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Vascular Access for Hemodialysis and Tattoos: A Consideration to Bear in Mind

Body tattoos have become a universal phenomenon in continuous growth (1). Patients with chronic kidney disease (CKD) are also involved with this topic. A 52-year-old parenteral drug use hepatitis C and HIV positive co-infected patient was forwarded to nephrological follow-up due to the presence of polycystic kidney disease. During the follow-up, progressive deterioration of his CKD to end-stage renal disease was observed. Hemodialysis was chosen as substitutive renal therapy and was referred for vascular access assessment. Extensive chromatic tattoos covered most of both upper extremities. After preoperative ultrasound evaluation, a humero-basilic arteriovenous fistula could be performed. In recent years, a popular increase in demand for decorative cutaneous tattoos has been documented (1). Despite the advances in tattoo techniques and universal hygienic measures, ink injection under the skin is not a risk-free procedure in short and long term. Medical complications associated with the use of color pigments with metallic composition such as mercury, cadmium, chromium, magnesium, titanium or zinc oxide is not uncommon. Local allergic reactions, pruritus, cutaneous granulomas, exacerbation of various dermatological diseases or cutaneous infections by Staphylococcus aureus or Streptococcus pyogenes are some of the current medical complications related to tattooing (2, 3). The presence of tattooed CKD patients, candidates for a native or prosthetic vascular access for hemodialysis should not surprise us in the next years. However, little is known about the potential risks of tattoos on arteriovenous dialysis access and there are no recommendations in relation to this topic in the published vascular access guidelines (4). Curiously, small but visible tattoos have also been proposed as a tool to facilitate cannulation, especially in home dialysis patients (5). Nevertheless, tattooed areas are avoided in clinical practice as site of vascular access, in order to prevent possible infections due to repeated punctures in each hemodialysis session. Moreover, reasonable doubts arise about the correct realization of vascular access in a preexisting tattooed area. Waiting for future recommendations, it would be mandatory to inform CKD patients about the implications of body tattoos in relation to the forthcoming vascular access as well as the potential complications derived from the use of previously tattooed territories as vascular access placement.