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A more accurate descriptive and clinically useful diagnosis based upon pathophysiology for what is commonly referred to as venous outflow stenosis is inflow-outflow imbalance. In these cases, the total outflow capacity of the AV access is inadequate to handle the inflow volume (Qa) without an increase in pressure. The relative inadequacy of the access outflow capacity in comparison to Qa results in increased outflow resistance and a proportional increase in intraluminal pressure. The clinical indicators associated with venous stenosis are the resulting manifestations of this imbalance. The point at which this occurs is dependent upon variations in these two parameters-Qa and outflow resistance. The variations in these two parameters are considerable and reciprocal. Excessive Qa results in or can lead to an entire list of serious problems that adversely affect patient morbidity and mortality. Most studies dealing with AV access Qa reduction have been for the treatment of an existing condition rather than its prevention; however, prevention of disease rather than waiting for its development is an important tenet of medical practice. The resulting clinical picture of inflow-outflow imbalance is taken as an indication for corrective treatment. In the past, in most cases this has meant angioplasty to open the outflow if it is reduced; however, this clinical picture may be associated with an excessive Qa and angioplasty in these cases creates the risk for a further increase in Qa. It is the authors' opinion that access flow measurements should be a part of the evaluation of these cases prior to planning treatment. Using this information, a bimodal approach to primary treatment should be adopted involving either angioplasty for cases with a low or normal Qa or flow reduction in cases with an elevated Qa., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale and Objective: This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials., Study Design: Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation., Setting and Participants: The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development., Analytical Approach: For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%., Results: The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance., Limitations: Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use., Conclusions: While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis., Competing Interests: Declaration of Conflicting InterestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that they have no conflicts of interest regarding patents or royalties, stock/stock options, or first-degree relatives with any of these relationships related to this work. No reimbursement was received for the development of the manuscript.DR, VN, MM, CR, ED, CG, TV, SH, PB, LD and patients CS, DDR, FM, and MB (see acknowledgements) received remuneration from Becton Dickinson (BD) for their participation in the Delphi process.GW, AH, and NF are employees of CRG-EVERSANA Canada Inc., which was contracted by BD to facilitate the Delphi panel process and analyze the results.EK and DC are employees of the American Association of Kidney Patients (AAKP) which was contracted by BD to advise on patient input and recruited the Patient Ambassadors.DR is a consultant for BD and Gore Medical. VN is a consultant for the NACCME – Moderator for AV Access Webcast, supported by an educational grant from Medtronic. SH is a consultant/speaker for BD, Merit Medical, Medtronic, and Gore Medical. ED is a consultant for WL Gore, Angiodynamics, and 3M/KCI. ED is a scientific advisor for Boston Scientific. TY is a consultant for BD, WL Gore and Merit Medical and a scientific advisory board member of BD and Medtronic. CK is a consultant for BD and ACI/Humacyte and advisory board member for Boston Scientific. CL is a consultant for BD, Gore, and Medtronic.Other ConflictsED, KW, and TY are authors and ED is an editor for UpToDate.

Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Portable ultrasounds are often referred to as the "new stethoscope." Their portability and affordability have led to improved diagnostic capabilities at the point of care in virtually every field of medicine, and hemodialysis access is no exception. However, though ultrasonography is increasingly used throughout the spectrum of hemodialysis access, its role in outpatient dialysis units in the United States has been limited so far. This may, in part, be due to limited ultrasound exposure, knowledge, and training of dialysis staff. This article details an educational protocol including hands-on simulation for training dialysis technicians and nurses in ultrasound-guided cannulation techniques.

End-stage kidney disease patients who are candidates for surgical arteriovenous fistula creation commonly experience obstacles to a functional surgical arteriovenous fistula, including protracted wait time for creation, poor maturation, and surgical arteriovenous fistula dysfunction that can result in significant patient morbidity. The recent approval of two endovascular devices designed to create a percutaneous arteriovenous fistula enables arteriovenous fistula creation to be placed in the hands of interventionalists, thereby increasing the number of arteriovenous fistula providers, reducing wait times, and allowing the patient to avoid surgery. Moreover, current studies demonstrate that patients with percutaneous arteriovenous fistula experience improved time to arteriovenous fistula maturation. Yet, in order to realize the potential advantages of percutaneous arteriovenous fistula creation within our hemodialysis patient population, it is critical to select appropriate patients, ensure adequate patient and dialysis unit education, and provide sufficient instruction in percutaneous arteriovenous fistula cannulation and monitoring. In this White Paper by the American Society of Diagnostic and Interventional Nephrology, experts in interventional nephrology, surgery, and interventional radiology convened and provide recommendations on the aforementioned elements that are fundamental to a functional percutaneous arteriovenous fistula.

Sonography is increasingly being used by nephrologists and the field of dialysis access is no exception. Advances in technology have allowed the addition of this universally available, portable, non-invasive tool to the nephrologist's armamentarium, which provides information on both morphology and physiology without the need for contrast or radiation. Ultrasound may be used across the spectrum of dialysis access, including central venous catheter placements, vascular mapping, regional anesthesia, creation, maintenance and assessment of hemodialysis access as well as assessment of the abdominal wall and peritoneal dialysis catheter placements. However, the lack of exposure in most training programs limits incorporation of routine use of ultrasounds in nephrology practice. As our specialty embarks on the ultrasound revolution, a two-pronged approach is essential to provide ample training opportunities while ensuring establishment of basic standards for training and competency.

Purpose: Central venous catheters (CVC) are associated with increased infection rates, morbidity and mortality compared to other hemodialysis vascular access. Chlorhexidine-impregnated transparent (CHG-transparent) dressings allow for continuous antimicrobial exposure and easy visibility of the CVC insertion site. We conducted a quality improvement project to compare catheter-related infection (CRI) rates in two dressing regimens - CHG-transparent dressings and adhesive dry gauze dressing in hemodialysis patients with tunneled CVCs., Methods: The study was conducted in two phases. In phase 1, CHG-transparent dressing was introduced to EDC hemodialysis unit, while EDG and EDN hemodialysis units, served as the control sites and maintained adhesive dry gauze dressing. Phase 2 of the study involved replacing the adhesive dry gauze dressing with CHG-transparent dressing at EDG and EDN and maintaining CHG-transparent dressing at EDC. CRI rates at each hemodialysis unit during the 12-month intervention were compared to CRI rates for the 12-month pre-intervention period for each study phase. CRI rates were also compared between all three hemodialysis units., Results: In phase 1, CRI rates (per 1000 days) in EDC (intervention site) decreased by 52% (1.69 vs. 0.82, p<0.05) and increased by 12% (1.80 vs. 2.02, p = 0.75) at EDG, and 35% (0.91 vs. 1.23, p = 0.40) at EDN. In phase 2, CRI rates at EDG and EDN (intervention sites) decreased by 86% (1.86 vs. 0.26 p<0.05), and 53% (1.89 vs. 0.88, p<0.05), respectively, and decreased by 20% at EDC (0.73 vs. 0.58, p = 0.65)., Conclusions: Replacing adhesive dry gauze dressing with CHG-transparent dressing for hemodialysis patients with tunneled CVC was associated with decreased CRI rates.