Which is the preferred vascular access in diabetic patients? A view from Europe

Decenzio Bonucchi, Gianni Cappelli and Alberto Albertazzi

Nephrology, Dialysis and Transplantation, University Hospital, Modena, Italy

Keywords: diabetes; vascular access

Introduction

After 35 years of experience with dialysis treatment, the prompt availability of a well-functioning, stable vascular access remains a disturbing problem, compared with the successful solutions formed for renal anaemia, water purity, biocompatibility and others. This is especially true when dealing with the issue of vascular access in diabetic patients, in which the increasing prevalence of the disease and the severity of vascular damage demand special efforts of the health staff.

Which kind of diabetes?

Proper classification of diabetes in end-stage renal disease is still a problem, mainly due to misinterpretation of the use of insulin treatment. It is clear that at present, from a clinical point of view, two different diseases are frequently taken together.

With vascular access (VA), type 2 diabetes adds the effect of ageing to that of the vascular alterations linked to the basic disease [1]. In addition, type 2 diabetes plays the most important role in terms of disease incidence and comorbidities, and therefore in terms of clinical requirements. Indeed, the recently observed increase in incidence and prevalence of diabetic disease in dialysis patients is mostly due to type 2 diabetes.

On the other hand, type 1 diabetes is also increasing, according to Uremidiab [2]. There is growing consensus that for this disease, not dialysis but combined kidney–pancreas transplantation is the gold standard of therapy. Since the survival of diabetic patients on dialysis is 50% at 3 and 30% at 5 years respectively, patients with type 1 diabetes should ideally be treated by a combined graft early in the course of renal failure, that is before the need for dialysis.

It is therefore clear that special attention should be given to the planning, availability and reliability of VA in diabetic patients. Its longevity mainly depends on correct planning (timely referral) and maintenance (regular follow-up during dialysis).

Strategy or technique?

The life expectancy of a VA should actually be matched with the life expectancy of the patient on dialysis. This consideration applies to the choice of VA in diabetes. In the young patient with type 1 diabetes, who is a suitable candidate for a double graft, the first VA should be the only one and devoid of complications. The choice is limited, since grafts and central venous catheters are subject to infectious and thrombotic complications. Native arterio-venous fistulae (AVF) are again the preferred option, but the site at which the VA should be constructed is still a matter of debate.

Since type 2 diabetes accounts for the great majority (90–95%) of diabetics on dialysis, the negative influence of age on VA is relevant [1]. In addition, as recently demonstrated by Konner and co-workers, peripheral vessels are very often calcified [3]. These calcifications hinder the maturation of distal (wrist) VA, preventing the hypertrophy of the feeding artery. The primary choice of an elbow AVF in general avoids frustrating attempts at the wrist, especially when late referral requires dialysis to be started rapidly.

Many technical variations are possible, such as the utilization of the perforating vein (Gracz AVF) or the radial artery at its origin, just below the elbow, or retrograde arterialization of forearm veins by means of the classical side-to-side brachio-cephalic AVF. The advantages of these surgical options are avoidance of early thromboses, a high chance of maturation and a low complication rate.

Long mobilization of a previously arterialized basilic vein and its tunnelling under the anterior aspect of the arm is another possible option based on native vessels. Forearm venous straight or loop transpositions are also possible when distal veins are still good.

Interventional radiology should play a pivotal role to maintain patency. However, a regular and frequent follow-up is required. Angioplasty and stents may prolong the life of VA in diabetic patients, provided that an active surveillance programme is initiated after the first diagnosis of stricture and placement of the device.

Different attitudes?

Although many colleagues overseas continue to report the successful use of grafts, a large number of US institutions have been successful in increasing the prevalence of native AVF by implementating a multi-professional programme, led by a nephrologist or by a renal nurse [4,5]. The increasing use of central venous catheters (CVC) for dialysis is a matter of concern all over the world [6].

With respect to fistulae for diabetic patients, strategies on the east and west coasts of the Atlantic Ocean are probably close. Reports demonstrating that elbow AVF have lower primary failures and higher maturation rates than wrist AVF have been published by both US [7] and European [3] teams.

In contrast, some reports from Europe have proposed conflicting strategies regarding the use of permanent catheters, the other major alternative of VA. The Catalan Registry still reported 79.6% of native vascular access in diabetics, with an 11% prevalence of CVC in this disease [8]. In contrast, a large CVC series from Italy contained a very high proportion of diabetic patients (26.9%), twice the prevalence of such patients on dialysis in Italy [9].

It is conceivable that the managing model (multi-professional with a nephrologist as co-ordinator) and the availability of resources (a cooperating vascular surgeon at the same institution) play a major role in determining the prevalence and success rate of different vascular access modalities. The sole management of VA by the vascular surgeon is the most likely explanation of the high prevalence of grafts in the USA, whereas nephrological self-sufficiency has led to the large-scale utilization of CVC in some European countries.

Either solution appears unsuitable. In each case, the VA should be customized to the patient's individual condition, taking into account vessel burden, referral time, dialysis need and various clinical features.

Conclusions

Each country appears to have its Achilles' heel such as grafts in the USA and CVC growing like weeds in Europe [10]. This means that problems in cooperating among different professionals involved in the creation of a VA are still unsolved, and a multi-professional model of VA management is still far from being achieved.

In addition, late referral has a special impact on diabetes, since it is common opinion that dialysis should be started earlier in these patients [11]. Therefore, practitioners must be alerted as to their key-role in referring diabetic patients with nephropathy to the nephrologist on time. Venous sparing, starting from the very beginning of renal failure, is another rule to be strictly adhered to by health-care professionals: too often forearm veins are repeatedly cannulated for infusions and blood drawings in candidates for extracorporeal renal replacement therapy.

Starting from diabetic patients and learning from the US experience, we should try to prevent similar and perhaps already widespread errors. Avoidance of primary permanent CVC and grafts and preference of native AVF should become mandatory in order to control the economical burden and clinical complications to VA. For a long time we bored our American colleagues by criticizing the very high AV graft prevalence in their country. It is time to be concerned by the growing prevalence of CVC in many European centres [10].

As regards diabetic patients, elbow fistulae could be the easiest and most effective vascular access, in terms of primary patency and rate of maturation. An agreement on the use of native elbow AVF [3,7] already exists between the USA and Europe. Several years will be required, however, before the effects of this profound change in strategy become apparent. In diabetic patients, the Cimino-Brescia will remain the best option, although its preferred site will move to the elbow.

Careful preoperative (Table 1Go) planning should allow the detection of the minority of patients with suitable peripheral vessels for a wrist AVF and those at high risk of distal ischaemia and steal syndrome. The Allen test, be it manual or instrumental, should not be skipped in diabetic patients. Skilled surgical technique should permit us to consistently prevent complications, although the flawless AVF is still far from reality in uraemic patients suffering from diabetes.


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Table 1. Ten suggestions for improved vascular access management in diabetes

 

Notes

Correspondence and offprint requests to: Decenzio Bonucchi MD, Nefrologia, Dialisi, Trapianto, Azienda Ospedaliera Policlinico, Via del Pozzo 71, I-41100 Modena, Italy. Email: bonuckidney{at}libero.it Back

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