National Kidney Foundation'sKidney Disease OutcomesQuality InitiativeDid you know that the National KidneyFoundation's Kidney Disease OutcomesQuality Initiative (NKF-KDOQI ) offersguidelines and commentaries that help yourdoctor and healthcare team make importantdecisions about your medical treatment? Theinformation in this booklet is based on thoserecommended guidelines.Stages of Kidney DiseaseThere are 5 stages of kidney disease. Theyare shown in the table below. Your doctordetermines your stage of kidney disease,based on the presence of kidney damage andyour glomerular filtration rate (GFR), which is ameasure of your level of kidney function. Yourtreatment is based on your stage of kidneydisease. Speak to your doctor if you have anyquestions about your stage of kidney diseaseor your treatment.STAGES OF KIDNEY DISEASEDescriptionGlomerularFiltration Rate (GFR)*1Kidney damage (e.g., proteinin the urine) with normal GFR90 or above2Kidney damage with milddecrease in GFR60 to 893aModerate decrease in GFR45 to 593bModerate decrease in GFR30 to 444Severe reduction in GFR15 to 295Kidney failureLess than 15Stage*Your GFR number tells your doctor how much kidneyfunction you have. As chronic kidney disease progresses,your GFR number decreases.

Hemodialysis Access:What You Need To KnowWhether you already get hemodialysistreatment, or you will need to startdialysis soon, this booklet will help youbetter understand the ways to reach(access) your blood for hemodialysis.It tells you: How to choose the accessthat is best for you About the pros and consof the different types of access Why your access is importantto getting the most from yourhemodialysis treatment How to care for your access How to keep your accessworking wellThe information in this booklet is basedon the recommendations from theNational Kidney Foundation’s KidneyDisease Outcomes Quality Initiative(KDOQI) Guidelines for VascularAccess. You may also be interestedin checking out the Other Resourcessection on page 23.WWW.KIDNEY.ORG3

What is a hemodialysis access?Hemodialysis is a treatment thatremoves wastes and extra fluid fromyour blood when your own kidneyshave failed. Before hemodialysis canbe done, a connection must be madeto the blood inside your blood vessels.Your hemodialysis access, or vascularaccess, is a way to reach your bloodfor hemodialysis. The access allowsyour blood to travel through soft tubesto the dialysis machine where it iscleaned as it passes through a specialfilter, called a dialyzer.Are different typesof access available?Yes. Three different types of accesscan be placed for hemodialysis. Theyare called a fistula, a graft, and acatheter. Your doctor should teachyou about the pros and cons of eachone. Your doctor should refer you toa special surgeon with hemodialysisaccess experience at least six monthsbefore you need to start treatment.This surgeon will evaluate you andhelp you choose the type of accessthat is best for you. Once your doctortells you that you will need dialysis,you should protect the arm where thesurgery will be done. Don’t allow4NATIONAL KIDNEY FOUNDATION

anyone to draw blood or give you aninjection in this arm. Also, never letanyone use a cuff to take your bloodpressure from this arm. You shouldwear a medical alert bracelet to informhospital staff about your arm.An AV (artery-vein)fistula is the bestchoice forVein (V)Artery (A)hemodialysis. It isAV Fistulapreferred becauseit usually lastslonger and hasfewer problems likeclotting and infections. A fistula shouldbe placed several months before youneed to start dialysis. This allows thefistula enough time to be ready forwhen you need treatment.Minor surgery is needed to create thefistula. It is made by connecting a veinto a nearby artery, usually in your arm.This creates a large blood vessel thathas a fast flow of blood. Your wristor elbow is the preferred location foryour fistula. A fistula will usually lastfor many years. A fistula usually takesone to four months to “mature” orenlarge before it can be used. If youare already receiving hemodialysisusing an AV graft or catheter, ask yourdoctor about the benefits of a fistula.WWW.KIDNEY.ORG5

