All those comments were so helpful to us about the buttonhole, pressures and scabs. I use an aksys machine 6 days a week. I am very clear that pressures respond to position of my arm. Sometimes if I fall alseep I fold in on myself and that can be problemmatic. When we were putting in the buttonhole, very consistent pressures running on 400, but with use of the buttonhole I have seen the change. This is only my third week. Even with twisting the needle on the venous, we find that we have to follow the blunt with another stik with sharp needle. Arterial is generally better only one stick with blunt needle. tonite I am going to use peroxide on the scab. It takes soooooo long otherwise and as someone ele said, eyesight and light make this challenging. Also I think I am kind of chicken to be so agressive with pulling the scab. I also use the 20 gauge needle to do it but itās like the proverbial rich man throguh the gates of heaven.
The arterial and venous pressures definitely increase or decrease with arm movement. The trick is to get things set-up so that they donāt increase or decrease outside of the alarm range with normal movement - like bending your arm, for example. Itās not too bad if youāre doing short daily, but if youāre doing nocturnal, you donāt want to have to reset the machine all the time.
A lot depends on the individual fistula, and also on the placement of the needles when youāre taping them. If you still get a lot of alarms, sometimes all it takes is to stuff another folded over 2x2 under the needle.
Sometimes, you might have to lower the blood pump speed a little to eliminate alarms. This is no problem at all for the long nocturnal treatments. For 2 hour short daily tx, you donāt want to go too slow or else you wonāt get enough treatment.
Pierre
Hi
Let me first say thanks once more to this board. Iāve been going over past posts. This one gets to my point of port vs fistulas. It seems to me that at this time there is no 100% right way. After reading posts and looking up things on other sites. And talking with others in center(not staff). The medical world has made the choice to use fistulas for the near future and everyone follows the leader. I talked with my doctor on 2/14/06 and once more we around and around on the subect. I got no where , he just went back to a office and downloaded the mantra. Which i see here very often. Iām 49 yrs old, back when I born my folks were told ājust put him in a homeā that was the medical world thinking back then. Iām so thankful to my folks for taken me home and teaching me how to live. Iāve go on to live a good life, and am looking to more of a good life, worked full time up to 98 , great wife, nice house. Can someone tell when this āgold standardā came to be ? I have not found the real time and date for āgold standardā
bobeleanor 
Hi yāall,
BobEleanor wrote:
Can someone tell when this āgold standardā came to be ? I have not found the real time and date for āgold standardā
Okay, letās take a step back in time. Dialysis was first done in the 1940s for acute kidney failure only. Why? Because for each treatment, a cut-down had to be done to find an artery to take blood out of and a vein to return it to. After the treatment, both vessels would have to be tied off and could not be used again. Needless to say, with a limited number of arteries and veins in the body, this couldnāt be done for long.
Fast forward to 1959. Dr. Belding Scribner came up with a way to reuse the same artery and vein for chronic dialysis. Called a shunt, it was a plastic tube that connected the two vessels together outside the skin of the wrist. It could be pulled out accidentally (not good). The tube wasnāt as smooth inside as real blood vessels, so blood cells would stick to it and clots would form. Since it was a portal into the skin, infections were frequent.
In 1966, Drs. Brescia, Cimino, Hurwich, and Appel figured out a way to surgically connect an artery and a vein under the skin. The fistula became the gold standard at that point, and remains so today. Why?
ā It uses your own artery and vein, so there is no inflammation caused by having artificial substances in your body.
ā The lining of your own blood vessels is smooth, so clotting is much less likely.
ā The fistula is completely under the skin, so infection is much more rare.
ā The walls of the fistula are muscular and can contract after a needle is pulled out, so they self-heal after each puncture.
ā A fistula can last for decades.
Now, letās look at a catheter:
ā Hmmm. Itās plasticāartificial material. This means it will cause inflammation.
ā It goes outside of the body. This means it is very prone to infection (sepsis, blood poisoningāone of the leading causes of death in people on dialysis).
ā Itās not as smooth as your own blood vesselsāthis means itās likely to clot.
ā Its blood flow rates are not very high, so you donāt get a very good dialysis treatment.
ā Plus, you canāt get it wet (this makes swimming impossible and bathing difficult).
