Optimizing Clinical Nursing Interventions for Hemodialysis Patients with Arteriovenous Fistula

Abstract

This review synthesizes current evidence on clinical nursing practices in the management of arteriovenous fistulas (AVFs) among patients undergoing hemodialysis (HD). It investigates the identification of risk factors and elements contributing to AVF dysfunction, emphasizing the crucial role of nursing professionals in maintaining, monitoring, and enhancing the long-term functionality of vascular access. The findings indicate that implementing upper limb exercise protocols can significantly support AVF maturation, enhance hemodynamic parameters, and improve vascular access outcomes. Notably, the review highlights the necessity of continuous education for nurses in AVF management, emphasizing their critical role in the successful preservation and optimization of vascular access, including the promotion of exercise interventions. These insights underscore the importance of equipping nursing staff with current knowledge and skills to improve patient outcomes in HD care.

1. Introduction

The clinical nursing care of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in hemodialysis (HD) patients is vital for maintaining vascular access integrity and ensuring effective treatment outcomes. Nurses play a key role in assessing, cannulating, and monitoring AVFs. This requires technical skills and sound clinical judgment. Proper site preparation and the use of appropriate cannulation techniques, such as the rope-ladder or buttonhole methods, are essential. Accurate needle placement helps minimize trauma to the fistula and reduces the risk of complications, including infiltration, hematoma, and infection. Continuous surveillance of dysfunction is also crucial. Nurses must be alert to changes in thrill or bruit, prolonged bleeding after dialysis, or signs of stenosis. Additionally, they are responsible for educating patients on protecting their access site and recognizing early signs of potential issues. Adopting a standardized, patient-centered approach to AVF care, grounded in best practices, greatly enhances access longevity. This approach also contributes to the overall safety and quality of dialysis therapy [1].

Professional nursing strategies can significantly reduce complication and dysfunction rates of AVFs during the perioperative period. These practices help prolong fistula usage time and enhance patients’ quality of life [2]. Key strategies include avoiding invasive procedures on the limb with the fistula and maintaining optimal blood pressure to prevent thrombosis. Correcting comorbid conditions, such as hypertension and hyperlipidemia, is also important. Additionally, encouraging handgrip exercises supports fistula maturation [3,4]. Pre-cannulation care involves regulating environmental temperature to prevent vasoconstriction and ensuring that clothing is loose to avoid compression. It also includes monitoring the surgical site for signs of infection or complications. During the initial use of the fistula, careful selection of puncture sites and appropriate needle sizes are essential. Gradually increasing blood flow rates helps prevent injury and ensures adequate dialysis. Regular monitoring for signs of bleeding, needle displacement, and sufficient blood flow is crucial. Educating patients on self-care behaviors and fistula exercises further supports successful AVF management and helps prevent complications [2].

Moreover, numerous studies have highlighted the beneficial effects of hand exercise training on AVFs maturation in HD patients. Research indicates that hand exercises significantly improve grip strength, forearm circumference, and vascular maturation [5]. Additionally, exercises involving arm tourniquets have been shown to enhance AVFs maturation and increase vein diameter [6]. Postoperative exercise programs have further demonstrated their role in promoting AVF maturation. Other studies emphasize the positive impact of both hand and isometric exercises on improving AVF outcomes [7,8]. Furthermore, exercises with dumbbells have proven effective in enhancing AVFs function in HD patients [9]. Collectively, these findings support the integration of structured exercise regimens into clinical care to improve AVFs maturation and reduce the risk of related complications.

This review aims to synthesize current evidence on clinical nursing practices in managing AVFs for HD patients. It focuses on identifying risk factors and elements that contribute to AVF dysfunction. The review also highlights the essential role of nurses in preserving vascular access and maintaining long-term functionality. Special attention is given to upper limb exercise protocols, which are implemented and supported by nurses to enhance AVF maturation and durability.

2. The Necessity of Clinical Nurses’ Education on AVFs/AVG Management

The most significant factor in overall AVFs or AVG management and clinical care is the educational level of dialysis nurses [10,11]. Inadequate nursing care or incorrect techniques can result in vascular injury, increased hospitalization rates, and a decreased quality of life for patients [12,13]. Therefore, it is essential to integrate standardized nursing protocols and provide continuous training in vascular access management to ensure the best possible outcomes for patients undergoing long-term HD therapy.

Existing literature reveals gaps in the knowledge and clinical competency of dialysis nurses regarding the management of AVFs (Table 1). These findings underscore the critical need for ongoing education and training initiatives aimed at enhancing nursing proficiency in AVFs care, which is essential for improving patient outcomes and minimizing vascular access complications. Abou Elazayiem Bayumi et al. [10], in a quasi-experimental study assessing the impact of an educational program on nurses’ performance in AVFs management, reported that 54% of dialysis nurses demonstrated inadequate clinical practices prior to the intervention. Following the implementation of the educational program, a significant improvement was observed, with 93% of the participants achieving competent performance levels in AVFs care. The researchers also identified a highly statistically significant association between the total knowledge scores of the participating nurses and both their educational attainment and years of clinical experience, observed consistently before and after the implementation of the educational program (p = 0.000). More specifically, nurses holding a bachelor’s or technical institute degree in nursing and those with longer durations of clinical experience (≥4 years) in dialysis units demonstrated significantly higher knowledge scores related to AVFs management. However, this study was conducted at a single center, limiting the generalizability of its findings. Moreover, the lack of a control group makes it challenging to attribute improvements solely to the intervention.