An AV (arteryvein) graft is theVein (V)second choiceArtery (A)for an access.AV GraftMinor surgery isdone using anartificial tubebetween a vein and a nearby artery.An AV graft is usually put inside thebend of your arm or in your upper arm.Sometimes, it may be placed in yourleg or chest wall. The AV graftgenerally needs to be in place at leasttwo weeks after surgery before itcan be used.A catheter ismost often usedfor a temporaryaccess. Forexample, it issometimes usedfor a short timein people who get an AV fistula andneed to start dialysis before the fistulais ready. Once the fistula is “mature,”the catheter will be removed.Sometimes a catheter is used over along period of time because a fistulaor graft is not possible.CatheterCatheters are made of soft plastictubing. There are two parts, one for6NATIONAL KIDNEY FOUNDATION

removing your blood and the otherfor returning the cleaned blood toyour body.A catheter is placed only when youneed to start dialysis. It is put in alarge vein, usually in your neck butsometimes in your upper chest.Catheters have more problems (likeclotting and infections) than fistulasor grafts. They may not have enoughblood flow for good dialysis treatment.AV FISTULA PROS AND CONSPros: Lasts longer Not proneto infection Provides excellentAV Fistulablood flow once itis ready to use Less likely to develop blood clotsand become blocked You can take showers once theaccess heals after surgery.Cons: Needs to mature one to fourmonths before it can be used Needles are inserted to connect tothe dialysis machine.WWW.KIDNEY.ORG7

AV GRAFT PROS AND CONSPros: Providesexcellent bloodflow once it isready to useAV Graft You can takeshowers oncethe accessheals after surgery.Cons: Lasts less time than an AV fistula More prone to infection than an AVfistula Needs at least two weeks before itcan be used Clotting can be a problem that mayrequire surgery or other treatmentto correct. Needles are inserted to connect tothe dialysis machine.8NATIONAL KIDNEY FOUNDATION

CATHETER PROS AND CONSPros: Can be usedCatheterright away No needlesare neededto connect tothe machine.Cons: Usually a temporary access Most prone to infection May not have the blood flowneeded for enough dialysis Blood clots can form that blockthe flow of blood through yourcatheter. You need to wear a protectivecover for your catheter to take ashower. Can cause narrowing of majorblood vesselsWhat happens aftermy access surgery?After your access is placed, you shouldfollow your doctor’s orders aboutcaring for your new access.WWW.KIDNEY.ORG9

Tips for Caring for Your AccessAfter SurgeryAV Fistula: Keep it dry; once it is healed youcan take showers. Watch for bleeding. Take all medicine that is prescribed. Get enough rest. Call your doctor if you:Notice redness, pain, swelling,or a feeling of warmth at theaccess siteFeel short of breathHave flu-like symptomsHave a temperatureof 99 degrees or higher Keep your arm straight and elevated(above your heart) while the accessis healing. Ask the nurse at the hospitalto show you how to check youraccess at home for a vibration(called a “thrill”) or for a sound(called a “bruit” pronounced“brew-ee”). Ask your doctor when you can startdoing exercises, such as squeezinga rubber ball, to help your accessmature and be ready to use.10NATIONAL KIDNEY FOUNDATION

Your doctor should check youraccess to make sure it is maturingproperly.AV Graft: Keep it dry; once it is healed youcan take showers. Watch for bleeding. Take all medicine prescribedfor you. Get enough rest. Call your doctor if you:Notice redness, pain, swelling,or a feeling of warmth at theaccess siteFeel short of breathHave flu-like symptomsHave a temperatureof 99 degrees or higher Keep your arm straight andelevated (above your heart) whilethe access is healing. Ask the nurse at the hospitalto show you how to check youraccess at home for a vibration(called a “thrill”) or for a sound(called a “bruit” pronounced“brew-ee”).WWW.KIDNEY.ORG11

Catheter: Keep the dressing dry; oncehealed, you can take showersusing a protective covering overyour catheter. Watch for bleeding. Take all medicine prescribedfor you. Get enough rest. Call your doctor if you:Notice redness, pain, swelling,or a feeling of warmth at theaccess siteFeel short of breathHave flu-like symptomsHave a temperatureof 99 degrees or higher12NATIONAL KIDNEY FOUNDATION

What happens when I start dialysis?If you have an AV fistula or AV graft,two needles are inserted into youraccess at the beginning of eachdialysis. These needles are connectedto soft plastic tubes that go to thedialysis machine. Your blood travelsto the machine through one of thesetubes. The blood passes through thedialyzer, or artificial kidney, where it iscleaned. It is returned to you throughthe other tube.If you have a catheter, it can beconnected directly to the dialysistubes, and no needles are used.What happens if my accessis not working well?If your access is not working well,it can decrease the amount of dialysisyou get. Getting enough dialysis isimportant to: Improve your overall health Help you live longer Improve your quality of life Keep you out of the hospitalTo make sure you are getting the rightamount of dialysis, your dialysis careteam will measure your delivered doseWWW.KIDNEY.ORG13

