Standardized definitions for hemodialysis vascular access

Efficacy of Primary Stent-Graft Placement in the Treatment of Vascular Access Graft Outflow Tract Stenosis

PURPOSE

The aim of this study is to present our personal experience using covered nitinol stent-graft in the treatment of outflow tract stenosis of arteriovenous grafts (AVGs) for hemodialysis access.

MATERIALS AND METHODS

Between May 2015 and October 2017, we retrospectively evaluated 36 (24 males, 12 females; mean age: 65.6 years) patients with AVGs on hemodialysis who underwent percutaneous angioplasty followed by endovascular stent-graft deployment for the treatment of stenosis of the venous outflow of the AVG. Indication for treatment included early restenosis (<3 months after previous percutaneous transluminal angioplasty [PTA]), long stenosis (stenoses >50% extending for a length >5 cm), and recoil of the stenosis after PTA performed with a noncompliant high-pressure balloon. Of 36 patients, 27 (75%) required surgical thrombectomy prior to endovascular procedure. Technical success, clinical success, primary and secondary patency, and safety were evaluated.

RESULTS

Technical success was 100%, and clinical success was 94.4%. Primary patency was 94.4%, 72.2%, 63%, 45.9%, and 45.9% at 1, 3, 6, 12, and 18 months (average: 215 days, range: 9-653 days); secondary patency was 94.4% and 86.1% at 1 and 3 months; 80.4% at 6, 12, and 18 months; and 53.6% at 24 months (average: 276.8 days, range: 9-744 days). No deaths were registered.

CONCLUSIONS

In selected cases, the use of stent-graft represents an effective and safe solution for the treatment of stenotic complications of the venous outflow of AVGs, even in the setting of access thrombosis.

Predictive Factors for Unsuccessful Use of Arteriovenous Fistula in a Population of End-Stage Renal Disease Patients in Southeastern Mexico

BACKGROUND

An arteriovenous fistula (AVF) is the preferred vascular access for long-term hemodialysis. The main disadvantage of AVF is the rate of nonmaturation or unsuccessful use for hemodialysis (FUHD). We described our findings in AVF creation and possible risk factors associated with FUHD.

METHODS

This is a retrospective study of AVFs during a 6-year period. Variables collected at the time of creation were demographics, comorbidities, replacement therapy, preoperative laboratory tests, and estimated 6-month mortality on hemodialysis. All AVFs were created in the upper arms. Outcomes were FUHD, cannulation failure, and cumulative survival. Univariate and multivariate analyses were performed to find possible risk factors for FUHD.

RESULTS

AVFs were created in 78 patients. Average age was 36.3 years, and 74.4% were male. Mean body mass index was 24.5 kg/m². The most common etiologies were glomerulopathy (53.6%) and diabetes mellitus (13.4%). Estimated six-month mortality was 4.2%. One patient underwent AVF before hemodialysis (mean dialysis time 2.2 years). Nineteen AVFs were considered FUHD (23.2%). Cannulation failure was 15.9%. AVF 1-year and 3-year survival was 67.8% and 63.5%, respectively. FUHD had higher estimated six-month mortality on hemodialysis, shorter prothrombin time, and lower serum albumin level than successful AVF (univariate analysis) (P < 0.05) Short prothrombin time and albumin were confirmed for FUHD (multivariate analysis). A 3.3-gr/dL serum albumin cutoff point (area under the curve, 0.715; receiver operating characteristic) (P < 0.05) was determined for FUHD.

CONCLUSIONS

The population referred for AVF creation possesses different characteristics in our center. Good AVF outcomes can be achieved. Preoperative serum albumin level and prothrombin time could be the possible risk factors associated with unsuccessful AVF use.

Static pressures, intra-access blood flow and dynamic Kt/V profiles in the prediction of dialysis access function

BACKGROUND

Hemodialysis machine-generated circuit pressures and clearance profiles are potential predictors of quality assurances. In our practice, we previously we observed that elevated static access pressures were associated with abnormal Kt/V values, high access recirculation and deviation of the Kt/V profile (Abnormal Kt/V profile) from normally expected values (Normal Kt/V profile).

AIM

To hypothesize that static or derived access pressures would correlate with direct intra-access blood flow rates and that clearance (Kt/V) profiles would correlate with measured Kt/V values.

METHODS

Static access pressures, real-time adequacy of dialysis and intra-access blood flow were investigated in end stage renal disease patients undergoing hemodialysis. Wilcoxon-Mann-Whitney test, chi-square test or Fisher’s exact test was used to investigate differences between the groups; Spearman’s rank correlation test to investigate relationships between static pressures, direct intra-access pressures and Kt/V profiles; and multinomial logistic regression models to identify the independent effect of selected variables on Kt/V profiles. Odds ratio were calculated to measure the association between the variables and Kt/V profiles.

RESULTS

One hundred and seven patients were included for analysis. There were no significant differences between genders, and types of vascular access between the normal vs. abnormal clearance (Kt/V) profile groups. No significant correlation could be demonstrated between static access pressures and Kt/V profiles, static access pressures and intra-access blood flow, intra-access blood flow and Kt/V profiles, measured Kt/V and Kt/V profiles or recirculation and Kt/V profiles.

