Vascular access for renal replacement therapy (RRT) is seen as one of the most challenging areas confronting the nephrology multidisciplinary team. The vascular access of choice is the arterio-venous fistula (AVF) followed by the arterio-venous graft (AVG) and central venous catheter (CVC). A successful vascular access programme requires forward planning ensuring that enough time is available for the preservation of the access site, its creation and maturation. Successful cannulation of the vascular access requires on the part of the nephrology nurse, clinical expertise and knowledge on the management of different types of vascular access including different cannulation techniques.

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Important CO2 unloading occurs during hemodialysis (HD) when acetate-buffered dialysate is used. This is accompanied by alveolar hypoventilation. To gain more insight into the mechanisms of this alveolar hypoventilation, breathing patterns were studied in 5 patients with end-stage renal failure during HD using acetate-buffered dialysate, which induces CO2 unloading, or bicarbonate without CO2 loss. Ventilation was continuously measured with calibrated respiratory inductance plethysmography using techniques of multiple linear regression analysis. At regular intervals, arterial blood gas was sampled and expired air was analyzed. Breathing patterns were analyzed for VE, VT, TI, TE, and VT/TI. All data were compared with the respective starting value and with the respective value in the other setup. A greater decrease in ventilation was seen during HD with an acetate-containing dialysate because of irregular breathing patterns that resulted in a prolongation of expiratory time. Important variations in tidal volumes, striking apnea periods, and occasional periodic breathing were observed. We suggest that these irregularities are due to CO2 unloading leading to the point where ventilation is totally mediated through the output of the peripheral chemoreceptors.

Introduction | The pilot project of the Research Board of EDTNA/ERCA handled the management of vascular accesses (VA) in European dialysis centres. In the first part of the study, centre policies related to VA management were investigated. This paper reports on the second part of the project, investigating VA related complications reported during an observational prospective study. Methods | A cohort of 1380 adult patients, randomly selected in 47 centres out of 16 European countries were followed during one year using a computerised data collection system. Data were collected at baseline, after six and 12 months and each time a VA complication occurred. Results | At the start of the observation period, 77% had a native AV fistula, 10% had an AV graft and 13% a catheter. A total of 489 complications were noted. Most frequently observed were thrombosis, stenosis, infection, bleeding and flow problems. Hospitalisation (mean duration=6.2 days) was required in 39% of complications and 29% of complications resulted in a definitive loss of VA. Complications were more frequently observed in catheters (27%) and AV grafts (37%) compared to AV fistulae (15%). When compared with AV fistulae, the risk for thrombosis was more than four times higher and for bleeding more than six times higher if an AV graft was used. Catheters showed an eightfold increased risk to develop infections and flow problems. Conclusion | This study revealed the high complication rate in VA and strengthened the actions to promote AV fistulae as first choice VA.

The pilot project of the Research Board of EDTNA/ERCA handled the management of vascular accesses (VA) in European dialysis centres. In the first part of the study, centre policies related to VA management were investigated. In the second part of the study, individual patients were followed prospectively during one year. This paper reports on several topics of the second part of the project, investigating complications of the VA related to centre, patient characteristics and dialysis techniques used. Complications most frequently observed were thrombosis, stenosis, infection, bleeding and flow problems. Gradually more infections and flow problems were observed if the centre size and the patients/nurse ratio went up. Complication rate was not significantly influenced by age, gender, renal diagnosis, time on dialysis or medication used by the patient. In contrast, the number of vascular accesses in the past and interventions in the VA before first use resulted in an increased number of complications. Nurses have a key role in the prevention, manipulation and outcome of vascular access related complications.