Minimizing delays to hemodialysis access maturation: A quality improvement analysis

INTRODUCTION

Pre-operative process optimization can expedite time-to-intervention and reduce overall health care costs. We hypothesized that the longest delay to hemodialysis (HD) access creation would be from pre-operative vessel mapping (mandatory in our practice), and that this would be correlated with increased catheter days.

METHODS

One hundred thirty patients (24 inpatients, 106 outpatients) who received initial hemodialysis (HD) access from 01/01/2017 to 12/31/2021, at the Veterans Affairs Puget Sound, Seattle, Washington, were identified. Median time differences between pre-operative events were compared between inpatients and outpatients using the Mann-Whitney U test. Outpatients were then stratified by time of catheter-based HD initiation (no catheter, pre-referral catheter, post-referral catheter) and compared. The impacts of mapping-related delays on catheter use were evaluated using regression.

RESULTS

Inpatients had shorter referral to access maturation times (125 days inpatient vs 146 days outpatient; p = 0.03). This was driven by shorter referral to mapping (2 days inpatient vs 27 days outpatient; p < 0.01) and mapping to pre-surgical evaluation (1-day inpatient vs 6 days outpatients; p < 0.01) times. Pre-surgical evaluation to OR times represented the longest pre-operative delay in both groups (51 days inpatient vs 29 days outpatient; p = 0.59). Among outpatients, tunneled catheter placement post-referral resulted in longer maturation times (74 days no catheter vs 67 days pre-referral vs 149 days post-referral; p < 0.01) but not additional pre-operative delays. No trend existed between increased mapping times and catheter-based dialysis duration (R2 = 0.08).

CONCLUSION

Preoperative vein mapping contributed up to 21% of referral to maturation times but was not associated with increased tunneled catheter duration. While tunneled catheter placement impacted access maturation it did not cause additional pre-operative delays. Earlier referrals for access creation and reduction of outpatient wait-time from referral to OR and increased AV graft placement may minimize catheter days in our system thereby mitigating the added delays caused by pre-operative vein mapping.

Application Value and Relevance Analysis of the Risk Evaluation System for Arteriovenous Fistula Puncture in Thrombosis after Puncture

Objective

To analyze the application value and relevance of risk evaluation system for arteriovenous fistula (AVF) puncture in thrombosis after puncture.

Methods

The clinical data of 180 patients treated with hemodialysis in the hemodialysis center of our hospital from November 2017 to November 2019 were retrospectively analyzed. After puncture, all patients received the digital subtraction angiography (DSA) examination, and based on whether they had AVF thrombosis, they were divided into the nonthrombosis group (n = 102) and thrombosis group (n = 78), and then, according to the parity of their admission numbers, the patients in the thrombosis group were subdivided into the study group (n = 39) and the reference group (n = 39), so as to analyze the risk factors of thrombosis after AVF puncture and the application value of the risk evaluation system for AVF puncture in preventing and treating thrombosis.

Results

Compared with the reference group after intervention, the study group had significantly higher mean internal fistula blood flow volume (P < 0.001) and significantly lower total incidence rate of vascular complications in fistulas (P < 0.05); according to the multifactor binary logistic regression analysis, it was found that diabetes, systolic blood pressure reduction, hemoglobin, low-density lipoprotein cholesterol (LDL-C), ultrafiltration rate, and elevation of blood phosphorus and platelet levels were the risk factors of thrombosis after AVF puncture in hemodialysis patients.

Conclusion

When risk factors of thrombosis are found in patients treated with hemodialysis, timely detection and intervention shall be applied in the early stage. Adopting the AVF puncture risk evaluation system has an extremely high application value in the clinic and is of important meaning in prolonging the service life of fistulas.

Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter, Randomized Trial

PURPOSE

To compare clinical performance of 2 widely used symmetric-tip hemodialysis catheters.

