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Harduin LDO, Barroso TA, Guerra JB, Filippo MG, de Almeida LC, de Castro-Santos G, Oliveira FAC, Cavalcanti DET, Procopio RJ, Lima EC, Pinhati MES, dos Reis JMC, Moreira BD, Galhardo AM, Joviliano EE, de Araujo WJB, de Oliveira JCP. Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery. J Vasc Bras 2023; 22:e20230052. [PMID: 38021275 PMCID: PMC10648056 DOI: 10.1590/1677-5449.202300522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/09/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.
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Affiliation(s)
- Leonardo de Oliveira Harduin
- Universidade Estadual do Estado do Rio de Janeiro - UERJ, Departamento de Cirurgia Vascular, Niterói, RJ, Brasil.
| | | | | | - Marcio Gomes Filippo
- Universidade Federal do Rio de Janeiro - UFRJ, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
| | | | - Guilherme de Castro-Santos
- Universidade Federal de Minas Gerais - UFMG, Escola de Medicina, Departamento de Cirurgia, Belo Horizonte, MG, Brasil.
| | | | | | - Ricardo Jayme Procopio
- Universidade Federal de Minas Gerais - UFMG, Escola de Medicina, Departamento de Cirurgia, Belo Horizonte, MG, Brasil.
| | | | | | | | - Barbara D’Agnoluzzo Moreira
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | | | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Departamento de Anatomia e Cirurgia, Ribeirão Preto, SP, Brasil.
| | - Walter Junior Boim de Araujo
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas, Departamento de Angioradiologia e Cirurgia Endovascular, Curitiba, PR, Brasil.
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Maggiani-Aguilera P, Raimann JG, Chávez-Iñiguez JS, Navarro-Blackaller G, Kotanko P, Garcia-Garcia G. Vascular Access and Clinical Outcomes in Underserved Hemodialysis Patients in Mexico. Blood Purif 2021; 51:756-763. [PMID: 34847560 DOI: 10.1159/000519878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Central venous catheter (CVC) as vascular access in hemodialysis (HD) associates with adverse outcomes. Early CVC to fistula or graft conversion improves these outcomes. While socioeconomic disparities between the USA and Mexico exist, little is known about CVC prevalence and conversion rates in uninsured Mexican HD patients. We examined vascular access practice patterns and their effects on survival and hospitalization rates among uninsured Mexican HD patients, in comparison with HD patients who initiated treatment in the USA. METHODS In this retrospective study of incident HD patients at Hospital Civil (HC; Guadalajara, MX) and the Renal Research Institute (RRI; USA), we categorized patients by the vascular access at the first month of HD and after the following 6 months. Factors associated with continued CVC use were identified by a logistic regression model. We developed multivariate Cox proportional hazards models to investigate the effects of access and conversion on mortality and hospitalization over an 18-month follow-up period. RESULTS In 1,632 patients from RRI, the CVC prevalence at month 1 was 64% and 97% among 174 HC patients. The conversion rate was 31.7% in RRI and 10.6% in HC. CVC to non-central venous catheter (NON-CVC) conversion reduced the risk of hospitalization in both HC (aHR 0.38 [95% CI: 0.21-0.68], p = 0.001) and RRI (aHR 0.84 [95% CI: 0.73-0.93], p = 0.001). NON-CVC patients had a lower mortality risk in both populations. DISCUSSION/CONCLUSION CVC prevalence and conversion rates of CVC to NON-CVC differed between the US and Mexican patients. An association exists between vascular access type and hospitalization and mortality risk. Prospective studies are needed to evaluate if accelerated and systematic catheter use reduction would improve outcomes in these populations.
