title: Frequent hemodialysis fistula infectious complications.
abstract: BACKGROUND
  Few studies have examined if infectious arteriovenous access complications vary with the cannulation technique and whether this is modified by dialysis frequency. We compared the infection rate between fistulas cannulated using buttonhole versus stepladder techniques for patients treated with short daily (SDH) or nocturnal hemodialysis at home (NHD). We also compared patients receiving conventional intermittent hemodialysis (CIHD) using stepladder cannulation.
  
  
  METHODS
  Data were prospectively collected from 631 patients dialyzed with a fistula from 2001 to 2010 (Toronto and Ottawa, Canada). We compared the person-time incidence rate of bacteremia and local fistula infections using the exact binomial test.
  
  
  RESULTS
  Forty-six (7.3%) patients received SDH (≥5 sessions/week, 2-4 h/session), 128 (20.3%) NHD (≥4 sessions/week, ≥5 h/session) and 457 (72%) CIHD (3 sessions/week, ≤4 h/session). Fifty percent of SDH and 72% of NHD patients used the buttonhole technique. There were 39 buttonhole-related bacteremias (rate: 0.196/1,000 fistula days) and at least 2 local buttonhole site infections. Staphylococcus aureus accounted for 85% of the bacteremias. There were 5 (13%) infection-related hospitalizations and 3 (10%) serious metastatic infections, including fistula loss. In comparison, there was 1 possible fistula-related infection in CIHD during follow-up (rate: 0.002/1,000 fistula days).
  
  
  CONCLUSIONS
  The rate of buttonhole-related infections was high among patients on frequent hemodialysis and more than 50 times greater than that among patients on CIHD with the stepladder technique. Most bacteremias were due to S. aureus - with serious consequences. The risks and benefits of buttonhole cannulation require individual consideration with careful monitoring, prophylaxis and management.
authors.affiliation: Division of Nephrology, Department of Medicine, Toronto General Hospital and University of Toronto, Toronto, Ont., Canada.
authors.forename: Charmaine E
authors.initials: CE
authors.lastname: Lok
authors.affiliation: Department of Epidemiology and Biostatistics, Western University, London, Ont., Canada.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Sontrop
authors.affiliation: Division of Nephrology, Department of Medicine, Toronto General Hospital and University of Toronto, Toronto, Ont., Canada.
authors.forename: Rose
authors.initials: R
authors.lastname: Faratro
authors.affiliation: Division of Nephrology, Department of Medicine, Toronto General Hospital and University of Toronto, Toronto, Ont., Canada.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Chan
authors.affiliation: Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, Ont., Canada.
authors.forename: Deborah Lynn
authors.initials: DL
authors.lastname: Zimmerman
keywords: Cannulation; Fistula; Hemodialysis; Infection