Balancing Fistula First With Catheters Last

Personalized decision-making for vascular access creation in hemodialysis

Selecting the appropriate kidney replacement therapy (KRT) is crucial in order to secure optimal care for chronic kidney disease (CKD) patients with end-stage renal disease (ESRD). Next to renal transplantation, the choice of dialysis modality directly affects patient well-being, treatment effectiveness, and long-term outcomes. Therefore, clinical decision-making must take into account a range of factors to tailor decisions to each patient's unique needs. Previously, when the dialysis population was less diverse and resources more limited, straight-forward algorithms could be effectively implemented both for selection of KRT as well as for hemodialysis (HD) vascular access (VA). Recently, the growing ESRD population with more elderly being considered for dialysis care together with improved treatment opportunities have resulted in more challenging decision-making where on-size-fits-all strategies are being replaced by more tailored and personalized strategies aimed to ensure "the right dialysis access - to the right patient - at the right time - for the right reason." In this review, recent trends enforcing a more personalized approach in the selection of VA for HD are summarized and discussed, where these concerns have become especially relevant.

Effects of the tip structure of temporary indwelling catheters on blood recirculation at various blood flow rates and diameters of the mock blood vessel

AIMS

The aim of the present study was to determine the effects of the tip structure of the catheters used for hemodialysis on blood recirculation at varying blood flow rates and diameters of the mock blood vessel in a well-defined in vitro experimental system, focusing on reverse connection mode.

METHODS

A mock circulatory circuit was created with silicon tubing (15 or 20 mm), a circulatory pump, connected through the catheter to dialysis circuit and dialyzer attached to dialysis machine. The tip of the inserted catheter was fixed to the center of the silicone tube, and 3 L of pig blood was poured into the blood side of the dialyzer and the recirculation rates were measured at blood flow rates of 100, 150, and 200 mL/min. Five types of commercially available catheters were used: (A) Argyle™, (B) Gentle Cath™ (Hardness gradient type), (C) Gentle Cath™, (D) Niagara™, and (E) Power-Trialysis®.

RESULTS

In the case of reverse connection mode, (1) the recirculation rates were lower in the catheter with a relatively large side hole (catheter C, 17%), catheters with a greater distance between the end hole and side hole (catheters C and D, 25%), and catheter with a symmetrical tip structure (catheter E, 10%) as compared with those in catheters A and B (40% and 25%); (2) increase of the blood flow rate in the dialysis machine was associated with a reduced recirculation rate; and (3) a wider inner diameter of the mock blood vessel and faster flow rate in the vessel were associated with a reduced recirculation rate.

CONCLUSION

The lowest recirculation was observed with the catheter with symmetrical holes, which produces a helical blood flow line that does not intersect with the blood streamline flowing out to the blood supply hole.

Using root cause analysis as a tool to reduce central venous catheters in haemodialysis patients

BACKGROUND

Haemodialysis remains the most common modality of renal replacement therapy. National and international guidelines continue to promote arteriovenous fistulas or grafts as the preferred vascular access for haemodialysis, given the increased risks associated with use of central venous catheters (CVCs). Our renal centre pursues a 'fistula first' culture and uses root cause analysis and a patient safety incident based approach to meet the recommended standards of minimal CVC use in dialysis patients.

METHODS

We undertook a retrospective observational review looking at patterns of CVC use amongst our patients to identify themes and changes over time. Using data collected over a 5 year period, we examined 100 patient safety incidents involving CVC use in planned haemodialysis patients. We used a contributory factors framework to identify systemic contributors to each incident.

RESULTS

During the study period our centre achieved the national standard of at least 60% of incident dialysis patients commencing planned haemodialysis via arteriovenous access. About 26% of cases of CVC use in incident dialysis patients were deemed potentially avoidable. The most common contributory factor identified in these cases was poor communication.

CONCLUSIONS

Using a root cause analysis based methodology to examine CVC use in haemodialysis is a novel approach to quality improvement in this area. Our methodology can be used as a framework by other centres to optimise the provision of safe, effective, and timely vascular access for dialysis, with multiple benefits for both renal services and individual patients.

The impact of vascular access type on survival in haemodialysis: time for a paradigm shift? A prospective cohort study

INTRODUCTION

Although arteriovenous autologous fistula is the vascular access of choice due to better long-term outcome than central venous catheters, the use of central venous catheters is increasing. Our study aims to describe the survival and epidemiological features of a cohort of dialysis patients with a focus on the role of vascular access.

METHODS

Our study comprises a follow-up period from 2001 to 2020 in a single center. Descriptive analysis was performed on baseline data. Moreover, we analysed predictive variables of death with univariable and multivariable logistic regressions. Predictors of survival were analysed by univariable and multivariable Cox regression.

RESULTS

Our analysis includes 754 patients undergoing chronic haemodialysis. In the multivariable logistic regression, the use of tunnelled catheters resulted protective against death from any cause (Odds Ratio 0.43; p = 0.017). In the multivariable Cox analysis, being "late referral" was associated with decreased survival in the first 6 months since haemodialysis start (Hazard Ratio 3.79; p = 0.001). In the subgroup of elderly (age ≥ 75 years) patients (n = 201/472) with a follow up of 7-60 months, multivariable logistic regression showed that tunnelled catheters at the start of haemodialysis were associated with lower mortality (Odds Ratio, 0.25; p = 0.021), whereas vascular disease was found to be the main risk factor for death (Odds Ratio, 5.11; p = 0.000). Moreover, vascular disease was confirmed as the only independent risk factor by Cox analysis (Hazard Ratio, 1.58; p = 0.017).

CONCLUSIONS

In our cohort, mortality was found to be more closely associated with comorbidities than with the type of vascular access. Tunnelled central venous catheters might be a viable option for haemodialysis patients.