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Affiliation(s)
- Pablo Maggiani-Aguilera
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Sciences Center, Guadalajara, Mexico
| | - Jochen G Raimann
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Chávez-Iñiguez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Sciences Center, Guadalajara, Mexico
| | - Guillermo Navarro-Blackaller
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Sciences Center, Guadalajara, Mexico
| | - Peter Kotanko
- Renal Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Sciences Center, Guadalajara, Mexico,
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Lin E, Mell MW, Winkelmayer WC, Erickson KF. Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access. Clin J Am Soc Nephrol 2018; 13:1866-1875. [PMID: 30385594 PMCID: PMC6302322 DOI: 10.2215/cjn.06660518] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/29/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients without Medicare who develop ESKD in the United States become Medicare eligible by their fourth dialysis month. Patients without insurance may experience delays in obtaining arteriovenous fistulas or grafts before obtaining Medicare coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective cohort study, we used a national registry to compare uninsured patients starting in-center hemodialysis with a central venous catheter between 2010 and 2013 with similar patients with Medicare or Medicaid. We evaluated whether insurance status at dialysis start influenced the likelihoods of switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection. We used multivariable logistic and Cox regression models and transformed odds ratios to relative risks using marginal effects. RESULTS Patients with Medicare or Medicaid were more likely to switch to an arteriovenous fistula or graft by their fourth dialysis month versus uninsured patients (Medicare hazard ratio, 1.63; 95% confidence interval, 1.14 to 2.43; Medicaid hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.38). There were no differences in rates of switching to arteriovenous fistulas or grafts after all patients obtained Medicare in their fourth dialysis month (Medicare hazard ratio, 1.17; 95% confidence interval, 0.97 to 1.42; Medicaid hazard ratio, 1.01; 95% confidence interval, 0.96 to 1.06). Patients with Medicare at dialysis start had fewer hospitalizations involving vascular access infection in dialysis months 4-12 (hazard ratio, 0.60; 95% confidence interval, 0.37 to 0.97). CONCLUSIONS Insurance-related disparities in the use of arteriovenous fistulas and grafts persist through the fourth month of dialysis, may not fully correct after all patients obtain Medicare coverage, and may lead to more frequent vascular access infections.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine and
- Centers for Health Policy and Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Division of Nephrology, Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Matthew W. Mell
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Sacramento, California
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and
- Baker Institute for Public Policy, Rice University, Houston, Texas
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Alquist M, Bosch JP, Barth C, Combe C, Daugirdas JT, Hegbrant JB, Martin G, McIntyre CW, O'Donoghue DJ, Rodriguez HJ, Santoro A, Tattersall JE, Vantard G, Van Wyck DB, Canaud B. Knowing What We Do and Doing What We Should: Quality Assurance in Hemodialysis. ACTA ACUST UNITED AC 2014; 126:135-43. [DOI: 10.1159/000361050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 02/24/2014] [Indexed: 11/19/2022]
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Affiliation(s)
- Rachel Fissell
- Vanderbilt University Medical Center; Nashville Tennesee
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Salgado TM, Moles R, Benrimoj SI, Fernandez-Llimos F. Pharmacists' interventions in the management of patients with chronic kidney disease: a systematic review. Nephrol Dial Transplant 2011; 27:276-92. [PMID: 21719712 DOI: 10.1093/ndt/gfr287] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease have multiple comorbidities and require complicated therapeutic regimens. The role of pharmacists caring for these patients has been documented, but no review of the impact of these interventions has occurred to date. The aim of this work is to assess the impact of pharmacists' interventions in patients with chronic kidney disease. METHODS Medline, International Pharmaceutical Abstracts, Pharmacy Abstracts and the Cochrane Library were searched for quantitative studies addressing the contribution of pharmacists' interventions in patients with