Death due to dialysis access haemorrhage: why does it happen and what are we doing about it?

Aim: To investigate deaths due to bleeding from haemodialysis vascular access.

Background: Haemodialysis requires access to the circulation via a synthetic vascular catheter or an arteriovenous fistula or graft. Whilst not common, every year there are deaths due to bleeding from dialysis vascular access.

Methods: A systematic search strategy including the National Coronial Information System (NCIS, containing coroner’s reports from all states and NZ), the Australian and New Zealand Dialysis and Transplant registry (ANZDATA), published cases from ANZ, State Renal Network reports and individual renal units for all persons dying where cause of death was reported as death due to dialysis access haemorrhage from 1st January 2000.

Results: A total of 83 people (55% female, mean age 67 years (range 30–89)) receiving renal replacement therapy died due to dialysis vascular access haemorrhage, identified through NCIS 54, ANZDATA 64, Publications 2, State networks 3 and individual renal units 2. Bleeds commonly occurred at home in people treated with satellite dialysis. Modality at the time of death was home HD in 12 people. Most deaths were attributable to problems with vascular access including infection (22%), dialysis catheter problems (17%), recent access intervention (15%) or use of a thigh AVF (11%). Use of Warfarin or cognitive impairment was identified in only 1 death each. Coronial inquests and Root Cause Analyses were identified in only 7 deaths with recommendations involving communication, staffing, clinical policy & practice changes and equipment modification.

Conclusions: Death due to dialysis access haemorrhage is an uncommon, catastrophic, but potentially preventable event. A minority of deaths have been investigated but where they have, critical recommendations for optimising future care are presented.