Cannulating tunneled dialysis access in the keloid-prone patient

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K eloids are benign overgrowths of scar tissue composed of overproduction of cellular matrix and dermal fi broblasts. As with all genetic diseases, the prevalence of keloids varies between different patient populations, ranging from 0.09% in Great Britain to 16% in the Congo.1 Patients with the genetic predisposition to keloid formation can form large overgrowths following any skin insult.2 In addition to cosmetic concerns and disfi gurement, keloids can also be painful.3 Recurrence of keloids is common despite both medical therapy and surgical removal. Patients on hemodialysis (HD) who are prone to keloid formation present a unique challenge. Multiple studies have shown that the preferred method of access for hemodialysis is via an arteriovenous fi stula (AVF).4 This was further promoted by the Fistula First initiative resulting in an increased prevalence of AVF. During cannulation of the AVF, the skin overlying the fi stula is traumatized, predisposing this population to keloid formation. Further K/DOQI guidelines suggest rotating the site of the needle placement along the AVF to decrease the incidence of pseudoaneurysms.5,6 While the K/DOQI guidelines are benefi cial to the HD population at large, if we generalize to include this unique population, we place them at risk for extensive scarring and keloid formation. To our knowledge, management of HD patients prone to keloids has not been addressed in the literature. We present four cases of patients on HD who developed keloids, and how they were managed. In our centers’ diverse patient population, the incidence of keloids is about 1 in 200.