If you’re just starting on dialysis or you’ve been on treatment for some time, you’ll know that there are many new things to pay attention to as you start your journey. From understanding your labs to learning about the foods you should be eating and those to avoid, there are many aspects to dialysis that you can help monitor and make changes as needed. One important aspect of dialysis is understanding and monitoring your dialysis access. There are three types of dialysis accesses: fistulas, grafts, and central venous catheters (CVCs). While there are important differences and things to monitor with each kind of access, this article will focus on the dialysis fistula. By the end of this article, you will have a better understanding of what a fistula is, how to care for your fistula, signs of potential issues with your fistula, and how to advocate for excellent care.
What is a fistula?
While many of you are likely familiar with the different types of accesses, we will start by talking about what an arteriovenous (AV) fistula is. A hemodialysis fistula is created by connecting an artery to a vein, in the forearm or upper arm (bicep area), and moving that vessel more superficially (or closer to the surface of your skin). Soon after the vascular surgeon creates the fistula, the vein begins to grow in size, because the flow of blood in an artery is more robust than that in a vein. Typically, after 6-8 weeks and a return visit to the vascular surgeon to give the approval, the fistula is large enough to place a needle in it (cannulate). The formation of an access, such as a fistula, is necessary for dialysis, because of the high blood flows required throughout treatments. These blood flows would not be possible with your native blood vessels as the vessel would simply collapse and cause damage, therefore, fistulas (or grafts and CVCs) are required before you start. Of the three vascular accesses in dialysis, a fistula is less prone to infection and tends to have fewer issues with clotting since the artery and vein are native to you, therefore, fistulas are preferred over the other kinds of accesses ("Hemodialysis Access: Your Lifeline for Treatment", 2022). Once healed and mature, your fistula will be your lifeline for many years to come. Summary:
● An arteriovenous (AV) fistula is a blood vessel created surgically between an artery and a vein in your arm.
● Fistulas typically take 6-8 weeks to heal before cannulation.
● It is normal for your fistula to grow in size as it matures.
● Fistulas are the preferred dialysis access as they are your native blood vessels, which typically means fewer complications, such as infections, and allow optimal blood flow.
How can I care for my fistula?
One of the first things you can do to care for your fistula initially is to help build up the vessel. As noted above, the fistula will begin to grow on its own based on the differences in blood flow between arteries and veins. However, you can help this process by doing exercises. One of the most common exercises to develop your fistula is squeezing a squishy toy, or a tennis ball. Roughly one week after your fistula is placed, or when you’ve received the okay from your dialysis team, you can begin this exercise.
Exercise: In the hand of the arm where the fistula is, you will hold the squishy toy or ball and squeeze it 10-15 times a minute for one to two minutes. You will want to repeat this 10-20 times throughout the day.
Also, you must keep and attend your follow-up appointments with the vascular surgeon that created the fistula, as they will evaluate your fistula via a Doppler scan that will detect any structural abnormalities in your access, and address them so that your fistula becomes functional.
Aside from this initial care, there are some different ways to care for your access ongoing, which will help to keep it healthy. These include not sleeping or sitting on your access arm, avoiding tight clothing and jewelry as well as carrying heavy items with that arm. You should avoid having blood draws on your access arm as well as blood pressures. Another great way to be proactive is learning how to check the blood flow in your fistula. Ask a nurse or tech at your dialysis center to help you with this if you’re having difficulty. However, once you locate your fistula, you should feel a distinctive and consistent buzzing sensation, otherwise known as the thrill. By checking the thrill of your fistula, you can monitor for any changes, and potentially head off issues before they present themselves. Lastly, once your fistula is cannulated (or needles placed in it), ensure that you are washing your access before every treatment to avoid any infections ("Taking care of your AV fistula", 2022).
Washing your access: For proper washing of your fistula, before your treatment, ensure that you use soap and warm water. You can apply the soap directly to your skin or on a paper towel and lather the entire length of your fistula to ensure all areas are cleaned appropriately. Afterward, make sure your fistula is completely dry.