chronic kidney disease. Quality of controlled studies was assessed using the Downs and Black scale. RESULTS The search identified 37 studies (38 articles), involving 4743 participants, eligible for inclusion in the review. An uncontrolled design corresponded with 80% of the studies. Twenty-one articles (55.3%) reported outcome measures and process indicators, 4 (10.5%) reported only outcome measures and 13 (34.2%) reported only process indicators. Pharmacists identified 2683 drug-related problems in 1209 patients. The results from eight controlled studies (average quality score 0.57, SD = 0.10) demonstrated that pharmacists' interventions reduced all-cause hospitalisations [mean (SD) 1.8 (2.4) versus 3.1 (3.0), P = 0.02] and cumulative time hospitalised [mean (SD) 9.7 (14.7) versus 15.5 (16.3) days, P = 0.06], reduced the incidence of end-stage renal disease or death in patients with diabetic nephropathy (14.8 versus 28.2 per 100 patient-years, adjusted relative risk 60%, P < 0.001), improved management of anemia (mean 69.8 versus 43.9%, P = 0.0001 and 64.8 versus 40.4%, P = 0.043 patients on goal hemoglobin and transferrin saturation, respectively), blood pressure [systolic mean (SD) 145.3 (16.8) versus 175.8 (33.9) mmHg, P = 0.029; diastolic mean (SD) 77.0 (10.2) versus 91.8 (12.0) mmHg, P = 0.020], calcium and phosphate parameters [serum phosphate levels mean (SD) 1.81 (0.54) versus 2.07 (0.25) mmol/L, P = 0.03; calcium-phosphate product mean (SD) 4.43 (1.20) versus 4.80 (0.51) mmol(2)/L(2), P = 0.04] and lipid management [total cholesterol mean (SD) 4.4 (1.1) versus 5.0 (1.4) mmol/L, P = 0.06; low density lipoprotein cholesterol mean (SD) 2.3 (0.9) versus 2.8 (1.0) mmol/L, P = 0.013]. Results from uncontrolled studies revealed positive impact of pharmacists' interventions on reduced number of transplant rejections [mean (SD) 0.22 (0.42) versus 0.50 (0.51) episodes, P = 0.008] and adverse events (49 in 16.0% patients versus 73 in 21.3% patients, P < 0.05). CONCLUSIONS The evidence of pharmacists' interventions in patients with chronic kidney disease is sparse, of variable quality and with heterogeneous outcomes. On the basis of best available evidence, pharmacists' interventions may have a positive impact on outcomes of patients with chronic kidney disease.
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Affiliation(s)
- Teresa M Salgado
- Research Institute for Medicines and Pharmaceutical Sciences (iMed.UL), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
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Lacson E, Wang W, Lazarus JM, Hakim RM. Change in vascular access and hospitalization risk in long-term hemodialysis patients. Clin J Am Soc Nephrol 2010; 5:1996-2003. [PMID: 20884778 PMCID: PMC3001775 DOI: 10.2215/cjn.08961209] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 06/15/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Conversion from central venous catheters to a graft or a fistula is associated with lower mortality risk in long-term hemodialysis (HD) patients; however, a similar association with hospitalization risk remains to be elucidated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a prospective observational study all maintenance in-center HD patients who were treated in Fresenius Medical Care, North America legacy facilities; were alive on January 1, 2007; and had baseline laboratory data from December 2006. Access conversion (particularly from a catheter to a fistula or a graft) during the 4-month period from January 1 through April 30, 2007, was linked using Cox models to hospitalization risk during the succeeding 1-year follow-up period (until April 30, 2008). RESULTS The cohort (N = 79,545) on January 1, 2007 had 43% fistulas, 29% catheters, and 27% grafts. By April 30, 2007, 70,852 patients were still on HD, and among 19,792 catheters initially, only 10.3% (2045 patients) converted to either a graft or a fistula. With catheters as reference, patients who converted to grafts/fistulas had similar adjusted hazard ratios (0.69) as patients on fistulas (0.71), while patients with fistulas/grafts who converted to catheters did worse (1.22), all P < 0.0001. CONCLUSIONS Catheters remain associated with the greatest hospitalization risk. Conversion from a catheter to either graft or fistula had significantly lower hospitalization risk relative to keeping the catheter. Prospective studies are needed to determine whether programs that reduce catheters will decrease hospitalization risk in HD patients.
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Affiliation(s)
- Eduardo Lacson
- Department of Clinical Sciences, Epidemiology, and Research, Fresenius Medical Care, North America, Waltham, MA 02451-1457, USA.
