Is the Fistula First Approach still valid?

Infection control Surveillance of dialysis events at outpatient hemodialysis centers in Saudi Arabia: A 3-year national data

Background

Monitoring dialysis events is very important in evaluating the risk of infection and antimicrobial use among this group of vulnerable patients. The objective was to calculate rates of dialysis events at outpatient hemodialysis centers in Saudi Arabia.

Methods

A retrospective cohort study of dialysis events collected from 152 outpatient hemodialysis centers in 20 Saudi regions between January 2019 and December 2021. The Saudi Health Electronic System Network (HESN) was used to report data from participating centers. Dialysis events included in-unit intravenous antimicrobial start, positive blood culture, and infection (pus, redness, and swelling) at the vascular access site.

Results

A total of 125,761 patient months of surveillance were monitored. The most frequent type of dialysis event was the in-unit intravenous antimicrobial start at 0.75 per 100 patient months, followed by positive blood culture at 0.41, and finally, local access of the infection site at 0.34. The rates of dialysis events were highest, with temporary central lines at 4.36, permanent central lines at 1.87, arteriovenous graft at 0.35, and finally, arteriovenous fistula at 0.17. After adjusting for the differences in the type of vascular access, the rates of dialysis events in the Saudi HESN were lower, 54%-83%, than those of the American National Healthcare Safety Network (NHSN, P<0.001 for each) and a less extent 27%-55% lower when compared with the published results from Chinese people.

Conclusions

The current findings provide benchmarking data for different dialysis events that can promote fair comparisons and interest in dialysis event surveillance.

Rebuilding vascular access: from the viewpoint of mechanics and materials

This review presents a comprehensive analysis of vascular access in hemodialysis, focusing on the current modalities, their associated challenges, and recent technological advancements. It closely examines the status of three primary types of vascular access: arteriovenous fistulas, arteriovenous grafts, and central venous catheters. The review delves into the complications and pathologies associated with these access types, emphasizing the mechanobiology-related pathogenesis of arteriovenous access. Furthermore, it explores recent clinical trials, biomaterials, and device innovations, highlighting novel pharmaceutical approaches, advanced materials, device designs, and cutting-edge technologies aimed at enhancing the efficacy, safety, and longevity of vascular access in hemodialysis. This synthesis of current knowledge and emerging trends underscores the dynamic evolution of vascular access strategies and their critical role in improving patient care in hemodialysis.

Factors affecting suboptimal maturation of autogenous arteriovenous fistula in elderly patients with diabetes:A narrative review

Autogenous arteriovenous fistula (AVF) is considered the preferred vascular access choice for individuals undergoing maintenance hemodialysis (MHD) and is widely utilized in China, as reported by the Dialysis Outcomes and Practice Patterns Study. Despite its popularity, the significant incidence of poor AVF maturation often leads to the need for central venous catheter insertion, increasing the risk of complications like superior vena cava stenosis and catheter-related infections, which in turn raises the overall mortality risk. With the prevalence of diabetes rising globally among the elderly and diabetic kidney disease being a leading cause of end-stage renal disease necessitating renal replacement therapy, our retrospective review aims to explore the various factors affecting AVF maturation in this specific patient population. While there have been numerous studies examining AVF complications in MHD patients, including issues like failure, patency loss, stenosis, thrombosis, poor maturation, and other influencing factors, there remains a gap in large-scale clinical studies focusing on the incidence and risk factors for immature AVF specifically in elderly diabetic patients. This paper delves into the pathophysiological mechanisms, diagnostic criteria, and unique considerations surrounding AVF maturation in elderly diabetic patients, distinguishing them from the general population. Our literature review reveals that elderly diabetic patients exhibit a higher risk of AVF immaturity compared to the general population. Additionally, there exists a continuing discourse regarding several aspects related to this group, including the choice of dialysis access, timing of AVF surgery, and surgical site selection. Furthermore, we delve into the management strategies for vascular access within this specific group with the goal of providing evidence-based guidance for the establishment and maintenance of functional vascular access in elderly diabetic patients.

Slowly moving the needle away from Fistula First

OBJECTIVE

In 2019, the management of end-stage kidney disease (ESKD) shifted away from "Fistula First" (FF) to "ESKD Life-Plan: Patient Life-Plan First then Access Needs." Indeed, some patients exhibit such excessive comorbidity that even relatively minor vascular surgery may be complicated. The purpose of this study was to retrospectively assess complications and mortality (and delineate operative futility) in patients undergoing arteriovenous fistula (AVF) creation in the FF era.

