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Schneider AR, Ravani P, King-Shier KM, Quinn RR, MacRae JM, Love S, Oliver MJ, Hiremath S, James MT, Ortiz M, Manns BR, Elliott MJ. Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study. Can J Kidney Health Dis 2023; 10:20543581231215858. [PMID: 38033483 PMCID: PMC10685780 DOI: 10.1177/20543581231215858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Background Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making. Objective To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection. Design Qualitative descriptive study. Setting Five outpatient hemodialysis centers in Calgary, Alberta. Participants Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists). Methods We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective. Results While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers. Limitations Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study. Conclusions Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.
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Affiliation(s)
| | - Pietro Ravani
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Kathryn M. King-Shier
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Robert R. Quinn
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Jennifer M. MacRae
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Shannan Love
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew T. James
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mia Ortiz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braden R. Manns
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan J. Elliott
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Mousavi SF, Sepehri MM, Khasha R, Mousavi SH. Improving vascular access creation among hemodialysis patients: An agent-based modeling and simulation approach. Artif Intell Med 2022; 126:102253. [DOI: 10.1016/j.artmed.2022.102253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 01/25/2022] [Accepted: 01/29/2022] [Indexed: 11/02/2022]
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Maksimov AV, Feiskhanov AK. [Surgical treatment of true aneurysms of permanent vascular access]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:106-113. [PMID: 34166350 DOI: 10.33529/angio2021212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Analyzed herein are the results of surgical treatment of true diffuse aneurysms of the permanent vascular access in 44 patients. Of these, there were 29 men and 15 women, mean age 48.1±2.3 years (19-78 years). The average time having elapsed since the formation of the native access was 109.4±9.5 months (12-276, median - 108 months). The indications for surgical treatment were as follows: haemorrhage including recurrent bleedings (3), thrombosis of the permanent vascular access (26), its dysfunction (5), high flow syndrome (3), large-size aneurysm with disordered function of the limb, pain syndrome or a pronounced cosmetic defect (7). In 14 cases, reconstruction was not performed. We carried out ligating operations, in some instances with partial removal of the aneurysm and establishing a new vascular access. 3 patients underwent resection of the aneurysm with replacement by a graft. In the remote period 1 patient at 46 months developed infection of the prosthesis, resulting in loss of the access. Follow up of the remaining 2 patients demonstrated satisfactory function of the vascular access at 6 and 60 months. 16 patients were subjected to total plasty of the aneurysm using autotissues. On a cylindrical template measuring 6 mm in diameter after dissection of excessive tissues along the posterior wall of the vein, an uninterrupted suture was formed followed by placing the formed transplant into a new bed. 11 patients underwent the operation according to the analogous technique, but the formed autotransplant was reinforced with a thin-wall exoprosthesis made of polytetrafluoroethylene up to 0.2-mm thick and 10 mm in diameter ('Ecoflon'). Two (12.5%) of 16 patients subjected to reconstruction of the aneurysm without reinforcement developed haemorrhage in the early postoperative period, and one developed thrombosis thus resulting in loss of the access. In-hospital patency amounted to 81.3%. In plasty with reinforcement, there were no complications in the early postoperative period. Long-term primary patency after total plasty without reinforcement at 1, 3, and 5 years amounted to 68.2±11.8%, 56.8±14.3%, and 22.7±13.7%, respectively, with secondary patency of 68.2±11.8% at the above-mentioned terms. In the majority of patients aneurysmatic transformation of the transplant occurred again in the remote period. Primary patency at 1, 3 and 4 years after plasty with reinforcement amounted to 80.8±12.2%, 80.8±12-2% and 60.6±19.8%, respectively, with the secondary patency rates of 90.9±8.7% at the above mentioned terms.