Similarly, Yousif et al. [14] demonstrated that implementing a structured educational program in Sudan grounded in the K/DOQI clinical practice guidelines significantly improved dialysis nurses’ knowledge of vascular access care for HD patients. Notably, the enhanced knowledge level was sustained for at least three months following the intervention. Despite these positive outcomes, the study lacked long-term follow-up to assess the sustainability of knowledge gains, which raises questions about the intervention’s lasting impact.

While, in a groundbreaking study, Smith and Ayars [15] examined the impact of an advanced educational module on vascular access presented to HD nurses and patient care technicians. This module focused on physical examination findings to identify dialysis access at risk of malfunction. The results showed a significant improvement in both theoretical knowledge and practical skills among the participants after the intervention, particularly in their ability to recognize early signs of potential access malfunction. However, the study also revealed a notable gap between theoretical knowledge and its application in practice, emphasizing the need for more targeted training programs to bridge this divide. The findings suggest that active learning strategies within educational modules better equip staff to effectively assess and manage vascular access in HD patients. Overall, the study underscores the importance of structured and ongoing educational interventions to improve the competency of dialysis staff, which is crucial for enhancing patient outcomes through optimal vascular access management. While their approach was practical and tailored to clinical settings, the study did not address potential biases such as self-selection, where more motivated nurses might have participated. This could have influenced the reported improvements.

Meng et al. [16] examined the knowledge, attitude, practice, and self-efficacy of dialysis nurses in Singapore. Results showed that participants exhibited an adequate level of knowledge; however, certain gaps were identified. Additionally, the findings indicated a high level of self-efficacy among the nurses, accompanied by a positive attitude toward incorporating ultrasound technology in vascular access cannulation. Although this study provided comprehensive data, it did not examine how variations in institutional protocols might have influenced the findings. Additionally, cultural and systemic differences could affect the applicability of results to other regions.

Other studies, such as those by Alsolami and Alobaidi [17] and Chen et al. [18], employed cross-sectional designs to assess nurses’ knowledge, attitudes, and practices regarding vascular access management. While these studies offer valuable insights into the current state of nursing practices, their descriptive nature limits causal inferences. Furthermore, self-reported data may introduce social desirability bias, as nurses might overstate their competencies.

Collectively, these studies highlight the positive impact of educational programs on nursing practices related to AVF management. However, the lack of methodological rigor in some studies, including limited follow-up and potential biases, warrants caution when interpreting these results. Future research should focus on multi-center, controlled studies to better establish the effectiveness of educational interventions.

Table 1. HD nurses’ knowledge, attitude, and practices on managing vascular access with or without education programs.

Author, Year	Design	Sample Size	Received Educational Program	Experimental Tools	Main Results
Abou Elazayiem Bayumi et al. [10], 2020	quasi-experimental study	40 dialysis nurses	Yes	Structured interviewing questionnaire and Observational checklists	Prior to intervention: 54% of dialysis nurses showed inadequate clinical practices. After the intervention: 93% showed improvement competent performance levels in AVF care
Smith and Ayars [15], 2025	quasi-experimental study	34 dialysis nurses and 25 patient care technicians	Yes	knowledge test	A gap between knowledge and practical application, indicating the need for targeted training. Active learning strategies were found to be more effective for staff in managing vascular access.
Alsolami and Alobaidi [17], 2024	Cross-sectional study	197 dialysis nurses	No	previously validated questionnaire	37% of participants had specialized training in vascular access management. Self-efficacy in VA cannulation was high, with 98% confident in performing AVF and AVG assessments before cannulation. Nurses with an undergraduate degree were 92% more likely to be knowledgeable about AVF or AVG (p < 0.05)
Chen et al. [18], 2022	Cross-sectional study	222 dialysis nurses	No	A questionnaire that was validated by the authors (Cronbach’s a was 0.896)	The total vascular access knowledge score was 87.52 ± 13.71, with basic knowledge (3.88 ± 0.60), assessment (3.62 ± 0.65), and AVF puncture techniques (3.22 ± 0.71). Multiple linear regression identified that longer work experience, advanced training, and working in a public hospital were significant predictors of higher vascular access knowledge (p < 0.05).
Meng et al. [16], 2024	Multicenter study cross-sectional study	70 dialysis nurses (23 nurses from community centers and 47 from tertiary hospitals)	No	The 37-items survey consists of four dimensions of questions relating to vascular access cannulation and management: knowledge, attitude, practice and self-efficacy.	The participants exhibited a satisfactory level of knowledge, though some gaps were identified. Additionally, the results highlighted the nurses’ strong self-efficacy and positive attitude toward incorporating ultrasound into vascular access cannulation
Yousif et al. [14], 2017	Multicenter pilot study	61 dialysis nurses working at dialysis centers in Khartoum State, Sudan	Yes	K/DOQI questionnaire	Twenty-two individual variables assessing knowledge based on the K/DOQI guidelines showed significant improvement in nurses’ knowledge after the educational intervention (p < 0.001). The structured educational program based on K/DOQI guidelines significantly enhanced dialysis nurses’ knowledge in vascular access care. The knowledge gained was maintained for at least three months post-intervention.

