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Canadian Society of Nephrology Guidelines for the Management of Patients With ESRD Treated With Intensive Hemodialysis

2013; Elsevier BV; Volume: 62; Issue: 1 Linguagem: Inglês

10.1053/j.ajkd.2013.02.351

1523-6838

Gihad Nesrallah, Reem A. Mustafa, Jennifer M. MacRae, Robert P. Pauly, David N. Perkins, Azim S. Gangji, Jean‐Philippe Rioux, Andrew Steele, Rita S. Suri, Christopher T. Chan, Michael A. Copland, Paul Komenda, Philip A. McFarlane, Andreas Pierratos, Robert M. Lindsay, Deborah Zimmerman,

Muscle and Compartmental Disorders

Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research. Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research. Longer and more frequent (“intensive”) hemodialysis has emerged as desirable alternative treatment strategies for patients with end-stage renal disease (ESRD). Although there is significant variability in prescription practices, 3 pragmatically defined categories encompass the majority of intensive dialysis prescriptions used in Canada and elsewhere: short daily ( 18 years) patients with ESRD receiving intensive hemodialysis: 1For adult ESRD patients receiving intensive home hemodialysis with an AVF, we suggest the use of rope-ladder cannulation over buttonhole cannulation unless topical antimicrobial prophylaxis is used (See Recommendation 2). (Conditional recommendation; very low-quality evidence ⊕○○○).2For adult ESRD patients using buttonhole cannulation for intensive home hemodialysis, we suggest the use of mupirocin antibacterial cream to reduce the risk of infection. (Conditional recommendation; very low-quality evidence ⊕○○○).3For adult ESRD patients receiving intensive hemodialysis we suggest the use of arteriovenous access (AVF or AVG) over tunneled CVC for vascular access. (Conditional recommendation; very low-quality evidence ⊕○○○).4For adult ESRD patients receiving intensive hemodialysis using a CVC for access we suggest the use of “closed connector” devices over usual care. (Conditional recommendation, very low-quality evidence ⊕○○○).5For adult ESRD patients treated with long or long-frequent hemodialysis, we suggest using a dialysate calcium of 1.50 mmol/L or higher, to maintain a neutral or positive calcium balance, while avoiding predialysis hypercalcemia and oversuppression of PTH. (Conditional recommendation, very low-quality evidence ⊕○○○).6For adult ESRD patients treated with long or long-frequent hemodialysis, we suggest using a phosphate dialysate additive to maintain the predialysis phosphate in the normal range if hypophosphatemia persists after stopping phosphate binders and liberalizing the diet. (Conditional recommendation, very low-quality evidence ⊕○○○).Note: For the purpose of this CPG, intensive hemodialysis refers to any of the following: (1) short daily ( 18 years) patients with ESRD receiving intensive hemodialysis: 1For adult ESRD patients receiving intensive home hemodialysis with an AVF, we suggest the use of rope-ladder cannulation over buttonhole cannulation unless topical antimicrobial prophylaxis is used (See Recommendation 2). (Conditional recommendation; very low-quality evidence ⊕○○○).2For adult ESRD patients using buttonhole cannulation for intensive home hemodialysis, we suggest the use of mupirocin antibacterial cream to reduce the risk of infection. (Conditional recommendation; very low-quality evidence ⊕○○○).3For adult ESRD patients receiving intensive hemodialysis we suggest the use of arteriovenous access (AVF or AVG) over tunneled CVC for vascular access. (Conditional recommendation; very low-quality evidence ⊕○○○).4For adult ESRD patients receiving intensive hemodialysis using a CVC for access we suggest the use of “closed connector” devices over usual care. (Conditional recommendation, very low-quality evidence ⊕○○○).5For adult ESRD patients treated with long or long-frequent hemodialysis, we suggest using a dialysate calcium of 1.50 mmol/L or higher, to maintain a neutral or positive calcium balance, while avoiding predialysis hypercalcemia and oversuppression of PTH. (Conditional recommendation, very low-quality evidence ⊕○○○).6For adult ESRD patients treated with long or long-frequent hemodialysis, we suggest using a phosphate dialysate