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Affiliation(s)
- A V Maksimov
- Department of Vascular Surgery, Republican Clinical Hospital of the Public Health Ministry of the Republic of Tatarstan, Kazan, Russia; Chair of Cardiology, Roentgenovascular and Cardiovascular Surgery, Kazan State Medical Academy, Kazan, Russia
| | - A K Feiskhanov
- Department of Vascular Surgery, Republican Clinical Hospital of the Public Health Ministry of the Republic of Tatarstan, Kazan, Russia
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López AG, Salgado OJ, Vachharajani TJ. Dialysis Vascular Access Training: A Nicaraguan Experience. Kidney Int Rep 2021; 6:1701-1703. [PMID: 34169211 PMCID: PMC8207323 DOI: 10.1016/j.ekir.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Alexis García López
- Nephrology Service, Renal Transplant and Vascular Access Surgery, Baptist Hospital, Manuel de Jesús Rivera Hospital, Managua, Nicaragua
| | - Octavio J Salgado
- Chair of Nephrology, School of Medicine, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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5
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Tazza L, Angelici L, Marino C, Di Napoli A, Bossola M, De Cicco C, Davoli M, Agabiti N. Determinants of venous catheter hemodialysis onset and subsequent switch to arteriovenous fistula: An epidemiological study in Lazio region. J Vasc Access 2020; 22:749-758. [PMID: 32993439 DOI: 10.1177/1129729820959942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The factors associated with the inability to start hemodialysis with an arteriovenous fistula (AVF) in chronic kidney disease patients are not fully understood. AIM Evaluating factors associated with type of vascular access at the first chronic hemodialysis and at 1 year after it. METHODS The study cohort includes patients registered in the Regional Dialysis and Transplant Registry of Lazio undergoing first hemodialysis between 2008 and 2015. Logistic regression models were used to evaluate the association between socio-demographic, clinical and care/organizational factors, and vascular access at first hemodialysis. Cox regression models were used to assess the odds of switching to AVF during the first year of hemodialysis among patients starting dialysis with central venous catheter (CVC). RESULTS In the cohort of 6208 incident hemodialysis patients, 52.7% had an AVF and 47.3% had a CVC. Among the 2939 incident patients with CVC, 27.4% switched to FAV after 1 year. A higher probability of starting dialysis with AVF was observed among males (OR = 1.83; 95% CI 1.63-2.06), while a lower probability was observed among patients aged >85 years (OR 0.64; IC 95% 0.51-0.80). Patients with early referral to a nephrologist had a triple probability of start dialysis with AVF. We observed a higher odds of switch to AVF among males (HR = 1.62; 95% CI 1.40-1.89) and a lower odds among patients over 65 years. CONCLUSION The observed high rate of AVF at the start of hemodialysis and of the switch from CVC to AVF in the first year, although declining since 2008, is a positive outcome. However, over one-third of patients maintain the CVC as vascular access for the first year because of unmodifiable factors, such as gender, age, comorbidity. The present study suggests that logistics/management and assistance/welfare problems may contribute to the delay or lack of AVF placement in incident hemodialysis patients or within the first year of dialysis.
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Affiliation(s)
- Luigi Tazza
- Catholic University, Rome, Rome, Italy.,Ars Medica Clinic, Rome, Italy
| | - Laura Angelici
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Claudia Marino
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Anteo Di Napoli
- National Institute for Health, Migration and Poverty, Rome, Italy
| | - Maurizio Bossola
- Department of Nephrology, Fondazione Agostino Gemelli, IRCCS, Rome, Italy
| | | | - Marina Davoli
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology of Lazio Regional Health Service, Rome, Italy
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Smyth B, Kotwal S, Gallagher M, Gray NA, Polkinghorne KR. Arteriovenous access practices in Australian and New Zealand dialysis units. J Vasc Access 2019; 20:740-745. [PMID: 31144566 DOI: 10.1177/1129729819851061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The creation and maintenance of dialysis vascular access is associated with significant morbidity. Structured management pathways can reduce this morbidity, yet practice patterns in Australia and New Zealand are not known. We aimed to describe the arteriovenous access practices in dialysis units in Australia and New Zealand. METHODS An online survey comprising 51 questions was completed by representatives from dialysis units from both countries. In addition to descriptive analysis, responses were compared between units inside and outside of major cities. RESULTS Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 38% of dialysis units in Australia and New Zealand. While 94% of units provided pre-dialysis education, only 60% reported a structured pre-dialysis pathway and 69% had a dedicated vascular access nurse. Most units routinely monitored fistula/graft function using flow rate measurement (73%) or recirculation studies (63%). A minority used routine ultrasound (35%). Thrombectomy, fistuloplasty and peritoneal dialysis catheter insertion were rarely performed by nephrologists (4%, 4% and 17% of units, respectively). Units outside of a major city were less likely to have access to a local vascular access surgeon (6/13 (46%) vs 35/35 (100%), P < 0.001). There were no other significant differences between units on the basis of location. CONCLUSION Much variation exists in unit management of arteriovenous access. Structured pre-dialysis pathways and dedicated vascular access nurses may be underutilised in Australia and New Zealand. The use of regular access blood flow measurement and ultrasound is common in both countries despite a lack of data supporting its effectiveness. There is room for both practice improvement and a need for further evidence to ensure optimal arteriovenous access care.