Smoking is associated with a higher complication and failure rate in arteriovenous grafts for haemodialysis: A multi-centre experience

INTRODUCTION

Arteriovenous grafts (AVG) for haemodialysis (HD) access are recommended as a second line modality due to higher morbidity and mortality rates than arteriovenous fistulae (AVF). Smoking is already established as a risk factor in lower extremity bypass graft failure used for peripheral vascular disease, but its effect on AVGs remains unclear. We aimed to investigate the relationship of smoking on AVG outcomes.

METHODS

A 3 year (01/08/2015-01/08/2018) multi-centre retrospective study was carried out on patients receiving an AVG for HD. Data included patient demographics, medical history, operation, type of graft, postoperative course and primary and secondary patency rates. Statistical analyses performed were Kaplan-Meier curves and Cox's proportional hazard regression.

RESULTS

Fifty-five AVGs were performed (1052 AVF performed) in this period. The most common complication was thrombosis (38.9%). Primary patency at 6, 12 and 24 months were 55%, 45% and 44% respectively. Secondary patency at 6, 12 and 24 months were 63%, 56% and 54% respectively. Smoking was found to be a poor prognostic factor for primary (HR 3.734 (1.818-7.668 95% CI) p < 0.001) and secondary patency (HR 6.238 (2.729-14.257) p < 0.001). Smoking was also significantly associated with graft thrombosis (HR 5.741 (2.380-13.848 95% CI) p < 0.001).

DISCUSSION

Primary patency rates are lower than previous reports whilst secondary patency is equivalent. Smoking results in a greater risk of thrombosis and poorer primary and secondary patency. This is recognised in vascular surgical grafts, but has not been previously described in AVGs for HD access. Smoking is a modifiable risk factor and as AVGs are typically used for end-stage vascular access patients. Pre-operative strategies to promote smoking cessation, including patient education and prehabilitation should be employed to improve outcomes.

Does temporary transfer to preoperative hemodialysis influence postoperative outcomes in patients on peritoneal dialysis? A retrospective cohort study

Background

The associations between preoperative transfer to hemodialysis (HD) and postoperative outcomes in patients on chronic peritoneal dialysis (PD) remain unknown. We conducted this retrospective cohort study to investigate whether preoperative HD could influence surgical outcomes in PD patients undergoing major surgeries.

Methods

All chronic PD patients who underwent major surgeries from January 1, 2007, to December 31, 2020, at Peking University First Hospital were screened. Major surgery was defined as surgical procedures under general, lumbar or epidural anesthesia, with more than an overnight hospital stay. Patients under the age of 18, with a dialysis duration of less than 3 months, and those who underwent renal implantation surgeries and procedures exclusively aimed at placing or removing PD catheters were excluded. Patients involved were divided into either HD or PD group based on their preoperative dialysis status for further analysis.

Results

Of 105 PD patients enrolled, 65 continued PD, and 40 switched to HD preoperatively. Patients with preoperative HD were significantly more likely to develop postoperative hyperkalemia. The total complication rates were numerically higher in patients undergoing preoperative HD. After adjustment, the incidence of postoperative hyperkalemia or any other postoperative complication rates were similar between groups. There were no differences in long-term survival between the two groups.

Conclusions

It does not seem indispensable for PD patients to switch to temporary HD before major surgeries.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Shared decision-making in hemodialysis vascular access practice

Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.

Provision of Kidney Disease Education Service Is Associated with Improved Vascular Access Outcomes among US Incident Hemodialysis Patients

Background

Pre-ESKD Kidney Disease Education (KDE) has been shown to improve multiple CKD outcomes, but its effect on vascular access outcomes is not well studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD.

Methods

In this retrospective USRDS analysis, we identified all adult patients on incident hemodialysis with ≥6 months of pre-ESKD Medicare coverage during the first 5 years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE cohort) and nonrecipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1, KDE alone; model 2, multivariate model encompassing model 1 with sociodemographics; model 3, model 2 with comorbidity and functional status; and model 4, model 3 with pre-ESKD nephrology care).

Results

Of the 211,990 qualifying patients on incident hemodialysis during the study period, 2887 (1%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (30% and 35%, respectively, compared with 14% and 17%), and pure catheter use about a third lower (40% compared with 65%) in the KDE cohort compared with the non-KDE cohort. The maximally adjusted odds ratios in model 4 for study outcomes were incident AVF use, 1.78, 99% confidence interval, 1.55 to 2.05; incident AVF/AVG use, 1.78, 99% confidence interval, 1.56 to 2.03; incident CVC with maturing AVF/AVG, 1.69, 99% confidence interval, 1.44 to 1.97; and pure CVC without any AVF/AVG, 0.51, 99% confidence interval, 0.45 to 0.58. The benefits of the KDE service were maintained even after accounting for the presence, duration, and facility of ESKD care.

Conclusion

The occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the effect of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.

Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates

Importance

National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned.

Objective

To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study.

Design, Setting, and Participants

The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants.

Interventions

All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation.

Main Outcomes and Measures

In this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis.

Results

Most participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications.

Conclusions and Relevance

The findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.

A novel technique using long segment patch angioplasty maturation to increase the maturation rate of arteriovenous fistulas

OBJECTIVE

Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation.

METHODS

We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates.

RESULTS

From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months.

CONCLUSIONS

Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.

Mid-term results of tunneled brachial venous hemodialysis catheter placement: Our single-center experience with 21 patients

Background

This study aims to analyze the safety and efficacy of permanent hemodialysis catheter insertion via the brachial vein in unsuitable patients for catheter insertion from other vascular access sites.