additive to maintain the predialysis phosphate in the normal range if hypophosphatemia persists after stopping phosphate binders and liberalizing the diet. (Conditional recommendation, very low-quality evidence ⊕○○○). Note: For the purpose of this CPG, intensive hemodialysis refers to any of the following: (1) short daily (<3 hours, 5-7 d/wk), (2) long (often nocturnal, ≥5.5 hours, 3-4 sessions per week), and (3) long-frequent (usually nocturnal, ≥5.5 hours, 5-7 sessions per week) hemodialysis. The majority of studies used to inform these CPGs were small, observational, lacked parallel control groups, and included case reports and case series. Very few published randomized controlled trials were applicable and only, when available, provided indirect evidence. Published information on patient values and preference was lacking. The quality of the body of evidence and the strength of the recommendations were graded according to GRADE (Grading of Recommendations Assessment, Development and Evaluation approach).11Guyatt G. Oxman A.D. Akl E.A. et al.GRADE guidelines: 1 Introduction—GRADE evidence profiles and summary of findings tables.J Clin Epidemiol. 2011; 64: 383-394Abstract Full Text Full Text PDF PubMed Scopus (4535) Google Scholar, 12Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar Quality of evidence denoted as follows: ⊕○○○, very low (equivalent to grade D in other systems); ⊕⊕○○, low (grade C); ⊕⊕⊕○, moderate (grade B); ⊕⊕⊕⊕, high (grade A). The strength of the recommendation (conditional or strong) is based on the committee's confidence that adherence to the recommendation will do more good than harm. The strength of recommendation incorporates the quality of the supporting body of evidence, balance between benefits and harms, patients' values and preferences, and, when appropriate, resource implications. For the purposes of this CPG, we were unable to identify any studies that directly evaluated patients' values and preferences; instead they were inferred based on the collective experience of the CPG panel. Although the CPG panel discussed the resource implications of the CPGs, the final recommendations were not affected by cost. A strong recommendation (phrased as “we recommend …”) implies that most patients in a given situation would want the recommended course of action and only a small proportion would not. A conditional recommendation (phrased as “we suggest …”) implies that the majority of patients would still wish to follow the recommendation but many patients would not, such that clinicians will need to be prepared to assist patients in making decisions that are consistent with their values and preferences. Abbreviations: AVF, arteriovenous fistula; AVG, arteriovenous graft; CVC, central venous catheter; CPG, clinical practice guideline; ESRD, end-stage renal disease; PTH, parathyroid hormone. To form the guideline panel (Box 2), physicians with an established clinical interest in intensive hemodialysis prescriptions were identified with representation from across Canada. Many of these physicians also have a background in clinical investigation, research methods, guideline development, and knowledge translation.Box 2Working Group MembershipChair of the Guidelines Group and the Mineral Metabolism Group: Deborah ZimmermanChair of the Vascular Access Group: Reem A. MustafaChair of the Buttonhole Cannulation Group: Gihad E. NesrallahMembers of the Mineral Metabolism Group: Christopher T. Chan, Michael Copland, Paul Komenda, Philip A. McFarlaneMembers of the Vascular Access Group: Azim Gangji, Jean-Philippe Rioux, Andrew Steele, Rita S. SuriMembers of the Buttonhole Cannulation Group: Jennifer MacRae, Robert P. Pauly, David N. PerkinsFinal Review: Andreas Pierratos, Robert Lindsay, Brenda Hemmelgarn, and the CSN Clinical Practice Guideline committee Chair of the Guidelines Group and the Mineral Metabolism Group: Deborah Zimmerman Chair of the Vascular Access Group: Reem A. Mustafa Chair of the Buttonhole Cannulation Group: Gihad E. Nesrallah Members of the Mineral Metabolism Group: Christopher T. Chan, Michael Copland, Paul Komenda, Philip A. McFarlane Members of the Vascular Access Group: Azim Gangji, Jean-Philippe Rioux, Andrew Steele, Rita S. Suri Members of the Buttonhole