CONCLUSION

In this study utilizing measured versus estimated data, we could not validate that dialysis machine generated elevated static pressures predict intra-access blood flow disturbances or that abnormal Kt/V profiles predict access recirculation or inadequate dialysis. These parameters, though useful estimates, cannot be accepted as quality assurance for dialysis adequacy or access function without further evidences.

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.

Factors associated with outcome after successful radiological intervention in arteriovenous fistulas: A retrospective cohort

Introduction:

Arteriovenous fistulas are the best form of vascular access for haemodialysis. A radiological balloon angioplasty is the standard treatment for a clinically relevant stenosis, but the recurrence rate is high. Data on factors associated with recurrence are limited.

Methods:

A single centre, retrospective analysis was performed for 124 consecutive patients who had successful interventions for dysfunctional arteriovenous fistulae, to examine factors associated with post-intervention patency. Follow-up was at least 1 year for all patients. Variables associated with primary and cumulative patency were pre-specified and assessed using both un-adjusted (univariate) and adjusted Cox proportional hazards models. Analysis was repeated for a subgroup of 80 patients with a single lesion only in order to examine the potential effects of stenotic lesion characteristics on patency.

Results:

Factors found to have a significant association with poorer outcomes (less time to loss of patency) included thrombosis at the time of intervention and a history of previous intervention. Fistula age (log days) was significantly associated with better outcomes (greater time to loss of patency). Non-white ethnicity, lesion length, and patient age were also significantly associated with accelerated loss of patency.

Discussion:

The factors we have identified as linked to poor outcome may help to identify patients in whom a balloon angioplasty is unlikely to provide a durable outcome. This may prompt exploring alternative treatment or dialysis options at an early stage.

Relevance of a skilled vascular surgeon and optimized facility practices in the long-term patency of arteriovenous fistulas: a prospective study

Introduction:

Arteriovenous fistulas (AVF) are the best hemodialysis vascular accesses, but their failure rate remains high. Few studies have addressed the role of the vascular surgeon's skills and the facility's practices. We aimed to study these factors, with the hypothesis that the surgeon's skills and facility practices would have an important role in primary failure and patency rates at 12 months, respectively.

Methods:

This was a single-center, prospective cohort study carried out from March 2005 to March 2017. Only incident patients were included. A single surgeon made all AVFs, either in the forearm (lower) or the elbow (upper). Vascular access definitions were in accordance with the North American Vascular Access Consortium.

Results:

We studied 113 AVFs (65% lower) from 106 patients (39% diabetics, 58% started with catheter). Time to first connection was 21.5 days (IR: 14 - 31). Only 14 AVFs (12.4%) underwent primary failure and 18 failed during the first year. Functional primary patency rate was 80.9% (SE 4.1) whereas primary unassisted patency rate, which included PF, was 70.6% (4.4). Logistic regression showed that diabetes (OR = 3.3, 95%CI 1.38 - 7.88, p = .007) and forearm location (OR = 3.03, 95CI% 1.05 - 8.76, p = 0.04) were predictors of AVF failure. Patency of lower and upper AVFs was similar in non-diabetics, while patency in diabetics with lower AVFs was under 50%. (p = 0.003).

Conclusions:

Results suggest that a long-lasting, suitable AVF is feasible in almost all patients. The surgeon's skills and facility practices can have an important role in the long term outcome of AVF.

Fish oil and aspirin effects on arteriovenous fistula function: Secondary outcomes of the randomised omega-3 fatty acids (Fish oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) trial

BACKGROUND

Arteriovenous fistulas (AVF) for haemodialysis often experience early thrombosis and maturation failure requiring intervention and/or central venous catheter (CVC) placement. This secondary and exploratory analysis of the FAVOURED study determined whether omega-3 fatty acids (fish oils) or aspirin affected AVF usability, intervention rates and CVC requirements.

METHODS

In 567 adult participants planned for AVF creation, all were randomised to fish oil (4g/d) or placebo, and 406 to aspirin (100mg/d) or placebo, starting one day pre-surgery and continued for three months. Outcomes evaluated within 12 months included AVF intervention rates, CVC exposure, late dialysis suitability failure, and times to primary patency loss, abandonment and successful cannulation.

RESULTS

Final analyses included 536 participants randomised to fish oil or placebo (mean age 55 years, 64% male, 45% diabetic) and 388 randomised to aspirin or placebo. Compared with placebo, fish oil reduced intervention rates (0.82 vs 1.14/1000 patient-days, incidence rate ratio [IRR] 0.72, 95% confidence interval [CI] 0.54-0.97), particularly interventions for acute thrombosis (0.09 vs 0.17/1000 patient-days, IRR 0.53, 95% CI 0.34-0.84). Aspirin significantly reduced rescue intervention rates (IRR 0.45, 95% CI 0.27-0.78). Neither agent significantly affected CVC exposure, late dialysis suitability failure or time to primary patency loss, AVF abandonment or successful cannulation.

CONCLUSION

Although fish oil and low-dose aspirin given for 3 months reduced intervention rates in newly created AVF, they had no significant effects on CVC exposure, AVF usability and time to primary patency loss or access abandonment. Reduction in access interventions benefits patients, reduces costs and warrants further study.

