Your Questions Answered, Your Care Made Clear

What is access flow?

Access flow refers to how much and how quickly blood moves through your fistula or graft. This is usually measured in milliliters per minute (mL/min).

Why is monitoring flow important?

• Healthy access means blood can travel through without any blockages.

• A common problem is a stenosis, or narrowing inside the access, which can slow down blood flow.

• If not treated, it may eventually cause a clot, blocking the access completely.

• Regular monitoring helps catch these issues early so they can be managed before becoming serious.

How is access flow measured?

There are several ways to check flow:

• Ultrasound exams may be done by your vascular center or radiologist. This allows them to see blood moving through your access and calculate the flow rate.

• During dialysis, your team may use special equipment like Twister® bloodlines or other devices attached to your dialysis lines to measure the flow.

How often should it be checked?

• Access flow should ideally be measured once a month.

• The test is most accurate if done in the first 1 to 1.5 hours of dialysis.

• If results show flow dropping below 600 mL/min in a graft or 400-500 mL/min in a fistula, more testing may be needed.

Other warning signs of narrowing (stenosis)

Watch for these problems, which could mean there’s reduced flow:

• Trouble inserting needles or frequent infiltrations

• Bleeding that takes longer than usual to stop after dialysis

• Changes when you check your access: less vibration (thrill) or a different whooshing sound (bruit)

• Machines needing lower speeds due to access issues

• Dialysis machines alarming often because of changes in access pressures

Tips to stay on top of your access health

• Keep track of your flow rates and notice any drops from previous tests.

• Learn other signs of access problems and speak up if you notice them.

• Understand that if your flow rate decreases, your doctor may order additional tests.

• By paying attention to these details, you help protect the health and function of your access.

Note: This information is meant for general education only and does not replace medical advice. Always consult your doctor about your individual care.

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What are they?

• An aneurysm is a bulge or balloon-like area that forms in the wall of a blood vessel.

• When this happens in a fistula, it’s called an aneurysm.

• A graft, which is made from synthetic material, can also develop similar bulges, but these are called pseudoaneurysms (or “false aneurysms”).

Why do these develop?

There are two main reasons why aneurysms or pseudoaneurysms can start and grow:

• Repeated needle sticks

  • Each time needles are inserted into your fistula or graft, it causes small injuries.

  • The surrounding skin and vessel walls need time to heal properly.

  • A natural vein (fistula) can repair itself to some extent, but a synthetic graft cannot.

  • This is why rotating needle sites at each dialysis session is so important—it allows different areas time to recover.

  • Repeatedly using the same spot (sometimes called “one-site-itis”) does not count as rotation and can cause serious damage.

• Narrowing inside the access (stenosis)

  • When part of the access becomes narrowed, pressure builds up behind that point.

  • Any areas already weakened by needle use may start to balloon out.

  • If needle sites aren’t rotated properly when stenosis is present, it can quickly lead to aneurysms or pseudoaneurysms.

What should you look for?

It’s essential to check your access daily for any signs of trouble, such as:

• New bulges or existing ones that are getting bigger

• Skin over the bulge that looks thin, shiny, or changes color (pink or white)

• Oozing or bleeding from the access site when bandages are removed

• Sores or scabs that aren’t healing

How to help protect your access

• Make sure needle sites are rotated with each dialysis treatment—ask your care team to do this consistently.

• Keep an eye out for any changes in your access and report them to your dialysis staff and doctor right away.

• Learn how to stop bleeding if it becomes heavy and know when to call 9-1-1 for emergencies.

• Remember: your access is your lifeline, and successful dialysis depends on it staying healthy.

Note: This guide is for general education and does not replace medical advice. Always speak with your physician about your individual care.

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What is a buttonhole?

A buttonhole is a small tunnel that forms through your skin and the tissue beneath, leading down to your vein. During dialysis, the needle lifts a tiny flap in the vein wall to allow blood flow. When the needles are removed, the flap closes, helping to prevent excess bleeding.

How is this different from rotating sites?

• With the buttonhole method, needles are placed into exactly the same spot in your fistula at each treatment.

  • At first, sharp needles are used to create the tunnel.

  • After the tunnel is well-formed, dialysis staff switch to using blunt needles.

• With site rotation, the needles are inserted into different locations along your fistula every time.

  • Sharp needles are always used, and there is no switch to blunt ones.

Why might your care team recommend buttonholes?

• Buttonholes are often suggested if your fistula is small, deep, or has limited spots for needle insertion.

• Patients who dialyze at home also commonly use this technique.

• Because each caregiver has their own style of inserting needles, it’s best if the same person cannulates each time while the tunnel is being created.

