Patients with end-stage kidney failure frequently require hemodialysis, a medical treatment that replaces the function of the kidneys by filtering blood and removing waste products. The site at which blood is removed from and returned to the body is called a vascular access site, which is typically created through a graft, fistula or a central venous catheter. Vascular access sites are associated with many potential complications, including infection and blood clotting. Severe hemorrhagic shock or death from excessive blood loss is one of the most serious and preventable of these complications. It can occur when a blood vessel graft or AV fistula erodes through the skin, a false aneurysm develops at the access site, or a central venous catheter is accidentally cut or dislodged. Use of any vascular access by untrained individuals for blood sampling, intravenous substance abuse by dialysis patients, or access site infections are other important factors, which may result in vascular access failures, potentially fatal hemorrhages or overwhelming septicemia.
Lethal vascular access related hemorrhagic complications occur in a very small percentage of hemodialysis patients. According to a recent study, 24 Maryland residents between 28 and 85 years of age died as a result of severe and uncontrolled bleeding from vascular access sites between the years 2000 and 2006. Of these patients, 63% were male and 75% were African American.
Some deaths from vascular access hemorrhage may have been preventable. An essential component of patient care is education, and hemodialysis patients should have repeated educational sessions concerning the clinical signs of vascular access site complications, including graft failure, infection or aneurysm formation. They also need to be clearly instructed that their vascular access is their dialysis lifeline and should only be used for treatment purposes by trained personnel for dialysis exclusively.
Furthermore, we recommend that nephrologists, vascular access surgeons and dialysis centers provide ongoing education on the risks of vascular access hemorrhage and the warning signs of graft failures. A more comprehensive policy on life saving measures in the event of severe hemorrhage from a vascular access site will be developed by the professional dialysis community in cooperation with the Maryland Kidney Commission.