Methods

A total of 21 patients (6 males, 18 females; mean age: 54.4±11.3 years; range, 48 to 77 years) who underwent permanent hemodialysis catheter insertion via the brachial vein between February 2019 and February 2020 were retrospectively analyzed. All patients underwent brachial venous tunneled catheter insertion under the ultrasound guidance and under local anesthesia. Transthoracic echocardiography was performed before and six months after catheter insertion. The primary patency rate of the catheter at six months of follow-up, potential associated complications of a permanent hemodialysis catheter including catheter thrombosis and catheter infections, and all-cause mortality rates were recorded.

Results

Catheter removal was required in eight patients (catheter thrombosis, n=5; catheter infection, n=2; and extensive hematoma, n=1). The catheters were patent in the remaining 13 (62%) patients at six months. Mortality occurred in one patient due to bacterial pneumonia. No life-threatening complications including hemothorax or pneumothorax and neurological injury was observed in any of the patients.

Conclusion

Our study results show that brachial venous tunneled catheter placement for hemodialysis can be a safe and valid alternative to catheter insertion from the jugular or subclavian veins for vascular access in patients with end-stage renal disease.

Challenges and novel therapies for vascular access in haemodialysis

Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.

Novel Approaches to Arteriovenous Access Creation, Maturation, Suitability, and Durability for Dialysis

Since the arteriovenous fistula (AVF) was first conceived over 50 years ago, the goal to create a vascular conduit with predictable and reproducible maturation and durability continues to elude caregivers. Recently, however, advances in the understanding of vascular biology and new technologies now provides us with some optimism; we are moving toward a viable solution. A quickly maturing, sustainable, and durable arteriovenous access may soon be attainable. This review will discuss these advances. There are novel approaches to AVF creation and devices to enhance maturation, advances in arteriovenous graft material(s), and devices to safely prolong the use of tunneled dialysis catheters. Although hemodialysis (HD) access remains a complex problem, these innovations may lead the way to optimizing the care and the quality of life of those patients who have no choice but to proceed with HD.

Perspectives in Individualizing Solutions for Dialysis Access

The vascular access is the lifeline for the hemodialysis patient. Previous national vascular access guidelines have emphasized placement of arteriovenous fistulas in most hemodialysis patients. However, the new Kidney Disease Outcomes Quality Initiative guidelines for vascular access, soon to be published, will focus on a patient's end-stage kidney disease "life plan" and take a patient "first" approach. One of the major themes of the new Kidney Disease Outcomes Quality Initiative guidelines is selecting the "right access, for the right patient, at the right time, for the right reason". Given the availability of new advances in biomedical technologies, techniques, and devices in the vascular access field, this shift to a more patient-centered vascular access approach presents unique opportunities to individualize the solutions and care for patients requiring a dialysis vascular access. This review article will address 3 potential areas where there is an unmet need to individualize solutions for dialysis vascular access care: (1) biological approaches to improve vascular access selection and selection of therapies, (2) vascular access care for the post-transplant patient, and (3) vascular access disparities in race, gender, and the elderly patient.

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

BACKGROUND

Several studies report lower costs associated with attaining and maintaining patency for arteriovenous (AV) fistulas as compared to AV grafts among patients receiving hemodialysis. However, these costs may vary according to the AV access's risk of failure to mature (FTM). The aim of this study was to examine the effect of AV access type and risk of FTM on the total costs of attaining and maintaining AV access patency over 1, 3, and 5 years postcreation, among incident accesses.

METHODS

All first AV access creations (January 1, 2002-January 1, 2018), revisions/resections, and interventions from a single academic institution were prospectively captured. The units costs (from 2011 in CA$) were estimated primarily through the provincial patient Ontario Case Costing Initiative database. The present value of total vascular access-related costs from a third-party payer perspective was calculated by multiplying specific unit costs by the number of AV access creations, revisions/resections, and interventions from the date of creation to 1, 3, and 5 years post creation. The potential associations of AV access type and FTM risk stratum with AV access cost were examined using log-linear models and generalized estimating equations.

RESULTS

A total of 906 patients were included in the study, of which 696 had fistulas and 210 had grafts. The median present value of total costs to attain and maintain AV access over 1, 3, and 5 years was positively associated with the highest FTM risk stratum in all models. It was not associated with AV access type when the interaction between AV access type and FTM risk stratum was considered.

CONCLUSIONS

The costs of attaining and maintaining AV access were increased among patients with high/very high FTM risk. Risk of FTM, related interventions, and costs should be considered when choosing vascular access type for an individual patient.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Surgeon Characteristics and Dialysis Vascular Access Outcomes in the United States: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

An arteriovenous fistula (AVF) is the preferred access for most patients receiving maintenance hemodialysis, but maturation failure remains a challenge. Surgeon characteristics have been proposed as contributors to AVF success. We examined variation in AVF placement and AVF outcomes by surgeon and surgeon characteristics.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

National Medicare claims and web-based data submitted by dialysis facilities on maintenance hemodialysis patients from 2009 through 2015.

EXPOSURES

Patient characteristics, including demographics and comorbid conditions; surgeon characteristics, including specialty, prior volume of AVF placements, and years since medical school graduation.

OUTCOMES

Percent of access placements that were an AVF from 2009 to 2015 (designated AVF placement), and percent of AVFs with successful use within 6 months of placement (maturation) from 2013 to 2014.

ANALYTICAL APPROACH

Multilevel logistic regression models examining the association of surgeon characteristics with the outcomes, adjusted for patient characteristics and dialysis facilities as random effects.

