SCOTTISH RENAL NURSING STRATEGY GROUP
BEST PRACTICE STATEMENT
FOR THE FORMATION AND CARE OF AV FISTULA AND GRAFT
DRAFT
Table of Contents
Introduction
3
KEY PRINCIPLES OF BEST PRACTICE STATEMENTS
4
KEY STAGES IN THE DEVELOPMENT OF THE STATEMENT
5
HOW CAN THE STATEMENT BE USED?
WHO WAS INVOLVED IN DEVELOPING THE STATEMENT?
6
GLOSSARY OF TERMS
7
INTRODUCTION TO STATEMENT
8
BEST PRACTICE STATEMENT: THE FORMATION AND CARE OF
12
AV FISTULA AND GRAFT
Section 1: PRE DIALYSIS PREPARATION & CARE
Section 2: PRE OPERATIVE PREPARATION & CARE
Section 3: INTRAOPERATIVE STAGE
Section 4: POST OPERATIVE CARE
Section 5 ACCESS SURVEILLANCE
Appendix 1: TOURNIQUET INFORMATION
32
Appendix 2: RECOMMENDED NEEDLE SIZES
33
Appendix 3: EMERGENCY PROCEDURES
34
Appendix 4: PRE- OP CARE GOOD PRACTICE EXAMPLE
35
Appendix 5: POST OP CARE GOOD PRACTICE EXAMPLE
36
Appendix 6: SOURCES OF EVIDENCE
37
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Introduction
NHS Quality Improvement Scotland (NHS QIS) was established in 2003 by the
Scottish Parliament and was an amalgamation of various organisations to take the
lead in improving the quality of care and treatment delivered by NHS Scotland. NHS
QIS does this by setting standards and monitoring performance, and by providing
NHS Scotland with advice, guidance and support on effective clinical practice and
service improvements.
Background to Best Practice Statements
While many examples of clinical guidelines exist, there is a lack of reliable statements
focusing specifically on nursing and midwifery practice.
The development of best practice statements reflects the current emphasis on
delivering care that is patient-centred, cost-effective and fair, and will attempt to
reduce existing variations in practice. The common practice that should follow their
implementation will allow comparable standards of care for patients wherever they
access services.
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Key Principles of Best Practice Statements
A best practice statement describes best and achievable practice in a specific area of
care. The term ‘best practice’ reflects the commitment of NHS QIS to sharing local
excellence on a national level. Best practice statements are underpinned by a
number of shared principles below:

Best practice statements are intended to guide practice and promote a consistent
and cohesive approach to care.
 Best practice statements are primarily intended for use by registered nurses,
midwives and the staff who support them, but they may also contribute to
multidisciplinary working and be of guidance to other members of the healthcare
team.
 Statements are derived from the best available evidence at the time they are
produced, recognising that levels and types of evidence vary.
 Information is gathered from a broad range of sources in order to identify existing
or previous initiatives at local and national level, incorporate work of a qualitative
and quantitative nature and establish consensus.
 Statements are targeted at practitioners, using language that is accessible and
meaningful.
 Consultation with relevant organisations and individuals is undertaken.
 Statements will be nationally reviewed and updated every 3 years.
 Responsibility for implementation of statements will rest at local level.
Key sources of evidence and available resources are provided.
Use of Evidence in Best Practice Statements
The need to embrace evidence in its broadest sense has been acknowledged by
NHS QIS in the development of best practice statements. Best practice statements
represent a unique synthesis of research evidence, evidence complemented by audit,
patient surveys and evidence derived from expert opinion, professional consensus
and patient/public experience.
The process for developing these statements adopts a rigorous, transparent and
consistent ‘bottom-up’ approach to articulating best practice that involves
professionals and patients, and is based on all types of available evidence.
The following stages describe the process of identifying and reviewing evidence for
inclusion in statements:
1 Define question
2 Review evidence from a range of sources including published literature, grey
literature and other relevant sources, eg patient groups, manufacturers,
professional groups
3 Evaluate evidence using recognized methods of evidence appraisal
4 Integrate evidence with patient-related factors, eg issues of access, equity and
ethics
5 Develop recommendations
6 Evaluate process and impact of recommendations.
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KEY STAGES IN THE DEVELOPMENT OF THE STATEMENT
The development of this best practice statement has been based on current
research to enhance practice.
Review Evidence
Research major reports, national, local guidelines and standards,
existing care guidance, expert nursing opinion and evidence from
patients.