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Affiliation(s)
- Brendan Smyth
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Sradha Kotwal
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Department of Nephrology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Martin Gallagher
- The George Institute for Global Health, UNSW, Newtown, NSW, Australia.,Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Nicholas A Gray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia.,Sunshine Coast Clinical School, University of Queensland, Brisbane QLD, Australia
| | - Kevan R Polkinghorne
- Department of Epidemiology and Preventive Medicine, Monash University, Prahran, VIC, Australia.,Departments of Nephrology & Medicine, Monash Medical Centre, Monash University, Clayton, VIC, Australia
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7
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Fila B, Roca-Tey R, Malik J, Malovrh M, Pirozzi N, Kusztal M, Gallieni M, Jemcov T. Quality assessment of vascular access procedures for hemodialysis: A position paper of the Vascular Access Society based on the analysis of existing guidelines. J Vasc Access 2019; 21:148-153. [DOI: 10.1177/1129729819848624] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Quality assessment in vascular access procedures for hemodialysis is not clearly defined. The aim of this article is to compare various guidelines regarding recommendation on quality control in angioaccess surgery. The overall population of end-stage renal disease patients and patients in need for hemodialysis treatment is growing every year. Chronic intermittent hemodialysis is still the main therapy. The formation of a functional angioaccess is the cornerstone in the management of those patients. Native (autologous) arteriovenous fistula is the best vascular access available. A relatively high percentage of primary failure and fistula abandonment increases the need for quality control in this field of surgery. There are very few recommendations of quality assessment on creation of a vascular access for hemodialysis in the searched guidelines. Some guidelines recommend the proportion of native arteriovenous fistula in incident and prevalent patients as well as the maximum tolerable percentage of central venous catheters and complications. According to some guidelines, surgeon’s experience and expertise have a considerable influence on outcomes. There are no specific recommendations regarding surgeon’s specialty, grade, level of skills, and experience. In conclusion, there is a weak recommendation in the guidelines on quality control in vascular access surgery. Quality assessment criteria should be defined in this field of surgery. According to these criteria, patients and nephrologists could choose the best vascular access center or surgeon. Centers with best results should be referral centers, and centers with poorer results should implement quality improvement programs.