RESULTS

Among 4,959 surgeons placing 467,827 accesses, median AVF placement was 71% (IQR, 59%-84%). More recent year of medical school graduation and general surgery specialty (vs vascular, cardiothoracic, or transplantation surgery) were associated with higher odds of AVF placement. Among 2,770 surgeons placing 49,826 AVFs, the median AVF maturation rate was 59% (IQR, 44%-71%). More recent year of medical school graduation, but not surgical specialty, was associated with higher odds of AVF maturation. Greater prior volume of AVF placement was associated with higher odds of AVF maturation: OR of 1.46 (95% CI, 1.37-1.57) for highest (>84 AVF placements in 2years) versus lowest (<14) volume quintile.

LIMITATIONS

The study relied on administrative data, limiting capture of some factors affecting access outcomes.

CONCLUSIONS

There is substantial surgeon-level variation in AVF placements and AVF maturation. Surgeons' prior volume of AVF placements is strongly associated with AVF maturation.

Maturing arteriovenous accesses in incident haemodialysis patients and first-year outcomes

INTRODUCTION

Nephrologists have increased arteriovenous access placement in patients with chronic kidney disease. Not yet usable 'maturing' arteriovenous fistulas and grafts are nearly as common as mature arteriovenous fistulas or grafts. Little has been reported about patients initiating haemodialysis with unready arteriovenous fistulas or grafts.

METHODS

The United States Renal Data System records for all adult patients initiating haemodialysis with central venous catheters between July 2010 and December 2011. Patients were categorized by whether a maturing arteriovenous fistula or graft was present. Transition to working arteriovenous fistula or graft was determined from linked Medicare claims. Modality changes and survival were ascertained. A logistic model for one-year survival and a subdistribution hazards model for transition to working arteriovenous fistula or graft, accounting for the competing risk of death, were constructed.

RESULTS

Compared to central venous catheter-only, maturing arteriovenous fistula or graft was associated with access conversion (hazard ratio = 2.23 (2.17-2.30) and 3.25 (2.97-3.56), respectively, p < 0.001 for both). Median time to conversion, among those who transitioned, was 95 days (interquartile range = 56-139) for patients with a maturing arteriovenous graft and 135 days (98-198) with a maturing arteriovenous fistula, versus 193 days (138-256) with central venous catheter-only. Pre-dialysis nephrology care, male sex and non-Caucasian race were associated with access conversion. Patients without a maturing arteriovenous fistula or graft had decreased odds of one-year survival (odds ratio = 0.61 (0.58-0.66), p < 0.001), which attenuated with adjustment for access conversion (adjusted odds ratio = 1.06 (0.98-1.13), p = 0.2).

CONCLUSION

Maturing arteriovenous fistulas or grafts were associated with enhanced first-year survival and increased opportunity for working arteriovenous fistulas or grafts, which may reflect pre-dialysis decision-making, quality of care and comorbid diseases. Central venous catheter exposure was substantial, even among patients with maturing access. Contributory factors prolonging conversion to arteriovenous access need to be identified and addressed.

Hemodialysis vascular access in the elderly-getting it right

Choosing the optimal hemodialysis vascular access for the elderly patient is best achieved by a patient-centered coordinated multidisciplinary team approach that aligns the patient's end-stage kidney disease Life-Plan, i.e., the individual treatment approach (supportive care, time-limited or long-term kidney replacement therapy, or combination thereof) and selection of dialysis modality (peritoneal dialysis versus hemodialysis) with the most suitable dialysis access. Finding the right balance between the patient's preferences, the likelihood of access function and survival, and potential complications in the context of available resources and limited patient survival can be extremely challenging. The framework for choosing the most appropriate vascular access for the elderly presented in this review considers the individual end-stage kidney disease Life-Plan, the patient life expectancy, the likelihood of access function and survival, the timing of dialysis relative to access placement, prior access history, and patient preference. This complex decision-making process should be dynamic in order to accommodate patients' changing needs and life and health circumstances. Effective and timely communication between the patient, their caregivers, and treating team is key to delivering truly patient-centered care. Delivering this care also requires overcoming the limitations of the currently available evidence that is predominantly based on observational data with its inherent risks of bias. While challenging, future randomized controlled studies exploring the risks, benefits, costs, and timing of placement of available access types in the elderly are required to help us "get it right" for our patients.

Hemodialysis vascular accesses in patients on chronic hemodialysis at the Kenyatta National Hospital in Kenya

INTRODUCTION

The objective of our study was to document the level of preparedness for renal replacement therapy assessed by incident hemodialysis vascular access and the access at least 3 months after initiation of hemodialysis at Kenyatta National Hospital, Nairobi.

METHODS

Between June and July 2018, we carried out a cross-sectional descriptive study on the preparedness for hemodialysis by patients who were on chronic hemodialysis in the Kenyatta National Hospital Renal Department. Sociodemographic, medical history, duration of follow-up, and state of preparedness parameters were obtained through interview and entered into the questionnaire. The data were entered in preprogrammed format in the Statistical Package for the Social Sciences (SPSS) version 20.0 for analyses.

RESULTS

Eighty-two patients were enrolled. Males were 50% (41). The mean age was 45.39 ± 15.96 years but females were 5 years younger than their male counterparts. About 85.4% of the patients were drawn from the hypertension and diabetes clinics, and the mean, mode, and median of the duration of follow-up were 41, 0, and 0 months, respectively, in these clinics. Almost three in every four patients (74.4%) were initiated on hemodialysis as emergency (p value < 0.001). About 80% were initiated hemodialysis via acute catheters placed in the jugular and subclavian veins (p value < 0.001). At least 3 months later, 40% still had acute catheters on the same veins (p value < 0.001). Acute venous catheters in the femoral veins were in 9.2% at initiation and 6.6% of the patients at least 3 months later. Less than 2% of the patients had arteriovenous fistulae at initiation, which rose to 14.5% in 3 months. Tunneled catheters were placed in 11.8% initially and at least 3 months, were almost in 40% of the patients.

