We propose arterial pCO2 as test to discover vascular access recirculation (VAR) in bicarbonate hemodialysis (HD). We selected 30 HD patients with a ascertained well-functioning arteriovenous fistula (Control). In these patients, we artificially created VAR through the reversion of HD lines (Reversed). Results of the arterial gas analysis were collected at the start of HD (baseline) and after 5 min. At baseline, no differences of pH, pCO2 and HCO3 were found between the 2 groups. At 5 min, pCO2 increased from 38.1 ± 3.3 to 47.2 ± 6.3 mm Hg (p < 0.0001) in Reversed, whereas no increase was found in Control (p = 0.052). Areas under curve of pCO2-increase was 0.96 (0.91-1.00) and pCO2 at 5 min 0.92 (0.85-0.98). pCO2-increase >4.5 mm Hg showed sensitivity 86.7% and specificity 100% with positive predictive value (PPV) 100% and negative predictive value (NPV) 89%. A pCO2 value above 43 mm Hg at 5 min showed sensitivity 80%, specificity 90%, PPV 89%, NPV 82%. pCO2 increase >4.5 mm Hg and/or pCO2 at 5 min >43 mm Hg may accurately detect VAR.

Kjellstrand CM: The Achilles' heel of the hemodialysis patient. Arch Intern Med 1978;138:1063-1064.
Winkelmayer WC: Tackling the Achilles' heel of hemodialysis. N Engl J Med 2011;364:372-374.
Vascular Access 2006 Work Group: Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(suppl 1):S176-S247.
Jindal K, Chan CT, Deziel C, Hirsch D, Soroka SD, Tonelli M, Culleton BF: Hemodialysis clinical practice guidelines for the Canadian society of nephrology. J Am Soc Nephrol 2006;17(3 suppl 1):S1-S27.
Tessitore N, Bedogna V, Verlato G, Poli A: The rise and fall of access blood flow surveillance in arteriovenous fistulas. Semin Dial 2014;27:108-118.
Besarab A, Sullivan KL, Ross RP, Moritz MJ: Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis. Kidney Int 1995;47:1364-1373.
Sherman RA, Levy SS: Assessment of a two-needle technique for the measurement of recirculation during hemodialysis. Am J Kidney Dis 1991;18:80-83.
Paulson WD, Gadallah MF, Bieber BJ, Altman SD, Birk CG, Work J: Accuracy and reproducibility of urea recirculation in detecting haemodialysis access stenosis. Nephrol Dial Transplant 1998;13:118-124.
Schneditz D, Wang E, Levin NW: Validation of haemodialysis recirculation and access blood flow measured by thermodilution. Nephrol Dial Transplant 1999;14:376-383.
Wang E, Schneditz D, Kaufman AM, Levin NW: Sensitivity and specificity of the thermodilution technique in detection of access recirculation. Nephron 2000;85:134-141.
Hester RL, Ashcraft D, Curry E, Bower J: Non-invasive determination of recirculation in the patient on dialysis. ASAIO J 1992;38:M190-M193.
Steuer R, Harris D, Connis J: A new optical technique for monitoring hematocrit and circulating blood volume: its application in renal dialysis. Dial Transplant 1993;22:260-265.
Mercadal L, Coevoet B, Albadawy M, Hacini S, Béné B, Deray G, Petitclerc T: Analysis of the optical concentration curve to detect access recirculation. Kidney Int 2006;69:769-771.
Lindsay RM, Burbank J, Brugger J, et al: A device and a method for rapid and accurate measurement of access recirculation during hemodialysis. Kidney Int 1996;49:1152-1160.
Mercadal L, Hamani A, Béné B, Petitclerc T: Determination of access blood flow from ionic dialysance: theory and validation. Kidney Int 1999;56:1560-1565.
Gotch FA, Buyaki R, Panlilio F, Folden T: Measurement of blood access flow rate during hemodialysis from conductivity dialysance. ASAIO J 1999;45:139-146.
Badr B, Bories P, Marais R, Frat B, Seigneuric B, Longlune N, Kamar N, Maggioni S, Rostaing L: Transonic, thermodilution, or ionic dialysance to manage vascular access: which method is best? Hemodial Int 2014;18:127-135.
Krivitski NM: Theory and validation of access flow measurement by dilution technique during hemodialysis. Kidney Int 1995;48:244-250.
Krivitski NM: Novel method to measure access flow during hemodialysis by ultrasound velocity dilution technique. ASAIO J 1995;41:M741-M745.