Cannulation Group: Jennifer MacRae, Robert P. Pauly, David N. Perkins Final Review: Andreas Pierratos, Robert Lindsay, Brenda Hemmelgarn, and the CSN Clinical Practice Guideline committee Intensive hemodialysis was defined as any hemodialysis schedule that included an increase in frequency and/or an increase in session duration compared to conventional hemodialysis (ie, 3 times per week, 3-5 hours per session). Short daily hemodialysis was defined as 5 or more dialysis sessions per week with fewer than 3 hours per session. Long hemodialysis was defined as greater than or equal to 5.5 hours per session, 3-4 times per week, and long-frequent hemodialysis was defined as greater than or equal to 5.5 hours per session for 5 or more sessions per week. The CSN has adopted the GRADE (Grading of Recommendations Assessment, Development and Evaluation; www.gradeworkinggroup.org) approach in evaluating the quality of evidence and developing recommendations.11Guyatt G. Oxman A.D. Akl E.A. et al.GRADE guidelines: 1 Introduction—GRADE evidence profiles and summary of findings tables.J Clin Epidemiol. 2011; 64: 383-394Abstract Full Text Full Text PDF PubMed Scopus (4535) Google Scholar, 12Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar Accordingly, we used the GRADE approach in developing this guideline. Initially, the panel members developed questions of interest in this area using PICO (population, intervention, comparison, and outcome) format.13Guyatt G.H. Oxman A.D. Kunz R. et al.GRADE guidelines: 2 Framing the question and deciding on important outcomes.J Clin Epidemiol. 2011; 64: 395-400Abstract Full Text Full Text PDF PubMed Scopus (1080) Google Scholar The questions covered 4 main areas, including patient selection, vascular access, dialysis prescription, and mineral metabolism. Panel members then rated the questions using a unipolar 9-point adjectival scale and retained the top-ranking questions (Item S1, available as online supplementary material) to be addressed in this clinical practice guideline. The panel also developed an exhaustive list of outcomes that should be considered when addressing each of the questions. Each outcome was rated from 1-9 based on their importance to patients, with only the important (score 4-6) and critical (score 7-9) outcomes for decision making retained for the guideline development (Item S2). Given the broad range of topics identified, the panel elected to focus the first guideline document on the 6 highest ranking questions, which focused specifically on aspects of clinical management. An experienced health information specialist conducted a large pragmatic literature search encompassing all 6 domains. The panel was divided into 3 subcommittees (each addressing 2 related questions) based on interest and to ensure balance in clinical and methodological expertise. After completion of the systematic reviews,14Zimmerman D.L. Nesrallah G.E. Chan C.T. et al.Dialysate calcium concentration and mineral metabolism in long and long-frequent hemodialysis: a systematic review and meta-analysis for a Canadian Society of Nephrology clinical practice guideline.Am J Kidney Dis. 2013; 62: 97-111Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 15Mustafa R.A. Zimmerman D.L. Rioux J.-P. et al.Vascular access for intensive maintenance hemodialysis: a systematic review for a Canadian Society of Nephrology clinical practice guideline.Am J Kidney Dis. 2013; 62: 112-131Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar we summarized the evidence and rated the quality of evidence based on the 5 domains of GRADE: risk of bias, imprecision, indirectness, inconsistency, and publication bias.16Balshem H. Helfand M. Schunemann H.J. et al.GRADE guidelines: 3 Rating the quality of evidence.J Clin Epidemiol. 