Innovation in dialysis access: From vision to reality

Ali Kordzadeh is a consultant vascular and access surgeon at Mid and South Essex NHS Foundation Trust (UK) and a visiting professor at Anglia Ruskin University (Chelmsford, UK).

The global burden of kidney disease has made dialysis a critical lifeline for millions, and the need for safer, more reliable, and more efficient access and its management has never been greater.¹ The intersection of technology and healthcare has been a catalyst for innovation in recent years, and dialysis access stands at a crossroads of innovation and transformation. As we look to the horizon, it’s clear that we’re on the precipice of a new era that promises unparalleled advancements from innovative bioengineering grafts, to sophisticated wearable monitoring devices and new trends that will impact the way we approach dialysis access.²

The development of cutting-edge technologies, techniques and artificial intelligence is set to transform this crucial aspect of patient care, promising a greater precision, improved patient safety, and fewer complications. These advancements are not confined to the distant future; they are within our grasp now, transforming the way we perceive, monitor, plan, perform and provide access. A dive into the potential of these innovations casts a spotlight on how they may revolutionise the landscape of dialysis access in the years to come.³

Since the initiation of intermittent peritoneal dialysis in the 1940s, our journey in renal care has altered significantly.⁴ Currently, we stand on the threshold of a new epoch characterised by 3D-printed, automated peritoneal dialysis (PD) through a dynamic interface reinforced by the precision of artificial intelligence and robotics.⁵ This consequential evolution is enhanced by cutting-edge optical chemical sensors, facilitating non-invasive, dynamic assessments of peritoneal protein loss in end-stage kidney disease (ESKD), and initiating precise dialysis even during sleep.⁶

Home pulse pressure monitoring has developed as a vital prognostic tool, precisely predicting mortality and cardiovascular events in PD patients.⁷ The addition of far-infrared therapy, meanwhile, offers potential improvements in PD by reducing the incidence of peritonitis.⁸ Their incorporation with point-of-care, self-driven, portable ultrasound and individualised peritoneal solutions through telemedicine is a testament to the strides that have been taken so far.^9,10

In addition to these trends, significant progress in vascular catheter design, novel materials, and the application of innovative coatings have significantly enhanced patient care. The diversification of central venous catheter design into step, split, symmetric and self-centring-tip with superior biocompatibility, continues to cater for unique and dynamic clinical circumstances.^11,12 The use of high-quality imaging data predicts and plans the optimal catheter placement and foresee potential complications, thereby enhancing procedural accuracy and safety. Improvements in real-time flow assessment at the catheter tip using microsensors provides immediate evaluation of central venous catheter (CVC) malfunction, limiting those complications that were once frequent.^13-16

In the realm of haemodialysis, arteriovenous fistulas (AVF) continue to be the gold standard for haemodialysis due to their durability, affordability and reliability. Annually, 5,000–6,000 patients in the UK and around 9.7 million globally require haemodialysis, a figure predicted to double by 2030. Their failure could have substantial psychological implications reducing quality-adjusted of life years (QALY).^17,18

Frequent interventions, recurrent hospital visits, failures in dialysis, and the implementation of interim modalities are directly associated with increases in all-cause mortality. For those of average-to-high socioeconomic status, life expectancy ranges between five to seven years, forecasted to reach nine years. These patients will generally require a new AVF every two to three years, with each typically necessitating two or more interventions to maintain their patency. Regrettably, this only applies to 40–60% of those AVFs that successfully mature and are subject to surveillance.¹⁹

Endovascular AVF (endoAVF) techniques represent another profound leap in the field of haemodialysis access. These innovative, minimally invasive procedures have emerged as a robust alternative to traditional open surgeries, marking a significant shift in the landscape of renal healthcare. Groundbreaking devices are at the forefront of this transformation, harnessing advanced image guidance technology for the precise creation of AVFs. The ramifications of these technological advancements are substantial: reduced hospital stay durations, accelerated patient recovery, and significantly decreased risk of infection. Consequently, the integration of endoAVF creation represents an important advancement in renal care, fostering improved patient outcomes and greater healthcare efficiency.²⁰