CONCLUSION

In conclusion, our young hemodialysis population mainly drawn from hypertension and diabetes clinic requires more input in hemodialysis vascular access planning. Focused individualized follow-up and early referrals to nephrologists are required. Uptake of arteriovenous grafts for hemodialysis might reduce the prevalence of hemodialysis catheters. As it is, this population is threatened with iterative vascular accesses complications as well as real danger of exhaustion of their vascular capital. There is real danger of increase in mortality from access complications.

Clinical and Regulatory Considerations for Central Venous Catheters for Hemodialysis

Central venous catheters remain a vital option for access for patients receiving maintenance hemodialysis. There are many important and evolving clinical and regulatory considerations for all stakeholders for these devices. Innovation and transparent and comprehensive regulatory review of these devices is essential to stimulate innovation to help promote better outcomes for patients receiving maintenance hemodialysis. A workgroup that included representatives from academia, industry, and the US Food and Drug Administration was convened to identify the major design considerations and clinical and regulatory challenges of central venous catheters for hemodialysis. Our intent is to foster improved understanding of these devices and provide the foundation for strategies to foster innovation of these devices.

Disruptive technological advances in vascular access for dialysis: an overview

End-stage kidney disease (ESKD), one of the most prevalent diseases in the world and with increasing incidence, is associated with significant morbidity and mortality. Current available modes of renal replacement therapy (RRT) include dialysis and renal transplantation. Though renal transplantation is the preferred and ideal mode of RRT, this modality may not be available to all patients with ESKD. Moreover, renal transplant recipients are constantly at risk of complications associated with immunosuppression and immunosuppressant use, and posttransplant lymphoproliferative disorder. Dialysis may be the only available modality in certain patients. However, dialysis has its limitations, which include issues associated with lack of vascular access, risks of infections and vascular thrombosis, decreased quality of life, and absence of biosynthetic functions of the kidney. In particular, the creation and maintenance of hemodialysis vascular access in children poses a unique set of challenges to the pediatric nephrologist owing to the smaller vessel diameters and vascular hyperreactivity compared with adult patients. Vascular access issues continue to be one of the major limiting factors prohibiting the delivery of adequate dialysis in ESKD patients and is the Achilles' heel of hemodialysis. This review aims to provide a critical overview of disruptive technological advances and innovations for vascular access. Novel strategies in preventing neointimal hyperplasia, novel bioengineered products, grafts and devices for vascular access will be discussed. The potential impact of these solutions on improving the morbidity encountered by dialysis patients will also be examined.

Arteriovenous Fistulae vs. Arteriovenous Grafts: A Retrospective Review of 1,700 Consecutive Vascular access Cases

Objective

Vascular access (VA) procedures are rapidly becoming the most prevalent surgery in the United States. It is estimated that there will be over 500,000 VA procedures done this year. Previously, surgeons in the US were attempting many more non-autogenous grafts than autogenous fistulae. In recent years, there has been a great push called “Fistula First” to promote arteriovenous fistulae (AVF) as the first line of treatment vs. non-autogenous grafts. The goal of this investigation is to determine if too many fistulae are now being performed without attention to specific patient profiles.

Methods

A retrospective review of 1700 consecutive cases was performed by one surgeon at one institution between 1997 and 2005. Patients were categorized by demographics, co-morbidities, previous access procedures, access location, and type of graft. Patency was calculated. Kaplan-Meier, Cox regression and the Log Rank Test were used to analyze data. Access endpoints and complications were also documented.

Results

The study reviewed 1700 procedures. The median age was 52 (60.2% male) with 58.7% fistulae and 41.3% grafts. Median patency time was 10 months, with no statistically significant difference between access types. There was no significant difference in length of patency when comparing upper arm (70.1%), lower arm (24.5%) and thigh (5.4%). Graft infection rate was 9.5% and fistula infection rate was 0.9% (p<0.001). The overall infection rate was 4.5%, and decreased patency significantly (4 vs. 11 months). Thrombosis occurred in 24.7% of grafts and 9.0% of fistulae. Thrombosed grafts had better salvage rates (8 vs. 4 months, p<0.001). The data showed diabetes, HTN and HIV have no overall impact on patency.

Conclusions

AVF and grafts are both useful in providing VA for patients requiring hemodialysis. Our data shows that grafts are equivalent in long-term patency. Therefore, it is apparent in those patients who are not candidates for an AV fistula; an AV graft for VA should be placed.

Graft for Immediate use as First Stage of a Native Fistula

The majority of patients in the United States begin hemodialysis with a catheter. Many have immature or inadequate fistulae. At 90 days 77% of these patients are still using a catheter or a graft. The morbidity and mortality from prolonged catheter use have been well delineated. Although most of us adhere to the DOQI and Fistula First tenets, a fistula at all costs can seem counterproductive. A new paradigm is needed. The techniques described in this paper offer a novel approach to circumvent the problems of increasing catheter use and long fistula maturation times. The graft for immediate use is placed in the forearm and allows the proximal vessels to mature while providing dialysis access without a catheter. When these vessels meet maturation guidelines, or when surveillance indicates impending graft failure, a native fistula can be constructed and used in a 2–3 week period. This approach minimizes or circumvents catheter use altogether.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients

OBJECTIVE

Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65-79 years, >80 years) to determine whether protocols should be modified to account for advanced age.

METHODS

All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan-Meier survival and Cox hazards models were used to compare access patency and risk factors for failure.

RESULTS

There were 941 autogenous arteriovenous accesses (median follow-up, 23 months; range, 0-89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss.

CONCLUSIONS

Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.

Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy

BACKGROUND AND OBJECTIVES

Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates.