The forearm arteriovenous graft between the brachial artery and the brachial vein as a reliable dialysis vascular access for patients with inadequate superficial veins

OBJECTIVE

The arteriovenous fistula (AVF) is recommended as the preferred hemodialysis access. However, placing an AVF in all patients may result in poor access outcomes and increased central venous catheter (CVC) use because of increased comorbid conditions, age, and suboptimal vessels. In patients with inadequate superficial veins for AVFs, the use of the brachial veins for creation of forearm arteriovenous grafts (AVGs) has received limited attention. This retrospective study aimed to evaluate outcomes of forearm brachial-brachial AVGs (BB-AVGs) placed in patients with poor superficial veins.

METHODS

We identified 111 BB-AVGs created in 111 consecutive patients, using standard-walled polytetrafluoroethylene grafts, between January 2010 and December 2015. After excluding 6 patients (non-dialysis initiation, missing information, and death within 1 month), we included 105 patients from 21 dialysis centers. We analyzed primary failures, time to cannulation, patency, complications, and revisions. Patency rates were calculated by the Kaplan-Meier method. The incidence of complications and revisions was expressed as number of events per person-year.

RESULTS

A total of 105 patients (median age, 69 years) were followed up for a median time of 21.2 months (interquartile range, 9.2-36.5 months). Of the patients, 72.4% were on chronic hemodialysis and had previously undergone one or more access procedures. At the time of BB-AVG placement, prior accesses were 39 AVFs, 20 tunneled CVCs, and 17 AVGs. BB-AVG rates of primary failure and revision before cannulation were 7.6% and 5.7%, respectively. BB-AVGs were cannulated after a median time of 3.4 weeks (interquartile range, 2.8-4.1 weeks). Primary patency rates at 12, 24, and 36 months were 49.5%, 29.5%, and 19.5%. Secondary patency rates at 12, 24, and 36 months were 76.3%, 62.7%, and 54.6%. After cannulation, the incidence of complications and revisions was 1.054 and 0.649 per person-year, respectively. Most complications and interventions were due to thrombosis (0.527 per person-year) or stenosis (0.381 per person-year) and related interventions (0.490 per person-year). A minority of patients experienced AVG infections (0.052 per person-year), with only two requiring access removal.

CONCLUSIONS

In patients with poor superficial veins, the forearm BB-AVG is a reliable access because of low access-related morbidity and considerable long-term access survival. BB-AVG placement has the advantage of preserving proximal vessels. In these patients, such an approach can delay both rapid exhaustion of vascular sites and early recourse to CVC permanent use.

Role of neutrophil-to-lymphocyte ratio as a prognostic indicator for hemodialysis arteriovenous fistula failure

OBJECTIVE

To evaluate the role of preoperative peripheral blood neutrophil-to-lymphocyte ratio in predicting early arteriovenous fistula failure. The impact of postoperative neutrophil-to-lymphocyte ratio on arteriovenous fistula failure was also investigated.

METHODS

Medical records from 470 patients who underwent first-time arteriovenous fistula creation were studied. Demographic, clinical, and laboratory data were obtained. Receiver operating characteristic curves were constructed to determine the optimal cutoff values of preoperative and postoperative neutrophil-to-lymphocyte ratios for predicting early arteriovenous fistula failure. Univariate and multivariate analyses were performed to evaluate whether the neutrophil-to-lymphocyte ratio parameters were prognostic indicators for arteriovenous fistula failure.

RESULTS

Complete data from 396 patients were studied. The prevalence of early arteriovenous fistula failure was 30.6%. The optimal cutoff values of preoperative and postoperative neutrophil-to-lymphocyte ratios for predicting early arteriovenous fistula failure were 2.7 (82.6% sensitivity and 52.0% specificity) and 2.9 (78.5% sensitivity and 73.1% specificity), respectively. By univariate and multivariate analyses, high preoperative and postoperative neutrophil-to-lymphocyte ratios were significantly associated with early arteriovenous fistula failure. The adjusted odds ratios were 5.46 (95% confidence interval: 3.15-9.48) and 7.19 (95% confidence interval: 4.12-12.55), respectively.

CONCLUSIONS

High preoperative and postoperative neutrophil-to-lymphocyte ratios significantly predict early arteriovenous fistula failure.

Sentinel vascular access monitoring after endovascular intervention predicts access outcome

BACKGROUND AND OBJECTIVES

The vascular access pressure ratio test identifies dialysis vascular access dysfunction when three consecutive vascular access pressure ratios are >0.55. We tested whether the magnitude of the decline in vascular access pressure ratio 1-week post-intervention could alert of subsequent access failure.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

The retrospective study included all vascular access procedures at one institution from March 2014 to June 2016. Data included demographics, comorbidities, vascular access features, %ΔVAPR = ((Pre-Post)/Pre] × 100% assessed within the first 2 weeks post-percutaneous transluminal balloon angioplasty, time-to-next procedure, and patency. The log-rank test compared the area under the curve, receiver operating curve, Kaplan-Meier arteriovenous graft and arteriovenous fistula survival curves. A multivariable Cox proportional hazard (CP) model was used to determine the association of %ΔVAPR with access patency.

