Late Complications of Haemodialysis Access: Appraisal and Management

Background: As a result of rapidly growing population with increased incidence of DM, chronic kidney disease (CKD) and end-stage renal disease (ESRD) increased markedly worldwide. This led to increased importance of haemodialysis access creation and the care for its possible complications. In Egypt, hypertension and diabetes mellitus are important causes of ESRD with their impact on the incidence of dialysis access complications. Late complications encountered during access use in dialysis may include late thrombosis, late infection at puncture sites, aneurysm and pseudoaneurysm formation, venous hypertension and steal syndrome. Cardiopulmonary and neurologic complications may be encountered also but they were not delt with in this study. Aim of work: To report and assess different types of complications of functioning haemodialysis access done at Alexandria main university hospital and medical research institute in one year follow up (from January 2013 to January 2014) for late complications and their management. Patients and methods: 160 patients with dialysis access done in the year 2012 and used for regular dialysis were included in this study. They were followed for one year, from January 2013 to January 2014 for late complications and their management aiming primarily for access salvage. Early access failure before dialysis and early infection cases were excluded from the study as well as mild neuropathy and subclinical steal. They were all subjected to clinical examination, laboratory investigations, imaging studies. Different management tools were used according to the type of complication encountered aiming primarily to life saving as well as limb and access salvage. Results: 160 patients were included in this study. They had ESRD with haemodialysis access constructed during the year 2012 at the main Alexandria university hospital and medical research institute. They all used their access for regular dialysis and were followed for late complications during the period from January 2013 to January 2014. They were 95 males (60%) and 65 females (40%). 80 patients (50%) had radiocephalic arterio-venous fistula (AVF) , 40(25%) brachi- basilic AVF, 28(17.5%) brachio-cephalic AVF, and 12(7.5%) brachioaxillary shunt PTFE grafts. 43 (26.8%) patients developed complications during the follow up period. 27 of the complicated cases (62.7%) were infective in the form of 24(55.8%) infected puncture site pseudoaneurysm of native fistula and 3(6.9%) cases of infected shunt graft. They, all, resulted in access loss. The remaining complications were 9 cases of thrombosis managed by thrombectomy , 3 cases of aneurysm formation repaired, 3 cases of venous hypertension treated by ligation and by angioplasty, and one case of clinically significant steal syndrome treated by distal revascularization interval ligation operation. The non infective complications management showed a good access salvage rate (75%) while salvage rate went down to (27.9%) when infected cases were included. Conclusion: The majority of complications reported in this study were infective and the limited use of prosthetic grafts minimizes this type of complications. Except for infectious complications, most of dialysis access complications can be treated and controlled or corrected with good access salvage rates. More attention and care should be given to infection control measures in dialysis units , health education and patients’ hygiene and immune status as well.