LETTER TO EDITOR
Year : 2006 | Volume
: 17 | Issue : 2 | Page : 231--232
Emergency Hemodialysis through Arterial Accesses: A Potential Controversy
Consultant Nephrologist, North Western Armed Forces Hospital, P.O. Box 100, Tabuk, Saudi Arabia
Consultant Nephrologist, North Western Armed Forces Hospital, P.O. Box 100, Tabuk
|How to cite this article:|
Abutaleb N. Emergency Hemodialysis through Arterial Accesses: A Potential Controversy.Saudi J Kidney Dis Transpl 2006;17:231-232
|How to cite this URL:|
Abutaleb N. Emergency Hemodialysis through Arterial Accesses: A Potential Controversy. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2021 Mar 5 ];17:231-232
Available from: https://www.sjkdt.org/text.asp?2006/17/2/231/35797
To the Editor:
Here is a personal experience that I would appreciate if shared by other colleague nephrologists. What would any colleague do when faced with an ESRD patient with no feasible vascular or peritoneal access? Over the last eight years of working as a consultant nephrologist at Tabuk, Saudi Arabia, I have faced five dialysis patients with no available vascular or peritoneal accesses. On these occasions, I resorted to arterial hemodialysis with dialysis lines inserted generally through femoral arteries. On one occasion, (for one single dialysis session) a carotid artery was cannulated for the purpose of hemodialysis. Informed consents were obtained from all patients prior to arterial dialysis line insertion. Stress on possible development of leg/central nervous system infarction was stressed. The lines utilized were the regular dual lumen hemodialysis catheters.
All patients were administered a prophylactic dosage of low molecular weight heparin (LMWH) (tanzaparin 4500 units s.c once daily). Most patients needed to stay on such dialysis for 2-3 months except for one patient (the only one dialyzed through carotid artery) who received a single dialysis session. No line (arterial) related complications developed during the above periods of arterial line usage. All patients (except one), however, died after about 2-3 months of receiving their regular hemodialysis through the arterial catheters.
Patients were, generally, fragile elderly individuals on maintenance dialysis with ongoing sepsis secondary to extensive (infected) deep bedsores and recurrent episodes of aspiration pneumonia. Peritoneal dialysis was not feasible. Two of the patients were middle aged females. The first female patient was originally on hemodialysis and shifted (by other colleagues in another hospital) into peritoneal dialysis therapy after she lost all her possible vascular access sites. She was then admitted to our hospital for the first time with prolonged fungal peritonitis. Combined antifungal therapy for one month failed to control the problem of peritonitis. Based on the results of earlier extensive evaluation by a vascular surgeon, and current refusal by surgery colleagues to consider her for even open line insertion, the patient was then shifted to hemodialysis through femoral artery catheter. The infected PD catheter was then removed. The aim was to re-introduce the PD catheter/dialysis 6-8 weeks later. However, the patient died two months later from overwhelming septicemia; the primary source of infection was not clear but did not seem to be secondary to line infection.
The second middle aged female patient was on maintenance hemodialysis through a permcath (as her last resort). Renal transplantation was contraindicated because of extensive bronchiectasis (post tuberculous). She required dialysis several years ago and no patent central vein could be identified. Peritoneal dialysis line insertion could not be done because of refusal of surgical and anesthetic colleagues in view of resistant, progressive hyperkalemia despite provision of maximum measures to control the same. Late that night, a single hemodialysis session through an arterial line has allowed this patient to survive on peritoneal dialysis for five years further (she died recently at home).
Cannulating central arteries (mainly femoral arteries) for the purpose of hemodialysis is a very risky and unacceptable procedure. However, this attitude may be questioned when the only alternative measure to this procedure is letting the patient die because of losing all dialysis accesses. Such instances, of course, will not be reached till losing both peritoneal membrane and all potential vascular access sites. Urgent renal transplantation is rarely feasible. It is usually contraindicated in such patients. The choice for arterial hemodialysis might be eased slightly by remembering the earlier practice of continuous arterio-venous hemofiltration (CAVH) and by the fact of relative rarity of reporting problems secondary to arterials lines in the ICU settings. I might also indicate here an old observation from a vascular surgery colleague who stated that he had noticed upon central lines removal that many of them were in fact arterial lines. I have not verified this observation; but it eased the consideration of arterial hemodialysis for real life saving situations. One difference, however, need to be remembered all the time. The 'venous' flow in the arterial dialysis will be directed distally, while that in CAVH is directed into the venous circulation. The distal limb circulation rather than the pulmonary bed (supported by the independent bronchial circulation) would receive any embolization. Risk of in-situ thrombosis may not be different from that associated with CAVH. In conclusion, I herewith forward this controversial suggestion for possible consideration by nephrology colleagues as last temporary resort. It might make impossible dialysis possible till more definitive measures can be planned.