RESULTS

Analysis of 138 subjects (females 51%; Black 87%) included 64 arteriovenous fistulas with 104 angioplasties and 74 arteriovenous grafts with 134 angioplasties. The area under the receiver operating characteristic curve for fistula failure at 3 months was 0.59, with optimal screening characteristics of 33.3%, sensitivity of 56.1%, and specificity of 63.2%. Arteriovenous fistula with <33.3% decline compared to >33.3% required earlier subsequent procedure (136 vs 231 days), lower survival on Kaplan-Meier analysis (P = 0.01), and twofold greater risk of failure (P = .006). Area under the receiver operating characteristic for arteriovenous graft failure at 3 months had a sensitivity of 52.3% and specificity of 67.4%. Arteriovenous graft with a post-intervention vascular access pressure ratio decline of <28.8% also required earlier subsequent procedure (144 vs 189 days), lower survival on Kaplan-Meier (P = 0.04), and a 59% higher risk for failure. The area under the receiver operating characteristic curve for combined access failure (arteriovenous fistula + arteriovenous graft) at 3 months had an optimal cut-point value of 31.2%, a sensitivity of 54.6%, and a specificity of 63.1%. Access with a <31.2% drop had a 62% increase in the risk of failure (hazard ratio 1.62; confidence interval 1.16, 2.27; P = 0.005).

CONCLUSION

The magnitude of post-intervention reduction in vascular access pressure ratio provides a novel predictive measure of access outcomes.

The effect of stellate ganglion block on the function of arteriovenous fistulas for hemodialysis: A randomized trial

BACKGROUND AND PURPOSE

The best access for hemodialysis is an autologous arteriovenous fistula (AVF). The most helpful way for vasodilation in the upper limb is stellate ganglion block. We aim to evaluate the effect of stellate ganglion block on outcome of vascular access for dialysis.

MATERIALS AND METHODS

Some 105 hemodialysis patients were randomly allocated to three groups: In group 1, stellate ganglion block was performed before fistula surgery. Group 2 had stellate ganglion block after surgery and group 3 was control group without any block. Primary outcome for all groups was functional dialysis, which is defined as successful hemodialysis for 1 month.

RESULTS

The three groups were similar in age, gender, and underlying diseases. Stellate ganglion block before operation had a meaningful increase in successful hemodialysis rate, when compared with the other groups (p = 0.02).

CONCLUSION

Stellate ganglion block before arteriovenous fistula surgery in the upper limbs improves hemodialysis success rate.

Chronic Renal Therapy

Chronic kidney disease (CKD) is a most challenging diagnosis for patients and their health care teams. Detection is often delayed because of the insidious nature of kidney failure and symptoms experienced by patients. It is not until later in the disease progression that laboratory test values begin to display values indicative of actual renal damage. Patients are then presented with life-changing alternatives that affect their work, lifestyle, relationships, and well-being. Therapies currently used in CKD and end-stage renal disease are described depicting choices patients have in maintaining and perhaps arresting some aspects of CKD.

Autologous arteriovenous fistula is associated with superior outcomes in elderly hemodialysis patients

BACKGROUND

The number of elderly patients with end-stage renal disease is increasing rapidly. The higher prevalence of comorbidities and shorter life expectancy in these patients make it difficult to decide on the type of vascular access (VA). We explored the optimal choice for VA in elderly hemodialysis patients.

METHODS

We included elderly patients (> 65 years) visiting our VA clinic and divided them into three groups as follows: radiocephalic arteriovenous fistula (AVF), brachiocephalic AVF, and prosthetic arteriovenous graft (AVG). The primary outcomes were VA abandonment and all-cause mortality. The secondary outcome was maturation failure (MF).

RESULTS

Of 529 patients, 61.2% were men. The mean age was 73.6 ± 6.0 years. The VA types were as follows: 49.9% radiocephalic AVF, 31.8% brachiocephalic AVF, and 18.3% AVG. Patients with an AVG tended to be older, female, and have a lower body mass index. More than half of patients (n = 302, 57.1%) started dialysis with central catheters, but the proportion of predialysis central catheter placement was not different among the VA types. Radiocephalic AVF was significantly superior to AVG in terms of VA abandonment (P = 0.005) and all-cause mortality (P < 0.001) in spite of a higher probability of MF. Brachiocephalic AVF was associated with a shorter time to the first needling and fewer interventions before maturation than radiocephalic AVF.

CONCLUSIONS

Autologous AVF was suggested as the preferred VA choice in terms of long-term outcomes in elderly patients.

Correlation between preoperative vein and artery diameters and arteriovenous fistula outcome in patients with end-stage renal disease

BACKGROUND AND AIMS

Arteriovenous fistula (AVF) maturation failure rates remain high in patients with end-stage renal disease (ESRD). Although preoperative morphological and functional assessment of blood vessels by duplex ultrasonography (DUS) has been shown to improve AVF maturation, there is no consensus regarding the optimal vein (VD) and artery (AD) diameters to be universally used for AVF creation. To improve patient selection, set out to investigate if there is a correlation between preoperative VD/AD and clinical covariates, and postoperative AVF outcome.

METHODS

This was a prospective cohort study conducted during January-August 2014. ESRD patients referred to "Niculae Stăncioiu" Heart Institute Cluj-Napoca, who had a VD ≥1.9 mm and AD ≥1.5 mm, as measured by DUS, and underwent AVF creation were enrolled. We assessed whether preoperative VD/AD and clinical covariates were associated with AVF maturation rate and primary patency at 2 years after AVF creation.