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Affiliation(s)
- Branko Fila
- Department of Vascular Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Ramon Roca-Tey
- Department of Nephrology, Hospital de Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Jan Malik
- 3rd Department of Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marko Malovrh
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Nicola Pirozzi
- Department of Clinical Science, Division of Nephrology and Dialysis, University La Sapienza, Rome, Italy
| | - Mariusz Kusztal
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, S. Paolo Hospital, Milan, Italy
- Department of Medicine, Surgery and Dentistry, University of Milan, Milan, Italy
| | - Tamara Jemcov
- Department of Nephrology, Clinical Hospital Centre Zemun, Belgrade, Serbia
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8
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Aragoncillo Sauco I, Ligero Ramos JM, Vega Martínez A, Morales Muñoz ÁL, Abad Estébanez S, Macías Carmona N, Ruiz Chiriboga D, García Pajares R, Cervera Bravo T, López-Gómez JM, Manzano Grossi S, Menéndez Sánchez E, Río Gomez J, García Prieto AM, Linares Grávalos T, Garcia Boyano F, Reparaz Asensio LM, Albalate Ramón M, de Sequera Ortiz P, Gil Casares B, Ampuero Mencía J, Castellano S, Martín Pérez B, Conty JLM, Santos Garcia A, Luño Fernandez J. Vascular access clinic results before and after implementing a multidisciplinary approach adding routine Doppler ultrasound. Nefrologia 2018; 38:616-621. [PMID: 29903522 DOI: 10.1016/j.nefro.2018.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/04/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A multidisciplinary approach and Doppler ultrasound (DU) assessment for the creation and maintenance of arteriovenous fistulas (AVF) for haemodialysis can improve prevalence and patency. The aim of this study was to analyse the impact of a new multidisciplinary vascular access (VA) clinic with routine DU. MATERIAL AND METHODS We analysed the VA clinic results from 2014 and 2015, before and after the implementation of a multidisciplinary team protocol (vascular surgeon/nephrologist) with routine DU in preoperative mapping and prevalent AVF. RESULTS We analysed 345 and 364 patients from 2014 and 2015 respectively. The number of surgical interventions was similar in both periods (p=.289), with a trend towards an increase in preventive surgical repair of AVF in 2015 (17 vs. 29, p=.098). 155 vs. 169 new AVF were performed in 2014 and 2015, with a significantly lower primary failure rate in 2015 (26.4 vs. 15.3%, p=.015), and a non-significant increase in radiocephalic AVF, 25.8 vs. 33.2% (n=40 vs. 56), p=.159. The concordance between the indication at the clinic and the surgery performed also increased (81.3 vs. 93.5%, p=.001). Throughout 2015 fewer complementary imaging test were requested from the clinic (78 vs. 35, p <.001), with a corresponding reduction in costs (€87,716 vs. €59,445). CONCLUSIONS Multidisciplinary approach with routine DU can improve VA results, with a decrease in primary failure rate, higher likelihood of radiocephalic AVF, better management of dis-functioning AVF and lower radiological test costs.
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Affiliation(s)
| | - José Manuel Ligero Ramos
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | - Ángel Luis Morales Muñoz
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | | | - Diego Ruiz Chiriboga
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Rosario García Pajares
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Teresa Cervera Bravo
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | - Soledad Manzano Grossi
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Elena Menéndez Sánchez
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Javier Río Gomez
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | | | - Fernando Garcia Boyano
- Servicio de Cirugía Vascular periférica, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | | | | | - Beatriz Gil Casares
- Servicio de Nefrología, Hospital Universitario del Sureste, Arganda del Rey, Madrid, España
| | - Jara Ampuero Mencía
- Servicio de Nefrología, Hospital Universitario del Sureste, Arganda del Rey, Madrid, España
| | | | | | - José Luís Martín Conty
- Facultad de Terapia Ocupacional, Logopedia y Enfermería de Castilla la Mancha, Talavera de la Reina, Toledo, España
| | - Alba Santos Garcia
- Servicio de Nefrología, Hospital General Universitario de Elche, Elche, Alicante, España
| | - José Luño Fernandez
- Servicio de Nefrología, Hospital Universitario Gregorio Marañón, Madrid, España
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9
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Alencar de Pinho N, Coscas R, Metzger M, Labeeuw M, Ayav C, Jacquelinet C, Massy ZA, Stengel B. Predictors of nonfunctional arteriovenous access at hemodialysis initiation and timing of access creation: A registry-based study. PLoS One 2017; 12:e0181254. [PMID: 28749967 PMCID: PMC5531527 DOI: 10.1371/journal.pone.0181254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 06/28/2017] [Indexed: 12/21/2022] Open
Abstract
Determinants of nonfunctional arteriovenous (AV) access, including timing of AV access creation, have not been sufficiently described. We studied 29 945 patients who had predialysis AV access placement and were included in the French REIN registry from 2005 through 2013. AV access was considered nonfunctional when dialysis began with a catheter. We estimated crude and adjusted odds ratio (OR) with 95% confidence intervals (CI) of nonfunctional versus functional AV access associated with case-mix, facility characteristics, and timing of AV access creation. Analyses were stratified by dialysis start condition (planned or as an emergency) and comorbidity profile. Overall, 18% patients had nonfunctional AV access at hemodialysis initiation. In the group with planned dialysis start, female gender (OR 1.43, 95% CI 1.32–1.56), diabetes (OR 1.28, 95% CI 1.15–1.44), and a higher number of cardiovascular comorbidities (OR 1.27, 95% CI 1.09–1.49, and 1.31, 1.05–1.64, for 3 and >3 cardiovascular comorbidities versus none, respectively) were independent predictors of nonfunctional AV access. A higher percentage of AV access creation at the region level was associated with a lower rate of nonfunctional AV access (OR 0.98, 95% CI 0.98–0.99 per 1% increase). The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with fewer than 2 cardiovascular comorbidities and 6 months in patients with diabetes or 2 or more such comorbidities. In conclusion, both patient characteristics and clinical practices may play a role in successful AV access use at hemodialysis initiation. Adjusting the timing of AV access creation to patients’ comorbidity profiles may improve functional AV access rates.
