Kirby GC, Meecham L, Evans RPT, Wessels J, Asquith JR, Leslie FM, Macano CAW, Nyasavajjala SM and Pherwani AD
Introduction: We present the dual use of an arteriovenous fistula (AVF) for contemporaneous administration of home parenteral nutrition (PN), and hemodialysis (HD). Case Report: A 52 year old female patient required PN due to short bowel syndrome, following extensive resection for ischemic bowel. After she was rendered dialysis dependent secondary to multifactorial renal failure, a left forearm basilica vein transposition onto the radial artery was undertaken. Venous access for PN was problematic. We commenced home PN via the AVF, using a ‘buttonhole’ technique to cannulate the fistula for both HD and PN. The peripheral administration of PN necessitated reduction in the osmolality, with larger volumes and longer administration times. This required adjustment of the HD regime to compensate.The patient received simultaneous PN and HD at home through the AVF successfully for seven weeks. Unfortunately after this time she suffered a staphylococcal fistula infection with septicemia. Discussion: We have shown that dual use of AVF for HD and PN is feasible, although not without risk. Reduction of osmolality and staggering of PN and HD sessions is required, with administration of PN over longer times. It has been shown that the buttonhole cannulation technique has a higher rate of infection than alternatives, and we propose this may have contributed to our patient’s complication. We believe this report would be helpful if dual use of AVF for PN and HD is contemplated.