New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making

Hemodialysis vascular access coordinator: Three-level model for access management

Management of vascular access is a challenge for the dialysis team, particularly to keep the arteriovenous access working. The vascular access coordinator can positively contribute to increase the number of arteriovenous fistulas and reduce central venous catheters. In this article, we introduce a new approach to vascular access management centered on (the results of setting up) the role of vascular access coordinator. We described the three-level model (3Level_M) for vascular access management organized in three levels: vascular access nurse manager, vascular access coordinator, and vascular access consultant. We defined the instrumental skills and training required to be developed by each element and clarify the articulation between the model and all members of the dialysis team related to vascular access.

A collaborative model between dialysis clinics and a hospital center improves the quality of vascular access care and intervention for hemodialysis patients

BACKGROUND

This study reports the outcomes of a collaborative program between dialysis clinics and a referral hospital, which consisted of clinical monitoring and supplementary routine surveillance, for improving the quality of vascular access care.

METHODS

This retrospective observational study was performed at five dialysis clinics as part of a 2-year collaborative program (2019-2020) in conjunction with a hospital-based dialysis access management center. A total of 392 hemodialysis patients (arteriovenous fistula [AVF], n = 339 and arteriovenous graft [AVG], n = 53) were included. Outcome measures included the prognosis of vascular access, clinic satisfaction, and referral rate to the hospital.

RESULTS

Increased vascular access flow was observed and critical flow events decreased from the first to the second year (AVF: 18.3% vs. 12.7%, p < 0.001; AVG: 26.2% vs. 20.1%, p = 0.30). There were fewer percutaneous transluminal angioplasty events in the AVG group (0.77 per person-year vs. 0.51 per person-year, p = 0.005). New AVF or AVG creation events also remained low. All dialysis clinics were satisfied with the program. The overall referral rate from the participating clinics increased (65.7% vs. 72.0%) during the study period independently of the physical distance between the dialysis clinic and the hospital.

CONCLUSION

The collaboration between dialysis clinics and a referral hospital for improving the quality of vascular access care was successful in this study, and the model can be used by other clinics and hospitals looking to improve care coordination in dialysis patients.

Hemodialysis vascular access in elderly patients: A comprehensive review

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Frailty predicts increased risk of reintervention in the 2 years after arteriovenous fistula creation

INTRODUCTION

Frailty is associated with adverse survival and increased hospital use in patients with end-stage kidney disease (ESKD). Dialysis access failure is an important source of morbidity and mortality for these patients. There is limited evidence about the interactions between frailty and haemodialysis access failure. This population-based cohort study aimed to determine if haemodialysis access reintervention was predicted by frailty.

METHODS

Routinely-collected hospital data linked with death records were analyzed for all patients with ESKD who had a new arteriovenous fistula or graft (AVF) created between 2010 and 2012 in New South Wales, Australia. Frailty risk was assigned by the Hospital Frailty Risk Score. Multivariate Cox-proportional hazard ratios (HR), adjusted for patient and procedural variables, quantified if frailty was prognostic for adverse haemodialysis access outcomes in the 2 years after AVF creation.

RESULTS

Almost one quarter of the 2302 patients who had a new AVF created during the study period were classified as high frailty risk (554, 24.1%). Compared to low frailty risk patients, patients with high frailty had a significantly greater risk of reintervention for AVF failure in the 2 years after creation (HR 1.68; 95% CI 1.45-1.96), adjusted for age, sex and prior AVFs. Frailer patients were also more likely to have perioperative complications, longer hospital length of stay and readmission to hospital. Frailty was associated with a higher risk of mortality at 2 years after AVF creation (adjusted HR 2.65; 95% CI 1.72-4.10).

CONCLUSION

Frailty predicted adverse haemodialysis access outcomes, with frailer patients having higher rates of AVF reinterventions. These results can assist clinicians engaging in shared decision-making discussions about dialysis access risks and help personalize dialysis access decisions.

Health inequities in dialysis care: A scoping review

MAIN PROBLEM

We aim to look at potential gaps in current dialysis literature on inequities and explore future research that could contribute to more equitable care.