In the last decade, a considerable amount of research has been conducted to identify the optimal investigative modalities and their timing for detection of failed or delayed functional maturation, early-onset stenosis, and thrombosis of AVFs. Despite this, a reliable and prompt protocol has yet to be established. This, coupled with the identification of different inflammatory biomarkers, has become a pivotal point of discussion amongst access providers and patients.^21,22

Surveillance against ailments

This has sparked the question: “What if a continuous, dynamic, wearable, and patient-focused surveillance programme could be implemented?” One that could eliminate the need for frequent hospital visits and instead be compatible with smartwatches or home devices for immediate identification and response to any complications.

The integration of non-invasive diagnostic techniques such as infrared, acoustic, optical stereoscopy, and duplex ultrasound sensors, along with measurements of flow velocity, pulse wave velocity, vascular resistance, and compliance has made such an idea plausible.²³ The driven data from these innovations are able to identify patterns and trends that may indicate AVF malfunction, allowing timely intervention. Furthermore, assimilation of inflammatory biomarkers in such algorithms has expanded the horizon of remote patient care in dialysis—eliminating the vast psychological, clinical and cost burdens.²⁴

Incorporation of these technologies into wearables, gadgets or smart patches is here. It is paving the way for a world of minimum patient contact with maximum clinical outcome. In the last few years, we have witnessed such breakthroughs, where a simple adhesive patch has the ability to detect various biomarkers without the need for repeated blood tests.²⁵

Indeed, the current advancements in wearable technology have reached a stage where a single wearable watch can utilise signal amplitude, venous calibre, and pulsation data to detect the possibility of stenosis. Through sophisticated algorithms, this information can be filtered, calibrated, and adjusted to accurately assess blood flow, facilitating the prediction of successful maturation in vascular access for haemodialysis.²⁶ This breakthrough represents a significant step forward in the field of haemodialysis access management, as it enables early detection and intervention, ultimately leading to improved patient outcomes and a more efficient and effective approach to dialysis care. As wearable devices and artificial intelligence continue to evolve, the future of haemodialysis access holds significant potential for enhancing patient care and transforming the landscape of renal therapy.^27,28

Collaboration between medical teams, engineers and patients is crucial for advancing such technologies in haemodialysis access. Collaboration with patients and caregivers, meanwhile, is equally vital, and involving them in the design and testing process ensures that the solutions developed truly meet the needs and preferences of those who will use them. Patient feedback is invaluable in refining wearable devices and algorithms to be user-friendly, reliable, and well-integrated into their daily lives.

References:

