Hemodialysis in the Morbidly Obese

Abstract

Obesity has increased substantially in the American population over the past two decades. Given this significant increase and the association with hypertension and diabetes, the hemodialysis access surgeon must be comfortable in creating functioning access in obese patients. Obese patients are at increased risk for surgical site infections, have deeper anatomic structures that may limit dialysis cannulation, and are in a systemic proinflammatory and prothrombotic state. The successful creation of hemodialysis access often requires adjunctive procedures to increase the produced reliable access, and techniques that have demonstrated efficacy include transposition, elevation, lipectomy, minimal incision superficialization technique (MIST), and suction lipectomy (liposuction). When autogenous fistula creation is not possible necessitating a graft for permanent access, adjunctive intraoperative procedures are useful, particularly with tunneling, in allowing repeated successful dialysis. Obese patients are also impacted by the need for tunneled dialysis catheters and may develop a central vein stenosis or occlusion. In this patient group, upper extremity dialysis access is preferred over the lower extremity, and Hemodialysis Reliable Outflow (HeRO) may provide a useful manner for successful dialysis.