METHODS

Following guidelines from the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review of health inequities in dialysis. PubMed and Ovid Embase were searched in July 2022 for articles published between 2016 and 2022 that examined at least one of the following NIH defined health inequities: race/ethnicity, sex/gender, LGBTQ+ identity, underserved rural populations, education level, income, and occupation status. Frequencies of each health inequity as well as trends over time of the four most examined inequities were analyzed.

RESULTS

In our sample of 69 included studies, gaps were identified in LGBTQ+ identity and patient education. Inequities pertaining to race/ethnicity, sex/gender, underserved rural populations, and income were sufficiently reported. No trends between inequities investigated over time were identified.

CONCLUSIONS

Our scoping review examined current literature on health inequities pertaining to dialysis and found gaps concerning LGBTQ+ and patients with lower levels of education. To help fill these gaps, and possibly alleviate additional burden to these patients, we recommend cultural competency training for providers and dialysis center staff as well as community-based educational programs to improve dialysis patients' health literacy.

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.

Patient and Clinician Perspectives on Shared Decision Making in Vascular Access Selection: A Qualitative Study

RATIONALE & OBJECTIVE

Collaborative approaches to vascular access selection are being increasingly encouraged to elicit patients' preferences and priorities where no unequivocally superior choice exists. We explored how patients, their caregivers, and clinicians integrate principles of shared decision making when engaging in vascular access discussions.

STUDY DESIGN

Qualitative description.

SETTING & PARTICIPANTS

Semistructured interviews with a purposive sample of patients, their caregivers, and clinicians from outpatient hemodialysis programs in Alberta, Canada.

ANALYTICAL APPROACH

We used a thematic analysis approach to inductively code transcripts and generate themes to capture key concepts related to vascular access shared decision making across participant roles.

RESULTS

42 individuals (19 patients, 2 caregivers, 21 clinicians) participated in this study. Participants identified how access-related decisions follow a series of major decisions about kidney replacement therapy and care goals that influence vascular access preferences and choice. Vascular access shared decision making was strengthened through integration of vascular access selection with dialysis-related decisions and timely, tailored, and balanced exchange of information between patients and their care team. Participants described how opportunities to revisit the vascular access decision before and after dialysis initiation helped prepare patients for their access and encouraged ongoing alignment between patients' care priorities and treatment plans. Where shared decision making was undermined, hemodialysis via a catheter ensued as the most readily available vascular access option.

LIMITATIONS

Our study was limited to patients and clinicians from hemodialysis care settings and included few caregiver participants.

CONCLUSIONS

Findings suggest that earlier, or upstream, decisions about kidney replacement therapies influence how and when vascular access decisions are made. Repeated vascular access discussions that are integrated with other higher-level decisions are needed to promote vascular access shared decision making and preparedness.

Chinese Clinical Practice Guideline for the Management of "CKD-PeriDialysis"-the Periods Prior to and in the Early-Stage of Initial Dialysis

The National Experts Group on Nephrology have developed these guidelines to improve the management of pre-dialysis and initial dialysis patients with chronic kidney disease (CKD) (two periods contiguous with dialysis initiation termed here 'PeriDialysis CKD'). The pre-dialysis period is variable, whereas the initial dialysis period is more fixed at 3 months to 6 months after initiating dialysis. The new concept and characteristics of 'CKD-PeriDialysis' are proposed in the guideline. During the CKD-PeriDialysis period, the incidence rate of complications, mortality and treatment cost significantly increases and the glomerular filtration rate (GFR) rapidly decreases, which requires intensive management. The guideline systematically and comprehensively elaborates the recommendations for indicators to be used in for disease evaluation, timing and mode selection of renal replacement therapy, dialysis adequacy evaluation, and diagnosis and treatment of common PeriDialysis complications. Finally, future research directions of CKD-PeriDialysis are proposed. CKD-PeriDialysis management is a difficult clinical issue in kidney disease, and the development and implementation of these guidelines is important to improve the management of CKD-PeriDialysis patients in China, which could ultimately improve survival rates and quality of life, and reduce the medical burden.