Dialysis Access and Complications: PA/Medical Student Handout
Learning Objectives
By the end of this module, students will be able to:
- Assess vascular access for functionality (bruit, thrill, flow adequacy)
- Identify common vascular access complications and distinguish between them
- Understand PICC line contraindications and permanent vascular damage they cause
- Describe evidence-based antibiotic dosing adjustments for dialysis patients
- Recognize and manage catheter-related infections
- Apply pharmacokinetic principles to extended-interval dosing strategies
Section 1: Vascular Access Assessment
Clinical Examination Techniques
Bruit (Auditory Assessment)
Definition: Whooshing sound created by turbulent flow through access
Technique: 1. Place stethoscope diaphragm directly over access 2. Listen for a low-pitched, continuous bruit (systolic and diastolic) (KDOQI 2019, Table 13.1) 3. Normal finding indicates adequate flow
Absence of bruit suggests: - Access clotting - Severe stenosis - Low flow state
Clinical Pearl: All functioning accesses should have an audible bruit. Absence is a RED FLAG for access dysfunction.
Thrill (Palpatory Assessment)
Definition: Vibration palpable over access from turbulent flow
Technique: 1. Place fingertips over access segment 2. Feel for continuous vibration synchronous with pulse 3. Should extend entire length of accessible access
Absence of thrill indicates: - Access clotting - Severe stenosis - Insufficient flow
Clinical Pearl: Stenosis changes the character of the thrill and bruit before it removes them: the thrill becomes weak, discontinuous, or systolic-only, and the bruit becomes high-pitched. Complete loss of both thrill and bruit is thrombosis until proven otherwise (KDOQI 2019, Tables 13.1-13.2). Serial assessment helps detect deterioration.
Flow Assessment
Qualitative: Observe needle cannulation and blood drawing - Brisk flow = adequate (>500-600 mL/min typical) - Sluggish flow = concerning (may indicate stenosis or poor needle placement) - Difficulty drawing blood = access malfunction until proven otherwise
Quantitative: Access flow studies (ultrasound dilution or thermal dilution) - Normal fistula flow: 800-1200+ mL/min - Normal graft flow: 600-1000 mL/min - Catheter: 300-400+ mL/min (dependent on lumen size) - Low (for example <500 mL/min) or falling flow: re-examine the access and look for clinical indicators of dysfunction. KDOQI 2019 treats flow measurement as supplementary to the physical exam and does not recommend intervention on a flow number alone (KDOQI 2019, Statements 13.4-13.7)
Section 2: Vascular Access Types
Arteriovenous Fistula: The Gold Standard
Surgical Anatomy: - Direct connection between artery and vein (no synthetic material) - Most commonly: radial artery to cephalic vein (forearm) - Alternative: brachial artery to basilic vein (upper arm) - Requires surgical creation under local or general anesthesia
Maturation Process:
| Timeline | Changes | Readiness |
|---|---|---|
| Week 1-2 | Acute dilation begins; no cannulation | Not ready |
| Week 3-4 | Progressive dilation; vein thickens | Approaching readiness |
| Week 4-6 | Maturation assessment (KDOQI 2019) | Cannulate when clinically ready |
| Not maturing as expected | Failure to mature is common | Refer for further investigation |
Why the wait: Vein must develop sufficient diameter (>4-5 mm) and wall thickness to withstand needle punctures and maintain hemostasis. Readiness is a clinical judgment, not a calendar date: KDOQI 2019 asks for a maturation assessment by 4-6 weeks (Statement 10.1) (KDOQI 2019), and cannulation within 14 days of creation was associated with a 2.1-fold higher risk of fistula failure (Rayner 2003).
