“Fistula First” Keeps Life-saving Options Open!

Linda Gromko, MD.

Linda Gromko, MD.

By Linda G., M.D. — Guest Blogger

Check Out Recent CDC Recommendations on Reducing Infections

The Centers for Disease Control and Prevention (CDC) announced in May 2013 results from a multi-center study on prevention of bloodstream infections in dialysis patients. The problem is enormous: during the study, 37,000 infections occurred in dialysis patients with central lines, at a cost of over $23,000 per admission. Dialysis patients also have a greater risk of contracting infections with resistant bacteria such as MRSA – and developing accompanying complications such as endocarditis (heart valve infection) and osteomyelitis (bone infection). Not to mention a significant mortality risk!
According to CDC Director Tom Frieden, MD, MPH, “Dialysis patients often have multiple health concerns, and the last thing they need is a bloodstream infection from dialysis. These infections are preventable. CDC has simple tools that dialysis facilities can use to help ensure patients have access to the safe healthcare they deserve.”
Following specific prevention protocols reduced the incidence of blood stream infections by over half. (Ref: http://www.cdc.gov/media/releases/2013/p0513-dialysis-infections.html)

What are some of the recommendations that reduce bloodstream infections?
It’s not rocket science! It’s often common sense (which we know isn’t all that common anywhere). Here are some examples:
• When possible, start hemodialysis via a fistula or graft – rather than a central IV line. Central line infections are more serious, but we know that 80% of new dialysis patients start with a central line – rather than a safer fistula or graft.
• Use the CDC Checklists for preparing for dialysis, and for attaching and disconnecting blood lines.
• Wash your hands!
• Wear clean gloves.
• Use a proper antiseptic such as chlorhexidine for cleaning access ports.
• Apply an appropriate antimicrobial ointment to the catheter or cannula exit-site, as recommended by your dialysis center.

More Personal Reflections on the concept of “Fistula First:”
For perspective, let me share with you the story of my late husband Steve and his first experience with hemodialysis.
When Steve was diagnosed with Chronic Kidney Disease Stage IV, we knew he was heading for kidney dialysis. The years of Type 2 Diabetes and high blood pressure had taken their toll on his kidneys. But we were expecting a timeline of months to years before dialysis would be needed.
Nothing could have prepared us for his very precipitous fall into End Stage Renal Failure!
Hit all at once with a sinus infection, bronchitis, and a dental abscess, Steve’s fragile balance tumbled out of control. He gained thirty pounds in two weeks. His creatinine rose from an already abnormal level of 4 to a high of 11 (normal is about 1). He became breathless, unsteady, and his body became twitchy. With arms outstretched and wrists flexed upward, Steve’s hands would flap repeatedly, exhibiting a medical phenomenon called “asterixis.” This was an ominous sign of nervous system irritability – associated with a variety of conditions including renal shutdown.
I remember the details so well.
“Sitting in the ER playing “Hangman” with me to pass the time, Steve looked bloated, yellow-gray, and scared to death. His speech was thick; the content was loopy but funny. Ironically, he lost our Hangman game on the word “urination.” The ER doctors noted his lab numbers to be “impressive” (a euphemism for “awful).”*
Steve was admitted emergently, with dialysis to start the next morning through a central catheter placed in the internal jugular vein in his neck.

What’s wrong with this picture?
While under nobody’s control, Steve’s rapid fall into CKD-5 eliminated any possibility of planning ahead! Had there been more warning, Steve would have been advised to get a fistula surgically created for hemodialysis or a peritoneal catheter placed for peritoneal dialysis.
He would have had the opportunity to weigh out his options for dialysis type. More importantly, there would have been time for access routes to heal and mature as he got ready to start dialysis.
But the real take-home message here is that central catheters carry a high risk of blood stream infections (septicemia). In fact, patients receiving dialysis treatments through central lines have a two-to-three-fold increase in admissions for infection and for death due to infectious complications!
I know that Steve’s urgent need for a central line was non-negotiable; we just didn’t have warning. But I believe the majority of patients do have warning, and time to plan.
If you or a loved one is moving toward dialysis, talk to your nephrologist about planning ahead. And if you’re on dialysis now, make sure the techniques used by you or your dialysis center are up to the CDC standards!
*Gromko, Linda, Complications: A Doctor’s Love Story. Bainbridge Books, 2009. Pages 32-33.

Linda Gromko MD is a Seattle family doctor who assisted her husband with both home hemodialysis and peritoneal dialysis for three-and-a-half years prior to his death in 2011. She is the author of three books pertaining to kidney disease and dialysis from a patient and family perspective.


  1. Blenda Minor says:

    I do appreciate your sharing. This is one of the few posts I can appreciate, now two years two months into dialysis.

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