RESULTS

Of 115 patients referred for AVF creation, 93 were included in the study. Mean (± standard deviation) VD was 3.3 ± 1.1 mm and VDs were distributed in quartile Q1 <2.55 mm, Q2: 2.56-3.10 mm, Q3: 3.11-3.70 mm and Q4: >3.71 mm. Mean AD was 3.3 ± 1.4 mm and ADs were distributed in Q1 <2.55 mm, Q2: 2.56-3.10 mm, Q3: 3.11-3.70 mm, and Q4, >3.71 mm. AVF maturation rate increased proportionally with VD from Q1 (62%) to Q2 (70%), Q3 (82%) to Q4 (96%) (p=0.03). Based on AD, a higher AVF maturation rate was observed in Q3 (86%), Q4 (83%) vs Q1 (71%) and Q2 (67%). Long-term primary patency of AVFs seemed not to be influenced by VD and AD. In older patients and those with peripheral arterial disease, AVF maturation failure tended to be higher.

CONCLUSIONS

Our findings suggest that a preoperative VD ≥1.9 mm and AD ≥1.5 mm have a successful maturation rate of AVF greater than 60% in ESRD patients. The maturation rate of surgical AVF increases proportionally with the size of VD used for AVF creation.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Rationale and design of the PHYSICALFAV trial: a randomized controlled trial to evaluate the effect of preoperative isometric exercise on vascular calibre and maturation of autologous arteriovenous fistulas

Background

A good vascular access (VA) is vital for haemodialysis (HD) patients. HD with an autologous arteriovenous fistula (AVF) is associated with higher survival, lower health care costs and fewer complications. Although a distal forearm AVF is the best option, not all patients are good candidates for this approach and the primary failure rate ranges from 20% to 50%. The optimal AVF depends mainly on the anatomical and haemodynamic characteristics of the artery and the vein chosen for the anastomosis. These characteristics can be modified by performing physical exercise. VA guidelines suggest that isometric exercises should be performed both before and after the AVF is created. While the literature contains few data on the potential efficacy of preoperative exercise, small observational studies point to an improvement in venous and arterial calibre. Postoperative exercise also seems to improve maturation, although there is no consensus on the appropriate exercise protocol.

Methods

The PHYSICALFAV trial (NCT03213756) is an open-label, multicentre, prospective, controlled, randomized trial designed to evaluate the usefulness of preoperative isometric exercise (PIE) in pre-dialysis patients or in prevalent HD patients who are candidates for a new AVF. Patients are randomized 1:1 to the PIE group (isometric exercises for 8 weeks) or the control group (no exercise). The main endpoint is whether the rate of primary failure is lower in the PIE group than in the control group.

Results

The trial has already started, with 40 patients having been enrolled as of 21 March 2018; 26.5% of the estimated sample.

Vascular access clinic results before and after implementing a multidisciplinary approach adding routine Doppler ultrasound

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.

Report of the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop on Establishing a Core Outcome Measure for Hemodialysis Vascular Access

Vascular access outcomes in hemodialysis are critically important for patients and clinicians, but frequently are neither patient relevant nor measured consistently in randomized trials. A Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop was convened to discuss the development of a core outcome measure for vascular access. 13 patients/caregivers and 46 professionals (clinicians, policy makers, industry representatives, and researchers) attended. Participants advocated for vascular access function to be a core outcome based on the broad applicability of function regardless of access type, involvement of a multidisciplinary team in achieving a functioning access, and the impact of access function on quality of life, survival, and other access-related outcomes. A core outcome measure for vascular access required demonstrable feasibility for implementation across different clinical and trial settings. Participants advocated for a practical and flexible outcome measure with a simple actionable definition. Integrating patients' values and preferences was warranted to enhance the relevance of the measure. Proposed outcome measures for function included "uninterrupted use of the access without the need for interventions" and "ability to receive prescribed dialysis," but not "access blood flow," which was deemed too expensive and unreliable. These recommendations will inform the definition and implementation of a core outcome measure for vascular access function in hemodialysis trials.

Regional Anesthesia for Arteriovenous Fistula Surgery May Reduce Hospital Length of Stay and Reoperation Rates

Background and Objectives:

Regional anesthesia has been proposed as the preferred mode of anesthesia for arteriovenous fistula surgery due to its associated vasodilatory effects and fistula patency rates. We analyzed patient outcomes after arteriovenous fistula surgery for their association with the type of anesthesia received.

Methods:

The National Surgical Quality Improvement Project database was accessed to identify a cohort of 3199 patients undergoing arteriovenous fistula surgery from 2007 to 2015. Multiple regression models were used to examine the association of anesthesia with 12 postoperative outcomes. Additional multivariate logistic regression was performed to assess significant independent variables predictive of anesthesia choice.

Results:

Patients who received regional anesthesia had the shortest postoperative length of stay (0.67 [standard deviation: 2.0] days) compared to monitored anesthesia care/intravenous (IV) sedation (0.77 [1.8] days) and general anesthesia (1.44 [2.8] days). Administration of regional anesthesia was associated with a shorter length of stay compared to general anesthesia (odds ratio [OR]: 0.55, P = .001). Patients who received monitored anesthesia care/IV sedation had a lower risk of reoperation compared to general anesthesia (OR: 0.65, P = .012) but not compared to regional anesthesia (OR: 0.89, P = .759). Anesthesia type had no significant effects on other measured postoperative complications. Predictors of the type of anesthesia were age and surgical procedure as defined by Current Procedural Terminology code ( P < .001).

Conclusions:

Use of regional anesthesia is associated with a shorter postoperative length of stay after arteriovenous fistula surgery and lower risk of reoperation compared to general anesthesia or monitored anesthesia care/IV sedation. Regional anesthesia may be an excellent choice for arteriovenous fistula surgery to reduce postoperative length of stay and risk of reoperation.