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Affiliation(s)
- Natalia Alencar de Pinho
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- * E-mail:
| | - Raphael Coscas
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- Division of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
| | - Marie Metzger
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
| | | | - Carole Ayav
- Epidémiologie et Evaluations Cliniques, Pôle S2R, CHRU Nancy, Nancy, France
- CIC-1433 Epidémiologie Clinique, Inserm, Nancy, France
| | | | - Ziad A. Massy
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
- Division of Nephrology, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
| | - Bénédicte Stengel
- Renal and Cardiovascular Epidemiology Team, CESP, INSERM U1018, Paris-Sud Univ, UVSQ, Paris Saclay University,Villejuif, France
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10
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Abstract
Many guidelines recommend that end-stage renal disease (ESRD) patients should have a permanent vascular access, preferably an autologous arteriovenous fistula (AVF), at the start of renal replacement therapy. Nevertheless, a large proportion of patients still start hemodialysis with a central venous catheter (CVC). On the other hand, there are increasing numbers of patients in whom an AVF has been created, but who never actually end up on dialysis, as well as a substantial number of patients in whom creation of a vascular access has been attempted unsuccessfully.To improve this situation, timely exploration to assess suitability for and creation of preemptive AVF should be promoted. Decision to construct an AVF should depend on the likelihood and rate of progression to ESRD. For this goal, some reliable prediction models are available. Also, the likelihood that such an attempt will result in a successful outcome should be taken into account, but suitable validated models to accurately make such estimates are lacking. Next to patient-specific factors, some local conditions such as easy access to a vascular surgeon should also be incorporated in the decision-making process between the nephrology team and the patient.
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11
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Vascular access registry of Serbia: a 4-year experience. Int Urol Nephrol 2016; 49:319-324. [DOI: 10.1007/s11255-016-1378-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022]
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12
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Mitsides N, Keane DF, Lindley E, Mitra S. Technology innovation for patients with kidney disease. J Med Eng Technol 2016; 39:424-33. [PMID: 26453039 DOI: 10.3109/03091902.2015.1088089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The loss of kidney function is a life-changing event leading to life-long dependence on healthcare. Around 5000 people are diagnosed with kidney failure every year. Historically, technology in renal medicine has been employed for replacement therapies. Recently, a lot of emphasis has been placed on technologies that aid early identification and prevent progression of kidney disease, while at the same time empowering affected individuals to gain control over their chronic illness. There is a shift in diversity of technology development, driven by collaborative innovation initiatives such the National Institute's for Health Research Healthcare Technology Co-operative for Devices for Dignity. This has seen the emergence of the patient as a key figure in designing technologies that are fit for purpose, while business involvement has ensured uptake and sustainability of these developments. An embodiment of this approach is the first successful Small Business Research Initiative in the field of renal medicine in the UK.