Do the recommended exercises after your fistula is placed to help develop it.
Keep your follow-up appointments with the vascular surgeon to ensure your fistula is monitored, and any potential issues are identified in a timely manner.
Avoid laying or sitting on your fistula arm, don’t wear any tight clothing or jewelry on this arm and do not carry heavy items with this arm as this may cause clotting in your access.
Do not have your blood pressure or blood taken on your access arm.
Check the thrill (buzzing sensation) of your fistula often by placing your fingers on it.
Wash your access before each treatment to prevent infection.
What are some signs that there may be an issue with my fistula?
While fistulas tend to have fewer infections and access issues than catheters and grafts, there is still a chance these things can occur. Some signs to monitor for and report right away include redness and swelling on your fistula. These signs could indicate a potential infection or clotting of your access. Any sudden onset of pain or changes in the pain level in your fistula should also be reported immediately. If you have a fever, report this to your doctor as this symptom can indicate an infection as well. Some other issues that may occur include swelling, temperature changes, and pain in the hand of the fistula arm. These signs could be an indication of a circulation issue or a condition known as steal syndrome, which interrupts the blood flow going to the hand as a result of the fistula placement (Malik, et al., 2008).
One of the more common problems with an AV fistula is stenosis, which is when your fistula begins to narrow. Stenosis reduces the blood flow through your fistula, which can cause problems with the quality of your dialysis treatment. Symptoms associated with this include prolonged bleeding after treatments (longer than 20 minutes), changes in the thrill (or buzzing sensation), or pain in the fistula. Repeated alarms going off on the dialysis machine can also be a sign that your fistula may be narrowing. If you start to notice some of these signs of narrowing, or stenosis, be sure to speak with your nephrologist right away.
While stenosis can be caused by several mechanisms that are occurring within the body, one crucial factor that can lead to stenosis is repeated needle sticks in the same area of your fistula over consecutive treatments, and medical procedures on your fistula, such as blood pressure readings, IVs, and blood draws. Because these things increase your risk for stenosis, it is vital that you monitor for and help prevent these things from occurring.
What you can do:
Monitor your fistula for signs of an infection or clotting, such as redness, swelling, and increased warmth, and be sure to report them right away.
Report any sudden pain or changes in pain level at your fistula site.
If you develop a fever, report this right away to your dialysis team as it may indicate infection.
If you begin to have swelling or pain in your hand on the same side as your fistula, tell your provider as this could be an indication of a circulation issue.
Report any changes in the thrill (buzzing sensation) of your access.
Speak with your dialysis team or case manager about any repeated dialysis instrument alarms or prolonged bleeding after dialysis treatment (over 20 minutes).
What happens if my fistula starts to narrow?
If your dialysis team suspects that there is a stenosis issue, they will start to check to see if your dialysis quality is impacted. One of the signs that the quality of dialysis is being affected is a decrease in your clearance during treatment. Often, there is a green light on the dialysis machine when a person’s treatment is good. However, it will turn yellow if the person is not clearing enough urea during each treatment. Another indication that the quality of dialysis is decreasing is a change in labs, particularly URR and pre-and post-BUN levels.
If these changes are present and your nephrologist feels that they are caused by a fistula stenosis, he or she will refer you back to the vascular surgeon. If a stenosis is detected, the vascular surgeon will opt for one of two procedures to clear it. The first option is angioplasty, in which the surgeon will insert a balloon catheter into the vessel and inflate the balloon to open the fistula up again. The second option is to place a permanent stent that will prevent the fistula from narrowing again in that part of the vessel ("What Causes Stenosis in an AV Fistula and How Do I Recognize It?", 2022). Both procedures are minimally-invasive, and you can expect to return to dialysis immediately. You will likely only have one to two sutures in place, and the dialysis staff will monitor and remove these after 10-14 days.
What your care team will do:
If your care team suspects that your fistula has narrowed and your dialysis is affected (which is determined by your clearance during treatment and labs), your nephrologist will send you to the vascular surgeon for evaluation and most likely to have an angioplasty, or a stent placed.
