What nephrologists need to know about vascular access cannulation.

This article describes cannulation events, especially problems, common and rare, minor and major, to aid the nephrologist (and mid-level providers e.g. nurse practitioner and physician's assistant) in decision-making to prevent or treat cannulation-related adverse outcomes. The usual management, potential outcomes, nephrologist intervention, and prevention are discussed and include: assessment of arteriovenous (AV) access and readiness for cannulation; initial cannulation of both arteriovenous fistulas and grafts; needle size and adequacy; needle direction and potential for recirculation; limited cannulation sites/buttonhole; pain and fear of pain; prevention of bleeding; management of infiltrations/extravasations; prevention and management of "one-site-itis"; prevention and management of infection. It concludes with the importance of the medical director as the leader of the continuous quality improvement (CQI) team in preventing/reducing cannulation-related adverse events.

Self-cannulation: enabling patients' independence.

Home hemodialysis was a modality of necessity in the early days of chronic renal replacement therapies. Patients had to be independent for all aspects of their care including self-cannulation of the hemodialysis needles. As the number of in-center staff provided hemodialysis centers has grown, the level of independence for hemodialysis patients has drastically decreased. Recent changes by the United States Centers for Medicare and Medicaid Services in the 'Conditions of Coverage for ESRD' encourages all US dialysis facilities to offer and allow patients to perform their own needle cannulation. This article briefly reviews the advantages and disadvantages of patient self-cannulation. Self-cannulation can be a stepping stone to patient independence including home hemodialysis modality.

Hemodialysis catheter-associated endocarditis: clinical features, risks, and costs.

Endocarditis associated with vascular access catheters for hemodialysis (HD) is a catastrophic but not widely appreciated phenomenon. Its current incidence, clinical outcome, and associated costs are not easily ascertained. Increasing use of tunneled catheters for HD access may result in a larger pool of patients at risk for endocarditis. We present two representative cases, review recent trends, and assess the current potential for additional cases.