Wijnen E, Essers S, van Meijel G, et al: Comparison between two on-line reversed line position hemodialysis vascular access flow measurement techniques: saline dilution and thermodilution. ASAIO J 2006;52:410-415.
Magnasco A, Alloatti S, Bonfant G, Copello F, Solari P: Glucose infusion test: a new screening test for vascular access recirculation. Kidney Int 2000;57:2123-2128.
Magnasco A, Alloatti S: Glucose infusion test (GIT) compared with the saline dilution technology in recirculation measurements. Nephrol Dial Transplant 2006;21:3180-3184.
Sombolos KI, Bamichas GI, Christidou FN, et al: pO2 and pCO2 increment in post-dialyzer blood: the role of dialysate. Artif Organs 2005;29:892-898.
Sombolos KI, Christidou FN, Bamichas GI, et al: HCO3 increment in arterial line can reveal significant vascular access recirculation in high-flux hemodialysis: a preliminary report. Hemodial Int 2006;10:88-93.
Huisman RM, van Dijk M, de Bruin C, et al: Within-session and between-session variability of haemodialysis shunt flow measurements. Nephrol Dial Transplant 2005;20:2842-2847.
Chin AI, Chang W, Fitzgerald JT, et al: Intra-access blood flow in patients with newly created upper-arm arteriovenous native fistulae for hemodialysis access. Am J Kidney Dis 2004;44:850-858.
Wiese P, Nonnast-Daniel B: Colour Doppler ultrasound in dialysis access. Nephrol Dial Transplant 2004;19:1956-1963.
Bandyk DF: Interpretation of duplex ultrasound dialysis access testing. Semin Vasc Surg 2013;26:120-126.
Malik J, Kudlicka J, Novakova L, Adamec J, Malikova H, Kavan J: Surveillance of arteriovenous accesses with the use of duplex Doppler ultrasonography. J Vasc Access 2014;15(suppl 7):S28-S32.
Schlebusch H, Paffenholz I, Zerback R, Leinberger R: Analytical performance of a portable critical care blood gas analyzer. Clin Chim Acta 2001;307:107-112.
Hunt JM, Chappell TR, Henrich WL, Rubin LJ: Gas exchange during dialysis. Contrasting mechanisms contributing to comparable alterations with acetate and bicarbonate buffers. Am J Med 1984;77:255-260.
Oettinger CW, Oliver JC: Normalization of uremic acidosis in hemodialysis patients with a high bicarbonate dialysate. J Am Soc Nephrol 1993;3:1804-1807.
Marano M: [Gas analysis in bicarbonate dialysis]. G Ital Nefrol 2013;30:gin/30.5.8.
Golper TA, Fissell R, Fissell WH, Hartle PM, Sanders ML, Schulman G: Hemodialysis: core curriculum 2014. Am J Kidney Dis 2014;63:153-163.
Oh MS, Uribarri J, Weinstein J, et al: What unique acid-base considerations exist in dialysis patients? Semin Dial 2004;17:351-364.
Symreng T, Flanigan MJ, Lim VS: Ventilatory and metabolic changes during high efficiency hemodialysis. Kidney Int 1992;41:1064-1069.
Ruzicka J, Novak I, Rokyta R, et al: Effects of ultrafiltration, dialysis, and temperature on gas exchange during hemodiafiltration: a laboratory experiment. Artif Organs 2001;25:961-966.
Pitcher WD, Diamond SM, Henrich WL: Pulmonary gas exchange during dialysis in patients with obstructive lung disease. Chest 1989;96:1136-1141.
Manca-Di-Villahermosa S, Tedesco M, Lonzi M, et al: Acid-base balance and oxygen tension during dialysis in uremic patients with chronic obstructive pulmonary disease. Artif Organs 2008;32:973-977.
Alfakir M, Moammar MQ, Ali MI, et al: Pulmonary gas exchange during hemodialysis: a comparison of subjects with and without COPD on bicarbonate hemodialysis. Ann Clin Lab Sci 2011;41:315-320.
Kirmizis D, Kougioumtzidou O, Vakianis P: Diagnostic accuracy of arterial line blood gas measurements as an estimate of arteriovenous fistula recirculation. Nephrology (Carlton) 2013;18:718-723.
Depner TA, Rizwan S, Cheer AY, Wagner JM, Eder LA: High venous urea concentrations in the opposite arm. A consequence of hemodialysis-induced compartment disequilibrium. ASAIO Trans 1991;37:M141-M143.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.