S. aureus infection almost seven-times higher for patients with buttonhole cannulation for dialysis
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Published research suggests access-related Staphylococcus aureus bacteremia rates were nearly seven-times higher for patients on hemodialysis who were cannulated using the buttonhole needling technique compared with stepladder/area puncture.
“Staphylococcus aureus is the leading cause of bacteremia in [hemodialysis] HD patients and is associated with severe complications such as endocarditis and osteomyelitis,” Rie Glerup, MD, of the department of nephrology at Aalborg University in Denmark, and colleagues wrote. “The pathogen is the main cause of infectious morbidity related to vascular access in HD patients and often causes patient death.”
The researchers argued the possible advantages of buttonhole cannulation — including longer arteriovenous fistula patency and fewer necessary access interventions — have not been “convincingly documented,” with more evidence indicating buttonhole cannulation increases risk of infection.
They conducted a prospective multicenter observational cohort study of 286 patients who received in-center hemodialysis in Denmark (144 cannulated with the buttonhole technique). Primary endpoints of the study were rates of access-related S. aureus bacteremia, as well as the HR for the first access related S. aureus bacteremia with the buttonhole technique compared with the HR for stepladder/area needling.
Patients in the buttonhole group were followed for a mean of 783 days, while those in the stepladder/area group were followed for a mean of 667 days. During follow-up, researchers identified 48 episodes of access-related S. aureus bacteremia. Of these, 43 patients (90%) were in the buttonhole group and five (10%) were in the stepladder/area group. In addition, the HR for the first access-related S. aureus bacteremia was significantly higher for buttonhole cannulation vs. stepladder/area needling (unadjusted HR 6.8; adjusted HR = 8.4)
“The data suggest that it might be advisable to identify and characterize the group of patients suitable for buttonhole cannulation to implement strict selection criteria,” the researchers wrote. “In our HD facilities, buttonhole and stepladder/area cannulation techniques have been equal first choices in in-center HD patients; however, the results question the use of buttonhole cannulation as a first choice. An individual restrictive attitude is recommended, with buttonhole as a second alternative to area technique when stepladder cannulation is not feasible.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Judy A Geissler, DNP, APNP, FNP-BC,CNN
The 2019 KDOQI practice guidelines for vascular access have been released and cannulation and the risk of infection for the dialysis patient continues to be a topic of discussion. What does the future hold for specific cannulation techniques for the AVFs and the new endovascular AVFs?
The KDOQI guidelines addressed many vascular access issues including rope and ladder (RL) and buttonhole (BH) cannulation techniques for the AVFs. Guideline 11 addresses cannulation and recommended (conditional recommendation, moderate quality of evidence) that RL technique is preferred for cannulation of AVFs (Lok CE, Huber TS, Lee T, and colleagues, 2020). The KDOQI clinical practice guideline’s expert recommendation is that the buttonhole technique should be utilized in special circumstances due to the higher rate of infection.
What rational is used to determine which cannulation techniques is the best? The KDOQI guidelines suggested that patient satisfaction does not differ significantly between RL or BH cannulation. Do we have to take into consideration the expertise of cannulators, access disinfection, scab removal techniques, patient age, immune status, or frequency of dialysis? In this paper, Glerup and colleagues completed a prospective multicenter study in Denmark. Five hemodialysis units participated in the study with a total of 286 patients, of which 144 were cannulated utilizing the BH cannulation. The study concluded that the BH cannulation had a high rate of Staphylococcus aureus bacteremia infections. Of the 48 infections reported, 43 (90%) were cannulated with the BH technique, whereas 5 (10%) were cannulated with the RL.
The study’s recommendation suggested that there should be specific assessment criteria for patients prior to the utilization of BH cannulation. As providers, we must continue to offer individualized treatment plans for our patients.
As new studies are completed and new technologies emerge, including the endovascular AVF’s, this will be a topic that will require further discussion.
Reference:
Lok CE, et al. Am J Kidney Dis. 2020;75(4): S1-S164.
Vascular Access Society of America
Committee member
National Kidney Foundation of Wisconsin
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