of dialysis. This tells them if enoughwastes are being removed from yourblood. Your delivered dose of dialysiswill be checked by doing a blood testto measure your Kt/V (pronounced“kay tee over vee”). Another testthat may be done to measure yourdelivered dose is called URR (ureareduction ratio). If you are gettingthe right amount of dialysis, yourKt/V should be 1.2 or more. If URRis measured, your result should be65 percent or more. If your numbersare too low, your access may not beworking well.Will my dialysis care team do anytests to check my access?Yes. They should check your accessat least once a month. Special testsshould also be done. These mayinclude: Measuring flow in your access Measuring pressure in your access An imaging test called duplexultrasound14NATIONAL KIDNEY FOUNDATION

Tips for Everyday Careof Your AV Fistula or GraftPrevent Infection Ask your dialysis care teamto teach you about preventinginfection and keeping your fistulaor graft working well. Wash your access site every daywith an antibacterial soap. Ask yourdialysis care team to recommenda good soap to use. Wash your access site before everydialysis treatment. Your dialysiscenter has hand washing sinks andantibacterial soap. Do not scratch your access.Your fingernails could bea source of infection. Your nurse or technician shouldclean your access site with anantiseptic before putting theneedles in. Do not touch youraccess area after it has beendisinfected. Your nurse or technician shouldwear a surgical mask, a face shield,and clean gloves when workingnear your access. Avoid coughing or sneezing onyour access site during treatment.WWW.KIDNEY.ORG15

Always wear a clean glove or use aclean gauze pad if you are holdingyour own access site after theneedles are pulled. Apply only gentle pressure to stopbleeding after the needles areremoved. Press only where theneedle was and just below. Neverpress above where the needle was. Call your dialysis care team at onceif the area of the access is sore,swollen, red, or feels hot.This could be a sign of infection.Protect Your AV Fistula or Graft Do not let anyone measure yourblood pressure on your accessarm. Your other arm should beused instead. Do not let anyone take blood fromyour access arm when you are noton dialysis. If the vibration (thrill) or sound(bruit) of your access is absentor seems different, call yourdialysis care team at once. Thiscould mean the access is notworking well. Ask your dialysis care team howto make your needle sticks ascomfortable as possible. They canuse different sites for the needles16NATIONAL KIDNEY FOUNDATION

during each dialysis. Or, if you havea fistula, a “button hole” techniquecan be used. This uses the samesite for each dialysis, and may beless painful.Tips for Everyday Careof Your CatheterPrevent Infection Ask your dialysis care teamto teach you how to preventinfections and keep your catheterworking well. Be sure your catheter has a clean,dry dressing during and after everydialysis. Make sure your nurse ortechnician checks your catheterfor signs of infection at everydialysis session. Make sure you wear a surgicalmask when you are beingconnected to or disconnectedfrom the dialysis machine. Make sure your nurse or technicianwears a surgical mask, face shield,and clean gloves when workingnear your catheter. Use a protective cover for yourcatheter to take a shower. Ask yourdialysis care team how to get oneof these covers.WWW.KIDNEY.ORG17

Ask your nurse or technicianto teach you or your family howto change the dressing. Keep extra dressing supplies athome in case you need to replaceyour dressing. Call your dialysis care teamright away if your catheter cuffis showing.What kinds of access problems canhappen? How are they treated?Sometimes, even when you take thebest care of your access, you mayhave problems. If an infection occurs,your doctor will order antibioticsfor you. If your access developsa clot, it needs to be treated withspecial medications. Sometimes this18NATIONAL KIDNEY FOUNDATION

medication can be given in the dialysisunit. Other times, you may needto go to the hospital for treatment.Sometimes surgery is needed toremove a clot or repair an access.Angioplasty may need to be doneto widen a narrowed fistula or graft.Your dialysis care team will check youraccess for problems. You, too, canhelp spot possible problems. Learn thewarning signs listed in the followingsection. Contact your doctor or dialysiscenter right away if you notice anyof them.Warning Signs of Access ProblemsInfectionWarning Signs: Redness, swelling,soreness, and/or a feeling of warmtharound your access site; fever, chills,and/or achy feeling.Steps to Take: Call your doctor ordialysis care team at once.You’ll need to take antibiotic medicineprescribed by your doctor.Clotting or Poor Blood Flowin Your AccessWarning Signs: Absence of thevibration (thrill) or sound (bruit) at yourfistula or graft site; swelling of yourWWW.KIDNEY.ORG19