Advantages: - Longest survival (10-15+ years possible) - Lowest infection rates - Highest achievable blood flow rates (400-600+ mL/min) - Avoidance of synthetic material
Disadvantages: - Cannot use immediately (wait required) - Requires advance planning before ESRD - Risk of steal syndrome with distal ischemia - Cardiac effects from high flow (right heart strain) - Requires adequate native vessels (rules out patients with prior dialysis catheter damage)
Complications:
| Complication | Mechanism | Management |
|---|---|---|
| Steal syndrome | Excessive flow diverts distal blood | Access ligation or revision; distal revascularization |
| Aneurysm | Repeated needle trauma; vein wall weakening | Surgical repair if symptomatic or expanding |
| Stenosis | Intimal hyperplasia at arterial or venous anastomosis | Angioplasty; surgical revision if severe |
| Thrombosis | Clot formation in fistula | Thrombectomy; re-evaluation for cause |
Arteriovenous Graft: Bridge Solution
Composition: Synthetic conduit (usually PTFE - polytetrafluoroethylene) connecting artery to vein
Advantages: - Faster maturation (2-4 weeks) - Can be used sooner than fistula - Option when native vessels inadequate
Disadvantages: - Higher infection rates than fistula (synthetic material provides bacterial nidus) - Higher thrombosis risk (stenosis develops more readily) - Shorter lifespan (typically 3-5 years vs. 10+ for fistulas) - Cannot place if previous PICC or central catheter damage present
Complications:
| Complication | Incidence | Characteristic |
|---|---|---|
| Infection | Bloodstream infection 0.39 per 100 patient-months (fistula 0.26; catheter 2.16) (NHSN 2014) | Higher than fistula; often requires graft removal |
| Thrombosis | More common than in fistulas | Often preceded by stenosis |
| Stenosis | Common | Usually at venous anastomosis |
| Pseudoaneurysm | Less common than fistula | Risk of rupture; requires repair |
Central Venous Catheter (CVC): Temporary Solution
Placement: Tunneled catheter, usually internal jugular vein (IJ) - Dual-lumen design allows simultaneous blood withdrawal and return - Subcutaneous tunnel reduces infection risk vs. non-tunneled catheters
Indications: - Acute dialysis initiation - Permanent access failure or maturation delay - Temporary use while fistula/graft matures - Patients without vascular access options
Advantages: - Immediate access (can use at insertion) - No vascular anatomy requirements - Suitable for acute situations
Disadvantages: - Highest infection rates: bloodstream infection 2.16 per 100 patient-months with a catheter vs 0.26 with a fistula (NHSN 2014); catheter-related bloodstream infection 1.1 to 5.5 per 1,000 catheter-days (Flythe 2024) - Risk of central venous stenosis/thrombosis - Mechanical dysfunction (kinks, clots) - Limitation to blood flow (approximately 300-400 mL/min typical)
Complications:
| Complication | Incidence | Prevention |
|---|---|---|
| Catheter-related bloodstream infection (CRBSI) | Most common | Aseptic technique; chlorhexidine hub and exit-site care; prophylactic antibiotic locks only for selected high-risk patients (KDOQI 2019 Statement 24.3), because resistance emerges (Landry 2010) |
| Central venous stenosis | Common; reported rates vary widely. Subclavian and internal jugular catheters, especially multiple or long-term ones, are the main cause (Agarwal 2013) | Avoid subclavian; prefer IJ; limit dwell time |
| Thrombosis | Common cause of catheter dysfunction; reported rates vary | Heparin or citrate lock and regular flushing; KDOQI 2019 recommends against prophylactic systemic anticoagulation for catheter patency (Statement 21.8) (KDOQI 2019) |
| Mechanical dysfunction | Common | Proper fixation; avoid kinks |
| Arrhythmias | Rare | From catheter malposition near SA node |
Clinical Pearl: Limit catheter use to temporary situations when possible. Each day of catheter use increases infection risk and damages future access options.