Note: HD: Hemodialysis; AVF: arteriovenous fistula; AVG: arteriovenous graft; K/DOQI: Kidney Dialysis Outcome Quality Initiative.

Table 1. HD nurses’ knowledge, attitude, and practices on managing vascular access with or without education programs.

Author, Year	Design	Sample Size	Received Educational Program	Experimental Tools	Main Results
Abou Elazayiem Bayumi et al. [10], 2020	quasi-experimental study	40 dialysis nurses	Yes	Structured interviewing questionnaire and Observational checklists	Prior to intervention: 54% of dialysis nurses showed inadequate clinical practices. After the intervention: 93% showed improvement competent performance levels in AVF care
Smith and Ayars [15], 2025	quasi-experimental study	34 dialysis nurses and 25 patient care technicians	Yes	knowledge test	A gap between knowledge and practical application, indicating the need for targeted training. Active learning strategies were found to be more effective for staff in managing vascular access.
Alsolami and Alobaidi [17], 2024	Cross-sectional study	197 dialysis nurses	No	previously validated questionnaire	37% of participants had specialized training in vascular access management. Self-efficacy in VA cannulation was high, with 98% confident in performing AVF and AVG assessments before cannulation. Nurses with an undergraduate degree were 92% more likely to be knowledgeable about AVF or AVG (p < 0.05)
Chen et al. [18], 2022	Cross-sectional study	222 dialysis nurses	No	A questionnaire that was validated by the authors (Cronbach’s a was 0.896)	The total vascular access knowledge score was 87.52 ± 13.71, with basic knowledge (3.88 ± 0.60), assessment (3.62 ± 0.65), and AVF puncture techniques (3.22 ± 0.71). Multiple linear regression identified that longer work experience, advanced training, and working in a public hospital were significant predictors of higher vascular access knowledge (p < 0.05).
Meng et al. [16], 2024	Multicenter study cross-sectional study	70 dialysis nurses (23 nurses from community centers and 47 from tertiary hospitals)	No	The 37-items survey consists of four dimensions of questions relating to vascular access cannulation and management: knowledge, attitude, practice and self-efficacy.	The participants exhibited a satisfactory level of knowledge, though some gaps were identified. Additionally, the results highlighted the nurses’ strong self-efficacy and positive attitude toward incorporating ultrasound into vascular access cannulation
Yousif et al. [14], 2017	Multicenter pilot study	61 dialysis nurses working at dialysis centers in Khartoum State, Sudan	Yes	K/DOQI questionnaire	Twenty-two individual variables assessing knowledge based on the K/DOQI guidelines showed significant improvement in nurses’ knowledge after the educational intervention (p < 0.001). The structured educational program based on K/DOQI guidelines significantly enhanced dialysis nurses’ knowledge in vascular access care. The knowledge gained was maintained for at least three months post-intervention.

Note: HD: Hemodialysis; AVF: arteriovenous fistula; AVG: arteriovenous graft; K/DOQI: Kidney Dialysis Outcome Quality Initiative.

3. Clinical Nursing Practices in the Care of AVFs

Clinical nursing practices are essential for maintaining the functionality and longevity of AVFs, the preferred vascular access for HD. This preference is due to AVFs having lower complication rates and superior patency than other access modalities [19]. Nurses are crucial in AVFs care, from preoperative assessments and patient education to postoperative surveillance and managing complications [2,20]. Their responsibilities include performing accurate vascular assessments, employing proper cannulation techniques, and identifying dysfunction signs. Nurses also implement evidence-based interventions to prevent thrombosis, stenosis, and infections. Furthermore, patient education led by nurses encourages self-monitoring, adherence to hygiene practices, and the avoidance of trauma to the access site, all of which are vital for preserving AVFs [2,12]. Interestingly Qin et al. [2], conducted a randomized controlled trial (RCT) to evaluate the impact of nursing strategies on patients undergoing HD maintenance remedy. The study revealed that patients in the observational group who received specialized nursing care for their internal fistula experienced a lower rate of complications (17.4% vs. 37.0%, p = 0.035) and dysfunction (15.2% vs. 34.8%, p = 0.030) during the perioperative period than those who received standard nursing care in the control group. Additionally, the observation group’s median duration of internal fistula usage was significantly longer (over 20 months, p < 0.001). Furthermore, the health, emotional, and psychological quality-of-life indices, based on SF-36 were notably higher for the observation group than for the control group (p < 0.001). Even though the study reported positive outcomes, including improved vascular access functionality and reduced complication rates, the research was conducted in a single center, which limits the generalizability of the findings. Additionally, the study design did not include a control group, making it difficult to isolate the impact of the nursing strategies from other variables. The lack of long-term follow-up also prevents conclusions about the sustained effectiveness of the interventions.

Similarly, He et al. [12], in a recent RCT evaluating the effects of comprehensive nursing interventions on AVFs in patients undergoing HD, demonstrated that the observation group exhibited significantly lower incidences of access-related complications, including stenosis, thrombosis, and infection, compared to the control group. In addition to the clinical outcomes, patients in the intervention group reported improved psychological well-being, enhanced physical functioning, and greater overall satisfaction with care, underscoring the multidimensional benefits of structured nursing protocols in AVF management. However, the study’s observational nature introduces potential biases, particularly in attributing positive outcomes directly to the nursing interventions. Moreover, as the study was conducted within a specific healthcare setting, the applicability of the results to broader clinical contexts remains uncertain.

