Home haemodialysis in Australia — is the wheel turning full circle?

TO THE EDITOR: The article on home haemodialysis by Agar and colleagues describes a changing pattern of practice that has seen many patients enjoy the freedom of dialysing at night in their home environment. One consideration not mentioned is the need for appropriate vascular access. For a patient to engage in self-cannulation, a fistula needs to be created for ease of use. This requires a few imperatives in fistula design to be met. In my practice, an attempt is made to create an autogenous fistula for vascular access whenever possible. It is well documented that an autogenous arteriovenous fistula (AVF) is superior to prosthetic graft or catheter access in terms of access longevity and patient-related complications. In the past 11 years, I have found it necessary to create a new AVF with prosthetic material in no more than 1% of cases. For some patients, however, a fistula may be positioned where it is accessible to renal nursing staff but not for self-cannulation. This would make nocturnal home dialysis difficult and underpins the importance of surgical access design to facilitate it. For self-cannulating patients, great effort is made to create vascular access in the nondominant arm, in the forearm rather than the upper arm, and with cephalic rather than basilic vein run-off. The cephalic vein lies on the upper outer aspect of the forearm with the limb in a neutral position, and a needle in it remains fairly secure when a patient is asleep. Guidelines on surgical placement of an AVF from the Society for Vascular Surgery, while not specifically prescriptive for patients wanting to self-cannulate, include the same recommendations. Use of a long saphenous vein loop fistula in the forearm, positioned appropriately, also provides ready access for a patient who may otherwise struggle with the dexterity required for venepuncture. A thigh loop is an alternative but less desirable option, as patients with chronic renal disease are likely to have lower-extremity occlusive disease, an increased incidence of groin infection, and a greater likelihood of vascular steal. I applaud efforts to facilitate nocturnal home dialysis, and enjoy the challenge of surgically creating vascular access to make this endeavour successful.