Draft Best Practice Statement
Identify nursing contribution, apply renal nursing values, and identify
level and type of evidence.
Circulate for consultation
Involve al l users, include practice development forums, pool
expertise from the renal community, and refine statement.
External consultation on the revised draft after evaluation
Disseminate and Update 3-yearly
Paper copies, on-line in PDF format, face-to-face seminars, training
for all staff. Pilot audit at 6 months, audit at 1 year
Review available evidence in 3 years time
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Who was involved in developing the statement?
Working Group members
Anne Allan
Clinical Ward Manager, Renal Unit Raigmore Hospital,
Inverness
Anne Petherick
Education Coordinator, Renal Unit, Edinburgh Royal
Infirmary
Barbara Killoran
Education Facilitator, Renal Unit, NHS Greater Glasgow
Carol Latta
Ward Manager , RDU Gartnavel General Hospital, NHS
Greater Glasgow Glasgow
Caroline Arnott
Ward Manager, Renal Unit, Queen Margaret Hospital,
Dunfermline
Geraldine Ovens
Renal Education Facilitator, Renal Unit, NHS Ayrshire &
Arran
Ippy Brown
Clinical Nurse Manager, Renal Unit, NHS Greater
Glasgow
Julie English
Clinical Educator, Renal Unit, Raigmore Hospital,
Inverness
Laurie Kirkland
Pre-dialysis Nurse, NHS Ayrshire & Arran
Margaret Boyd
Clinical Facilitator, Renal Unit, Monklands General
Hospital
Morag McGhee
Clinical Nurse Manager, Renal Unit, Monklands General
Hospital
Noreen McMahon
Ward Manager, Crosshouse Hospital, Kilmarnock
Rhona Lochiel
Vascular Access Nurse, Edinburgh Royal Infirmary
Temby Chigaru
Clinical Educator, Queen Margaret Hospital, Dunfermline
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Wider reference group
Sister Aileen Heminglsey
Dr W Smith,
Dr M Hand,
Dr I Shilliday
Dr H Oun,
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HD sister
Consultant
Consultant
Consultant
Associate specialist
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Glossary of terms
TERM
DEFINITION
Adequacy
refers to how well dialysis replaces
the function of the kidneys
Anastomosis
an artificial connection between two
tubular organs eg two blood vessels
Arterio-venous fistula
a surgical connection between an
artery and a vein, usually in a limb, to
create arterial and venous access for
haemodialysis. It can be a direct
anastomosis between the artery and
vein
Asepsis
the complete absence of bacteria,
fungi, viruses or other microorganisms that could cause disease
Autogenous
originating in the body of the patient
Bruit
a sharp or harsh systolic sound heard
on auscilation that is due to turbulent
blood flow in a peripheral artery.
Bruits can be heard over arteriovenous fistulae
Cannula
a hollow tube designed for insertion
into a body cavity or blood vessel
Cannulation
insertion of a cannula
Co morbidity
the presence of one or more disorder
or disease in addition to the primary
disease
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DOQI
Dialysis
the national kidney foundation
Outcomes Quality Initiative.
established in 1995 in the USA
Duplex imaging
a diagnostic technique used to study
the flow in blood vessels.
End stage renal failure (ESRF)
the most advanced stage of kidney
failure, which is reached when the
glomerular filtrate rate falls to5mls/min
(Normal GFR =120ml/min)
Extravasation
the leakage and spread of blood or
fluid from vessels into the surrounding
tissues e.g. following injury
Glomerular Filtration Rate (GFR)
the rate at which substances are
filtered from the blood of the
glomerulus into the bowman’s
capsule of the nephron. It is
calculated by measuring the
clearance of specific substances and
is an index of renal function.
Haematoma
an accumulation of blood within the
tissues that clots to form a solid
swelling.
Haemodialysis
a technique of removing waste
materials or poisons from the blood
using the principle of dialysis.
Haemodialysis is performed on
patients whose kidneys have ceased
to function.
Heparin
an anticoagulant, which acts by
inhibiting the action of the enzyme
thrombin in the final stage of blood
coagulation
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Infiltration
the abnormal entry of a substance
into tissue. e.g. blood
Intima
the inner layer of a wall of an artery or
vein.
NHS Quality Improvement
Scotland (NHS QIS)
a statutory body established as a
special health board in January 2003.