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Affiliation(s)
- Nicos Mitsides
- a NIHR D4D Healthcare Technology Co-operative, Department of Renal Medicine, Central Manchester University Hospital NHS Foundation Trust , Second Floor, Manchester Royal Infirmary, Oxford Road , Manchester M13 9WL , UK .,b NIHR Devices For Dignity Healthcare Technology Co-operative , Sheffield , UK .,c School of Cardiovascular Sciences, The University of Manchester , Manchester , UK , and
| | - David F Keane
- b NIHR Devices For Dignity Healthcare Technology Co-operative , Sheffield , UK .,d Department of Renal Medicine and Medical Physics , Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Elizabeth Lindley
- b NIHR Devices For Dignity Healthcare Technology Co-operative , Sheffield , UK .,d Department of Renal Medicine and Medical Physics , Leeds Teaching Hospitals NHS Trust , Leeds , UK
| | - Sandip Mitra
- a NIHR D4D Healthcare Technology Co-operative, Department of Renal Medicine, Central Manchester University Hospital NHS Foundation Trust , Second Floor, Manchester Royal Infirmary, Oxford Road , Manchester M13 9WL , UK .,b NIHR Devices For Dignity Healthcare Technology Co-operative , Sheffield , UK .,c School of Cardiovascular Sciences, The University of Manchester , Manchester , UK , and
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Lomonte C, Forneris G, Gallieni M, Tazza L, Meola M, Lodi M, Senatore M, Morale W, Spina M, Napoli M, Bonucchi D, Galli F. The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology. J Nephrol 2016; 29:175-184. [PMID: 26780568 PMCID: PMC5429362 DOI: 10.1007/s40620-016-0263-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/04/2016] [Indexed: 12/28/2022]
Abstract
The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.
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Affiliation(s)
- Carlo Lomonte
- U.O.C. di Nefrologia e Dialisi, Ente Ecclesiastico Ospedale "F.Miulli", 70021, Acquaviva delle Fonti, Italy.
| | - Giacomo Forneris
- Struttura Complessa a Direzione Universitaria di Nefrologia e Dialisi, Ospedale Giovanni Bosco, Turin, Italy
| | | | - Luigi Tazza
- Dipartimento di Scienze Chirurgiche, Policlinico Gemelli, Università Cattolica Sacro Cuore, Rome, Italy
| | - Mario Meola
- Dipartimento di Medicina, Università di Pisa, Pisa, Italy
- Scuola Superiore Sant'Anna, Pisa, Italy
| | - Massimo Lodi
- Unità di Nefrologia e Dialisi, Ospedale Santo Spirito, Pescara, Italy
| | - Massimo Senatore
- U.O.C. di Nefrologia e Dialisi, Ospedale Annunziata, Cosenza, Italy
| | - Walter Morale
- Unità di Nefrologia e Dialisi, A.O. Cannizzaro, Catania, Italy
| | - Monica Spina
- Unità di Nefrologia e Dialisi, Ospedale San Gavino Monreale, Cagliari, Italy
| | - Marcello Napoli
- U.O.C. di Nefrologia e Dialisi, Ospedale Santa Caterina Novella, Galatina, Italy
| | | | - Franco Galli
- Unità di Nefrologia IRCCS, Fondazione Salvatore Maugeri, Pavia, Italy
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Preoperative radial artery volume flow is predictive of arteriovenous fistula outcomes. J Vasc Surg 2016; 63:429-35. [DOI: 10.1016/j.jvs.2015.08.106] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/27/2015] [Indexed: 11/20/2022]
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Masengu A, Maxwell AP, Hanko JB. Investigating clinical predictors of arteriovenous fistula functional patency in a European cohort. Clin Kidney J 2016; 9:142-7. [PMID: 26798475 PMCID: PMC4720209 DOI: 10.1093/ckj/sfv131] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/05/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Arteriovenous fistula (AVF) failure to mature (FTM) rates contribute to excessive dependence on central venous catheters for haemodialysis. Choosing the most appropriate vascular access site for an individual patient is guided largely by their age, co-morbidities and clinical examination. We investigated the clinical predictors of AVF FTM in a European cohort of patients and applied an existing clinical risk prediction model for AVF FTM to this population. METHODS A prospective cohort study was designed that included all patients undergoing AVF creation between January 2009 and December 2014 in a single centre (Belfast City Hospital) who had a functional AVF outcome observed by March 2015. RESULTS A total of 525 patients had a functional AVF outcome recorded and were included in the FTM analysis. In this cohort, 309 (59%) patients achieved functional AVF patency and 216 (41%) patients had FTM. Female gender [P < 0.001, odds ratio (OR) 2.03 (CI 1.37-3.02)] and lower-arm AVF [P < 0.001, OR 4.07 (CI 2.77-5.92)] were associated with AVF FTM. The Lok model did not predict FTM outcomes based on the associated risk stratification in our population. CONCLUSIONS In this European study, female gender was associated with twice the risk of AVF FTM and a lower-arm AVF with four times the risk of FTM. The FTM risk prediction model was not found to be discriminative in this population. Clinical risk factors for AVF FTM vary between populations; we would recommend that units investigate their own clinical predictors of FTM to maximize AVF functional patency and ultimately survival in dialysis patients. Clinical predictors of AVF FTM may not be sufficient on their own to improve vascular access functional patency rates.