RESULTS

We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively.

CONCLUSION

Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.

Central venous catheters for chronic hemodialysis: Is "last choice" never the "right choice"?

Since the publication of the first vascular access clinical practice guidelines in 1997, the global nephrology community has dedicated significant time and resources toward increasing the prevalence of arteriovenous fistulas and decreasing the prevalence of central venous catheters for hemodialysis. These efforts have been bolstered by observational studies showing an association between catheter use and increased patient morbidity and mortality. To date, however, no randomized comparisons of the outcomes of different forms of vascular access have been conducted. There is mounting evidence that much of the difference in patient outcomes may be explained by patient factors, rather than choice of vascular access. Some have called into question the appropriateness of fistula creation for certain patient populations, such as those with limited life expectancy and those at high risk of fistula-related complications. In this review, we explore the extent to which catheters and fistulas exhibit the characteristics of the "ideal" vascular access and highlight the significant knowledge gaps that exist in the current literature. Further studies, ideally randomized comparisons of different forms of vascular access, are required to better inform shared decision making.

The Burden of Tunneled Central Venous Catheters for Hemodialysis in a County Hospital

Prolonged use of central venous catheters (CVCs) for hemodialysis (HD) is associated with greater morbidity and mortality when compared with autogenous arteriovenous fistulas (AVF). The objective was to assess compliance with CVC guidelines in adults referred for hemoaccess at a county teaching hospital. Out of 256 patients, 172 (67.2%) were male, with a mean age of 50.0 ± 12.4 years. Overall 62.5 per cent initiated dialysis via CVC. Patients were divided into two groups (those with CVC (62.5%) and those without (37.5%)). Male gender was associated with initiation of dialysis via CVC versus no CVC (72.5 vs 58.3%, P = 0.02), as was a history of prior vascular access (P < 0.01). There were no significant differences between the groups regarding age, diabetes, smoking, ambulatory status, or insurance status. There were no differences in gender, age, insurance status, or prior vascular access between prolonged CVC use (≥90 days) and short-term CVC use (<90 days). We conclude that most patients initiated HD with CVC and exceed the recommended CVC duration. Men are more likely to initiate HD via CVC. Insurance status was not associated with CVC use. Multidisciplinary action may address barriers to reducing CVC duration.

A prospective comparison of the performance and survival of two different tunnelled haemodialysis catheters: SplitCath® versus DuraMax®

BACKGROUND

Despite their well-recognised shortcomings, haemodialysis catheters (HDCs) remain an important form of haemodialysis access for many patients. There are several HDCs commercially available, each differing considerably in design, which is known to significantly influence performance and survival. We sought to determine which of two tunnelled HDCs, DuraMax® (Angiodynamics, NY, USA) or SplitCath® (MedComp, PA, USA) delivers the best performance, safety and reliability for dialysis patients.

METHODS

Eighty-six patients were prospectively randomised to receive either DuraMax® (DM) or SplitCath® (SC). Outcomes included: (i) mean flow rates (mL/min) averaged over the first 10 weeks of dialysis, and urea reduction ratio (URR); and (ii) long-term catheter survival with appraisal of any events leading to catheter dysfunction and early removal.

RESULTS

Median flow rates (interquartile range) in the DM and SC groups were 321 (309-343) and 309 (294-322) mL/min, respectively (p = 0.002). URR values for the DM and SC groups were 71 (65-76) and 74 (70-78), respectively, (p = 0.094). There was no significant difference in long-term survival or frequency of incidents that required early HDC removal (9/43 in the DM group, 5/43 patients SC). A slightly higher incidence of HDC dislodgement was noted in the DM group, although this study was not statistically powered to determine its significance.

CONCLUSIONS

We conclude that DM yields slightly higher flow rates in the first 10 weeks of dialysis, and a similar low incidence of complications and long-term survival for both DM and SC HDCs.

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.

Does antimicrobial lock solution reduce catheter-related infections in hemodialysis patients with central venous catheters? A Bayesian network meta-analysis

PURPOSE

The purpose of our study is to carry out a Bayesian network meta-analysis comparing the efficacy of different antimicrobial lock solutions (ALS) for prevention of catheter-related infections (CRI) in patients with hemodialysis (HD) and ranking these ALS for practical consideration.

METHODS

We searched six electronic databases, earlier relevant meta-analysis and reference lists of included studies for randomized controlled trials (RCTs) that compared ALS for preventing episodes of CRI in patients with HD either head-to-head or against control interventions using non-ALS. Two authors independently assessed the methodological quality of included studies using the Cochrane risk of bias tool and extracted relevant information according to a predesigned extraction form. Data were analysed using the WinBUGS (V.1.4.3) and the Stata (V.13.0).

RESULTS

Finally, 18 studies involving 2395 patients and evaluating 9 ALS strategies were included. Network meta-analysis showed that gentamicin plus citrate (OR 0.07, 95% CrI 0.00-0.48) and gentamicin plus heparin (OR 0.04, 95% CrI 0.00-0.23) were statistically superior to heparin alone in terms of reducing CRBSI. For exit site infection and all-cause mortality, no significant difference in the intervention effect (p > 0.05) was detected for all included ALS when compared to heparin. Moreover, all ALS were similar in efficacy (p > 0.05) from each other for CRBSI, exit site infection and all-cause mortality.

CONCLUSIONS

Our findings indicated that gentamicin plus heparin may be selected for the prophylaxis of CRI in patients undergoing HD with CVCs. Whether this strategy will lead to antimicrobial resistance remains unclear in view of the relatively short duration of included studies. More attentions should be made regarding head-to-head comparisons of the most commonly used ALS in this field.

Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?