Angioplasty and stent placement help open up your fistula so that optimal blood flow is reached during treatment and the quality of your dialysis will improve again.
Angioplasties and stents are minimally-invasive, and you will return to your regular dialysis schedule immediately.
The dialysis team will monitor your access following angioplasty/stents, and will likely remove the sutures.
How can I make sure my dialysis team properly cares for my fistula?
Your dialysis team including nurses and dialysis technicians undergo extensive training when specializing in dialysis and should be very knowledgeable on monitoring and caring for your fistula. Even so, it is important that you advocate for good care. One expectation throughout all of healthcare, but especially in dialysis, is proper hand hygiene. Proper hygiene applies to you as well, so you are encouraged to clean your access before your treatment.
One way to advocate for excellent care is to have conversations with your nurse or tech to find out how they ensure they are following protocol. Another way to advocate for your care is to have ongoing conversations about your access. Before each cannulation, your nurse or tech should be feeling and listening to your fistula. Ask questions about what they hear or feel, and contribute with what you’ve observed in the sensation of your fistula and its appearance. Lastly, ask to discuss needle sites before your nurse or tech start to cannulate. Between your input on the last needle placement, and the nurse or tech’s knowledge on appropriate needle placement, you can avoid placing needles in the same spot, and potentially causing trauma and narrowing in your access. And, of course, another great way of advocating for yourself is being involved in every aspect of your care. So, if there are things you don’t quite understand, or you’d like to know more about, simply ask questions. The dialysis team is there to help you through your experience.
What you can do:
Be your own advocate for your care, ask questions of the person setting up your dialysis. If you are dialyzing at home keep below suggestions in mind for yourself.
Make sure you and your nurse or technician are practicing good hygiene – both of you should wash hands before starting treatment and your access area should be cleaned before any needles are placed.
Share information with the person doing your dialysis. Ask your nurse or technician what they feel when listening to your fistula and share what you have noticed.
Keep track of the needle placement in your fistula.
Tell your nurse or technician where the needle was placed at your last dialysis session. Remember you won’t always have the same person managing your dialysis at each session and the nurses and technicians see many people, a reminder is helpful to them. Telling your nurse or technician who is taking care of your dialysis ensures that you both do your best to keep your fistula healthy.
Make sure that the placement of needles into your fistula is rotated; Rotating needle placement will help keep your fistula healthy.
Never hesitate to ask questions if you need clarification or want to be more involved. You know yourself best, and your contributions are valued.
In closing, while there are several options for dialysis access, an arteriovenous fistula is the first choice due to decreased chances of infections and other access issues. Some ways that you can monitor your access are to check for any signs of infections, such as redness or swelling along your access, fever, pain, or changes in the sensation of your fistula. Because your fistula is your lifeline, it is also important to monitor for signs of stenosis, such as repeated alarms during treatment, prolonged bleeding after treatment that lasts longer than 20 minutes, and changes in the thrill of your fistula.
Your dialysis team is a highly-trained resource, and they are familiar with signs of the various access issues that may arise. However, you can also advocate for excellent care each time you are at treatment in the dialysis center. Some of the ways to advocate for yourself is ensuring good hand/access hygiene is performed before each procedure (like cannulation or wound care), collaborating with the dialysis team to monitor your fistula, and working with your nurse or tech to alternate the needle sites. If you are on home dialysis, communicating any changes you see with your dialysis care team and making an appointment to be seen as soon as you notice any changes discussed above can help you address any problems early on. As always, never be afraid to speak up if you have questions.
Guidelines for Activities After Dialysis Access Surgery. Beth Israel Deaconess Medical Center.
Hemodialysis Access: Your Lifeline for Treatment. Fresenius Kidney Care.
Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention, and treatment strategies. Malik, J., et al., The journal of vascular access 9(3),155–166 (2008).
Hemodialysis Access. National Kidney Foundation.
What Causes Stenosis in an AV Fistula and How Do I Recognize It?. Azura Vascular Care, a division of Fresenius Medical Care North America.