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Affiliation(s)
- Agnes Masengu
- Regional Nephrology Unit, Belfast City Hospital, Belfast, UK; Nephrology Research Group, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital, Belfast, UK
| | - Alexander P Maxwell
- Regional Nephrology Unit, Belfast City Hospital, Belfast, UK; Nephrology Research Group, Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital, Belfast, UK
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Optimizing outcomes in the elderly with end-stage renal disease--live long and prosper. J Vasc Access 2015; 16:439-45. [PMID: 26109536 DOI: 10.5301/jva.5000440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The elderly form an expanding proportion of patients with chronic kidney disease and end-stage renal disease worldwide. The increased physiological frailty and functional morbidity associated with the aging process pose unique challenges when planning optimal management of an older patient needing renal replacement therapy (RRT). AIMS This position paper discusses current evidence regarding the optimal management of end-stage renal disease in the elderly with an emphasis on hemodialysis since it is the most common modality used in older patients. Further research is needed to define relevant patient-reported outcome measures for end-stage renal disease including functional assessments and psychological impacts of various forms of RRT. For those older patients who have opted for dialysis treatment, it is important to study the strategies that encourage greater uptake of home-based dialysis therapies and optimal vascular access. CONCLUSIONS The management of advanced chronic kidney disease in the elderly can be challenging but also extremely rewarding. The key issue is adopting a patient-focused and individualized approach that seeks to achieve the best outcomes based on a comprehensive holistic assessment of what is important to the patient.
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Lomonte C, Basile C. Preoperative assessment and planning of haemodialysis vascular access. Clin Kidney J 2015; 8:278-81. [PMID: 26034588 PMCID: PMC4440469 DOI: 10.1093/ckj/sfv022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 03/19/2015] [Indexed: 11/12/2022] Open
Abstract
Effective haemodialysis (HD) requires a reliable vascular access (VA). Clinical practice guidelines strongly recommend the arteriovenous fistula (AVF) as the preferred VA in HD patients. The creation of an AVF should be promoted in all eligible patients who choose HD, as it improves outcomes and reduces costs when compared with central venous catheters. Fistula eligibility is a ‘work in progress’. Three steps in order to increase the pool of eligible patients can be individualized: (i) process of care, which includes three fundamental items: the VA team, early VA education and timely VA surgery referral; (ii) preoperative evaluation; (iii) surgical strategy. Nephrologists should be able to play a leading and coordinating role of the VA team. They should design a plan that identifies a sequence of options that can be used to provide adequate renal replacement therapy throughout the life span of every end-stage renal disease patient. The main points of this strategy are (i) early vascular education, in which a ‘save the vein program’ should always be implemented; (ii) timely VA surgery referral and preoperative evaluation: careful examination of arterial and venous beds is mandatory before VA placement; physical examination in addition to colour Doppler ultrasound mapping improves AVF outcomes; (iii) surgical strategy: a successful VA strategy must take into account vascular anatomy, clinical factors and prognosis.
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Affiliation(s)
- Carlo Lomonte
- Division of Nephrology , Miulli General Hospital, Acquaviva delle Fonti , Italy
| | - Carlo Basile
- Division of Nephrology , Miulli General Hospital, Acquaviva delle Fonti , Italy
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