There are substantial variations in arteriovenous fistula (AVF) use among hemodialysis patients in different countries, in different regions of the U.S., and even in different hemodialysis units within a single metropolitan area. These variations persist after adjustment for patient demographics and comorbidities, suggesting that practice patterns play a major role in determining the frequency of AVF use. These observations led to vascular access guidelines urging nephrologists and surgeons to increase AVF creation in patients with chronic kidney disease. Over the past 20 years, as clinicians have adopted these guidelines, the prevalence of AVF use in hemodialysis patients has increased substantially. At the same time, clinicians have recognized important limitations of an unwavering "Fistula First" approach. First, a substantial proportion of AVFs fail to mature even when routine preoperative vascular mapping is used, leading to prolonged catheter dependence. Second, certain patient subgroups are at high risk for AVF nonmaturation. Third, nonmaturing AVFs frequently require interventions to promote their maturation. Fourth, AVFs that require such interventions have shortened cumulative patency. Fifth, arteriovenous grafts (AVG) have several advantages over AVFs, including lower primary failure rates, fewer interventions prior to successful cannulation, and shorter duration of catheter dependence with its associated risk of bacteremia. All these observations have led nephrologists to propose an individualized approach to vascular access, with AVG being preferred in patients who initiate hemodialysis with a catheter, particularly if they are at high risk for AVF nonmaturation and have a relatively short life expectancy.

The Survival Benefit of "Fistula First, Catheter Last" in Hemodialysis Is Primarily Due to Patient Factors

Patients needing hemodialysis are advised to have arteriovenous fistulas rather than catheters because of significantly lower mortality rates. However, disparities in fistula placement raise the possibility that patient factors have a role in this apparent mortality benefit. We derived a cohort of 115,425 patients on incident hemodialysis ≥67 years old from the US Renal Data System with linked Medicare claims to identify the first predialysis vascular access placed. We compared mortality outcomes in patients initiating hemodialysis with a fistula placed first, a catheter after a fistula placed first failed, or a catheter placed first (n=90,517; reference group). Of 21,436 patients with a fistula placed first, 9794 initiated hemodialysis with that fistula, and 8230 initiated dialysis with a catheter after failed fistula placement. The fistula group had the lowest mortality over 58 months (hazard ratio, 0.50; 95% confidence interval, 0.48 to 0.52; P<0.001), with mortality rates at 6, 12, and 24 months after initiation of 9%, 17%, and 31%, respectively, compared with 32%, 46%, and 62%, respectively, in the catheter group. However, the group initiating hemodialysis with a catheter after failed fistula placement also had significantly lower mortality rates than the catheter group had over 58 months (hazard ratio, 0.66; 95% confidence interval, 0.64 to 0.68; P<0.001), with mortality rates of 15%, 25%, and 42% at 6, 12, and 24 months, respectively. Thus, patient factors affecting fistula placement, even when patients are hemodialyzed with a catheter instead, may explain at least two thirds of the mortality benefit observed in patients with a fistula.

Interventions for Failed Wrist Fistulae: Is it Worthwhile?

A well-functioning forearm fistula is considered as the most suitable access for dialysis. It is easy to construct, has the fewest number of complications and lasts for a long time. Many patients fail to enjoy this benefit due to the high rates of thrombosis and the failure to mature associated with this procedure. Attempts to salvage failed and failing fistula suggest that there is a group of patients where interventions can help provide this benefit. This article provides a brief review of current experience using surgical and interventional techniques to salvage failing forearm fistulae. It attempts to classify modes of presentation of access failure and different modalities used to salvage them. It also suggests an algorithm that can be used to identify patients who may benefit from these interventions and a guide to make the decisions related to selection of a treatment modality. Successful salvage of a failing forearm fistula provides the patient with an opportunity to enjoy all the benefits of this access.

Conversion from temporary to tunneled catheters by nephrologists: report of a single-center experience

Background

Nephrologists have increasingly participated in the conversion from temporary catheters (TC) to tunneled-cuffed catheters (TCCs) for hemodialysis.

Objective

To prospectively analyze the outcomes associated with TCC placement by nephrologists with expertise in such procedure, in different time periods at the same center. The impact of vancomycin or cefazolin as prophylactic antibiotics on the infection outcomes was also tested.

Patients and methods

Hemodialysis patients who presented to such procedure were divided into two cohorts: A (from 2004 to 2008) and B (from 2013 to 2015). Time from TC to TCC conversion, prophylactic antibiotics, and reasons for TCC removal were evaluated.

Results

One hundred and thirty patients were included in cohort A and 228 in cohort B. Sex, age, and follow-up time were similar between cohorts. Median time from TC to TCC conversion was longer in cohort A than in cohort B (14 [3; 30] vs 4 [1; 8] days, respectively; P⩽0.0001). Infection leading to catheter removal occurred in 26.4% vs 18.9% of procedures in cohorts A and B, respectively, and infection rate was 0.93 vs 0.73 infections per 1,000 catheter-days, respectively (P=0.092). Infection within 30 days from the procedure occurred in 1.4% of overall cohort. No differences were observed when comparing vancomycin and cefazolin as prophylactic antibiotics on 90-day infection-free TCC survival in a Kaplan–Meier model (log-rank = 0.188). TCC removal for low blood flow occurred in 8.9% of procedures.

Conclusion

Conversion of TC to TCC by nephrologists had overall infection, catheter patency, and complications similar to data reported in the literature. Vancomycin was not superior to cefazolin as a prophylactic antibiotic.

Epidemiology of haemodialysis catheter complications: a survey of 865 dialysis patients from 14 haemodialysis centres in Henan province in China

OBJECTIVES

To investigate the incidence rates and risk factors for catheter-related complications in different districts and populations in Henan Province in China.

DESIGN

Cross-sectional.