• It usually takes 2-3 weeks or more for a proper tunnel to form. Once it does, only blunt needles will be used.

Pros and cons of buttonholes

• Benefits:

  • Blunt needles often cause less discomfort.

  • You might bleed for a shorter time after dialysis.

  • There may also be fewer aneurysms that develop over time.

• Risks:

  • Infections can happen if cleaning and insertion techniques aren’t followed exactly.

  • The tunnel could stretch, leading to oozing around the needles.

  • If the tunnel and the vein flap don’t line up well, it can make needle insertion harder.

Key things to remember

• Buttonholes can only be created in a fistula, not in a graft.

• Special training and supplies are needed to care for buttonholes.

• Learn and carefully follow the proper cleaning routine to reduce the risk of infection.

• Sharp needles should only be used on your fistula when the buttonhole sites are not being used.

Note: This material is for general education only and is not a substitute for personalized medical advice. Always talk with your doctor about your specific situation.

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Why catheter flow matters

Hemodialysis catheters often have problems with maintaining good blood flow. For your dialysis to work effectively—clearing waste and excess fluid—your catheter must be able to deliver enough blood to the dialysis filter (the artificial kidney).

Your prescribed blood flow rate (BFR)

• Your kidney doctor will decide on a blood flow rate (BFR) that’s right for you.

• This is the amount of blood moving through your catheter to the dialyzer and back each minute, measured in mL/min.

• The prescribed rate is set to make sure you’re getting adequate removal of toxins and fluid.

• If the machine’s pump speed shows a number different from what your doctor ordered, ask your care team to explain why.

Other readings your team watches

Your caregivers will also keep an eye on:

• Arterial pressure (AP) – measures how well the catheter pulls blood out to send to the dialysis filter.

• Venous pressure (VP) – measures how easily blood is returned to your body after it’s cleaned.

How blood lines are set up

• Your catheter and blood lines are color coded:

  • Red line attaches to the red limb of your catheter to send blood out for cleaning.

  • Blue line attaches to the blue limb to return blood back to you.

• If your catheter isn’t reaching the needed flow with safe pressures, staff may temporarily reverse the lines for one treatment to finish that dialysis session.

• Reversing lines is a sign that your catheter’s flow may be compromised.

What you should know

• Learn where to check your machine’s blood flow rate, arterial pressure, and venous pressure.

• Know your prescribed BFR and what your usual AP and VP numbers are.

• Be aware if your blood lines are reversed during a treatment.

• A properly working catheter should provide at least 300 mL/min of blood flow.

• Arterial pressure should stay above -260.

If your catheter starts showing ongoing signs of poor performance, your doctor may suggest replacing it. Over the long term, the best solution is to have an internal vascular access, like a fistula or graft.

Note: This information is for general education only and does not replace professional medical advice. Always consult your healthcare provider about your specific care.

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A healthy vascular access is essential for your dialysis and overall health. By checking your fistula or graft daily, you can spot any changes early. This allows for quick treatment, which can help your access last longer.

How to check your access: three simple steps

Each day, do these three things:

1. Look at your access

2. Feel for the thrill (the buzzing)

3. Listen for the bruit (the whooshing sound)

What to look for on the skin

• The skin over your access should be free of redness, tenderness, or any drainage—these could be signs of infection.

• Both arms (or legs if that’s where your access is) should be the same size.

• Watch for color changes. Your hand or fingers shouldn’t look pale or bluish.

• Keep an eye on aneurysms (bulges under the skin). They shouldn’t be getting bigger.

• Shiny skin over an aneurysm, blood that keeps oozing, sores that won’t heal, or a rapidly enlarging bulge are all warning signs.

• If you see these, call your doctor or dialysis clinic right away.

• If there is bleeding you can’t stop, apply pressure and call 9-1-1.

What to feel for

• Gently run your hand along your access starting at where the artery and vein (or artery and graft) connect.

• You should feel a soft buzzing vibration (called the thrill) and maybe your heartbeat.

• If you feel a very strong pulse that seems to overpower the buzz, it could mean there’s too much pressure inside.

• If you can’t feel the thrill or a pulse at all, contact your dialysis team immediately.

What to listen for

• If you have a stethoscope, move it along your access, starting at the connection point.

• A steady, low whooshing sound is normal.

• A high-pitched or whistling noise could be a sign of narrowing.

• If you don’t have a stethoscope, bring your access close to your ear—you should still be able to hear the bruit.

• If you can’t hear it, call your doctor or clinic right away.

Key things to remember

• Know what an infection looks like and when to call for help.

• Know how your thrill and bruit should normally feel and sound.

• Let scabs from previous needle sites heal completely—don’t pick at them.