4. Key Factors for Successful AVF/AVG Cannulation in HD Patients

Successful AVF or AVG cannulation is critical to the long-term efficacy of HD treatment and requires the integration of several clinical and interpersonal competencies (Figure 1). Key factors contributing to successful cannulation include comprehensive anatomical knowledge of the vascular access site, technical proficiency in using appropriate cannulation techniques (e.g., rope-ladder or buttonhole methods), and the consistent application of aseptic protocols to minimize infection risk. Equally important are non-technical factors such as effective communication with patients, accurate assessment of the vascular access condition prior to cannulation, and the ability to recognize early signs of dysfunction, including stenosis, infiltration, or thrombosis. Ongoing clinical training, access to advanced tools such as ultrasound guidance, and interprofessional collaboration further enhance success rates. Moreover, self-awareness, reflective practice, and patient-centered care approaches have been shown to positively influence cannulation outcomes, suggesting that both technical skill and holistic nursing practice are essential components in ensuring the reliability and longevity of vascular access in HD patients [21,22,23]. According to Etkin et al. [24], end-stage renal disease (ESRD) patients, should have a Life Plan in place, focusing on “the right access, for the right patient, at the right time, for the right reasons.” While it’s generally recommended to create arteriovenous access distally in the nondominant arm with autogenous fistulas, each patient’s preferences and characteristics should guide the final decision. Furthermore, maintaining effective arteriovenous access is crucial for reducing the need for central venous catheters in HD patients. The AVF is preferred for its long-term benefits, but maturation issues can limit its success. Proper function relies on the integrity of the arterial and venous systems as well as adequate cardiac output. Surgically, preserving vascular structures is crucial for the creation and maturation of AVFs. There are also concerns about the long-term effects of trans-radial access in coronary interventions. Therefore, it’s also essential to educate patients and ensure that healthcare providers for those with ESRD are aware of strategies for preserving vascular health [25].

Harwood et al. [22], conducted a study to identify key factors that contribute to the successful cannulation of arteriovenous fistulas AVFs in HD patients. They performed qualitative interviews with 18 nurses considered proficient in AVF cannulation. From these interviews, the researchers identified four critical themes: patient-centered care, teamwork, opportunities for skill development, and nurse self-awareness. The findings underscored that AVFs cannulation success is not solely dependent on technical proficiency but also on the ability to provide individualized patient care, foster collaborative efforts among healthcare teams, and ensure continuous skill development. Additionally, the emotional intelligence and self-reflection of nurses were found to play significant roles in achieving positive cannulation outcomes. These results suggest that improving AVFs cannulation outcomes requires a comprehensive approach, incorporating both technical expertise and supportive interpersonal and professional qualities within the clinical setting. Although the study highlighted key practices linked to positive outcomes, it was limited by its retrospective design. This approach inherently risks recall bias and does not allow for establishing causality. Furthermore, the study was conducted at a single center, which restricts the generalizability of the findings.

Likewise, Coventry et al. [21], in a prospective cohort study that investigated 1946 cannulation events in 149 HD patients, aiming to identify patient, access, and nurse-related factors influencing cannulation outcomes, found a relatively low miscannulation rate of 4.4%, with older AVFs access, absence of a stent, and the use of fistulas rather than grafts being significantly associated with higher cannulation success. Interestingly, the study also reported that the absence of ultrasound or tourniquet use, as well as nurses without postgraduate renal nursing certification, were predictors of successful cannulation. These counterintuitive findings suggest that experienced clinical judgment may sometimes outweigh reliance on assistive tools. The study also emphasizes the potential for developing a vascular access cannulation complexity tool to match patients with nurses whose cannulation skill level has been competency-assessed. Such tools could reduce complications like infiltration, hematoma, or infection, ultimately improving patient safety and preserving access functionality. The study’s strength lies in its prospective design, which reduces the risk of bias compared to retrospective analyses. However, one limitation is the potential for selection bias, as participants were drawn from a specific healthcare setting. Additionally, while the study identified factors such as patient anatomy and nurse experience as crucial, it did not extensively address how differences in cannulation protocols might influence outcomes. Further research into the role of ultrasound guidance and structured training remains essential for optimizing outcomes in vascular access management.

In the same context, Pinto et al. [1], aimed to consolidate current evidence and guideline recommendations concerning best practices for arteriovenous fistula AVF cannulation in HD patients. Their review emphasizes the critical role of evidence-based cannulation practices in ensuring vascular access patency, minimizing access-related complications, and enhancing the overall quality of dialysis care. Their findings highlight the clinical advantages of the rope-ladder and buttonhole techniques over the area technique, citing their association with reduced risks of infiltration, aneurysm development, and infection. In addition, the review underscores the necessity of structured training programs and ongoing competency assessments for nursing staff, as well as the importance of maintaining cannulation consistency through skilled personnel. The integration of aseptic techniques, proper site rotation, and patient education are also identified as essential components in promoting long-term AVFs function and reducing morbidity. The review supports the implementation of guideline-based cannulation protocols as a critical strategy to adjust vascular access outcomes and improve patient safety in HD settings. However, even though the review effectively synthesized existing guidelines and best practices, it lacked a critical analysis of the evidence underlying those recommendations. As a narrative review, it did not systematically assess the quality of the included studies, potentially introducing publication bias. Furthermore, the review did not address how variations in local practices might affect the implementation of guidelines.