Section 3: Devastating Impact of PICC Lines in Dialysis Patients
The PICC Line Problem: A Cautionary Tale
PICC Line Definition: Peripherally inserted central catheter; placed through peripheral vein (usually basilic or cephalic), advanced to central circulation
Vascular Damage Statistics
Central Venous Stenosis/Thrombosis: - Post-PICC stenosis: 7% of dialysis patients - Central and peripheral vein abnormalities: 7.5% overall - Pre-post venography: 4.8% develop central stenosis; 2.7% complete central occlusion
Thrombosis Incidence (Most Damaging): - Overall venographic detection: 23-57% in dialysis patients - By site: - Cephalic vein: 57% thrombosis (destroys best fistula vein!) - Basilic vein: 14% thrombosis (alternative fistula vein) - Brachial vein: 10% thrombosis
Hazard Ratios for Upper Extremity Deep Vein Thrombosis: - PICC recipients: 10-fold increased hazard (HR 10.49, 95% CI 5.23-21.04) - Overall VTE risk: 3-fold increase
Impact on Dialysis Access Creation
The Catastrophic Problem: Damaged vessels cannot support arteriovenous fistula
Evidence: - Prior PICC use: lack of a functioning AVF about 3 times as likely (OR 3.2, 95% CI 1.9-5.5; adjusted OR 2.8, 95% CI 1.5-5.5) in a case-control study of 282 HD patients (El Ters 2012) - Case-control analysis: 44% without functioning AVF had prior PICC vs. only 20% with successful AVF
Why This Matters: Damaged vessels mean: - Failed fistula creation attempts - Forced dependence on AVG or catheter - Chronic infection risk - Repeated access procedures and surgeries - Permanent compromise of future options
Professional Guidelines
All major organizations strongly discourage PICC placement:
KDOQI 2019 Update (Statement 6.10, Expert Opinion): Protect all central and peripheral veins in patients with CKD G3-G5 or on dialysis, avoiding PICCs and unnecessary venipuncture (KDOQI 2019). The often-quoted wording that forearm and upper-arm veins in CKD stage 4 or 5 “should NOT be used for venipuncture or placement of PICC lines” (with a “Grade B” label) is not in the 2019 update, which does not use letter grades.
Rationale: Preserves “ESKD Life-Plan” - comprehensive care ensuring available dialysis options throughout life
American Academy of Family Physicians - Choosing Wisely: > “Don’t place central lines or PICCs in pediatric patients with advanced CKD without nephrology consultation”
Goal: Avoid adverse events, preserve long-term access, prevent unnecessary costly procedures
Society of Interventional Radiology & Infectious Diseases Society of America: - Recommend tunneled catheters over PICCs for central access >3 weeks duration - Explicitly note thrombosis risks
Clinical Pearl
There is NO good reason to place PICC in a dialysis patient. Superior alternatives exist that don’t damage future access options.
Section 4: Superior Alternatives to PICC Lines
Strategy 1: Use Existing Dialysis Access
Optimal approach for patients with functioning fistula or graft: - Administer antibiotics during scheduled dialysis sessions - No additional catheter required - Eliminates infection risk from additional access - Preserves all veins for future options - Improves quality of life (no daily hospital visits or home infusion setup)
Works best with: - Extended-interval antibiotics (daptomycin, ceftriaxone) - 3x/week dosing aligned with dialysis schedule - Thrice-weekly post-dialysis dosing
Strategy 2: Small-Bore Tunneled Internal Jugular Catheter
Design: 4-6 French tunneled catheter (much smaller than dialysis catheters)
Advantages over PICC: - Longer functional duration (weeks to months vs. days to weeks) - Avoids peripheral and subclavian veins (preserves forearm/upper arm vessels) - Compatible with antibiotic lock therapy - Minimal vascular trauma - No evidence of symptomatic central venous thrombosis when placed via IJ approach
Disadvantages: - Requires separate procedure for placement - Daily access increases infection risk vs. dialysis-integrated approach - Not suitable for long-term (months) use
Technical advantage: IJ placement superior to subclavian (which causes 42% stenosis rate)