Its role is to focus on improving the
quality of patient care and the health
of patients. Now incorporates
Clinical Standards Board for
Scotland
which a statutory body, established as
a special health board in April
1999.Its role, in line with the Scottish
executive’s commitment to quality,
openness and public accountability, is
to promote public confidence that the
services provided by the NHS are
safe and that they meet nationally
agreed standards , and to
demonstrate that , within the
resources available , the NHS is
delivering the highest possible
standards of care
Patency
the condition of being open e.g. blood
flow present
Protocol
correct procedure
(should be evidence based)
Thrombosed
affected by thrombosis
Thrombosis
a condition in which the blood
changes from a liquid to a solid state
and produces a blood clot
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Tourniquet
an instrument for the compression of
a blood vessel by application around
an extremity to control the circulation
and prevent the flow of blood to or
from the area
Venepuncture
the puncture of a vein for any
therapeutic purpose.
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INTRODUCTION TO THE STATEMENT
Over the last few years, there has been an increase in the prevalence of renal
replacement therapy for patients who reach end stage renal failure.
The Scottish Renal Registry report of 2000 – 2001 indicates that the incidence of new
patients starting renal replacement therapy has increased from 1479 (1991) to
2673(2001) with projections of an increase in this number by 2005. The annual take
in rate is currently 600 per year.
The median age range for patients commencing RRT has gone from 58.2years 1992
to 66.4 years 2001 (source SRR 2003 report) Co-morbidity has risen considerably
requiring increased nursing intervention.
There are ten adult renal units in Scotland with nine satellite or annexe units. In
addition there is one paediatric renal unit.
The Scottish Renal Nursing Strategy Group have committed to looking at ways in
which the services can be developed. The largest growth area is in Haemodialysis
The philosophy of this group is to identify nursing priorities for renal services within
Scotland to provide clear direction for nurses working within the specialty. The
strategy will be developed in collaboration with representatives from all Scottish
Renal units' and in consultation with relevant national groups.
The purpose of this Best Practice Statement is to guide all haemodialysis nursing and
technical staff in the best way to manage and preserve vascular access. Poor
vascular access for haemodialysis may contribute to increased risk of infection,
unnecessary repeated admissions to hospital and potentially increased mortality.
The National Service Framework for Renal Services suggests that:
STANDARD TWO All children, young people and adults approaching established
renal failure are to receive timely preparation for renal replacement therapy, so the
complications and progression of their disease are minimised, and their choice of
clinically appropriate treatment options maximised.
STANDARD THREE All children, young people and adults with established renal
failure are to have timely and appropriate surgery for vascular or peritoneal access,
which is monitored and maintained to achieve maximum longevity.
Scottish Renal Association and QIS Standards require that:
70% of established patients should have functioning AVF or Graft
60% of new starts should have functioning AVF
If known to renal service for more than 3 months.
An AV fistula/ graft is a prerequisite for carrying out haemodialysis. The ideal blood
vessel should:
o Be easily accessible for cannulation by patient and staff
o Be suitable for cannulation 1month-4 months after creation (DOQI guideline 9,
2000) (for PTFE graft 3- 6weeks after placement, DOQI guideline 9, 2000).
o Have adequate barrier to infection to maintain skin integrity
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Premature cannulation of a fistula may result in a higher incidence of infiltration with
associated compression of the vessel by haematoma and permanent loss of the
fistula (DOQI guideline 9,2000)
The AV fistula/ graft should be:
o Patent
o Palpable with bruit present
o Clean and free from signs of infection
The success of vessel access is best assessed by it’s capability to supply and return
blood to the general circulation at acceptable flow rates, its duration of effective
function, the degree of patient discomfort and limitation and the rate and severity of
complications.
Why create a fistula first
The arterio-venous fistula remains the gold standard access to haemodialysis,
showing better survival and lower complication rates than grafts and catheters
(Brunori et al 2005). The presence of a catheter and/or its complications may affect
the longevity of a native fistula through its earlier utilisation or less favourable
maturation. (Rayern et al 2003). DOQI guideline 3 states that in order to determine
which type of access is most suitable to the individual patient, an evaluation of the
patients venous, arterial and cardiopulmonary systems must be performed. Previous
placement of central venous catheter is associated with central venous stenosis.