ā It can be uncomfortable.
In another recent thread, I posted an article that proved, among more than 5,500 patients, that people who have catheters are more likely to die. http://www.homedialysis.org/boards/viewtopic.php?p=5128&highlight=fistula#5128
Many folks on dialysis will need a catheter at some point. But using one long-term if a fistula is possible for you is not a good choice.
hi
I know about that post to, I looked up more information on that study. It was done I think in the 90ās in centers. Has a study been done yet on home hemo with ports vs fistula? Was the study done on just people who had no other problems? I think the study you noted had people who other ills. Heart problems and diabetes plus age over 60.
Bobeleanor
Has a study been done yet on home hemo with ports vs fistula?
There are only an estimated 1,500 patients in the U.S. doing home hemo. The numbers are too small to do this type of comparison. Plus, there is no reason to believe that the outcomes related to access would be any different in the home than they are in-center. Medicare did not differentiate for Fistula First between home and in-center patients.
I think the study you noted had people who other ills. Heart problems and diabetes plus age over 60.
This pretty much describes the dialysis populationāall of itāwhether patients are home or in-center. The diseases that cause 70% of all kidney failure (diabetes, high blood pressure) also cause vascular damage and heart damage. Regardless of which treatment is chosen, catheters still have the same problems.
In Lynchburg, VA (the first nocturnal home hemo program in the U.S.), my understanding is that they use a catheter with a valve that can help prevent some of the infections that would otherwise be likely. But this doesnāt get around the other problems that catheters have.
Hi
Thank You Ms Schatell. I was just on another web page where I saw that national avg. for fistula was 35 % as of 2004. As for the study Iām not over 60 I donāt have heart problems and diabetes. As for the home hemo folks will they follow their rates over next 10 years?
Once more thank you for the board and answers.
bobeleanor
Hi Bobeleanor,
You wrote:
As for the study Iām not over 60 I donāt have heart problems and diabetes.
Good! Then you should be able to look forward to a long and active life. 
But I still wouldnāt recommend a catheter if you can have a fistula. Itās just too risky.
As for the home hemo folks will they follow their rates over next 10 years?
I would sure think so. The lowest year for home hemo was 2002, with just 1,149 patients in the U.S. using it. But the rate has been rising since then, and there are waiting lists at a number of the home hemo programs. As the numbers grow, it will be easier to do comparative analyses. Also, there are registries in various countries (we link to them under Links) that track data, including one in the U.S. and Canada of āquotidianā (short daily & long nocturnal) therapies.
I donāt need any studies or statistics. Iāve been in dialysis and have known other dialysis patients long enough to have observed the difference between those with native fistula, those with grafts and those with catheters. The catheter people are by far on the bottom of that totem pole.
Fistulas arenāt perfect, but they are much closer to perfection than any other access.
Pierre
dori writes:
there are registries in various countries (we link to them under Links) that track data, including one in the U.S. and Canada of āquotidianā (short daily & long nocturnal) therapies.
Has any info been tracked to this point?
When learning to do conventional sticking can someone explain how you prepare the tape and gauze and apply it with your free hand? Also, how do you pull the needles?
I pull two pieces of paper tape and fold over the ends and tear 1/4 strip for the cross over piece and leave them stuck to the table. I insert my arterial, holding the end of the tubing in my fistula hand. When it is in it stays put long enough to put on the first piece of tape. Once that is done the rest of the taping is easy.
When getting off I remove all tapes, pull it out slightly, with my free hand I hold a guaze folding in half twice and then with my fistula hand I pull out the needle by pulling the tubing. I do have one that goes sideways so tape it to the table and pull back my arm, works really well, took only a couple of days to get used to it.
Cathy
self home hemo 9/04
PKD
I just prepare all gauzes and tapes for putting in and taking out beforehand - which nurses do in most dialysis centres anyway, so, nothing really different there. I prepare this while my machine is priming and running its alarm test.
The one thing I have to do that others might not is that once Iāve disconnected both needle lines when Iām taking myself off, I attach a scissor clamp to each one. This gives me an extension I can easily grap onto with the fingers of my fistula arm hand - so I can pull the needle out at the same time as Iām holding the gauze over the needle with my other hand. Otherwise, the needle lines are not quite long enough that I can grab them easily.