Strategy 3: Antibiotic Lock Therapy
Concept: High-concentration antibiotic solution instilled into catheter lumen between uses
Standard Preparations: - Vancomycin 5 mg/mL OR ceftazidime 0.5 mg/mL (IDSA 2009, Table 9) - Combined with heparin (anticoagulation) - Dwell throughout interdialytic period
Efficacy: - Eradicates biofilms within catheter - Catheter salvage depends on the organism: 87-100% for Gram-negative bacilli, 75-84% for S. epidermidis, only 40-55% for S. aureus (IDSA 2009; Poole 2004) - A treatment lock, given with systemic antibiotics for 10-14 days, treats an established catheter infection when the catheter must stay; it is not the same as prophylaxis
Mechanism: Lock concentrations far exceed systemic levels; vancomycin is used at a concentration at least 1,000 times the organism’s MIC (IDSA 2009)
Section 5: Pharmacokinetic Principles for Dialysis Patients
Why Standard Dosing Fails
Problem: Drugs eliminated by kidney function and dialysis in ways that differ from patients with normal renal function
Key Principle: Dialysis REMOVES some drugs but not others: - Highly protein-bound drugs: Not dialyzable (>90% bound) - Large molecular weight drugs: Not removed by standard dialysis - Small, water-soluble drugs: Removed efficiently by all dialysis modalities - Middle-molecular-weight drugs: Partially removed; more with high-flux or HDF
Daptomycin Pharmacokinetics in ESRD
Normal renal function: - Half-life: 8-9 hours - Clearance: Primarily renal - Protein binding: 90-95%
ESRD (Dialysis Patients): - Half-life: 28-52 hours (3-6x prolongation!) - Clearance: Minimal renal excretion; 90-95% protein binding protects from dialysis - Clinical implication: Can use extended-interval dosing (48-72 hours)
Pharmacokinetic Evidence: - Daptomycin 6-9 mg/kg every 48 hours achieves area-under-curve comparable to normal daily dosing - Monte Carlo simulations support thrice-weekly post-dialysis administration at 10-12 mg/kg - Clinical validation: Successful treatment of complex cases including vancomycin-resistant enterococcal prosthetic valve endocarditis
Dosing Strategy: 8-10 mg/kg every 48 hours OR 12 mg/kg every 72 hours post-dialysis
Ceftriaxone Pharmacokinetics in ESRD
Normal renal function: - Half-life: 6-8 hours - Elimination: Renal (33-67%) + hepatic biliary (33-67%) - Protein binding: 83-95%
ESRD (Dialysis Patients): - Half-life: 14-17 hours (2-3x prolongation) - Plasma clearance: Decreases to 529-705 mL/h - Dialytic removal: Only 41% over 4 hours (poorly dialyzable despite moderate protein binding) - Result: Drug accumulation with repeated dosing
Population Pharmacokinetic Evidence: - Three-times-weekly post-dialysis 2-gram dosing maintains unbound concentrations above 1 mg/L for organisms with MIC ≤1 mg/L (98% probability) - Compatible with extended interval strategies
Safety Concern - Neurotoxicity: - Threshold: Serum concentrations >100 μg/mL - Risk factors: Age >60, hypoalbuminemia, hepatic dysfunction, duration >7 days - Manifestations: Confusion, myoclonus, seizures, choreoathetosis - Management: Discontinue; switch to alternative (meropenem, ciprofloxacin)
Clinical Pearl: Ceftriaxone neurotoxicity appears related to accumulation, not dose. Careful monitoring essential when extended-interval dosing used.
Extended-Interval Dosing Combinations
Daptomycin + Ceftriaxone (Standard Extended-Interval Regimen)
Dosing: - Daptomycin: 8-10 mg/kg every 48 hours post-dialysis - Ceftriaxone: 2 grams three-times-weekly post-dialysis
Evidence: - Pharmacokinetic modeling supports bactericidal activity comparable to daily regimens - Clinical validation: Successful treatment of vancomycin-resistant enterococcal endocarditis - Practical advantage: Both given during dialysis; no additional catheter needed
Monitoring: - Daptomycin: Weekly CPK (risk of myopathy); target trough >24.3 mg/L - Ceftriaxone: Serial neurological exams; therapeutic drug monitoring if available (target <100 μg/mL)
Teicoplanin (European Alternative)
Availability: Limited to Europe and Asia (not available in U.S.)
