title: Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review.
abstract: OBJECTIVE
  The relative merits of buttonhole (or blunt needle) versus rope ladder (or sharp needle) cannulation for hemodialysis vascular access are unclear.
  
  
  METHODS
  Clinical outcomes by cannulation method were reviewed in 90 consecutive home hemodialysis patients. Initially, patients were trained in rope ladder cannulation. From 2004 on, all incident patients were started on buttonhole cannulation, and prevalent patients were converted to this cannulation method. Coprimary outcomes were arteriovenous fistula-attributable systemic infections and a composite of arteriovenous fistula loss or requirement for surgical intervention. Secondary outcomes were total arteriovenous fistula-related infections and staff time requirements. Additionally, a systematic review evaluating infections by cannulation method was performed.
  
  
  RESULTS
  Seventeen systemic arteriovenous fistula-attributable infections were documented in 90 patients who were followed for 3765 arteriovenous fistula-months. Compared with rope ladder, buttonhole was not associated with a significantly higher rate of systemic arteriovenous fistula-attributable infections (incidence rate ratio, 2.71; 95% confidence interval, 0.66 to 11.09; P=0.17). However, use of buttonhole was associated with a significantly higher rate of total arteriovenous fistula infections (incidence rate ratio, 3.85; 95% confidence interval, 1.66 to 12.77; P=0.03). Initial and ongoing staff time requirements were significantly higher with buttonhole cannulation. Arteriovenous fistula loss or requirement for surgical intervention was not different between cannulation methods. A systematic review found increased arteriovenous fistula-related infections with buttonhole compared with rope ladder in four randomized trials (relative risk, 3.34; 95% confidence interval, 0.91 to 12.20), seven observational studies comparing before with after changes (relative risk, 3.15; 95% confidence interval, 1.90 to 5.21), and three observational studies comparing units with different cannulation methods (relative risk, 3.27; 95% confidence interval, 1.44 to 7.43).
  
  
  CONCLUSIONS
  Buttonhole cannulation was associated with higher rates of infectious events, increased staff support requirements, and no reduction in surgical arteriovenous fistula interventions compared with rope ladder in home hemodialysis patients. A systematic review of the published literature found that buttonhole is associated with higher risk of arteriovenous fistula-related infections.
authors.affiliation: Renal and Metabolic Division, The George Institute for Global Health, Sydney, Australia;, †Department of Medicine, Blacktown Hospital, Sydney, Australia;, ‡Sydney Medical School, University of Sydney, Sydney, Australia;, §Nephrology Department, Princess Alexandra Hospital, Brisbane, Australia;, ‖Department of Nephrology, Monash Medical Centre, Clayton, Australia;, ¶Departments of Medicine, Epidemiology, and Preventative Medicine, Monash University, Melbourne, Australia;, *Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, Australia, ††Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Muir
authors.forename: Sradha S
authors.initials: SS
authors.lastname: Kotwal
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Hawley
authors.forename: Kevan
authors.initials: K
authors.lastname: Polkinghorne
authors.forename: Martin P
authors.initials: MP
authors.lastname: Gallagher
authors.forename: Paul
authors.initials: P
authors.lastname: Snelling
authors.forename: Meg J
authors.initials: MJ
authors.lastname: Jardine
mesh_terms: D000328:Adult; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D055499:Catheter-Related Infections / Q000209:etiology; D002404:Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006437:Hemodialysis, Home / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009339:Needles; D010353:Patient Education as Topic; D011677:Punctures; D012189:Retrospective Studies; D012307:Risk Factors; D012648:Self Care; D013997:Time Factors; D016896:Treatment Outcome