For putting in the needles, I think a key point to realize is what Cathy already said: once the needle is in, it stays in until you can tape it down.
Pierre
Did you find it awkward to butterfly the needles with one hand?
Do you ever have a time when you are holding and blood leaks through the gauzeā¦what do you do in a case like this?
Is it best for both needles to be cannulated retrograde so you can remove them easier at the end?
How long did it take you to be trained for conventional cannulation and to feel totally comforatable with it? Were you trained for cannulation at the same time that you were getting the machine training? Would it be better to be trained for cannulation prior to starting machine training?
Did you find it awkward to butterfly the needles with one hand?
No, not at all.
Do you ever have a time when you are holding and blood leaks through the gauzeā¦what do you do in a case like this?
Yes. When this happens to me itās simply because my finger isnāt quite on the right spot. I just move it a bit by sliding it as best I can, and/or by applying more pressure with more of my finger.
Is it best for both needles to be cannulated retrograde so you can remove them easier at the end?
Not exactly sure I know what you mean by retrograde. Itās not a term weāve used in my training (but I trained in French). Do you mean the needles being inserted pointing towards the shoulder? If so, thatās what I do for both. Yes, it makes it easier to remove them after from my upper arm.
How long did it take you to be trained for conventional cannulation and to feel totally comforatable with it? Were you trained for cannulation at the same time that you were getting the machine training? Would it be better to be trained for cannulation prior to starting machine training?
It took like 5 minutes to train, but I did have a lot of previous experience watching the nurses do it on me in the dialysis centre. Yes, same time as getting the machine training. On the very first day, we did a short daily, my nurse cannulated the venous while showing me what to do, and I cannulated the arterial needle. Simple as that. I think it probably helps to already have a big, well-used fistula.
Pierre
It seems amazing to us that you picked up on the skills for cannulation so speedily, because it is not a natural thing to stick oneself with needles. Did the other home patients adapt as quickly as you? Did you have any trouble at first with finding the right angles or going in at the right speed?
How soon after being trained for conventional cannulation did they start you on BH training?
It seems amazing to us that you picked up on the skills for cannulation so speedily, because it is not a natural thing to stick oneself with needles. Did the other home patients adapt as quickly as you? Did you have any trouble at first with finding the right angles or going in at the right speed?
I trained by myself. At the time, the only other patients training were PD patients, so, I donāt really know how long it took other home hemo patients (oops, I guess you guys donāt like that āpatientā word, eh!). It just never seemed very difficult to me. But like I said, my fistula had already been in use for 2-1/2 years. By that time, I had no fear of pain (it deadens after a while), and my vein was fairly large and hard to miss. As long as Iām aiming at the middle of that vein and going in at an angle of 10 to 20 degrees, itās going in no problem. I approximated the same angle each time, as best I could. The sideways angle was pretty easy because my needles are perfectly aligned with the axis of my vein where the needles to in.
How soon after being trained for conventional cannulation did they start you on BH training?
Like I said, day 1, I put in my own venous, with my nurseās guidance. The sites chosen on day 1 were already what were intended to be my buttonholes. We continued with the sharps for 6 days, and then we switched to the dull needles.
Pierre
I started dialysis in my home training unit so I had a āvirginā fistula. I was ready to try self cannulation my first day. My training nurse inserted my venous needle and I inserted my arterial. I did all the other needles from then on. It is better for you to create your buttonhole so that you know the angles etc.
Things I wish I knew then that I do now:
Pay attention to the position of your arm and hand, not only the needle and donāt fight too hard with the buttonhole needle, use a sharp when needed.
I havenāt used a sharp in months and have two sets of buttonholes, three position the needle towards my shoulder and one positions the needle sideways towards my body. I do all my cannulations myself as well as set up, taping and removing. It is not hard at all.
Cathy
self home home 9/04
PKD
Thanks Cathy, and everyone else in this thread. Hubby will (we hope!) start home hemo training w/ a āvirginā fistula, and from the start be making a āBHā, so ALL of the advice is greatly appreciated.
Just keep in mind that it can take a lot of patience. Buttonholes donāt always work well every treatment until they are months old. New fistulas can also give trouble like cramps, numbness in the fingers, etc. This all fades after a while.
Pierre