The Spectrum of Hand Dysfunction After Hemodialysis Fistula Placement

Abstract

IntroductionContemporary dogma has classically attributed hand dysfunction following hemodialysis arteriovenous fistula (AVF) placement to regional ischemia. We hypothesize that hemodynamic perturbations alone do not entirely explain the postoperative changes in hand function and, furthermore, that various elements of hand function are differentially affected following surgery.MethodsBilateral wrist and digital pressures and upper extremity nerve conduction tests were recorded preoperatively and at 6 weeks and 6 months following upper extremity AVF construction in 46 patients. Concurrently, biomechanical tests were administered to evaluate multiple limb functional domains, including grip strength, dexterity, sensation, and perception of hand function.ResultsMean participant age was 59 ± 14 years (75% male), and 48% were on hemodialysis at the time of access placement. Of the participants, 69% had a brachial-based AVF, and the remainder had radial-based accesses. Six weeks following AVF placement, a significant decrease in access-side digital pressures was observed, with only partial recovery at 6 months (P < 0.0001). Grip strength was significantly worse in the access-side limb (P = 0.0003), and the Disability of Arm, Shoulder and Hand (DASH) questionnaire score substantially worsened postoperatively (P = 0.06). Digital sensation and limb dexterity did not differ between limb sides (P > 0.1) or change significantly over time (P > 0.1). Principal component analyses demonstrated that nerve conduction parameters tended to track the biomechanical parameters, yet both were relatively independent of the hemodynamic parameters.DiscussionOur findings suggest that ischemia alone does not completely explain access-related hand dysfunction and that future study is needed to elucidate alternative mechanisms.

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

“…Considering that older patients experience shorter survival on dialysis, seamless transitions from a TCVC to an AV access is critical, rather than pursuing access strategies with slower and unpredictable maturation. Moreover, hemodynamic perturbations and local inflammation that occur following placement of an AV access can have a negative impact on hand function [ 24 ]; consequently, patient's independence level can dramatically change postoperatively. This manuscript describes the design and methodology of a randomized pilot trial to evaluate feasibility of graft-first AV access placement and relationships between initial AV access approach and outcomes important to health and quality of life in older patients.…”

Influence of arteriovenous fistula on daily living behaviors involving the upper limbs in hemodialysis patients: a cross-sectional questionnaire study

“…Once an AVF is made, many patients experience difficulties in using their upper limbs [ 3 ] and suffer a decline in quality of life [ 4 ], firstly since they must constantly protect the AVF even during non-dialysis [ 1 , 2 ], secondly because of decreased cosmesis due to vasodilation [ 5 ], thirdly as the range of upper-limb motion may become limited from the dilated blood vessel and modification of blood flow [ 6 ], and fourthly because moving the arm during dialysis becomes impaired by connection to the dialysis machine. The above issues represent a severe problem for many individuals, who understandably feel uneasy at pre-AVF consultation [ 7 ].…”

Association of gait speed and grip strength with risk of cardiovascular events in patients on haemodialysis: a prospective study

“…In addition, fistula placement in HD may influence the HGS. HGS was reported to be significantly lower in the access-side limb than in the opposite side after arteriovenous fistula placement [38], and was directly related to thenar oxygenation and to finger systolic pressure only in the access-side extremity [39]. There is a need for the standardization of the techniques used for HGS evaluation in HD patients.…”