Friday, October 30, 2009

A patient asks, "Why should I get a fistula months before I need dialysis?"

I have a lovely 65-year-old patient with a history of diabetes and high blood pressure--the two leading causes of kidney failure. We have been following her kidney function by way of her blood tests for several years. Last summer, we could see that her "eGFR," or "estimated glomerular filtration rate" was hovering a bit above 15. A normal eGFR is well over 60.

I have been taught that most diabetic patients will need serious dialysis planning by the time their eGFRs are 15, and non-diabetics by the level of 10. (Your doctor may give you different guidelines; listen to him/her for information re: your situation!)

To begin dialysis (kidney machine) treatments, you must have "access." This means a catheter surgically placed near the belly button for Peritoneal Dialysis, or a surgically enlarged vein called a "fistula" usually in the arm. Both devices require take time to arrange, and time for the day surgery and necessary healing. And a fistula may take months to "mature" before it is ready to use!

In Steve's case, he became so sick so fast that we didn't have time for this elegant planning. As a result, he had a central line: an IV line the size of a finger placed in the internal jugular vein of his neck. While these lines are easy to use for dialysis--even Home Dialysis, they carry a serious risk of infection. These "line infections" can be life-threatening. One nephrologist told me, "It's not  a matter of if the central line becomes infected, it's a matter of when!"

So my wonderful patient now has both an Peritoneal Dialysis catheter--and a fistula--at the ready! She'll probably need dialysis soon, but when she does, nobody will be eyeing the blood vessels of her neck or upper chest!

What motivated her to get this done?

"Dr. Gromko," she said, "when you told me about Steve's IV in his neck, I knew you were serious!"

So, that's the story of "Fistula First!" If you know dialysis is on the way, prepare for it by ensuring usable dialysis access before the fact. It's a matter of living longer and living better! Linda Gromko, MD

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