5. Challenges and Optimal Management of AVF/AVG in Elderly HD Patients

Creating AVF in elderly HD patients presents significant clinical challenges due to factors such as vascular aging, existing health conditions, and individual patient characteristics. Elderly patients frequently exhibit vascular calcification and reduce elasticity in their blood vessels. Additionally, comorbidities like diabetes and cardiovascular disease can hinder the maturation of the AVF and increase the risk of losing its functionality [26]. Optimal timing for creating an AVF is essential. Early placement may benefit HD patients requiring long-term treatment, but it might not be appropriate for those with limited life expectancy or poor vascular health [27]. While AVF has potential advantages, such as lower infection rates and greater durability compared to catheters, older adults often face extended maturation periods and increased rates of primary failure, especially when preexisting vascular conditions hinder fistula development [28]. AVF placement should ideally be tailored to individual health status, balancing the anticipated duration of dialysis with the HD patient’s comorbid burden and quality of life considerations. Nursing staff play a crucial role in managing AVF care, especially in the elderly population. Effective management includes regular assessment of the fistula for signs of thrombosis, stenosis, or infection, as well as routine monitoring of blood flow and bruit to ensure patency. Educating patients on self-monitoring techniques, such as palpation for thrill and recognizing early signs of complications, empowers them to participate in their care. Additionally, maintaining meticulous hygiene during cannulation and using advanced techniques to minimize vessel trauma is essential for preserving fistula function [29].

In an interesting study by Misskey et al. [30], researchers aimed to compare patency, maturation, survival, and complications across different age groups (<65 years, 65–79 years, >80 years) to determine if treatment protocols should be adjusted for older patients. They found that patients aged 65 to 79 years and those over 80 years had worse primary, primary assistance, and secondary patency and maturation compared to patients younger than 65 years. Additionally, when examining the types of access, brachiocephalic accesses showed lower patency and maturation rates than brachiocephalic accesses in both the 65 to 79 age group and the over 80 age group. Radiocephalic accesses were also identified as an independent predictor of secondary patency loss, particularly in women [31]. While in a more recent study by Wang et al. [31], researchers examined 596 HD patients with an average age of 62.8 ± 13.7 years who underwent AVF creation between 2014 and 2018 using balloon-assisted maturation (BAM). The study found that small veins can be effectively used for AVF creation, with lower yet still favorable maturation rates, when BAM interventions are applied, particularly in male patients. Additionally, the research indicated that only a limited number of BAM procedures are needed for small veins to develop into functional fistulas [31].

6. Challenges and Management of Dialysis Access-Associated Steal Syndrome

As the prevalence of ESRD rises, along with increased patient age and prolonged duration of dialysis, complications related to chronic dialysis, including dialysis-associated steal syndrome (DASS), become more common. DASS is a vascular complication of AVF or AVG creation in HD patients, characterized by distal limb ischemia due to blood flow diversion from the arterial to the venous system. DASS occurs when arterial blood preferentially flows through low-resistance venous access, leading to inadequate distal limb perfusion, especially in patients with preexisting vascular disease or compromised arterial integrity. The primary risk factors for DASS include advanced age (over 60-year-old), female gender [32], diabetes mellitus, peripheral arterial disease and the use of brachial-based or high-flow AVF configurations, which predispose patients to decreased distal perfusion. Clinical manifestations range from mild symptoms, such as coldness and pain in the affected limb, to severe ischemia with ulceration, tissue necrosis, or gangrene. Evaluation typically involves a thorough physical examination, Doppler ultrasound to assess blood flow patterns, and angiography for anatomical visualization when necessary. Management strategies depend on the severity of ischemia and include both conservative and surgical approaches. Mild cases may be managed with thermal protection and observation, while more severe cases necessitate interventions such as flow-limiting procedures (banding), distal revascularization with interval ligation (DRIL), or, in critical situations, ligation of the AV access to restore adequate perfusion. Although no reliable predictive tool for DASS exists, treating significant arterial inflow or outflow lesions before access creation is advised. Severely diseased or heavily calcified vessels should be avoided. Preventive measures such as prophylactic PAI may be considered in high-risk patients. Surgical techniques like limiting inflow size, maintaining arteriotomy length (4–6 mm), using continuous sutures, and preferring end-to-side anastomosis can help reduce DASS risk [33].

Early diagnosis and intervention are also crucial to preserving limb function and maintaining vascular access. Moreover, given the complex nature of DASS in elderly patients, nursing management must be proactive, with careful monitoring, patient education, and coordination of care to reduce the risk of irreversible ischemic damage and to preserve both limb function and dialysis access [33,34].

7. Upper Limb Exercise Intervention May Benefit AVF

Upper limb exercise enhances arterial inflow to the arm and venous return to the heart. Several physiological mechanisms have been proposed to explain the improvement in brachial artery blood flow observed with hand exercise. These include increased transmural pressure and shear stress on endothelial cells, elevated nitric oxide (NO) bioavailability, and reduced oxidative stress [35]. NO plays a key role in vascular remodeling by stimulating matrix metalloproteinases (MMP-2 and MMP-9), which facilitate vasodilation and promote permanent outward vascular remodeling [36,37]. Consequently, hand exercise may contribute positively to AVF maturation in patients with kidney failure [38] (Figure 2).