• Remember: changes you notice when you look, feel, or listen may be early warnings of access problems.

• You are the first line of defense—no one knows your access better than you.

Note: This handout is for general education only. It doesn’t replace medical advice. Always consult your doctor about your individual care.

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What is a hemodialysis catheter?

A hemodialysis catheter is a flexible tube placed into a large vein, typically in your neck, though sometimes in the groin. The inside tip sits in the upper chamber of your heart, while the outside portion comes out through a small tunnel under your skin on your chest or thigh.

Why is it used?

• Catheters are usually meant for short-term use, helping you get dialysis until a more permanent access—like a fistula (a connection made between an artery and vein) or a graft (a synthetic tube connecting an artery to a vein)—is ready to be used.

• Some patients may need to keep a catheter long-term if their veins or arteries can’t support a fistula or graft.

Common catheter terms you might hear

• Central Venous Catheter (CVC) or tunneled cuff catheter are names often used for this type of access.

• The exit site is where the catheter comes out of your skin on the chest or thigh.

• The tunnel is the path under the skin that leads from the exit site to the large vein.

• A cuff is a small band of material under your skin that your body grows into, helping secure the catheter and act as a barrier against infection.

General tips for caring for your catheter

• Keep the dressing covering your exit site clean, dry, and secure.

• If you notice redness, pain, or any drainage around the site, contact your doctor or dialysis team right away.

• Be careful not to catch your catheter on clothing or other objects—this could pull it out.

• Avoid using scissors or anything sharp near your catheter.

• Always follow your doctor’s instructions about showering, bathing, or swimming.

• Never let air enter your catheter. The clamps and caps should always be closed when it’s not in use.

Important things to remember

• Understand that while the catheter comes through your skin, the tip actually sits inside your heart.

• Know and follow all the general care guidelines your care team provides.

• Be familiar with how long the part of your catheter that’s outside your body normally is. If it suddenly looks longer, it may have shifted or pulled out.

• Remember: if you have a catheter, your doctor and dialysis team will likely discuss transitioning to a fistula, which is the preferred long-term access option.

Note: This information is meant for general education only. It does not replace personalized advice from your healthcare provider. Always talk to your doctor about your specific care needs.

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What is a HeRO graft?

A standard dialysis graft uses a synthetic tube that connects an artery to a vein, allowing blood to flow for dialysis. In contrast, a HeRO graft also starts at an artery, but instead of connecting to a nearby vein, it’s linked to a special outflow device that channels blood directly into the heart.

Why are standard grafts sometimes not an option?

• The connection between the graft and the vein can narrow over time, leading to clots.

• Large veins in the chest may already be damaged by things like dialysis catheters, pacemakers, defibrillator wires, or prior PICC lines.

• Some veins are simply too small to handle the high blood flow needed for dialysis.

• These problems are common in patients who have had multiple failed fistulas or standard grafts.

Why consider a HeRO graft?

• HeRO stands for Hemodialysis Reliable Outflow.

• It was designed specifically for patients who have trouble with other access options.

• The HeRO graft bypasses small or damaged veins in the arm and chest, using a tube that routes blood directly back to the heart.

How is it used for dialysis?

• Your dialysis team will use fistula needles, just like with a traditional fistula or graft.

• They might apply a light tourniquet before inserting the needles to help the graft swell slightly for easier access.

• It’s very important not to use clamps after dialysis, as these can cause clotting in the graft.

How to check your HeRO graft daily

Treat your HeRO graft just like you would a fistula or regular graft. Each day:

• Look for redness, swelling, tenderness, or any other signs of infection.

• Listen for a soft, continuous whooshing sound (called the bruit).

• Feel for a steady buzzing or vibrating sensation (called the thrill).

Key things to keep in mind

• A HeRO graft might be an excellent choice if you’ve been relying on long-term catheters.

• Always perform your daily look, listen, and feel checks.

• Report any changes or concerns to your doctor or dialysis team right away.

Note: This information is provided for general education and does not replace medical advice. Always consult your healthcare provider for guidance specific to your situation.

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What is peritoneal dialysis?

Peritoneal dialysis (PD) is a treatment for kidney failure that uses your own abdominal lining—called the peritoneum—as a natural filter. This process helps remove waste products and extra fluid from your body.

How does PD work?

• A sterile solution called dialysate is gently infused into your abdomen.

• As it sits there, it absorbs waste and excess water from the tiny blood vessels in your peritoneum.

• After the fluid collects these waste products, it’s drained out and replaced with fresh dialysate.

• To receive this type of dialysis, you need a special access tube known as a PD catheter.

What is a PD catheter?

