in that dad's catheter was good for 5 years. However, it did get infected and we are switching to a fistula. I would prefer to use a catheter it does have advantages. No bleeding to stop. Easy connect. and yes I think they are safer but I think it's more important to reduce the chance of infection as much as one can. I do agree with you though no one should be afraid of using a catheter. I think if my options were graft or catheter, I'd take catheter.

  6. #6
    Join Date
    06-16-05
    Location
    Saratoga, California
    Posts
    113

    Default

    Marty, I agree that a catheter is preferable to a graft. I'd add a couple of other points. First, if bacteremia is suspected or diagnosed the catheter is often assumed to be the culprit and is automatically replaced. Don't let this happen -- insist on the "gold standard" test which is to draw simultaneous cultures from the catheter and the opposite arm. If the organism doesn't start growing from the catheter specimen 30 or more minutes before the arm specimen then it is highly likely the catheter is not the source of the infection. My wife had a couple of catheters unnecessarily replaced before I understood this -- it turned out the infection source was an old, failed graft! I've had to demand this test in two different hospital ERs and even had to do the catheter draws myself as there is never a dialysis nurse around when you need one. In neither case was the catheter the infection source. If you don't insist they'll automatically take it out, and you'll still have the infection.

    My second point is that catheter replacement -- whether through the old tunnel or not -- seems far less traumatic than fistula or graft placement or revision.

    Vancomycin-resistant bacteremia is a serious matter, but in my judgment it's not a reason to avoid catheters or yank them out at the first sign of infection. Proceed carefully and logically.

    Mel

  7. #7
    Anonymous Guest

    Default Another Concern

    Mel, I don't know if you have heard of this and how common or uncommon it is. When dad was in the hospital and the decision was made to remove the catheter, the surgeon told us that they had, had 2 patients where the catheter had actually attached itself to the heart. If the catheter didn't come out easy they were going to send dad to another hospital as they weren't capable of performing such a complex surgery. The nephrologist told me they were debating on pulling catheters every 2 years infected or not to try and prevent any attachment. The nephrologist has been in practice a long time and it wasn't until a couple of years ago that he had run into this problem and had no idea how common it was or if other nephrologist were thinking of pulling catheters for prevention. Has anyone every discussed this with you? I have printed your post and will carry it in my purse in case I am faced with the infection situation again. I am going to go the fistula route only because some do last for years. I am very skeptical because dad's first fistula had to have an angioplasty done and became infected and unuseable in less than 2 years.

  8. #8
    Anonymous Guest

    Default port vs fistula

    Hi
    Thanks for all the input. I know that there are problems, but life is full of problems. It up to each person to find out the best way for themselves to deal with or solve the problems. I'm looking into home hemo so I can set a time that's best for me, not for the center.

    [quote="Pierre"]Hang around dialysis centers a little longer. It won't take too long to see who the sicker people are: the ones without a fistula. They get frequent infections, clotting, etc. and the frequent hospitalizations that go along with that.

    As to being in the center, to me it seems that the getting sick or having problems might stem from the fact that people are right on top of one another, (no screens or curtains). The techs you get may take their job very seriously and do a great job or you may get a tech who is just there to get a paycheck. I've been around long enough in medical settings to know that some people look at it as a calling but most just look at it as a job. The reason I asked this to start with was the people in the center seem to be so negative. Telling you all the things that will go wrong. If I had taken all the negative things to heart I would have quit many many years ago. I've always lived my life upbeat, and I'm not going to stop.
    Thanks to all for all the info and suggestions!
    Bob

  9. #9
    Anonymous Guest

    Default

    Bob writes:
    As to being in the center, to me it seems that the getting sick or having problems might stem from the fact that people are right on top of one another, (no screens or curtains). The techs you get may take their job very seriously and do a great job or you may get a tech who is just there to get a paycheck. I've been around long enough in medical settings to know that some people look at it as a calling but most just look at it as a job. The reason I asked this to start with was the people in the center seem to be so negative. Telling you all the things that will go wrong. If I had taken all the negative things to heart I would have quit many many years ago. I've always lived my life upbeat, and I'm not going to stop.
    Couldn't agree with you more, Bob. It's very sad, but many units are run as by "Slumlords". I hold the companies and doctors responsible, because surely they know standards of hygeine and cleanliness are not met, but they turn a blind eye. I have often wondered how when my doctors make rounds in their impecable suits and see the dirty conditions we patients are chained to it does not prick their consciences. By dirty I mean, the cleaning serivice hits the floors and a little cleaning in the more obvious areas, but there has been no cleaning since the day the units open in every crack and crevice and medical equipment will have yrs. of built up dust and dirt hanging off of it. The filth is in-your-face obvious. Those who are charged with the responsiblity to ensure unit cleanliness ignore the regulations yr. after yr. as there is no one to enforce same ( I know, the state can be called in, but as soon as they are out the door, the infractions begin again).

    I often see things like my tech or nurse has not washed his hands from the previous patient, has gloves stuffed in their pockets, they then grab one out brushing it against their soiled uniform or turn on the light switch etc. And it's obvious to see that this is not just a staff problem. Because I have doctors and administrators that think they can touch patients accesses without washing their hands or putting on gloves. Do they think that because they are the highest on the totem pole that they do not carry germs and bacteria on their unwashed hands? Where is their leadership and example?

    You said it right, Bob, and I agree and must add that there is a blatant disregard for following unit protocol, state/fed. regulations and just plain common sense about safety and hygeine. So, God only knows how unsafe the unit envionment is.

    If there are units that abide by the rules and keep to hygienic standards, my hat goes off to them, but I have been in numerous units and have not encountered one yet. Add to that the negative approach to everything that Bob spoke of and unit care is a prescription for failure and a shortened life.

    It is sad to say, but exiting the unit into home txs. is essential if one wants to preserve his life. The blatant disregard for safety and optimal care in units is a problem that no one has solved yet. It has to start at the top.

  10. #10
    Anonymous Guest

    Default

    Hi all,

    II also am new to this. Monday I was in the hospital and had a fistula put in. waiting to staart dialysis. I feel pretty misirable right now having not started idalysis. MY Question: am I going to feel instantly better when I start dialysis in 30 days????

    Emery

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