Upper limb exercises are commonly incorporated into routine clinical care following AVFs surgery, despite the current lack of conclusive evidence supporting their efficacy in promoting AVF maturation or function [5,6]. A variety of exercise modalities have been employed in patients with chronic kidney disease (

Table 2. Upper limb exercise intervention studies’ results.

Author, Year	Design	Sample Size	Duration, Measurements, Type of Exercise and Groups	Main Results	Stenghs/Limitations or Potential Bias
Kong et al. [5], 2014	RCT	18 HD patients that have AVF surgery	4 weeks exercise program Group A: n = 10 HD patients, who performed hand-squeezing exercise with a handgrip tool (GD grip) Group B: n = 8 HD patients used a soft ball	GD Grip and Soft Ball exercises both improved cephalic vein size, blood flow volume, and forearm circumference. GD Grip was more effective in enhancing pinch and grip strength, while blood flow velocity remained unchanged in both groups.	Lack of randomization and control group limits causality; small sample size reduces statistical power; single-center design limits generalizability.
Oder et al. [6], 2003	cross-sectional study	23 HD patients with newly created AVF (mean 2.8 months)	Acute exercise Duplex ultrasound was used to assess the fistula diameter three times before and after a 5-min rubber ball squeezing exercise.	An increase in diameter was observed in 20 out of 23 patients, with a statistically significant average increase of 9.3% (p < 0.0001).	Small sample size and lack of a well-defined control group limit findings; conducted over two decades ago, which may reduce relevance due to changes in clinical practices.
Mo et al. [9], 2020	RCT	86 HD patients	3 months exercise program Group A: n = 38 HD patients, held 6-pound dumbbells on non-dialysis days Group B: n = 40, squeezed rubber balls	The study found a significant increase in blood flow of the draining vein in the dumbbell exercise group at three months, with a mean difference of 359.50 mL/min (95% CI: 111.90–829.05; p = 0.001). However, no significant differences were observed between the groups regarding blood flow in the AVF proximal artery and brachial artery, draining vein diameter, or adverse event incidence.	Randomization strengthens reliability; however, variations in participants’ baseline physical fitness were not addressed, which could have influenced the results.
Fontseré et al. [40], 2016	RCT	69 HD patients	Group A: n = 38 HD patients that followed an ambulatory daily exercise program with flex band for 1 month after arteriovenous fistula creation. Group B: n = 31 HD patients that did not exercise	The study found no statistically significant differences in clinical or ultrasonographic maturation rates between exercise and control groups (94.7% vs. 80.6%, p = 0.069; 81.6% vs. 74.2%, p= 0.459). However, after adjusting for confounding factors such as AVF localization using stepwise logistic regression, the exercise group demonstrated significantly greater odds of clinical maturation (OR 5.861, 95% CI: 1.006–34.146), though no significant difference was observed for ultrasonographic maturation (OR 2.403, 95% CI: 0.66–8.754).	Short follow-up period limits long-term AVF durability conclusions; did not account for baseline vascular health differences among participants.
Salmi et al. [39], 2013	RCT	50 HD patients	Group A: n = 25 HD patients followed simple hand exercise (opening and closing the fingers), two days after the AVF surgery. Group B: n = 25 HD patients followed an isometric exercise program, which was initiated for two days postoperatively and implemented through a combination of supervised sessions and home-based practice.	Post-exercise ultrasound assessments revealed significant increases in draining vein diameter, vein wall thickness, vein area, and blood flow rate (p = 0.009, 0.04, 0.02, and 0.02, respectively). Additionally, a significantly higher number of patients in the exercise group achieved clinical AVF maturation compared to the control group (13 vs. 5; p = 0.008).	Reported improved vein dilation; lacked clear exercise intensity/frequency details; cross-sectional design limits long-term outcome tracking.
Tapia Gonzalez et al. [7], 2021	prospective study	60 HD patients	8 weeks exercise and follow-up after 24-months Group A: n = 30 HD patients followed isometric exercise protocoled program. Group B: n = 30 HD patients received usual care. Muscle strength, Doppler ultrasound parameters, AVF maturation, and vascular access complications were assessed at 4 and 8 weeks to evaluate the impact of an upper limb isometric exercise program on AVF maturation.	The exercise group demonstrated higher clinical maturation rates at 4 weeks (control group 33.3% vs. exercise group 70%, p = 0.009) and 8 weeks (control group 33.3% vs. exercise group 76.7%, p = 0.002). Additionally, duple ultrasound maturation was better in the exercise group in both 4 weeks (control group 40% vs. exercise group 80%, p = 0.003) and 8 weeks (control group 43.3% vs. exercise group 83.3%, p = 0.003).	Observational design raises bias concerns; self-reported adherence may overestimate compliance.
Nantakool et al. [8], 2022	RCT	50 HD patients	10 weeks exercise program Group A: n = 25 HD patients followed an isometric hand exercise program. Group B: n = 25 HD patients followed an isotonic hand exercise program. intensity of 30% maximum voluntary contraction every day for 10 weeks	At weeks 6 and 10, the group A showed significantly larger cephalic vein diameters compared to the group B (week 6: 7.1 ± 1.2 mm vs. 6.2 ± 1.0 mm; week 10: 7.1 ± 1.0 mm vs. 6.2 ± 1.1 mm). The group A also demonstrated a higher number of patients achieving ultrasound-defined maturation at weeks 2, 6, and 10 (8 vs. 2; 16 vs. 8; 21 vs. 12, respectively), as well as greater clinical maturation at week 10 (25 vs. 18). No adverse events were reported during the study period.	Robust design with randomization and control group enhances validity; lacks assessment of confounding factors like baseline physical activity.