• A PD catheter is a soft, flexible plastic tube designed to allow dialysate to flow in and out of your belly.

• Most of the catheter stays inside your lower abdomen, with a small portion exiting your skin.

• The catheter has small cuffs made of polyester material. Your body grows around these cuffs to help secure the catheter and block infection.

• There are many types and designs of PD catheters. Your doctor will recommend the one best suited for you.

How is a PD catheter placed?

• In most cases, placing a PD catheter is a minor procedure, often done in an outpatient clinic or hospital.

• It’s typically performed by a nephrologist, radiologist, or surgeon.

• A local anesthetic is usually enough—meaning general anesthesia is not needed.

• The doctor makes a small incision, generally just below and to the side of your belly button, and carefully positions the catheter.

• After the procedure, your care team will give you detailed instructions on how to care for your new catheter.

Key things to know

• PD may be a great option for some patients needing dialysis.

• For most people, placing the catheter is a straightforward process with few complications.

• Your care team will make sure you know what to expect before, during, and after the procedure.

Note: This information is for general education and does not replace personal medical advice. Always discuss your specific situation with your healthcare provider.

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What is stenosis?

A stenosis is simply a narrowing inside a blood vessel that restricts blood flow. It can occur:

• Inside your fistula or graft

• In the artery that supplies blood to your access

• Or in the vein that carries blood back to your heart

Why does it matter?

• Stenosis is one of the most common problems that can affect any type of vascular access.

• It might develop soon after your access is created, or later on as it gets older.

• The good news is that if it’s caught early, it’s often straightforward to treat.

Warning signs of a stenosis

Your dialysis team checks for signs of narrowing at every treatment. You can also watch for these at home:

• Changes in the thrill or bruit:

  • The thrill is the buzzing you feel when you touch your access.

  • The bruit is the whooshing sound you hear with a stethoscope or by placing your access near your ear.

  • If these feel or sound different, it could indicate a problem.

• Dialysis machine changes:

  • Increased alarms or changes in arterial and venous pressure readings.

• Bleeding concerns:

  • Bleeding that lasts longer than usual after dialysis, or starts up again after it had stopped.

• Visible changes:

  • New bumps (aneurysms) or existing ones that are getting bigger.

• Needle difficulties:

  • Trouble placing needles or more pain than normal during insertion or removal.

• Lab results:

  • Drops in your bloodwork that measure dialysis effectiveness.

How to check your access at home

• Ask your dialysis nurse or technician to show you how to do a simple look, feel, and listen exam just like they perform at the clinic.

• Doing this daily helps catch problems early.

Important things to know

• Know how to feel the thrill and listen for the bruit in your access.

• Understand what the dialysis machine alarms mean.

• Be aware of your usual bleeding time after treatment so you’ll notice if it increases.

• Keep track of your lab numbers, and ask your care team why they might change.

• Remember: most cases of stenosis, when detected early, can be managed easily and with little discomfort.

Note: This handout is for general information only and does not replace medical advice. Always speak with your healthcare provider about your individual care.

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What is vessel mapping?

Vessel mapping, also called vascular mapping, is a key first step before creating a permanent dialysis access. It involves special tests done before surgery to help plan the best approach.

Why is vessel mapping important?

• This process carefully checks your blood vessels to see if they’re suitable for making a fistula or if a graft would be a better option.

• It also helps decide where to place the access—usually in the non-dominant arm (the arm you don’t use to write), to protect the arm you use most.

• If you currently have a catheter, remember that it’s meant only as a temporary solution until a fistula or graft is ready.

How is vessel mapping done?

You may have one or more of the following tests:

• Blood pressure checks: taken in both arms.

• Ultrasound imaging:

  • A gel is placed on your skin and a probe sends sound waves that help examine the arteries’ pulse and measure the size of arteries and veins.

  • This ensures they are big enough to support a new access.

• Evaluation of circulation:

  • Both the radial and ulnar arteries (in your wrist area) are checked to make sure your hand will still have good blood flow after surgery.

• Venogram:

  • This is a special x-ray where dye is injected to highlight your veins. It helps find any blockages or narrow spots that could affect blood flow.

Key things to know

• Vessel mapping greatly improves the chances of a successful access surgery.

• Based on your results, your doctor will recommend either a fistula (which connects your vein directly to an artery) or a graft (a synthetic tube linking an artery to a vein).

• A fistula is preferred whenever possible, as it tends to last longer and have fewer complications.

• Vessel mapping can be done in an access center, a surgeon’s office, or a hospital’s interventional radiology department.

Note: This handout is for general education and does not replace individual medical advice. Always discuss your specific situation and questions with your healthcare provider.

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