The answer for the dialysis quiz from June 10, 2012 is A. A left AV fistula and right-sided internal jugular catheter is most appropriate in this right-handed patient who needs acute and chronic dialysis access. Short-term use of subclavian catheters is associated with a higher incidence of venous stenosis and should be avoided. The more thorny question is whether for an elderly patient and AV graft should be utilized - the thinking here is that if the patient has limited longevity a graft can be used very quickly (in 1 to 2 weeks time) and one doesn't have to wait for the 3 to 6 months for an AV fistula to mature. The key issue in decision-making is what other co-morbidities the patient has (e.g., an underlying terminal cancer etc). In general, though, an AV fistula is preferred.
A 75-year man is evaluated in the emergency department for nausea, vomiting, and weakness. He has no history of kidney disease. BUN is 160 mg/dL, and serum creatinine is 13 mg/dL. Ultrasound examination reveals small kidneys without obstruction or stones. You believe hemodialysis should be initiated promptly and expect the patient to need chronic dialytic therapy. After discussing therapeutic options with him, he concurs that chronic hemodialysis would best suit his needs. You consult a vascular surgeon for placement of both temporary and permanent angioaccess.
Which of the following would be the optimal combination for this right-handed patient?
A. A left forearm primary arteriovenous fistula and a right internal jugular tunneled cuffed catheter
B. A right forearm primary arteriovenous fistula and right internal jugular tunneled cuffed catheter
C. A left subclavian noncuffed catheter and a right forearm synthetic arteriovenous graft
D. A right subclavian noncuffed catheter and a left forearm primary arteriovenous graft