Pharmacokinetics: - Normal half-life: 50 hours - ESRD half-life: 83-182 hours (γ-phase elimination) - Protein binding: 90-95% - Dialytic clearance: Negligible
Dosing: - Loading: 6 mg/kg every 12 hours × 3 doses - Maintenance: 400-800 mg every 72 hours (every 3 days) - Alternative: 800 mg loading, then 400 mg on days 2, 3, 5, 12, 19
Advantages: Even more favorable extended-dosing pharmacokinetics than daptomycin
Evidence: 40-patient Italian cohort demonstrated excellent tolerance and efficacy
Section 6: Evidence-Based Antibiotic Therapy for Enterococcal Endocarditis in Dialysis Patients
Standard First-Line Therapy
Regimen: Ampicillin 2g every 4-6 hours + Ceftriaxone 2g every 12 hours × 6 weeks
Why This Combination? - Dual β-lactam approach superior to traditional gentamicin combinations - Landmark trial (Gavaldà, 43 patients): 67.4% clinical cure rate - Spanish multicenter trial: Equivalent efficacy to ampicillin-gentamicin with significantly less nephrotoxicity (0% vs. 23%, p<0.001) - Meta-analyses: Non-inferiority confirmed; reduced treatment discontinuation (OR 0.11, 95% CI 0.03-0.42)
Vascular Access for Standard Therapy: - Small-bore tunneled IJ catheter (4-6 French) - Allows daily infusions without peripheral vein damage - Requires 6 weeks of daily hospital/infusion visits OR complex home therapy setup
Limitations: - Ampicillin has substantial dialytic clearance (71%) and shorter ESRD half-life (17.4 hours) - Not suitable for 48-hour dosing intervals (subtherapeutic concentrations by hour 36) - Ceftriaxone dose-dependent neurotoxicity at daily 2g dosing for 6 weeks - Daily catheter access increases cumulative infection risk
Extended-Interval Alternative for Selected Patients
Target Population: - Hemodynamically stable patients - Non-complicated native valve endocarditis (no perivalvular abscess, no prosthetic valve) - Prioritize quality of life and reduced healthcare utilization - Good adherence likelihood
Regimen: Daptomycin 8-10 mg/kg every 48 hours + Ceftriaxone 2g three-times-weekly (both post-dialysis)
Advantages: - Eliminates need for additional catheter (uses existing dialysis access) - Reduces healthcare resource utilization - Improves patient quality of life (no daily visits; no home infusion setup) - Reduces cumulative infection risk from daily catheter manipulation - Pharmacokinetically sound per modeling studies
Evidence: - Daptomycin pharmacokinetics in ESRD support 48-hour dosing - Cephalosporin dosing studies validate thrice-weekly post-dialysis administration - Clinical case reports document successful treatment of complex cases
Monitoring Requirements: 1. Daily neurological assessment (ceftriaxone neurotoxicity risk) 2. Weekly CPK (daptomycin myopathy) 3. Blood cultures (clearance by 48-72 hours expected) 4. Echocardiography (vegetation size; complications) 5. Therapeutic drug monitoring when available
Why PICC Placement Is Absolutely Contraindicated
Reasoning: 1. Excellent alternative (dialysis access) available 2. Small-bore IJ catheter option if additional access needed 3. PICC causes permanent vascular damage (documented 7-57% thrombosis rates) 4. Damages vessels critical for future dialysis access 5. Professional guidelines unanimously prohibit PICC in CKD stage 4-5
Medico-Legal Implications: - Explicit guideline recommendations against PICC use - Clear documentation of superior alternatives - Predictable vascular complications - Healthcare system liability substantial if PICC complications occur - Recommendation: Hard stops in electronic ordering systems requiring nephrology approval for any patient with eGFR <60 mL/min/1.73m²
Section 7: Access Functionality Assessment and Monitoring
Pre-Dialysis Assessment Checklist
| Component | Assessment | Normal Finding | Concerning Finding |
|---|---|---|---|
| Bruit | Auscultation over access | Continuous whooshing | Absent → clotting/stenosis |
| Thrill | Palpation along access | Continuous vibration full length | Absent → thrombosis until proven otherwise; weak or discontinuous → stenosis (KDOQI 2019) |
| Appearance | Visual inspection | No unusual swelling/discoloration | Edema, erythema → infection |
| Temperature | Palpation | Warm; slightly elevated vs. contralateral arm | Cool → possible steal syndrome |
| Cannulation ease | Needle insertion | Brisk blood flow into tubing | Sluggish flow → access dysfunction |
| Hemostasis | Post-dialysis | Bleeding stops with pressure in <10 min | Prolonged bleeding → venous outflow stenosis (KDOQI clinical indicator), anticoagulation, or access trauma (KDOQI 2019) |
Access Flow Monitoring
Methods: 1. Qualitative (bedside): Observe cannulation difficulty, flow rate during treatment 2. Quantitative (ultrasound dilution or thermal dilution): Direct measurement of mL/min
Monitoring Frequency: - Physical examination before every cannulation (KDOQI 2019 Statement 11.1); access flow measurement (surveillance) is supplementary: KDOQI 2019 finds inadequate evidence to recommend routine surveillance for fistulas and does not suggest it for grafts (KDOQI 2019, Statements 13.4-13.5) - More frequent if clinical concern (loss of bruit/thrill, difficult cannulation)
Interpreting Flow Results: - Flow <500 mL/min or a falling trend: examine the access and look for clinical indicators; act on flow plus clinical findings, not flow alone (KDOQI 2019 does not recommend angioplasty of a stenosis without clinical indicators, Statements 13.6-13.7) - Flow <300 mL/min: Likely inadequate for standard dialysis - Progressive decline: Trend analysis important (acute drop vs. gradual decline)
Practice Questions
1. A patient on hemodialysis has a functioning AVF. You note loss of the previously palpable thrill over the access. What is the most likely diagnosis?
