Buttonhole versus Stepladder Cannulation for Home Hemodialysis

Abstract

Background and objectivesCanadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique.Design, setting, participants, & measurementsAll patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented.ResultsPatient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted.ConclusionsWe were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.

Pain on arteriovenous fistula cannulation: A narrative review

“…Out of 158 participants they managed to randomize only 14. There were no differences in cannulation pain between the groups but the sample is too small to consider the results conclusive 63 . Pooled observational studies have yielded a statistical reduction in pain with buttonhole cannulation, 64 but no difference in cannulation pain was found among randomized controlled trials 65 .…”

“…There were no differences in cannulation pain between the groups but the sample is too small to consider the results conclusive. 63 Pooled observational studies have yielded a statistical reduction in pain with buttonhole cannulation, 64 but no difference in cannulation pain was found among randomized controlled trials. 65 The discrepancy on cannulation pain between the Buttonhole and rope-ladder techniques is explained by Di Nicolo from the fact that daily home dialysis patients are cannulating almost daily the AVF and therefore the tunnel has not entirely healed whereas in a dialysis center using the classic thrice-weekly rhythm, the healing process is longer and cannulation is more difficult causing greater discomfort for the patient.…”

Staphylococcus aureus Bacteremia Risk in Hemodialysis Patients Using the Buttonhole Cannulation Technique: A Prospective Multicenter Study

“…20 Our study describes and reflects daily clinical practice. A larger RCT with long follow-up might help, but recruitment can be difficult, as seen in a recent pilot trial 21 examining the feasibility of such a study in HHD patients. The authors succeeded in randomly assigning only 14 of 158 patients who started HHD training.…”

Complications and challenges of home hemodialysis: A historical review

“…Avoidance of the buttonhole cannulation technique is recommended if possible until more data become available. The patient reported outcomes of decreased pain with needling, and missed needle sticks are not as better as initially touted and even when a quality assurance project was undertaken with in‐center staff, buttonhole infection rates initially improve but worsen again with dire consequences 25‐27 . If buttonholes must be used, strict skin preparation and use of topical mupirocin prophylaxis to buttonhole cannulation sites have been endorsed in guidelines pertaining specifically to HHD patients 19 …”