Arteriovenous fistula recirculation in hemodialysis
- Michael Berkoben, MD
Michael Berkoben, MD
- Associate Professor of Medicine
- Duke University Medical Center
- Peter J Blankestijn, MD
Peter J Blankestijn, MD
- Associate Professor in Nephrology
- University Medical Center, Utrecht, The Netherlands
- Section Editor
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
Hemodialysis access recirculation is an important cause of inadequate dialysis delivery to individual patients. It is important to diagnose recirculation in order to optimize dialysis delivery. In addition, screening for recirculation may be used as a surveillance technique for the early detection of fistula stenosis, the correction of which may prevent thrombosis.
This topic reviews hemodialysis access recirculation. Other causes of decreased dialysis delivery are discussed elsewhere. (See "Prescribing and assessing adequate hemodialysis".)
Other methods of surveillance of fistulas and grafts to prevent thrombosis are discussed elsewhere. (See "Monitoring and surveillance of hemodialysis arteriovenous fistulas to prevent thrombosis" and "Monitoring and surveillance of hemodialysis arteriovenous grafts to prevent thrombosis".)
DEFINITION AND MECHANISM
Hemodialysis access recirculation occurs when dialyzed blood returning through the venous needle re-enters the extracorporeal circuit through the arterial needle, rather than returning to the systemic circulation (figure 1).
The re-entry of dialyzed blood into the extracorporeal circuit reduces solute concentration gradients across the dialysis membrane by mixing already dialyzed blood with undialyzed blood. Such mixing reduces the efficiency of dialysis. Significant recirculation can lead to a discrepancy between the amount of hemodialysis prescribed (prescribed Kt/V urea) and the amount of hemodialysis delivered (delivered Kt/V urea). (See "Prescribed versus delivered dialysis: Importance of dialysis time" and "Prescribing and assessing adequate hemodialysis", section on 'Causes of inadequate dialysis'.)
- Dinwiddie LC, Ball L, Brouwer D, et al. What nephrologists need to know about vascular access cannulation. Semin Dial 2013; 26:315.
- Basile C, Ruggieri G, Vernaglione L, et al. A comparison of methods for the measurement of hemodialysis access recirculation. J Nephrol 2003; 16:908.
- Coyne DW, Delmez J, Spence G, Windus DW. Impaired delivery of hemodialysis prescriptions: an analysis of causes and an approach to evaluation. J Am Soc Nephrol 1997; 8:1315.
- Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
- Brancaccio D, Tessitore N, Carpani P, et al. Potassium-based dilutional method to measure hemodialysis access recirculation. Int J Artif Organs 2001; 24:606.
- Sherman RA, Matera JJ, Novik L, Cody RP. Recirculation reassessed: the impact of blood flow rate and the low-flow method reevaluated. Am J Kidney Dis 1994; 23:846.
- Sherman RA. The measurement of dialysis access recirculation. Am J Kidney Dis 1993; 22:616.
- Depner TA, Rizwan S, Cheer AY, et al. High venous urea concentrations in the opposite arm. A consequence of hemodialysis-induced compartment disequilibrium. ASAIO Trans 1991; 37:M141.
- Carson RC, Kiaii M, MacRae JM. Urea clearance in dysfunctional catheters is improved by reversing the line position despite increased access recirculation. Am J Kidney Dis 2005; 45:883.
- Atherikul K, Schwab SJ, Conlon PJ. Adequacy of haemodialysis with cuffed central-vein catheters. Nephrol Dial Transplant 1998; 13:745.
- Depner TA, Krivitski NM, MacGibbon D. Hemodialysis access recirculation measured by ultrasound dilution. ASAIO J 1995; 41:M749.
- Senécal L, Saint-Sauveur E, Leblanc M. Blood flow and recirculation rates in tunneled hemodialysis catheters. ASAIO J 2004; 50:94.
- Pannu N, Jhangri GS, Tonelli M. Optimizing dialysis delivery in tunneled dialysis catheters. ASAIO J 2006; 52:157.