SETTING

Fourteen hospitals in Henan Province.

PARTICIPANTS

865 patients with renal dysfunction undergoing dialysis using catheters between October 2013 and October 2014.

MAIN OUTCOME MEASURES

The main outcome measures were complications, risk factors and patient characteristics. Catheter-related complications included catheter-related infection (catheter exit-site infection, catheter tunnel infection and catheter-related bloodstream infection), catheter dysfunction (thrombosis, catheter malposition or kinking, and fibrin shell formation) and central vein stenosis.

RESULTS

The overall incidence rate was 7.74/1000 catheter-days, affecting 38.61% of all patients, for catheter infections, 10.58/1000 catheter-days, affecting 56.65% of all patients, for catheter dysfunction, and 0.68/1000 catheter-days, affecting 8.79% of all patients, for central vein stenosis. Multivariate analysis showed that increased age, diabetes, primary educational level or below, rural residence, lack of a nephropathy visit before dialysis and pre-established permanent vascular access, not taking oral drugs to prevent catheter thrombus, lower serum albumin levels and higher ferritin levels were independently associated with catheter infections. Rural residence, not taking oral drugs to prevent thrombus, lack of an imaging examination after catheter insertion, non-tunnel catheter type, lack of medical insurance, lack of nephropathy visit before dialysis and pre-established permanent vascular access, left-sided catheter position, access via the femoral vein and lower haemoglobin level were independently associated with catheter dysfunction. Diabetes, lack of nephropathy visit before dialysis and pre-established permanent vascular access, lack of oral drugs to prevent catheter thrombus, left-sided catheter location and higher number of catheter insertions, were independently associated with central vein stenosis.

CONCLUSIONS

The rate of catheter-related complications was high in patients with end-stage renal disease in Henan Province. Our finding suggest that strategies should be implemented to decrease complication rates.

Interrupting Rivaling Access-flow with Nonsurgical Image-guided ligation: the "IRANI" Procedure

The presence of collateral veins is one of the most common causes of fistula failure to mature. The traditional approach to eliminate collateral vessel flow is coil embolization under fluoroscopy or surgical cut down and branch vessel ligation. However, both approaches are expensive and time consuming. Here, we described an image-guided nonsurgical method to ligate collateral veins. The collateral veins were ligated using Hawkins-Akins needle under ultrasound guidance. The average time for one ligation procedure was 17 minutes. There was a significant increase of blood flow in the venous outflow postligation procedure. Four weeks postprocedure ultrasound demonstrated occlusion of the target vessels. This procedure was well tolerated without major complications. In summary, the novel procedure described here offers an image-guided nonsurgical approach for collateral vein occlusion.

Effect of a Rapid Clinical Protocol to the Conversion from Central Venous Hemodialysis Catheter to Arteriovenous Access

Purpose

Evaluation of the rapid conversion protocol that includes an ambulatory dialysis access center (DAC), and a three-step clinical pathway, to the conversion rate from central venous hemodialysis (HD) catheter to functioning arteriovenous (AV) access.

Methods

Prospective data were collected on 97 consecutive catheter-dependent HD patients. DAC is defined as an ambulatory unit, able to accommodate clinic visits, ultrasound examinations, surgical, interventional and hybrid procedures. Step I: initial evaluation, vein mapping and creation of AV access. Step II: clinical evaluation in two weeks and if failure identified, secondary procedure to restore function. Step III: evaluation in four weeks after creation, and additional procedure to promote maturation if indicated. The success rate, time to conversion and time to catheter removal were recorded.

Results

From the 97 consecutive referred patients, eight patients were excluded. From the remaining 89 patients, 99% were successfully converted to AV access. Seventy-three percent of the patients were converted to native arteriovenous fistulae and 27% of the patients to prosthetic arteriovenous shunts. The median time from creation to HD catheter removal was 63 (SD 41) days. Fifty-two percent of the patients required at least one additional secondary procedure to accomplish successful conversion

Conclusions

High rates of timely conversion from catheter to AV access, primarily AV fistulae, can be accomplished within the context of the rapid conversion protocol.

Vascular access for incident hemodialysis patients in Catalonia: analysis of data from the Catalan Renal Registry (2000-2011)

Purpose

Arteriovenous fístula is the best vascular access (VA) for hemodialysis. We analyzed the VA used at first session and the factors associated with the likelihood to start hemodialysis by fistula in 2000-2011.

Methods

Data of VA type were obtained in 9,956 incident hemodialysis patients from the Catalan Registry.

Results

Overall, 47.9% of patients initiated hemodialysis with a fistula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. The percentage of incident patients with fistula and catheter has remained stable at around 50% over the years. The likelihood to start hemodialysis with fistula was significantly lower in females [adjusted odds ratio: 0.69, 95% confidence interval (CI): 0.61-0.75], patients aged 18-44 years (0.78, 95% CI: 0.64-0.94), patients with comorbidity (0.67, 95% CI: 0.60-0.75) and tended to be lower in patients aged over 74 years (0.89, 95% CI: 0.78-1.01). The probability to use fistula was significantly higher in patients with polycystic kidney disease (2.08, 95% CI: 1.63-2.67), predialysis nephrology care longer than 2 years (4.14, 95% CI: 3.63-4.73) and steady chronic kidney disease (CKD) progression (10.97, 95% CI: 8.41-14.32). During 1 year of follow-up, 67.2% and 59.6% of patients using untunneled and tunneled catheter changed to fistula, respectively.

Conclusions

Starting hemodialysis by fistula was related with nonmodifiable patient characteristics and modifiable CKD practice processes, such as predialysis care duration. Half of the incident patients were exposed annually in Catalonia to potential catheter complications. This scenario can be improved by optimizing the processes of CKD care.