Proposed standards for reporting outcomes of treating biliary injuries

BACKGROUND

There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries.

METHODS

The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of "patency" and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access.

RESULTS

The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series.

CONCLUSIONS

A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.

Difficulties with tunneling of the cuffed catheter: a single-centre experience

Tunneling of the cuffed catheter for hemodialysis is an important part of insertion procedure with faulty techniques being the cause of catheter dysfunctions. We retrospectively analyzed 737 double-lumen cuffed catheter procedures between 2008 and 2015 in patients aged 60 ± 15years, requiring renal replacement therapy. Complications of tunneling included kinking, bleeding and other problems. In 20 of 737 (2.7%) procedures, the catheter kinked, which was observed in 7.7% of silicone and 0.6% of polyurethane catheters. Repositioning was attempted in 4, but was successful in only 2 cases. Catheter exchange was necessary in 16 cases, but the function was adequate in 2 cases, despite radiological signs of kinking. In 6 cases (1 patient with diabetes, 2 with chest anatomy changes and medical devices, 2 with systemic sclerosis and 1 with greatly enlarged superficial jugular veins) we faced particular difficulties requiring an individual solution by tunneling; these are described in detail. The cumulative catheter patency rate were 69%, 52% and 37% at 3, 6 and 12 months, respectively. In conclusion, the most frequent complication of tunneling was kinking, usually necessitating catheter exchange. The silicon catheter kinked more often than the polyurethane one. An individual approach is sometimes needed by patients with diabetes and anatomical changes of the chest.

Vascular Access Outcomes Reported in Maintenance Hemodialysis Trials: A Systematic Review

BACKGROUND

Many randomized controlled trials have been performed with the goal of improving outcomes related to hemodialysis vascular access. If the reported outcomes are relevant and measured consistently to allow comparison of interventions across trials, such trials can inform decision making. This study aimed to assess the scope and consistency of vascular access outcomes reported in contemporary hemodialysis trials.

STUDY DESIGN

Systematic review.

SETTING & POPULATION

Adults requiring maintenance hemodialysis.

SELECTION CRITERIA

All randomized controlled trials and trial protocols reporting vascular access outcomes identified from ClinicalTrials.gov, Embase, MEDLINE, and the Cochrane Kidney and Transplant Specialized Register from January 2011 to June 2016.

INTERVENTIONS

Any hemodialysis-related intervention.

OUTCOMES

The frequency and characteristics of vascular access outcome measures were analyzed and classified.

RESULTS

From 168 relevant trials, 1,426 access-related outcome measures were extracted and classified into 23 different outcomes. The 3 most common outcomes were function (136 [81%] trials), infection (63 [38%]), and maturation (31 [18%]). Function was measured in 489 different ways, but most frequently reported as "mean access blood flow (mL/min)" (37 [27%] trials) and "number of thromboses" (30 [22%]). Infection was assessed in 136 different ways, with "number of access-related infections" being the most common measure. Maturation was assessed in 44 different ways at 15 different time points and most commonly characterized by vein diameter and blood flow. Patient-reported outcomes, including pain (19 [11%]) and quality of life (5 [3%]), were reported infrequently. Only a minority of trials used previously standardized outcome definitions.

LIMITATIONS

Restricted sampling frame for feasibility and focus on contemporary trials.

CONCLUSIONS

The reporting of access outcomes in hemodialysis trials is very heterogeneous, with limited patient-reported outcomes and infrequent use of standardized outcome measures. Efforts to standardize outcome reporting for vascular access are critical to optimizing the comparability, reliability, and value of trial evidence to improve outcomes for patients requiring hemodialysis.

Selective placement of autogenous arteriovenous fistulae in an over 80-year-old population

INTRODUCTION

With improved life expectancy and quality of life, elderly patients constitute a progressively larger fraction of consumers utilising renal replacement therapy (RRT). Although substantial data exist for younger cohorts, minimal evidence exists for outcomes of arteriovenous fistula (AVF) and central catheters (CVC) placed in those patients over 80 years. We examined outcomes of primary AVF placement in this cohort to ascertain durability and benefits of AVF in the over 80-year-old population.

METHODS

Retrospective analysis was undertaken of all autogenous AVFs and CVCs placed in patients aged over 80 years at Gold Coast University Hospital between March 2010 and February 2016. Prospectively collected demographic data, co-morbidities and operative factors were analysed.

RESULTS

Sixty-five AVF and 12 CVC patients were identified. Mean age at intervention was 83.9 years and 76% of the patients were male. The majority of procedures were autogenous radio-cephalic AVF; median post-operative length of stay was 2 days. Cumulative AVF patient survival at 12 and 24 months was 82% and 72%, respectively. This was significantly better than survival rates of CVC patients, with 12-month survival of 45%. Primary patency at 6, 12 and 24 months was 58%, 39% and 31%. There were 113 follow-up procedures in 41 patients required to maintain patency.

CONCLUSIONS

Although patency rates are inferior and re-intervention rates higher than in younger patients, AVF can be a durable option for RRT in selected elderly patients with improved mortality rates compared with CVC. Age alone should not preclude primary AVF placement.