Note: RCT: Randomized Controlled Trial; HD: Hemodialysis.

), including isolated hand exercises and combined hand and arm exercises, with or without the use of a tourniquet [39,40]. However, the type, intensity, and frequency of these exercises differ widely across clinical settings [5,6,7,8,9,39,40]. Studies have shown that hand grip exercises may enhance pinch strength, grip strength, and forearm circumference more effectively than exercises using a soft ball, although they do not appear to significantly impact vein diameter. In contrast, hand exercises performed with a tourniquet have been associated with improvements in vein diameter, wall thickness, blood flow, and AVF maturation rates, though these findings are based on limited sample sizes [39]. Similarly, hand and arm exercises using elastic bands have not demonstrated significant effects on vascular parameters, but may contribute to higher clinical maturation rates [40]. Recent evidence suggests that isometric exercise yields more favorable outcomes than isotonic hand exercise in terms of both clinical maturation and cephalic vein diameter. Notably, these findings are strengthened by the relatively robust sample sizes of the studies, each involving 50 or more participants [7,8]. Overall, further high-quality studies are needed to establish more consistent and conclusive evidence on the impact of upper limb exercises on AVF development, highlighting the current gaps and variability in existing research findings [38].

Nurses play a crucial role in the implementation and success of hand exercise training programs aimed at promoting AVF maturation in HD patients. As primary caregivers in dialysis units, nurses are ideally positioned to assess patient eligibility, educate individuals on the importance of pre- and postoperative upper limb exercises, and ensure proper technique and adherence. Their responsibilities include instructing patients on specific isometric or isotonic exercise protocols, monitoring progress, identifying potential complications, and reinforcing compliance during routine dialysis sessions. Moreover, nurses contribute to individualized care by tailoring exercise regimens based on the patient’s vascular condition, physical capabilities, and surgical outcomes. By integrating evidence-based exercise interventions into clinical practice and coordinating closely with nephrologists and vascular surgeons, nurses enhance AVF maturation rates, reduce reliance on central venous catheters, and support long-term vascular access patency. Their role is essential not only in facilitating physical outcomes but also in empowering patients through education and continuous support [14,18,41].

Despite their essential role in the implementation of postoperative interventions following AVFs creation for HD, dialysis nurses frequently encounter significant challenges that may hinder optimal patient outcomes. A key concern is the insufficient training and education related to AVFs care and maturation [10,12,20]. As highlighted in the literature, limited knowledge and skill in this area can lead to suboptimal clinical practices, reducing the effectiveness of strategies aimed at promoting AVF maturation and preserving vascular access functionality [10,12,15]. Enhancing the educational preparation of dialysis nurses is therefore critical to improving the overall quality of AVFs/AVG management and ensuring the successful implementation of evidence-based practices.

8. Contextual Variations in AVF Management Practices

AVF management practices vary significantly across continents, influenced by differences in healthcare infrastructure, training protocols, and the adoption of guidelines. Understanding these variations is crucial for interpreting study findings and making globally relevant recommendations.

In North America, particularly in the United States, the management of AVF is primarily guided by the KDOQI Clinical Practice Guidelines. These guidelines emphasize the importance of standardized training for nurses, routine monitoring of vascular access, and the use of advanced technologies such as ultrasound-guided cannulation. Additionally, there is a strong emphasis on continuous professional education to maintain high standards of vascular access care. However, challenges remain, including variations in practices across healthcare facilities and disparities in access to necessary resources [42].

Management of AVFs in Africa is often hindered by limited healthcare infrastructure and a shortage of specialized training for dialysis nurses, which negatively impacts the quality and consistency of care. In many areas, the primary focus is on basic maintenance and infection prevention. In contrast, advanced interventions, such as ultrasound-guided cannulation and structured exercise programs, are less frequently implemented due to resource limitations [43]. The shortage of skilled healthcare professionals and inadequate nurse training further exacerbate these challenges, particularly in sub-Saharan Africa, where nursing education often faces obstacles related to faculty capacity, curriculum relevance, and limited clinical training opportunities [44]. As a result, AVF outcomes in Africa are frequently compromised, with higher rates of complications and shorter AVF patency compared to regions with more robust healthcare systems. Addressing these disparities requires capacity-building initiatives and context-specific training programs to improve the technical skills of dialysis nurses. Investing in educational resources and implementing locally adaptable guidelines are essential to enhancing AVF care and ultimately improving the quality of life for patients undergoing HD [43,44].

In Europe, countries often follow the European Renal Best Practice (ERBP) guidelines, which advocate nurse education, AVF monitoring, and standardized cannulation techniques to enhance vascular access outcomes [45]. The European Society for Vascular Surgery (ESVS) also provides specific recommendations for vascular access care, including the use of preoperative vascular mapping to enhance AVF maturation and durability [46]. However, practices can vary significantly between Western and Eastern Europe, largely due to differences in healthcare funding, nurse training availability, and access to advanced equipment. In countries with more robust healthcare systems, such as Germany and France, the integration of advanced imaging techniques, routine preoperative assessments, and structured upper limb exercise protocols is more common. These practices contribute to higher AVF success rates and longer patency. Conversely, in regions where healthcare resources are limited, such as parts of Eastern Europe, the application of preoperative vascular mapping and standardized exercise protocols may be less feasible. As a result, the implementation of ERBP and ESVS recommendations can be inconsistent, highlighting the need for locally adaptable guidelines and capacity-building programs to bridge these disparities [41,42].