arm; lower skin temperature aroundthe access site; a decrease in yourdelivered dose of dialysis (Kt/V orURR); or changes in other lab values.Steps to Take: Call your doctor ordialysis center. Keep a record of yourKt/V or URR and other labs. Speak toyour dialysis care team when thereare changes.Bleeding From Your AccessWarning Signs: Bleeding froma fistula or graft that lasts morethan 20 minutes after your dialysistreatment is over.Any bleeding from a catheter siteor catheter tube.Steps to Take: For bleeding froma fistula or graft, gently press youraccess with a clean gauze pad to stopthe blood; if bleeding lasts more than20 minutes, call your doctor or dialysiscenter at once.For bleeding from a catheter site ortube, call your doctor or dialysis centerat once, or go to the emergency roomat your local hospital.20NATIONAL KIDNEY FOUNDATION

Decreased Circulationin Your Access ArmWarning Signs: Feelings of numbness,tingling, coldness or weakness in yourarm; blue fingers or sores at the tipsof your fingers.Steps to Take: Call your doctor ordialysis center right away (this mustbe treated at once to prevent nervedamage in your access arm).Key Points to Remember Keeping your access working wellwill help you get the most fromhemodialysis, and help you feelyour best. If your access is not working well,it can decrease the amount ofdialysis you receive. This will affectyour overall health and how longyou live on dialysis. A fistula is the preferred type ofaccess. If you are already receivinghemodialysis and you do not havea fistula, ask your doctor or dialysiscare team if you are a candidatefor a fistula. Make sure your dialysis care teamchecks your access often. Theyshould do some special tests tomake sure it is working well.WWW.KIDNEY.ORG21

Do not let anyone measure yourblood pressure on your accessarm, or take blood from youraccess arm when you are notgetting dialysis. Your other armshould be used to measure bloodpressure and do blood tests. Ask your dialysis care team toteach you the steps for goodaccess care to prevent infectionand keep your access working well. Know the warning signs forproblems with your access. Track your important test results,such as your Kt/V and your URR. Ask your dialysis care teamif you have any questions aboutyour access or any other aspectsof your hemodialysis care.22NATIONAL KIDNEY FOUNDATION

Other ResourcesCall the NKF Cares Patient HelpLine toll-free at 855.NKF.CARES(855.653.2273) or [email protected] more at www.kidney.orgThe following free NKF booklets maybe helpful:Choosing a Treatment for KidneyFailure (11-10-0352)Dialysis Lab Log (11-50-0224)Dining Out With Confidence(11-10-0405)Coping Effectively: A Guide for Patientsand Their Families (11-10-0503)Hemodialysis Catheters: How to KeepYours Working Well (English 11-10-0302;Spanish 11-10-0305)Hemodialysis: What You Need to Know(11-50-0214)Home Hemodialysis (11-10-0329)Kidney Transplantation (11-10-0304)If You Choose Not to Start DialysisTreatment (11-10-0330)Nutrition and Hemodialysis (11-50-0136)WWW.KIDNEY.ORG23

Staying Fit With Chronic Kidney Disease(11-10-0331)Travel Tips for Kidney Patients(11-10-0513)What You Need to Know About DialyzerReuse: A Guide for HemodialysisPatients and Their Families (11-10-0335)When Stopping Dialysis is Your Choice(11-10-0331)Working With Kidney Disease:Rehabilitation and Employment(11-10-0501)24NATIONAL KIDNEY FOUNDATION

MY DIALYSIS CARE TEAMNephrologist (kidney doctor):name:phone:Primary care nurse:name:phone:Dietitian:name:phone:Social worker:name:phone:Patient care technician:name:phone:Access surgeon:name:phone:WWW.KIDNEY.ORG25



The National Kidney Foundation is the leadingorganization in the U.S. dedicated to theawareness, prevention, and treatment of kidneydisease for hundreds of thousands of healthcareprofessionals, millions of patients and theirfamilies, and tens of millions of Americans at risk.Help fight kidney disease.Learn more at www.kidney.org30 East 33rd StreetNew York, NY 10016800.622.9010 2006 National Kidney Foundation, Inc. 11-50-0216 IBD

AV GRAFT PROS AND CONS Pros: Provides excellent blood flow once it is ready to use You can take showers once the access heals after surgery. Cons: Lasts less time than an AV fistula More prone to infection than an AV fistula Needs at least two weeks b