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Lacson E, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim RM. Balancing Fistula First With Catheters Last. Am J Kidney Dis 2007; 50:379-95. [PMID: 17720517 DOI: 10.1053/j.ajkd.2007.06.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 06/15/2007] [Indexed: 11/11/2022]
Abstract
The success of Fistula First nationwide has been accompanied by an unplanned increase in hemodialysis catheters. Complications related to prolonged hemodialysis catheter use include increased morbidity, mortality, and cost. We hypothesize that the national focus on increasing fistulas may have inadvertently diverted attention away from initiatives to decrease dependence on hemodialysis catheters. Based on a synthesis of guidelines, reviews, published evidence, and the authors' opinions, we propose that the national vascular access initiative be revised to have a dual goal of Fistula First and "Catheters Last." These goals are not mutually exclusive, but rather complementary. We recommend a systematic refocus on interventions that not only increase fistulas, but help avoid extended catheter use. Clearly, the ideal practice for hemodialysis vascular access remains early placement of fistulas with enough maturation time such that they can be used for initiating long-term hemodialysis therapy when the need arises. To effect this change, a reimbursement policy covering the costs associated with permanent access placement before the need for dialysis is essential. Individualized patient management strategies may consider such innovative approaches as initiating patients on peritoneal dialysis therapy or using nonautogenous grafts as bridge accesses in lieu of catheters. For patients who are dialyzing using catheters, immediate active planning for permanent access placement and removal of the catheter is necessary. In the same vein as Fistula First, the renal community should once again be galvanized in working together toward controlling the catheter epidemic in our dialysis population.
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Affiliation(s)
- Eduardo Lacson
- Fresenius Medical Care, North America, Waltham, MA 02451-1457, USA.
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Plantinga LC, Fink NE, Jaar BG, Sadler JH, Levin NW, Coresh J, Klag MJ, Powe NR. Attainment of clinical performance targets and improvement in clinical outcomes and resource use in hemodialysis care: a prospective cohort study. BMC Health Serv Res 2007; 7:5. [PMID: 17212829 PMCID: PMC1783649 DOI: 10.1186/1472-6963-7-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 01/09/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical performance targets are intended to improve patient outcomes in chronic disease through quality improvement, but evidence of an association between multiple target attainment and patient outcomes in routine clinical practice is often lacking. METHODS In a national prospective cohort study (ESRD Quality, or EQUAL), we examined whether attainment of multiple targets in 668 incident hemodialysis patients from 74 U.S. not-for-profit dialysis clinics was associated with better outcomes. We measured whether the following accepted clinical performance targets were met at 6 months after study enrollment: albumin (> or =4.0 g/dl), hemoglobin (> or =11 g/dl), calcium-phosphate product (<55 mg2/dl2), dialysis dose (Kt/V> or =1.2), and vascular access type (fistula). Outcomes included mortality, hospital admissions, hospital days, and hospital costs. RESULTS Attainment of each of the five targets was associated individually with better outcomes; e.g., patients who attained the albumin target had decreased mortality [relative hazard (RH) = 0.55, 95% confidence interval (CI), 0.41-0.75], hospital admissions [incidence rate ratio (IRR) = 0.67, 95% CI, 0.62-0.73], hospital days (IRR = 0.61, 95% CI, 0.58-0.63), and hospital costs (average annual cost reduction = 3,282 dollars, P = 0.002), relative to those who did not. Increasing numbers of targets attained were also associated, in a graded fashion, with decreased mortality (P = 0.030), fewer hospital admissions and days (P < 0.001 for both), and lower costs (P = 0.029); these trends remained statistically significant for all outcomes after adjustment (P < 0.001), except cost, which was marginally significant (P = 0.052). CONCLUSION Attainment of more clinical performance targets, regardless of which targets, was strongly associated with decreased mortality, hospital admissions, and resource use in hemodialysis patients.
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Affiliation(s)
- Laura C Plantinga
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
| | - Nancy E Fink
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - John H Sadler
- Independent Dialysis Foundation, Baltimore, MD21201, USA
| | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Michael J Klag
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Neil R Powe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
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