2011; 64: 401-406Abstract Full Text Full Text PDF PubMed Scopus (3942) Google Scholar We summarized the available body of evidence, its quality, and judgments about each of the domains in GRADE evidence profile tables using GRADE Profiler software.17GRADEpro. [Computer program]. Version 3.6 for Windows. Jan Brozek, Andrew Oxman, Holger Schünemann, 2012.Google Scholar After summarizing the evidence in GRADE evidence profiles, each subcommittee drafted an “evidence to recommendations” table, which summarized the overall quality of the body of evidence, balance between risks and benefits, and patients' values and preferences. Although resource implications can also be considered in the GRADE framework, the guideline committee decided a priori that this would not be considered in this iteration of the guidelines. The final draft of the guideline was reviewed by 2 clinical content experts (A.P. and R.L.) who were not involved in the data abstraction and recommendations development phases. After approval by the entire guidelines panel, the document was submitted to the CSN Clinical Practice Guidelines Committee for external peer review and approval. The Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) Knowledge Translation (KT) Committee will develop an integrated knowledge translation and communication strategy for this guideline, based on the priorities of and with input from CANN-NET knowledge users (heads of renal programs across Canada). In conjunction with the Canadian Organ Replacement Register (CORR), the CANN-NET KT group will also develop and implement a monitoring strategy that will evaluate the effectiveness of knowledge translation interventions that will accompany these recommendations. At the time of this writing, modifications to the CORR database are underway, which will enable relevant indicators to be tracked longitudinally. More information about CANN-NET KT initiatives can be found at www.csnscn.ca. Recommendation 1 is provided in Box 3.Box 3Recommendation 1For adult ESRD patients receiving intensive home hemodialysis with an AVF, we suggest the use of rope-ladder cannulation over buttonhole cannulation, unless topical antimicrobial prophylaxis is used. (Conditional recommendation; very low-quality evidence ⊕○○○).Underlying Values and Preferences:This recommendation places a high value on preventing systemic infections with buttonhole cannulation and a relatively low value on the avoidance of repeated needle cannulation and potentially shorter training times for home hemodialysis.Remarks: •This recommendation pertains specifically to home intensive hemodialysis patients and does not address buttonhole cannulation in in-center intensive hemodialysis patients (see text).•Patients with short usable segments, aneurysmal dilatation, or those unable to self-cannulate using rope-ladder cannulation may benefit from buttonhole cannulation.•When buttonhole cannulation is used, we suggest using it in conjunction with topical antimicrobial prophylaxis (See Recommendation 2).•Due to uncertainty regarding infection risk with buttonhole cannulation, clinicians should engage patients in shared decision-making and obtain informed consent prior to adopting this cannulation technique.Note: See Box 1 for explanation of the grading of the quality of the body of evidence and the strength of the recommendations. For adult ESRD patients receiving intensive home hemodialysis with an AVF, we suggest the use of rope-ladder cannulation over buttonhole cannulation, unless topical antimicrobial prophylaxis is used. (Conditional recommendation; very low-quality evidence ⊕○○○). Underlying Values and Preferences: This recommendation places a high value on preventing systemic infections with buttonhole cannulation and a relatively low value on the avoidance of repeated needle cannulation and potentially shorter training times for home hemodialysis. Remarks: •This recommendation pertains specifically to home intensive hemodialysis patients and does not address buttonhole cannulation in in-center intensive hemodialysis patients (see text).•Patients with short usable segments, aneurysmal dilatation, or those unable to self-cannulate using rope-ladder cannulation may benefit from buttonhole cannulation.•When buttonhole cannulation is used, we suggest using it in conjunction with topical antimicrobial prophylaxis (See Recommendation 2).•Due to uncertainty regarding infection risk with buttonhole cannulation, clinicians should engage patients in shared decision-making and obtain informed consent prior to adopting this cannulation technique. Note: See Box 1 for explanation of the grading of the quality of the body of evidence and the strength of the recommendations. “Buttonhole” or same-site cannulation has been in use since the 1970s18Twardowski Z. Different sites versus constant sites of needle insertion into arteriovenou fistulas for treatment by repeated dialysis.Dial Transplant. 