Central venous catheters should be discouraged as permanent vascular access. In
the absence of factors associated with contraindications for the formation of A-V
fistula, this would be the first preference for vascular access. (DOQI 2000)
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Section One: Pre- Dialysis Stage
Key point: Frequent monitoring of fistula parameters is required
STATEMENT
REASON FOR STATEMENT
Referral for vascular
To enable planned intervention ensuring best
access at the pre-dialysis
permanent access with fewer complications
stage should be made
This will also allow for any remedial intervention
when the GFR falls to
if required
HOW IS IT BEING ACHIEVED
By implementation of local patient pathway and
audit
approximately 14ml/min
(Renal Association
standard 10, 2002)
The site of fistula should be To reduce inconvenience to the patient and
By maintaining and supporting, open
identified and all other co-
facilitate easier care of fistula site.
communication between patient, nursing staff
morbidities should be
To facilitate easier access of the fistula during
and surgeon.
considered
cannulation
Staff are able to identify best possible fistula
To identify optimum site for a fistula
sites
Patients requiring vascular
If vessels are accessed frequently for
Once it is identified that the patient requires
access for haemodialysis
venepuncture the vessel becomes fragile and
access surgery, all Healthcare workers should
should have their veins
may not be sustainable as adequate vascular
be advised that vessels on “fistula” arm are not
DRAFT
preserved and not utilized
access for haemodialysis.
used for venepuncture/ cannulation or for blood
for any intervention before
pressure
access is created.
During inpatient stay a local means of
identification is applied to indicate that this arm
should not be used for venepuncture/
cannulation or blood pressure measurement
Key challenge: Reasons for failure should be documented and action plan should be out in place
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Section 2 pre-operative and peri-operative stage
Key point: Minimum of urea & electrolyte levels must be checked before theatre
Key point: Fistula mapping may be implemented at time of surgery
STATEMENT
REASON FOR STATEMENT
HOW IS IT BEING ACHIEVED
The patient should be
To empower the patient to make
Designated person provides information, advice and
educated regarding access
informed decisions about the forth
support for patients and carer where appropriate before
formation using a selection
coming procedure and encourage
access formation.
of evidenced based
participation in recommended
A record is kept of information distributed to patients in
material tailored to suit the
treatment (CSBS, standard 12, 2002)
the pre dialysis period
Peri-operative care should
To ensure patient suitability and safety
Implementation of local protocol
be implemented as per
during peri-operative period
Staff involved in the peri-operative period are familiar with
individual needs of the
patient
local protocol
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local protocol
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Section 3 Post operative care
STATEMENT
REASON FOR STATEMENT
HOW IS IT BEING ACHIEVED
Post operative care-
Early detection of
Observations are performed in accordance with local protocol and
following surgery, all
complications To maintain AV
the needs of the individual patient
patients will require
fistula/graft patency
Patency of fistula should be documented
The patient is given
To ensure that staff and patient
Local development of post op guidelines.
available advice following
are aware of the appropriate
Clear and concise information and advice should be given
AV fistula / vein graft
after care following access
regarding continuing care and maintenance of fistula patency
surgery.
formation
monitoring of their fistula/
graft
Key challenge: comprehensive training and education of staff is required
Key challenge: Renal Unit Staff should ensure that relevant information regarding care of vascular access accompanies all
patients to non-renal areas
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Section 4- Surveillance of AV Fistula
STATEMENT
REASON FOR STATEMENT
HOW IT IS BEING ACHIEVED
Pre surgery assessment
To assess potency, vessel size Attend designated vascular clinic
and suitability for creation of
Duplex scan
vascular access
Pre admission assessment
Date for surgery
Post surgery assessment
To assess success of surgery
Pre Dialysis patients:
Telephone follow-up, 2-3 days post surgery
Established Dialysis patients:
Review within 48hrs of surgery
All patients:
Follow-up vascular access clinic
Repeat Duplex scan
Cannulation difficulties newly
established fistula
Re-assess access
Refer to vascular access nurse
Discuss with dialysis nurse difficulties experienced during
cannulation
Duplex scan
Re-refer to surgeon
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Continued
Routine surveillance
To highlight potential problems
Pre Dialysis patients:
Routinely assess at low clearance clinic, only referred back to
vascular access nurse if complication occurs
Established Dialysis patients:
6 mthly Blood Temperature monitoring/re circulation/transonic
Routine monitoring of arterial and venous pressure
Highlight any complication to vascular access nurse
To source problem with
Refer to vascular access nurse
established vascular access
Duplex scan
Discuss with surgeon or interventional radiographer
Thrombosed vascular access
Rescue vascular access
Emergency admission protocol
Refer to vascular access nurse
Refer to surgeon or interventional radiographer
Key challenge: Renal Unit Staff should ensure that relevant information regarding care of vascular access accompanies all
patients to non-renal areas
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Section 6 First Cannulation
STATEMENT
REASON FOR STATEMENT
HOW IS IT BEING
ACHIEVED
New fistula should be examined by
nephrologists/vascular surgeon/
interventional radiologist or
designated senior renal nurse prior to
first cannulation.
