Current Status of Synthetic and Biological Grafts for Hemodialysis

Patients with chronic kidney disease (CKD) stage 4 or 5 have the option of kidney transplantation, hemodialysis (HD), peritoneal dialysis (PD), or conservative management.1 National Kidney and Urologic Disease Information Clearinghouse reported that in 2007, there were 368, 544 U.S. residents with ESRD who were receiving dialysis, of whom 341, 264 were undergoing HD.2 Quality of life and long-term survival of patients with CKD who are on HD depends on the successful placement of vascular access, as autogenous arteriovenous access, prosthetic arteriovenous access, or tunneled central venous catheter. DOQI guidelines are emphatic that autogenous arteriovenous access placement should be considered first, as it provides the optimal vascular access, followed by prosthetic grafts if autogenous arteriovenous access placement is not possible. There is a great deal of controversy regarding the choice of synthetic or biological material, as the guidelines suggest that it should be based on surgeon's experience and preference. The evidence to support the superiority of tapered versus uniform tubes, thickversus thinwalled characteristics, elastic versus non-elastic arterial, stretch vs. standard PTFE, externally supported vs. unsupported grafts, is still evolving. An ideal vascular graft would have the following characteristics: 1) appropriate size to match host vessels, 2) mechanical strength, 3) low thrombogenicity/ complete endothelialization, 4) rapid/ complete healing, 5) ease of handling, 6) resistance to infection, 7) structural durability in face of repeated needle puncture, 8) low incidence of hyperplastic intimal changes and 9) low cost.3 In this chapter, we will review the development of vascular grafts over the years and discuss the advantages of one over the other.