METHODS

Consecutive AVFs created in a single institution before 2021 were retrospectively reviewed. Operative futility was defined as never-accessed fistula, no initiation of dialysis, failure of access maturation (despite secondary intervention), hemodialysis access-induced distal ischemia requiring ligation, early loss of secondary patency, and/or patient mortality within the first 6 postoperative months.

RESULTS

A total of 401 AVFs were created including radial-cephalic (44%), brachial-cephalic (41%), and brachial-basilic (15%) constructions. Patients exhibited a mean age of 69 ± 15 years; 63% were male, and most (74%) were already being hemodialyzed at the time of fistula creation. Forty-five patients (11%) suffered a cardiac event, and five patients died (1%) within 90 days of their access surgery. Perioperative cardiac events were significantly more common after age 80 (19% vs 8%; P = .004); age >80 years was an independent predictor of major 90-day complications (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.04-3.39; P = .036) and the sole independent predictor of major morbidity defined as cardiopulmonary complications, stroke, or death within the first year (OR, 2.01; 95% CI, 1.24-3.25; P = .004). Operative futility was encountered in 52% of the cohort (n = 208 patients): 40% (n = 160) of primary AVFs failed to mature despite assistance, 19% (n = 77) had lost secondary patency by 6 months, 13% of patients (n = 53) were never started on dialysis after access creation, 4% (n = 16) were dead by 6 months, 2% of AVFs (n = 10) matured but were never accessed, and 2% (n = 9) required ligation for hemodialysis access-induced distal ischemia. Not surprisingly, the sole independent protector against operative futility was that catheter-based dialysis had been established prior to AVF creation (OR, 0.36; 95% CI, 0.22-0.59; P < .01).

CONCLUSIONS

Approximately 50% of primary AVF operations performed in the aggressive FF era were deemed futile. Octogenarians were particularly prone to futility and complications during this era. A paradigm shift, from FF to an "ESKD Life-Plan" will, hopefully, more thoughtfully match vascular access strategies to individual patient needs.

Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

Health insurance provider and endovascular treatment availability are associated with different hemodialysis vascular access profiles: A Brazilian national survey

In Brazil, most hemodialysis (HD) patients are treated by the country's public health system. However, accessibility to healthcare is different for public and private patients. This study aimed to identify the profile of vascular access in a Brazilian HD sample. Additionally, it aimed to examine the influence of public and private health insurance, accessibility to endovascular treatments, and timely arteriovenous access creation on the prevalence of tunneled catheters (TCs), non-tunneled catheters (NTCs), and arteriovenous (AV) access. We conducted a cross-sectional electronic survey across 834 centers. Centers were inquired about the number of patients with public and private health insurance, the profiles of vascular access, time for AV access creation, accessibility to TC insertion and endovascular treatments, and the availability of peritoneal dialysis and kidney transplantation. Logistic regression and multilevel logistic regression were performed to evaluate possible interactions between the independent variables. A total of 7,973 patients across 47 HD centers were included in the survey. Public health patients accounted for 77% of the study sample. The overall vascular access profiles of the public and private insurance groups were significantly different (p < 0.001). For patients with public health insurance, the prevalence of any catheter was 25%, while that for private patients was 31.8% (p < 0.001). The prevalence of TCs was more common in private patients (15.3% vs. 23.1%, p < 0.001). AV accesses were more common in public health patients (75% vs. 68.2%, p < 0.001), as were fistulas (72.4% vs. 63.1%, p < 0.001). AV grafts were more prevalent among patients with private insurance (2.6 vs. 5.1%, p < 0.001). The availability of endovascular treatments increased the chance of having a TC by 2.3-fold (OR = 2.33, 95% CI = 1.30-4.18); however, it did not reduce the chance of having any catheter. A high chance of having a catheter was found when the time to AV access creation exceeded 60 days. The differences between public and private patients may be explained by underpayments and the decreased accessibility to care infrastructure in the public system, especially for endovascular treatments. In this sample, public health patients had a decreased risk of having a TC over an NTC. Differences in care accessibility and insurance type might influence the type of vascular access.