To establish readiness for
cannulation.
Local policy in place
and mechanism for
assignment of staff to
initial cannulation.
It is essential that vascular access
should be
 Free from redness
 Free from signs of infection
 Bruit is present
First and subsequent cannulations
while fistula is developing are
performed by designated staff
members
Strict aseptic technique should be
used to clean the fistula site prior to
cannulation, sterile gloves should be
worn during the procedure
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Local policy in place for
examination of new
fistula.
To ensure continuity and cannulation
by staff with suitable level of
knowledge and demonstrating best
practice cannulation technique
To prevent bleeding into surrounding
tissue.
To prevent contamination and
minimise transfer of skin flora during
cannulation process.
Aqueous chlorhexidine 0.25- 2% is
recommended for cleaning the fistula
site.
All patients should be encouraged to
wash their hands and fistula arm
Local heparin policy in
place.
Local policy in place,
staff education.
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when they arrive at the dialysis unit
Use 2 x 17-gauge needles OR if
dialysis catheter in place 1 x 17gauge needle for arterial line and
catheter as venous return line. Keep
needles a minimum of 1.5-2 cm away
from anastamosis.
A tourniquet should be applied to the
upper arm so that it is tight enough to
dilate the vessel though does not
occlude or impede venous outflow.
The patient may be encouraged to
grip their fistula arm instead of using
a tourniquet. Gently pull the skin in
the opposite direction to the needle
insertion and cannulate the fistula
using a 25 degree angle with the
bevel of the needle UP. Tape needle
at the angle of insertion DO NOT
flatten against the skin; stabilise the
butterfly with tape and secure
Never force the needle against
resistance to completely flatten the
angle before securing the wings
Nursing staff must be made aware of
the importance of securing needles.
Needles for vascular access should
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Small gauge needles to minimise risk
of infiltration, minimum distance from
anastomosis to prevent damage to
anastamosis.
Compresses peripheral nerve
endings between epidermis and
dermis with less skin surface area
contacting cutting edge of needle
Use of KDOQI
guidelines
Local Policy in place
Staff education
Audit
Taken from KDOQI
Stabilises access and dilates fistula.
Bevel UP to ensure cutting edge of
needle against the skin, and
facilitates smoother incision of skin.
Less steep angles increase risk of
dragging cutting edge of needle along
surface of vessel. Steeper angles
increase risk of perforating underside
Local Policy
of vessel.
Staff education
See table for BFR and
Pressing the needle shaft flat against
Needle gauges.
the skin moves the needle tip from
the desired position within the vessel
lumen.
Local policy
To prevent swelling and damage to
Staff education
the fistula should infiltration occur.
To avoid trauma to the intima of the
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be secured with appropriate dressing
Cannulation sites should be
monitored throughout the dialysis
session
Dialysis lines should be secured to
the patient’s arm or clothing NOT the
pillow or arm rest
Use blood flow rate of 200 ml/min
MAX and reduce to 180ml/min if not
tolerated, increase blood flow rates
ONLY if infiltration or other problems
are not noted.
Needles should be removed at the
same angle as insertion, firm but
gentle pressure should be applied
AFTER the needle has been
completely removed from the vessel.
Pressure should be applied for at
least 10 mins without being released
Clamps should NOT be used.
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vessel.
Needles should be secured to ensure
that there is no clinical risk to patient.
Movement of needles may result in
trauma to fistula and /or haemorrhage Local policy
Staff /Patient education
To avoid accidental dislodgement.
Audit of fistula care/
examination.
To prevent displacement of needles
and thus prevent infiltration.
Blood flow rate should be matched
with the correct needle gauge.
Local policy
Staff /patient education
To allow time for clot formation to
occlude the puncture site and to
prevent bruising from seepage under
the skin between the skin surface and
the vessel wall.
Clamps can damage the fistula as
there is no control on the amount of
pressure being used, thus the clamp
could occlude the fistula.
Local policy
Local policy will dictate
needle size and blood
flow rate.
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Map the fistula and cannulation sites
used, report any problems to
designated vascular access
nurse/nephrologists/surgeon/radiologi
st.
To inform next cannulation.
If first week is successful continue to
week 2 changing to 16 gauge
needles, rotating cannulation sites
and increasing blood flow rate.