1. Kovesdy CP. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl (2011). 2022 Apr;12(1):7-11. doi: 10.1016/j.kisu.2021.11.003. Published online 2022 Mar 18.
2. Thimbleby H. Technology and the future of healthcare. J Public Health Res. 2013 Dec 1;2(3):e28. doi: 10.4081/jphr.2013.e28.
3. Davenport T, Kalakota R. The potential for artificial intelligence in healthcare. Future Healthc J. 2019 Jun;6(2):94-98.
4. Foo, Marjorie W Y, and Htay Htay. “Innovations in peritoneal dialysis.” Nature Reviews Nephrology 16,10 (2020): 548-549.
5. Domenici A, Giuliani A. Automated Peritoneal Dialysis: Patient Perspectives and Outcomes. Int J Nephrol Renovasc Dis. 2021 Oct 7;14:385-392.
6. Kuznetsov A, Frorip A, Sünter A, et al. Optical Chemical Sensor Based on Fast-Protein Liquid Chromatography for Regular Peritoneal Protein Loss Assessment in End-Stage Renal Disease Patients on Continuous Ambulatory Peritoneal Dialysis. Chemosensors. 2022; 10(6):232.
7. Panuccio V et al. “Home Pulse Pressure Predicts Death and Cardiovascular Events in Peritoneal Dialysis Patients.” Journal of Clinical Medicine 12,12 3904. 7 Jun. 2023,
8. Chang Y et al. “Does Far-Infrared Therapy Improve Peritoneal Function and Reduce Recurrent Peritonitis in Peritoneal Dialysis Patients?.” Journal of Clinical Medicine 11,6 1624. 15 Mar. 2022,
9. Buckup M et al. “Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients.” Scientific Reports 12,1 14046. 18 Aug. 2022,
10. Thajudeen B, Issa D, Roy-Chaudhury P. Advances in hemodialysis therapy. Fac Rev. 2023 May 16;12:12. doi: 10.12703/r/12-12. PMID: 37284495; PMCID: PMC10241346.
11. Sohail MA, Vachharajani TJ, Anvari E. Central Venous Catheters for Haemodialysis: The Myth and the Evidence. Kidney Int Rep. 2021 Oct 11;6(12):2958-2968. doi: 10.1016/j.ekir.2021.09.009.
12. Balamuthusamy S et al. “Self-centering split-tip catheter versus conventional split-tip catheter in prevalent hemodialysis patients.” J Vasc Access 17,3 (2016): 233-8.
13. Vachharajani, Tushar J et al. “New Devices and Technologies for Hemodialysis Vascular Access: A Review.”American Journal of Kidney Diseases 78,1 (2021): 116-124.
14. Brattain LJ, Pierce TT, Gjesteby LA et al. AI-Enabled, Ultrasound-Guided Handheld Robotic Device for Femoral Vascular Access. Biosensors (Basel). 2021 Dec 18;11(12):522.
15. Jung S, Oh J, Ryu J et al. Classification of Central Venous Catheter Tip Position on Chest X-ray Using Artificial Intelligence. Journal of Personalized Medicine. 2022; 12(10):1637.
16. Hirata I, Mazzotta A, Makvandi P et al. Sensing Technologies for Extravasation Detection: A Review. ACS Sens. 2023 Mar 24;8(3):1017-1032.
17. De Siqueira J, Jones A, Waduud M, et al. Systematic review of interventions to increase the use of arteriovenous fistulae and grafts in incident haemodialysis patients. J Vasc Access. 2022 Sep;23(5):832-838.
18. Huber, Thomas S et al. “Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates.” JAMA Surgery 156,12 (2021): 1111-1118.
19. Kordzadeh, Ali et al. “Independent association of arteriovenous ratio index on the primary functional maturation of autologous radiocephalic arteriovenous fistula.” Journal of Vascular Surgery 67,6 (2018): 1821-1828.
20. Shahverdyan, Robert et al. “Comparison of Outcomes of Percutaneous Arteriovenous Fistulae Creation by Ellipsys and WavelinQ Devices.” Journal of Vascular and Interventional Radiology (JVIR) vol. 31,9 (2020).
21. Richards, James et al. “Surveillance arteriovenous fistulas using ultrasound (SONAR) trial in haemodialysis patients: a study protocol for a multicentre observational study.” BMJ Open 9,7 e031210. 23 Jul. 2019,
22. Chen CH, Tao TH, Chou YH, et al. Arteriovenous Fistula Flow Dysfunction Surveillance: Early Detection Using Pulse Radar Sensor and Machine Learning Classification. Biosensors (Basel). 2021 Aug 26;11(9):297.
23. Fu B, Cheng Y, Shang C, et al. Optical ultrasound sensors for photoacoustic imaging: a narrative review. Quant Imaging Med Surg. 2022 Feb;12(2):1608-1631..
24. Sikkandar MY, Padmanabhan S, Mohan B et al. Computation of Vascular Parameters: Implementing Methodology and Performance Analysis. Biosensors. 2023; 13(8):757.
25. Miller, Forrest, et al. “wearable device for continuous, non-invasive monitoring of vascular access health and fluid status in haemodialysis PATIENTS.” Journal of the American College of Cardiology Supplement (2020): 1282-1282.
26. https://vascularnews.com/handheld-ecg-device-scoops-cx-2023-innovation-showcase-prize/
27. Thimbleby H. Technology and the future of healthcare. J Public Health Res. 2013 Dec 1;2(3):e28.
28. Marwaha JS, Raza MM, Kvedar, JC. The digital transformation of surgery.NPJ Digit. Med. 6, 103 (2023).