Hemodialysis and Peritoneal Dialysis

A 55-year-old woman with ESKD and hypertension presents for evaluation of left upper extremity swelling. She had AVG placement in the left forearm a week ago. Vital signs are normal. There is mild erythema in the path of the graft, but no warmth, purulent drainage, or bleeding.

Q1: What is the cause of the left upper extremity swelling?

1. Trauma due to surgery

2. Central venous occlusion

3. Deep venous thrombosis

4. Cellulitis

A1: Upper extremity swelling is commonly seen after AVG placement. This is most likely due to trauma from the AVG placement and usually resolves over 3 to 4 weeks. Elevation of the arm (especially at night) may be helpful. However, edema of an extremity following AVG insertion may also be an indication of an occult central venous stenosis or occlusion or possibly venous thrombosis, especially if the edema is severe and/or does not resolve over time with arm elevation. In this case, a Duplex ultrasound or venography should be performed. Erythema of a new dialysis AVG is not indicative of infection providing the redness is limited to the path of the graft.

Q2: How do you determine the direction of blood flow in the AVG?

1. Palpate the vibration throughout the graft.

2. Compress the graft and determine where the graft is pulsatile and where it is nonpulsatile.

3. It is not necessary to know the direction of blood flow.

A2: It is important to know the direction of blood flow in a graft because that will indicate the correct way to insert the needles for hemodialysis. The arterial needle should be placed in the more proximal part of the AVG and the venous needle should be placed more distally in order to prevent recirculation. To determine the direction of blood flow, one must compress the middle of the graft and determine where the graft is pulsatile (i.e., arterial side) and where the blood is nonpulsatile (i.e., venous side).

A 71-year-old white man with diabetic kidney disease and coronary artery disease presents for evaluation of chest pain. A stress test is positive for coronary ischemia, and cardiac catheterization confirms a 90% right coronary artery stenosis and 90% left main disease. The patient subsequently has a coronary artery bypass graft. In recovery in the intensive care unit, he develops worsening of his kidney function.

Before surgery:

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