Week 3 : as week 2 or if tolerated
well increase to 14/15 gauge needles
and required BFR
To reach optimum delivered blood
flow and dialysis adequacy.
Infiltration guidelines
If the fistula infiltrates let it rest for 1
week then go back to smaller gauge
needles. Notify nephrologist.
If it infiltrates a second time rest for 2
weeks and then reduce needle size.
Notify nephrologist.
If infiltration occurs a third time notify
nephrologists/radiologist/surgeon or
designated vascular access nurse/coordinator.
To prevent further damage to fistula,
and allow healing.
Fistula needle should be removed
immediately before pressure is
applied
To prevent trauma to the intima of the Staff/ patient education
vessel caused by the cutting edge of
and training
the needle and to minimise pain
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Local policy
Accurate documentation
at all stages.
Staff/ patient education
and training
Consecutive infiltration could signify a
problem with the fistula that requires
radiological or surgical intervention.
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Key point: Closely monitor heparin according to local policy.
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Section 7- Emergency Care
STATEMENT
REASON FOR
HOW IS IT BEING ACHIEVED
STATEMENT
All patients should be
Patient must be aware of
Patient should be provided with information regarding their access
informed about simple
what action to take in event
site through easily understood verbal and written communication
emergency procedures and
of haemorrhage
A record is kept of information given to patients
how to best care for their
Patient plays an important
dialysis access
role in the development
and preservation of the
fistula and in early
detection of complications
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Appendix 1
Tourniquet information
o A tourniquet should be used even when the vessel size does not appear to
necessitate it. This will prevent unnecessary trauma
o A tourniquet is not required when cannulating an av graft
Patient education
o Encourage the patient to exercise their fistula arm for vessel development
approximately 10-14 days post operatively. There should be no swelling
around anastomosis before exercises begin.
o A rubber ball or rolled up sock may be used or a hand grip. The ball should be
squeezed while the other hand is squeezing the upper arm to impede not
occlude venous outflow.
o If a tourniquet is used then a pulse should be palpable above the applied
tourniquet to avoid complete obstruction of flow
o Each exercise should be completed four times daily for 5-10 mins each time
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Appendix 2
Recommended needle size and blood flow rates
Size 17g- new fistula
Aim for size 15g for established fistula
Aim for 14g if adequacy requires improvement
For single needle dialysis
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Appendix 3
Patient Education –Emergency Procedures
Emergency advice for patients following fistula formation
Guideline 10 of the DOQI guidelines state that patient education following fistula
formation should include:




Patients should be taught how to compress bleeding access
Patients should be taught how to recognise signs and symptoms of infection
Patients should be taught how to palpate for bruit/thrill/pulse daily and after
episodes of hypotension, dizziness or light-headedness
Patients should be taught to listen for bruit with ear opposite access site if cannot
palpate for any reason
Patients should be given contact name and number following formation of their fistula
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References
Beathard G A (1992) Physical Examination of AV Grafts Sem Dialysis 5 74
Beathard G A (2002) Improving Dialysis Vascular Access Dialysis and Transplantation 31: 4 pp 210217.
Brouwer D, Peterson P (2002) The arteriovenous graft: How to use it effectively in the dialysis unit
Nephrology News and Issues Nov 2002: pp 41-49.
Fistula First National Vascular Access Improvement Initiative (2003) A practitioners resource guide to
Physical Examination of Dialysis Vascular Access. Available at:
http://www.esrdnetwork.org/fistula_first_qip.htm#pe
Konner K, Nonnast-Daniel & Ritz E (2003) The Arteriovenous Fistula Journal of the American Society of
Nephrology 14: 1669-1680.
Merrill D, Brouwer D, Briones P (2005) Haemodialysis Access: A guide for caregivers and patients.
Dialysis and Transplantation. 34:4; 200-206.
National Kidney Foundation K/DOQI Clinical Practice Guidelines for vascular Access 2000 (2001)
American Journal Kidney Diseases 37:S137-S181 (supplement 1).
Vanholder R (2001) Vascular Access: care and monitoring of function Nephrology Dialysis
Transplantation 16: 1542-1545.
Brunori G, 2005 Fistula maturation, doesn’t time matter at all? NDT. April, 20(4) pp 684-687
Rayner, H 2003 Creation, cannulation and survival of atrerio-venous fistulae:Data from the Dialysis
Outcomes and Practice Study. Kidney International. Jan, 63(1) pp 325-330.
Vanholder R, 2001 Vascular Access: Care monitoring and function. NDT 16 p1542-1545
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