Trouble getting started on HD

I am a US person and been on PD for almost three years. The clearance is not as well as my Doctor wants, so I have decided to eventually go to home-HD, because I am still working.
Make a long story short; Home HD will not accept me into its training program until I am able to tolerate a certain blood-flow measurement.
So I started this perperation back in the end of June with an AV fistula in my left wrist. After the ‘recovery’ period I was asked to exercise with a rubber ball to help develop the fistula. I almost immediately began to develop blisters with clear fluid right around the fistula site. As time went by they would break and drain and begin to heal, however, I began to notice it was the exercising with the rubber ball that would cause the blister to redevelop. No one (nephrologist, PD nurses, HD nurses, vascular surgeon), knows what is causing this and do not address it.
At this point I have attempted twice to start the cannulation to begin HD without success. The only reasoning I get from the surgeon is my skin is too thick but the fistula is fine from the ultrasound testing performed at his office.
My question is have you encountered this type of blistering before, so it can be resolved and I can strengthen the fistula (exercising w/ rubber ball) and hopefully the vein access could be easier?
Any help would be greatly appreciated.
Thanks in advance.

Interesting question … yes, got some idea … will get to answer tomorrow afternoon … today/tonight frantic here

Dear ‘Guest’

It is very difficult to be sure what is happening here … but it is my guess that you might be referring to one of two possible problems here.

(1) A recurrent ‘seroma’.

A ‘seroma’ is a clear, fluid-filled collection of fluid which, though very uncommon, has been (when present) most commonly associated with a PTFE grafts but can occur as a complication of any arteriovenous fistula. Tjhe name ‘seroma’ arises from the fact that the fluid that seeps from the graft into the surrounding tissue and the skin layers is an acellular (= cell-free: i.e. lacking the red cell, white cell or platelet components of blood) filtrate of blood … serum.

It is impossible for me to tell if this is so … only your team can do that … but a seroma is a well documented, occasionally encountered complication of arteriovenous fistula formation and can be very difficult, and sometimes impossible, to control or correct without closing the fistula and ‘starting again’.

Are they ‘anybody’s fault’? … no … not at all … they just (a) very occasionally occur and (b) are regarded as bad luck! They are not a fault of surgical technique and, as they are rare, their cause remains uncertain.

The reason I suggest this possibility is your observation (and it is a very astute one, too) that exercising seems to increase the fluid accumulation/collection. My guess (again, this is just theoretical as I have no proof that this is so) is that exercise increases the flow and thus the leak.

I have never been a strong believer in the view that squeezing a ‘fistula ball’ makes any difference to the maturation and growth of an arteriovenous fistula. Some believe it. Some don’t. I’m in the ‘don’t’ basket.

I think they give the patient something concrete to ‘do’ that promotes the sense that ‘you are helping’ … and in that sense, they can be ‘beneficial’ to some patients … but, does it work? … of that, I am less certain.

Maybe in this instance, stopping the squeezing would be sensible to start with - especially if the squeezing seems to make it worse. There really are no studies that I am aware of that show benefit other than the possible psychological benefit of ‘the patient contributing to the cause’.

As for skin being too thick to needle? … no skin (in my experience, anyway) is too thick to needle. BUT … and here again (from far away across the Pacific) I begin to wonder … is the skin pseudo-‘thick’ (made to ‘seem’ thick) due to the presence of lymphoedema.

(2) Lymphatic obstruction

Lymphoedema can (1) cause the skin to thicken and (2) cause a ‘blistering’ fluid accumulation. Occasionally (again) … just as it is a well-known and not uncommon complication of transplantation … where a surgical incision in the groin to implant a transplant inadvertently ‘cuts across’ the normal (and microscopic) lymph channels that drain lymph from the periphery (legs - or, possibly in your case, arms) to the central lymphatic system.

The surgeon cannot see these channels when operating so he cannot ‘avoid’ them. It just ‘happens’ sometimes … as one of those complications of surgery that pop up to bedevil us later … and, it is almost surprising that it doesn’t seem to happen more often than it does.

In transplantation, this causes a ‘lymphocoele’ around the transplant. These are really quite common - in many series, in between 5-15% of all transplants, to some degree.

In fistula surgery … the same can happen. Have I seen this? … yes. I can remember one or two - especially, though, with transverse incisions at the cubital fossa rather than with longitudinal incisions at the wrist. They cause puckering swelling of the skin, maybe some tissue swelling distal (beyond the fistula in the hand or fingers) and blistering or weeping wounds or skin.

My guess … and it really is just a guess … its one of these two! At least it would be worth having both considered by your team.

As for a resolution? That may be harder.

Seromas will, most commonly ‘seal’ and stop with time. Circumferential pressure runs the risk of occluding a fledgling fistula and - if applied at all - would need to be done very gently and cautiously. Time may be the best bet. And … I’d stop the exercising routine. There really is no evidence that it does more than make the patient feel good about themselves because ‘they are making a positive contribution to fistula maturation’.

Lymphoedema is similarly problematic. Again, time may be the best medicine - but then … your PD ultrafiltration is running down and time isn’t your friend.

At the end of the day - and I hate to say this - but, a new fistula at a different site may be the best resolution if time and patience are not possible.

I don’t know if that has helped … its the best I can come up with from ‘afar’. And, of course, your team are by far the best to assess and see whether either of my thoughts ‘hold truth’ … or whether all that has been just ‘hot air over the net’!

Hi…we were told that exercising the fistula is really a waste of time. The only way the fistula will " grow " and fatten up is by cannulation. Could you be allergic to the rubber ball??

Dear Needled

Sorry - I missed your post during my travel to and back from Denver for the ASN.

Re using a rubber squeezie ball (or similar) to exercise the fistula … I have to say I agree with what you were told: it is more an exercise to make the patient think that they are contributing to fistula maturation than to actually do anything useful towards fistula growth … i.e. a ‘power of the mind’ exercise!

As for being allergic to the rubber ball - I really don’t think so. In my view, it is far more likely to be one of the issues I dealt with in my 1st response post. If this were an allergy to a squeeze ball, then it’d be ‘a first’ for me.