- Aneurysm formation
- Steal syndrome
- Access thrombosis
- Infection
Correct Answer: C) Access thrombosis A previously palpable thrill that is now absent means flow through the access has stopped: thrombosis until proven otherwise, which needs same-day escalation. Stenosis usually changes the character of the thrill first (weak, discontinuous, systolic-only) rather than abolishing it. Aneurysm and infection do not remove the thrill, and steal syndrome presents with hand ischemia (coolness, pain, numbness) (KDOQI 2019).
2. A dialysis patient with CKD stage 5 being treated for bacteremia is scheduled for PICC line placement for antibiotics. What is the appropriate response?
- Approve PICC placement as planned
- Consult nephrology to discuss alternatives before proceeding
- Obtain informed consent specifically for risk of central venous stenosis
- Place the PICC but limit dwell time to <3 weeks
Correct Answer: B) Consult nephrology to discuss alternatives before proceeding PICC lines are contraindicated in ESRD patients due to high thrombosis rates (23-57%) and damage to vessels critical for dialysis access. This patient should be offered alternatives: (1) administration via dialysis access if infection timing allows, or (2) small-bore tunneled IJ catheter if immediate daily dosing essential.
3. A 70-kg hemodialysis patient with enterococcal endocarditis (native valve) is stable. You propose extended-interval daptomycin dosing post-dialysis rather than ampicillin-ceftriaxone daily therapy. Which pharmacokinetic principle justifies this approach?
- Daptomycin is not removed by dialysis
- Daptomycin’s half-life is 3-6x longer in ESRD than normal renal function
- Daptomycin doesn’t require therapeutic drug monitoring
- All dialysis patients tolerate daptomycin better than ampicillin
Correct Answer: B) Daptomycin’s half-life is 3-6x longer in ESRD than normal renal function Daptomycin is highly protein-bound and has minimal renal clearance. In ESRD, its half-life extends from 8-9 hours to 28-52 hours, allowing 48-72 hour dosing while maintaining therapeutic levels. This justifies post-dialysis administration every 48 hours.
Key Takeaways
Access assessment: Bruit and thrill are critical clinical findings; a change in their character suggests stenosis, and complete loss suggests thrombosis
Access hierarchy: Fistula >> Graft >> Catheter in terms of infections, longevity, and flow
PICC prohibition: Absolutely contraindicated in dialysis patients; 23-57% thrombosis rates cause permanent vascular damage
Superior alternatives: Use dialysis access when possible; if additional access needed, small-bore IJ catheter
Pharmacokinetic principles: Extended drug half-lives in ESRD enable extended-interval dosing for highly protein-bound drugs
Extended-interval endocarditis therapy: Daptomycin + ceftriaxone post-dialysis practical alternative to daily ampicillin-ceftriaxone
Key References
- Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–S164. PMID: 32778223
- Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1–45. PMID: 19489710
- Poole CV, Carlton D, Bimbo L, Allon M. Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen. Nephrol Dial Transplant. 2004;19(5):1237–1244. PMID: 14993504
- Landry DL, Braden GL, Gobeille SL, et al. Emergence of gentamicin-resistant bacteremia in hemodialysis patients receiving gentamicin lock catheter prophylaxis. Clin J Am Soc Nephrol. 2010;5(10):1799–1804. PMID: 20595689
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601–608. PMID: 22704142
- Rayner HC, Pisoni RL, Gillespie BW, et al. Creation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study. Kidney Int. 2003;63(1):323–330. PMID: 12472799
- Nguyen DB, Shugart A, Lines C, et al. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol. 2017;12(7):1139–1146. PMID: 28663227
- Flythe JE, Watnick S. Dialysis for chronic kidney failure: a review. JAMA. 2024;332(18):1559–1573. PMID: 39356511
- Agarwal AK. Central vein stenosis. Am J Kidney Dis. 2013;61(6):1001–1015. PMID: 23291234
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