Dialysis Access and Fistula Care in Singapore

Haemodialysis needs a reliable way to take blood to a dialysis machine and return it to the body. This is called vascular access. The main options are an arteriovenous fistula, an arteriovenous graft and a dialysis catheter. The choice should fit your blood vessels, general health, timing of dialysis and longer-term kidney-care plan. I work with nephrology colleagues to assess and manage access; the aim is a suitable plan for the person, rather than one access type for everyone.

When does a dialysis access problem need urgent help?

Heavy, spurting or uncontrolled bleeding from an access is an emergency. In Singapore, call 995 immediately. Apply firm, direct pressure to the bleeding point with clean gauze or a clean cloth while waiting for help, and follow the emergency dispatcher's instructions. Do not wait for a routine appointment.

Contact your dialysis unit or treating team urgently if the usual vibration, or thrill, disappears, dialysis flow becomes poor, or you develop new swelling, redness, warmth, discharge or increasing pain. Fever or chills may indicate infection. A catheter that moves, leaks or becomes damaged also needs urgent attention. Do not wait until the next dialysis session to report these changes.

A newly cold, painful, numb or weak hand needs urgent assessment. If symptoms are severe or sudden, or you have collapse, marked weakness, chest pain or breathlessness, seek emergency care. If the treating team cannot be reached promptly for an urgent access problem, attend an emergency department.

What are the different types of dialysis access?

Arteriovenous fistula

A fistula connects one of your arteries to a vein, usually in the arm. The increased flow allows the vein to enlarge and strengthen so that it can be used with dialysis needles. A suitable, functioning fistula can offer durable access with a relatively low infection risk, but it needs time to develop and some fistulas do not become usable without further treatment.

Arteriovenous graft

A graft uses a tube, usually synthetic, to join an artery to a vein. It may be appropriate when a person's own veins are unsuitable for a fistula or when other factors favour it. Grafts can often be used sooner than fistulas, although timing depends on the graft and clinical situation. Infection, narrowing and clotting remain possible.

Dialysis catheter

A catheter is a tube placed into a large vein. It can provide access when dialysis is needed before a fistula or graft is ready, or when these options are unsuitable. Catheters carry risks including infection, poor flow and narrowing of major veins. A tunnelled catheter may be used for longer periods in selected circumstances, with careful ongoing care.

How is access planned?

Planning considers when haemodialysis is likely to start, previous access procedures or catheters, the condition of your vessels, other illnesses and your preferences. Protecting options for future access is part of the discussion. A fistula is often a useful option, but urgency, the likelihood of successful maturation and your wider kidney-treatment plan can favour another approach.

The dialysis access creation guide compares fistula, graft and tunnelled catheter planning.

Assessment includes examination of the arms and may include ultrasound to map vessels or investigate an existing access. My introduction to duplex ultrasound explains the general scan; the exact examination depends on the access question. Previous operations and scan reports help avoid planning in isolation.

Before a procedure, discuss its purpose, alternatives, possible complications and what happens if the access is not ready when dialysis is needed. Complex or previously exhausted access may require an individual surgical or endovascular plan. My article on safer vascular care and shared decisions suggests useful questions to bring.

Looking after a fistula, graft or catheter

• Follow your dialysis team's instructions on cleaning, dressings and checking the access.

• Learn how your fistula or graft normally feels and check its thrill as instructed.

• Protect the access arm from tight pressure and tell healthcare staff before blood-pressure checks, blood tests or intravenous lines.

• Keep catheter dressings clean and dry; report a wet, loose or damaged dressing to the care team.

• Report changes in skin, swelling, needle-site bleeding or dialysis performance promptly.

Routine monitoring helps identify problems, but a new symptom still deserves attention between scheduled visits. Do not adjust, flush or manipulate a dialysis catheter yourself.

Common questions about dialysis access

How long does a fistula take to become usable?

It commonly takes several weeks and sometimes longer. Your team checks its development and readiness; an operation date alone cannot tell you when needling is safe. Some fistulas need further treatment or an alternative access.

Can a narrowing or clot be treated?

Depending on the cause, options may include balloon angioplasty, selected stenting, clot removal or surgical revision. Treatment aims to restore useful access, but success is not guaranteed. The plan must also address how dialysis will continue if the current access cannot be used.

Explore dialysis access salvage for more detail on angioplasty, clot removal and surgical revision.

Is a fistula always the best choice?

No. Its advantages need to be weighed against your vessels, health, treatment plans and preferences. Access selection should be agreed with you and the team managing your kidney disease.

Arrange a planned access review in Singapore

For access planning or a non-emergency review, contact Andrew Choong Vascular Surgery at Mount Elizabeth Novena Specialist Centre, #09-22, 38 Irrawaddy Road, Singapore 329563. Bring your nephrologist's referral information if available, medication list and records of previous access procedures or scans. Learn more about Dr Andrew Choong's vascular and endovascular practice.

Vascular patient education

Watch Dr Andrew Choong’s introduction to the work of a vascular surgeon, which includes dialysis access. The video library’s dialysis access section brings together written guides on creating access and treating access problems.