AVF management practices in Asia show considerable variability, largely influenced by differences in healthcare infrastructure, training availability, and cultural factors. In high-income countries such as Japan, where HD is highly standardized, there is a strong focus on nurse-led AVF monitoring, structured exercise interventions, and the consistent application of evidence-based protocols. This approach has contributed to higher AVF success rates and better long-term outcomes. In contrast, countries in South and Southeast Asia, including India and Indonesia, often face significant challenges due to limited training opportunities for healthcare staff and inconsistent implementation of standardized AVF care protocols [47]. These factors contribute to variations in AVF outcomes and complicate the adoption of best practices. Cultural and social factors may also significantly influence the management of AVF in certain regions. For instance, in Aceh, Indonesia, a patient’s adherence to HD protocols (such as AVF care and recommended exercises) can be affected by cultural beliefs, family support, and social obligations [48]. Such factors may hinder consistent follow-up and adherence to exercise regimens, affecting AVF maturation and patency. Addressing these challenges requires context-specific interventions and improved nurse training programs tailored to local healthcare settings.

Lastly, in Australia, AVF management is governed by national standards such as the KHA-CARI (Kidney Health Australia—Caring for Australasians with Renal Impairment) guidelines, which advocate for the preferential use of AVFs as the primary vascular access for HD. These guidelines emphasize the importance of early planning and creation of AVFs, prioritizing preoperative vascular assessment and ongoing nurse-led monitoring to maximize AVF longevity and minimize complications [49]. A central component of the KHA-CARI guidelines is the emphasis on preoperative planning, incorporating vascular mapping via Doppler ultrasound to evaluate the suitability of veins and arteries. This strategic approach is aimed at optimizing surgical outcomes and ensuring long-term AVF functionality. Postoperative care is similarly prioritized, with the guidelines recommending routine monitoring, including physical examination and ultrasound surveillance, to identify early indicators of stenosis or dysfunction. Data from the ANZDATA Registry further underscores the commitment to maintaining AVF patency through standardized cannulation techniques. The use of methods such as the rope-ladder and buttonhole techniques is widespread, reflecting best practices aimed at minimizing trauma and infection risks [50]. Additionally, the increasing incorporation of advanced technologies, such as ultrasound-guided cannulation, has been associated with improved clinical outcomes and reduced AVF failure rates. Despite the robust framework provided by the KHA-CARI guidelines, challenges persist, particularly in rural and remote areas, where specialized training and advanced technological resources may be limited. Addressing these disparities requires a targeted approach to education and resource allocation, ensuring that high-quality AVF management is accessible across diverse healthcare settings. Enhanced training initiatives and capacity building are crucial for maintaining equitable care standards nationwide.

9. Suggestions on How to Improve AVF Management

Improving nurse education on AVF management is essential to enhance HD patient outcomes, particularly regarding AVF maturation and long-term patency. Nurses play a crucial role in postoperative care for HD patients, implementing upper limb exercises that enhance AVF maturation by improving arterial inflow, venous return, and vascular remodeling (Figure 3). Structured training programs should provide nurses with a thorough understanding of the physiological benefits of exercises, specifically their role in increasing NO bioavailability and reducing oxidative stress. Practical workshops and simulation-based training can help nurses master techniques for instructing patients on isometric and isotonic exercises while also monitoring complications such as thrombosis or DAAS. Additionally, developing educational resources tailored for nurses, such as interactive e-learning modules and visual guides, can promote consistent, evidence-based practices. Regular multidisciplinary meetings and case discussions can further enhance nurses’ critical thinking and collaborative care skills. By adopting a proactive approach to AVF management, nurses can significantly improve AVF maturation rates and reduce complications, ultimately optimizing vascular access care in HD settings.

10. Conclusions

In conclusion, enhancing the proficiency of dialysis nurses in AVF access techniques is essential for improving outcomes in HD patients. As outlined in the KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update [42], the implementation of annual educational training programs is crucial for strengthening the technical skills and clinical knowledge required for effective AVF management. These programs should cover key areas such as AVF cannulation, maintenance, and monitoring, while also emphasizing the role of pre- and post-operative hand exercises in promoting AVF maturation. Integrating evidence-based practices, as recommended in the KDOQI guidelines [42], into routine care ensures that healthcare professionals are equipped to increase the longevity and functionality of AVF access, ultimately improving clinical outcomes and enhancing the quality of life for HD patients. While current evidence strongly supports the importance of continuous education and exercise protocols, several knowledge gaps remain, particularly concerning the standardization of exercise regimens and their long-term impact on AVF function. Future studies should explore optimal exercise intensity, frequency, and duration, as well as examine the influence of patient-specific factors on the success of these interventions. Additionally, while existing research supports annual training and exercise protocols, the effectiveness of new strategies and personalized approaches still requires further validation. By addressing these knowledge gaps and aligning clinical practices with established guidelines, healthcare facilities can better prepare their staff to optimize AVF access. This will ultimately lead to improved patient outcomes and enhanced long-term care for HD patients.