Arteriovenous Fistulae for Haemodialysis: A Systematic Review and Meta-analysis of Efficacy and Safety Outcomes

BACKGROUND

Arteriovenous fistulae are the currently recommended gold standard vascular access modality for haemodialysis because of their prolonged patency, improved durability, and low risk of infection for those that mature. However, notable disadvantages are observed in terms of protracted maturation time, associated high rates of catheter use, and substantial abandonment rates. The aim of this study was to quantitatively summarize the outcomes of fistula patency, infection, maturation, and abandonment published in the scientific literature.

METHODS

This was a systematic review and meta-analyses of studies evaluating fistula outcomes. Literature searches were conducted in multiple databases to identify observational and interventional studies of mean fistula patency rates at 1 year, infection risk, maturation time, and abandonment. Digitisation software was used to simulate individual patient level data from Kaplan-Meier survival plots.

RESULTS

Over 8000 studies were reviewed, and from these, 318 studies were included comprising 62,712 accesses. For fistulas the primary unassisted, primary assisted, and secondary patency rates at one year were 64%, 73% and 79% respectively, however not all fistulas reported as patent could be confirmed as being clinically useful for dialysis (i.e. functional patency). For fistulas that were reported as mature, mean time to maturation was 3.5 months, however only 26% of created fistulas were reported as mature at 6 months and 21% of fistulas were abandoned without use. Overall risk of infection in fistula patients was 4.1% and the overall rate per 100 access days was 0.018.

CONCLUSIONS

Reported fistula patency rates may overstate their potential clinical utility when time to maturation, maturation rate, abandonment and infection are considered. Protracted maturation times, abandonment and infection all have a significant impact on evaluating the clinical utility of fistula creation. A rigorous and consistent set of outcomes definitions for hemodialysis access are necessary to clarify factors contributing to fistula success and the clinical consequence of fistula failure.

Plasma cell neoplasm as a risk factor for early thrombosis of arteriovenous fistula

INTRODUCTION

We hypothesized that presence of plasma cell neoplasms might be a risk for thrombosis of arteriovenous fistulas (AVFs) as well as other well-known factors including age, sex, race, and presence of diabetes mellitus or certain vascular disorders.

METHODS

In this single-center, retrospective study based on medical record data, we investigated the influence of plasma cell neoplasms and the above-mentioned factors on the occurrence of complete occlusive thrombosis of the AVF within 30 days after surgery for creation of the AVF. Thrombosis was defined as the absence of bruit or thrill on auscultation and palpation, throughout systole and diastole.

FINDINGS

We retrospectively assessed the medical records of 91 patients with end-stage renal failure, including 8 patients with plasma cell neoplasm (5 with multiple myeloma and 3 with amyloid light-chain amyloidosis), who underwent surgical creation of an AVF at the wrist or anatomical snuff box for the first time between April 2014 and December 2016. Early thrombosis (i.e., within 30 days of surgery) occurred in 50.0% (4/8) and 10.8% (9/83) of patients with and without plasma cell neoplasm, respectively (P = 0.013). Multivariate analysis revealed that, after adjusting for baseline characteristics, plasma cell neoplasm was the only significant risk factor for early AVF thrombosis (odds ratio, 38.8; 95% confidence interval, 4.0-378.9; P = 0.0017).

DISCUSSION

Considering the poor prognosis of plasma cell neoplasm and its association with higher risk for AVF thrombosis, another type of vascular access is likely to be more suitable than AVF in such patients.

Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT)

BACKGROUND

Hemodialysis arteriovenous fistulas (AVFs) are suboptimally used primarily due to problems with maturation, early thrombosis, and patient nonacceptance. An endovascular approach to fistula creation without open surgery offers another hemodialysis vascular access option.

STUDY DESIGN

Prospective, single-arm, multicenter study (Novel Endovascular Access Trial [NEAT]).

SETTINGS & PARTICIPANTS

Consecutive adult non-dialysis-dependent and dialysis-dependent patients referred for vascular access creation at 9 centers in Canada, Australia, and New Zealand.

INTERVENTION

Using catheter-based endovascular technology and radiofrequency energy, an anastomosis was created between target vessels, resulting in an endovascular AVF (endoAVF).

OUTCOMES

Safety, efficacy, functional usability, and patency end points.

MEASUREMENTS

Safety as percentage of device-related serious adverse events; efficacy as percentage of endoAVFs physiologically suitable (brachial artery flow ≥ 500mL/min, vein diameter ≥ 4mm) for dialysis within 3 months; functional usability of endoAVFs to provide prescribed dialysis via 2-needle cannulation; primary and cumulative endoAVF patencies per standardized definitions.

RESULTS

80 patients were enrolled (20 roll-in and 60 participants in the full analysis set; the latter are reported). EndoAVFs were created in 98% of participants; 8% had a serious procedure-related adverse event (2% device related). 87% were physiologically suitable for dialysis (eg, mean brachial artery flow, 918mL/min; endoAVF vein diameter, 5.2mm [cephalic vein]). EndoAVF functional usability was 64% in participants who received dialysis. 12-month primary and cumulative patencies were 69% and 84%, respectively.

LIMITATIONS

Due to the unique anatomy and vessels used to create endoAVFs, this was a single-arm study without a surgical comparator.

CONCLUSIONS

An endoAVF can be reliably created using a radiofrequency magnetic catheter-based system, without open surgery and with minimal complications. The endoAVF can be successfully used for hemodialysis and demonstrated high 12-month cumulative patencies. It may be a viable alternative option for achieving AVFs for hemodialysis patients in need of vascular access.