MATERIALS AND METHODS

Patients with end-stage renal disease initiating or resuming hemodialysis were randomized to receive an Arrow-Clark VectorFlow (n = 50) or Palindrome catheter (n = 50). Primary outcome was 90-d primary unassisted catheter patency. Secondary outcomes were Kt/V ([dialyzer urea clearance × total treatment time]/total volume of urea distribution), urea reduction ratio (URR), and effective blood flow (Q_B).

RESULTS

Primary unassisted patency rates with the VectorFlow catheter at 30, 60, and 90 d were 95.5% ± 3.3, 87.2% ± 7.3, and 80.6% ± 9.8, respectively, compared with 89.1% ± 6.2, 79.4% ± 10.0, and 71.5% ± 12.6 with the Palindrome catheter (P = .20). Patients with VectorFlow catheters had a mean Kt/V of 1.5 at 30-, 60-, and 90-day time points, significantly higher than the mean Kt/V of 1.3 among those with Palindrome catheters (P = .0003). URRs were not significantly different between catheters. Catheter Q_B rates exceeded National Kidney Foundation-recommended thresholds of 300 mL/min at all time points for both catheters and were similar for both catheters (median, 373 mL/min). Catheter failure, ie, poor flow rate requiring guide-wire exchange or removal, within the 90-day primary outcome occurred in 3 VectorFlow subjects and 5 Palindrome subjects (P = .72). Infection rates were similar, with 0.98 infections per 1,000 catheter days for VectorFlow catheters compared with 2.62 per 1,000 catheter days for Palindrome catheters (P = .44).

CONCLUSIONS

The 90-day primary patency rates of Palindrome and VectorFlow catheters were not significantly different, and both achieved sustained high Q_B through 90 day follow-up. However, dialysis adequacy based on Kt/V was consistently better with the VectorFlow catheter versus the Palindrome.

Balancing the Covid-19-motivated vascular access guidelines and patient-centred care of pre-dialysis candidates

The recommendations recently proposed by the European and American Vascular Societies in this new 'Covid-19' era regarding the triage of various vascular operations into urgent, emergent and programmed based on the nature of their pathology aim at reserving health care expenses and hospital staff towards managing the current unexpected worldwide pandemic to the highest possible degree. The suggestion for implementation of these changes into real-world practice, however, does not come without a cost. In particular, the recommendation for deferral of access creation in pre-dialysis patients, ethical, socio-economic and medico-legal issues arise which should be seriously taken into consideration. At the end of the day, vascular access creation is the lifeline of haemodialysis patients and the indication for surgery warrants patient-specific clinical judgement rather than 'group labelling'.

Causes of the delay in creating permanent vascular access in hemodialysis patients

Majority of the chronic kidney disease (CKD) patients undergo hemodialysis (HD) with central venous catheter which has multiple complications. This study aims to identify the physicians' perspectives regarding the reasons of delayed arteriovenous fistula (AVF) creation in the Kingdom of Saudi Arabia to improve the quality of CKD patients' care and prognosis and prevent complications. A cross-sectional descriptive study was conducted on KSA nephrologists using a questionnaire which includes factors associated with delay in AVF creation, which were categorized into patient, physician, and hospital factors. The optimal timing of starting dialysis was also assessed. In a total of 212 participants, 131 (61.8%) were of consultant level, with the largest numbers being from the Central region (52.4%). The most important patient factors associated with delay in AVF creation were denial of kidney disease or the need of AVF (76.4%), dialysis fears and practical concern (75.9%), and patient refusal (73.1%). The most important physician and hospital factors were insufficient conduction of predialysis care and education (63.7%) and late referral to a nephrologist (56.6%). Participants would create AVF when the patient reaches Stage 4 CKD (69.3%) or Stage 5 (27.4%), and 88.7% of the participants would do so 3-6 months before the anticipated start of HD. Over two-thirds of the participants (68.4%) chose patient as the main factor contributing to the delay of permanent vascular access. A validated approach to patient selection, patient-centered predialysis care, and referral to vascular access creation that could be applied on different types of patients in different regions is required.