1979; 8: 978-980Google Scholar and has recently gained popularity among home hemodialysis programs. While the conventional “rope-ladder” or rotating-site cannulation technique allows for skin healing and new puncture sites with consecutive cannulation procedures, the buttonhole technique results in fibrotic track (buttonhole site) formation, which ultimately allows for conversion to blunt needles. Self-cannulation with the buttonhole technique is an important theoretical advantage that has likely contributed to the adoption of the technique by hemodialysis programs and the publication of enthusiastic anecdotal reports supporting its use.19Kregness A. Believing in the buttonhole technique.Nephrol News Issues. 2008; 22 (40, 42): 36PubMed Google Scholar, 20Murcutt G. Buttonhole cannulation: should this become the default technique for dialysis patients with native fistulas? Summary of the EDTNA/ERCA Journal Club discussion Autumn 2007.J Ren Care. 2008; 34: 101-108Crossref PubMed Scopus (25) Google Scholar, 21Hartig V. Smyth W. “Everyone should buttonhole”: a novel technique for a regional Australian renal service.J Ren Care. 2009; 35: 114-119Crossref PubMed Scopus (8) Google Scholar Cannulation by a nurse in-center differs technically from self-cannulation at home. Differences in operator and treatment frequency, for example, may result in different outcomes. Because there were no studies that specifically addressed buttonhole cannulation in intensive in-center hemodialysis and the technique differs from buttonhole cannulation at home, this guideline did not address buttonhole cannulation in-center. No randomized controlled trials were available to address this recommendation directly. The quality of the available evidence from observational studies was very low. The absolute risk of Staphylococcus aureus bacteremia with buttonhole cannulation for patients receiving intensive home hemodialysis ranged from 0.15-0.60 episodes per 1,000 patient-days across 4 studies.22Lok CE, Kosa SD, Chan CT, Zimmerman DL. Frequent hemodialysis fistula infectious complications [abstract SA-OR460]. Presented at American Society of Nephrology 2011 Meeting; November 8-13, 2011; Philadelphia, PA.Google Scholar, 23Muir CA, Kotwal S, Hawley CM, Gallagher MP, Snelling P, Jardine MJ. Buttonhole versus sharp needle cannulation: clinical outcomes in a home hemodialysis cohort [abstract FR-PO1950]. Presented at American Society of Nephrology 2011 Meeting; November 8-13, 2011; Philadelphia, PA.Google Scholar, 24Nesrallah GE, Cuerden M, Wong J, Pierratos A. S. aureus bacteremia in patients receiving home nocturnal HD using button-hole cannulation with AV fistulae: long-term safety and the efficacy of prophylactic antimicrobial cream [abstract SA-PO2501]. Presented at American Society of Nephrology 2009 Meeting; October 27-November 1, 2009; San Diego, CA.Google Scholar, 25Van Eps C.L. Jones M. Ng T. et al.The impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access.Hemodial Int. 2010; 14: 451-463Crossref PubMed Scopus (51) Google Scholar However, in an indirect comparison between intensive home hemodialysis with buttonhole cannulation versus in-center conventional hemodialysis with rope-ladder cannulation, the relative risk for bacteremia ranged from 30-120 in a single-center study of 56 consecutive home hemodialysis patients using buttonhole cannulation. Importantly, the majority of buttonhole-related systemic infections in this home intensive hemodialysis cohort were with S aureus, which was associated with metastatic complications including septic arthritis, septic pulmonary emboli, vertebral osteomyelitis, and death.26Nesrallah G.E. Cuerden M. Wong J.H. Pierratos A. Staphylococcus aureus bacteremia and buttonhole cannulation: long-term safety and efficacy of mupirocin prophylaxis.Clin J Am Soc Nephrol. 2010; 5: 1047-1053Crossref PubMed Scopus (80) Google Scholar Increased rates of bacteremia and metastatic infection have also been reported with buttonhole cannulation in patients undergoing conventional in-center hemodialysis.27van Loon M.M. Goovaerts T. Kessels A.G. van der Sande F.M. Tordoir J.H. Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique.Nephrol Dial Transplant. 2010; 25: 225-230Crossref PubMed Scopus (137) Google Scholar, 28Labriola L. Crott R. Desmet C. Andre G. Jadoul M. Infectious complicatons following conversion to buttonhole cannulation of native arteriovenous fistulas: a quality improvement project.Am J Kidney Dis. 2011; 57: 442-448Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Ease of cannulation and reduced pain have been anecdotally reported as potential benefits of the buttonhole (vs rope-ladder) method.29Ball L.K. Treat L. Riffle V. Scherting D. Swift L. A multi-center perspective of the buttonhole technique in the Pacific Northwest.Nephrol Nurs J. 2007; 34: 234-241PubMed Google Scholar, 30Doss S. Schiller B. Moran J. Buttonhole cannulation—an unexpected outcome [ADC abstract].Hemodial Int. 2008; 12: 119Google Scholar However, we were unable to find any literature specific to intensive hemodialysis patients to support this assertion. Given the potential differences between self-cannulation at home and buttonhole cannulation by a nurse in-center, we did not attempt to draw inferences related to cannulation pain from the in-center hemodialysis literature. It is noteworthy that one study of 33 patients failed to detect a difference in pain scores using a visual analogue scale among patients converting from rope-ladder to buttonhole cannulation for home conventional hemodialysis.31Verhallen A.M. Kooistra M.P. van Jaarsveld B.C. Cannulating in haemodialysis: rope-ladder or buttonhole technique?.Nephrol Dial Transplant. 2007; 22: 2601-2604Crossref PubMed Scopus (112) Google Scholar Two studies in conventional hemodialysis populations suggested that buttonhole cannulation resulted in less aneurysm formation or even healing of aneurysmal segments.27van Loon M.M. Goovaerts T. Kessels A.G. van der Sande F.M. Tordoir J.H. Buttonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique.Nephrol Dial Transplant. 2010; 25: 225-230Crossref PubMed Scopus (137) Google Scholar, 32Marticorena R.M. Hunter J. Macleod S. et al.The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators.Hemodial Int. 2006; 10: 193-200Crossref PubMed Scopus (56) Google Scholar No similar study has been reported in home intensive hemodialysis patients. We found no published data addressing the impact of buttonhole cannulation on home dialysis training time. Our collective experience suggests that buttonhole cannulation may be of value to some patients who must self-cannulate, and that the adoption of the buttonhole technique may enable such patients to undergo dialysis at home instead of in-center or with a catheter. However, we found no published evidence to support this either. Although the absolute risk of bacteremia with buttonhole cannulation is less than 0.3 episodes per patient-year, the large relative risk compared with rope-ladder cannulation is of major concern and is comparable to bacteremia rates observed with tunneled central venous dialysis catheters.33Dryden M.S. Samson A. Ludlam H.A. Wing A.J. Phillips I. Infective complications associated with the use of the Quinton ‘Permcath’ for long-term central vascular access in haemodialysis.J Hosp Infect. 1991; 19: 257-262Abstract Full Text PDF PubMed Scopus (58) Google Scholar Buttonhole cannulation, particularly in the absence of topical antimicrobial prophylaxis, is associated with an increased risk of systemic infection that may have devastating consequences. Uncontrolled studies suggest that buttonhole cannulation can restore function in structurally abnormal fistulas and promotes self-cannulation, which may facilitate home therapy. For patients who continue to use the buttonhole technique as their preferred form of cannulation, studies to identify mechanisms to reduce the risk of infection are needed. Studies properly assessing patients' values and preferences, impact on quality of life, and complexity of training with buttonhole versus rope-ladder cannulation are also needed. Such studies should consider potential differences between treatment settings (home vs center) and operator (self vs health care professional) in affecting outcomes with buttonhole cannulation.