Cilostazol May Improve Maturation Rates and Durability of Vascular Access for Hemodialysis

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case–control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Effect of ethnicity and socioeconomic status on vascular access provision and performance in an urban NHS hospital

BACKGROUND

The aim of this study was to examine the effect of ethnicity, socioeconomic group (SEG) and comorbidities on provision of vascular access for haemodialysis (HD).

METHODS

This was a retrospective review of two databases of HD sessions and access operations from 2003-11. Access modality of first HD session and details of transplanted patients were derived from the renal database. Follow-up was until 1 January 2015. Primary failure (PF) was defined as an arteriovenous fistula (AVF) used for fewer than six consecutive dialysis sessions. AVF survival was defined as being until the date the AVF was abandoned. Ethnicity was coded from hospital records. SEG was calculated from postcodes and 2011 census data from the Office of National Statistics. Comorbidities were calculated with the Charlson Comorbidity Index.

RESULTS

Five hundred incident patients started chronic HD in the study period. Mode of starting HD was not associated with ethnicity (P = 0.27) or SEG (P = 0.45). Patients from ethnic minorities were younger when starting dialysis (P < 0.0001). Some 928 AVF patients' first AVF operations were analysed: 68% Caucasian, 26% Asian and 6% Afro-Caribbean. Half were in the most deprived SEG and 11% in the least deprived SEG. PF did not differ by ethnicity (P = 0.29), SEG (P = 0.75) or comorbidities (P = 0.54). AVF survival was not different according to ethnicity (P = 0.13) or SEG (P = 0.87). AVF survival was better for patients with a low comorbidity score (P = 0.04). The distribution of transplant recipients by ethnic group and SEG was similar to the distributions of all HD starters.

CONCLUSION

Ethnicity and socioeconomic group had no effect on mode of starting HD, primary AVF failure rate or AVF survival. Ethnic minorities were younger at start of dialysis and at their first AVF operation.

Aortic Arch Calcification as a Predictor of Repeated Arteriovenous Fistula Failure within 1-Year in Hemodialysis Patients

Objectives

The aim of the study was to identify the factors associated with repeated arteriovenous fistula (AVF) failure within 1-year, especially the impact of aortic arch calcification (AAC) on patency of AVF.

Materials and Methods

We retrospectively assessed chest radiography in hemodialysis patients who had undergone initial AVF. The extent of AAC was categorized into four grades (0–3). The association between AAC grade, other clinical variables, and repeated failure of AVF was then analyzed by binary logistic regression analysis.

Results

This study included 284 patients (158 males, mean age 61.7 ± 13.1 years). Patients with higher AAC grade were older, had more frequently diabetes mellitus and cardiovascular disease, had lower diastolic blood pressure, and had higher corrected calcium and lower intact parathyroid hormone levels. In multivariate analysis, the presence of higher AAC grade (odds ratio (95% confidence interval): 2.98 (1.43–6.23); p = 0.004), lower mean corrected calcium (p = 0.017), and mean serum albumin level (p = 0.008) were associated with repeated failure of AVF.

Conclusions

The presence of higher AAC grade, lower mean corrected calcium and mean serum albumin level were independently associated with repeated AVF failure within 1 year in hemodialysis patients.

Complications of the Arteriovenous Fistula: A Systematic Review

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

Vascular imaging for hemodialysis vascular access planning

INTRODUCTION

Central venous catheters (CVC) increase risks associated with hemodialysis (HD), but may be necessary until an arteriovenous fistula (AVF) or graft (AVG) is achieved. The impact of vascular imaging on achievement of working AVF and AVG has not been firmly established.

METHODS

Retrospective cohort of patients initiating HD with CVC in 2010-2011, classified by exposure to venography or Doppler vein mapping, and followed through December 31, 2012. Standard and time-dependent Cox models were used to determine hazard ratios (HRs) of death, working AVF, and any AVF or AVG. Logistic regression was used to assess the association of preoperative imaging with successful AVF or AVG among 18,883 individuals who had surgery. Models were adjusted for clinical and demographic factors.

FINDINGS

Among 33,918 patients followed for a median of 404 days, 39.1% had imaging and 55.7% had surgery. Working AVF or AVG were achieved in 40.6%; 46.2% died. Compared to nonimaged patients, imaged patients were more likely to achieve working AVF (HR = 1.45 [95% confidence interval [CI] 1.36, 1.55], P < 0.001]), any AVF or AVG (HR = 1.63 [1.58, 1.69], P > 0.001), and less likely to die (HR = 0.88 [0.83-0.94], P < 0.001). Among patients who had surgery, the odds ratio for any successful AVF or AVG was 1.09 (1.02-1.16, P = 0.008).

DISCUSSION

Fewer than half of patients who initiated HD with a CVC had vascular imaging. Imaged patients were more likely to have vascular surgery and had increased achievement of working AV fistulas and grafts. Outcomes of surgery were similar in patients who did and did not have imaging.

Arteriovenous Access Failure, Stenosis, and Thrombosis

Vascular access–related complications can lead to patient morbidity and reduced patient quality of life. Some of the common arteriovenous access complications include failure to mature, stenosis formation, and thrombosis.

Arteriovenous Vascular Access Selection and Evaluation

When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.