Delay in Permanent Vascular Access Formation and Referral to a Nephrologist in Incident Hemodialysis Patients: A Single Center Experience.

Natasha Khatri,Murtaza Dhrolia,Ruqaya Qureshi,Kiran Nasir,Aasim Ahmad

doi:10.7759/cureus.20728

Abstract

Objective: This study assessed the factors associated with delayed referral to a nephrologist and delay in formation of a permanent vascular access in incident hemodialysis (HD) patients.Methods: This prospective cross-sectional study was conducted from February 2021 to July 2021 on end stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD) at our center. Data were collected at the bedside during the HD session about a referral to a nephrologist, about when they were asked for permanent vascular access formation and the reason for the delay in its formation. Results: Out of 296 patients recruited in our study, 168 (56.8%) were male and 128 (43.2) were female. The mean age was 53.5±15 years (minimum of 19 years and maximum of 90 years). The most common reason for refusal of making permanent vascular access [arterio-venous fistula (AVF) or arterio-venous graft (AVG)] was fear of pain in our patients 65 (43.3%) followed by the denial of the disease 32 (21.3%). Among the study subjects, 231 (78%) patients were referred to the nephrologist immediately or within one month of their diagnosis. Some 152 (51.4%) of the patients were not in favor of making AVF whereas 151 (51%) refused for starting HD, hence most of our patients 181 (61.1%) initiated HD in emergency by a central venous catheter (CVC).Conclusion: Early referral should be done by primary care physicians (PCPs) for the timely management of CKD patients. As CKD is a progressive disease, it requires special attention by a nephrologist for adjustment of patient’s medications, timely follow-up, counseling, the early formation of AVF for HD, and planning for renal transplant. In our study, the majority of our patients initiated their HD via CVC because of the delayed visit to a nephrologist. Most patients were asked for AVF formation on the same day of presentation to our nephrology unit as they had advanced CKD (Stage 5) 134 (51.4%). Most patients in our study delayed AVF formation 152 (51.4%). With timely referral to a nephrologist, the nephrologist will be able to do better and repeated counseling about the disease, its progression, and the need for permanent vascular access for initiation of HD while patients and their families will get more time to make decisions.

Highlights

Chronic kidney disease (CKD) is a leading cause of mortality and morbidity globally [1]
The National Kidney FoundationKidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for vascular access suggest that an arteriovenous fistula (AVF) or an arteriovenous graft (AVG) is preferred to a central venous catheter (CVC) in most incident and prevalent HD patients due to the lower infection risk [6]
Participants included in this study were adult end stage renal disease (ESRD) patients on maintenance hemodialysis (MHD) at our center, who willingly participated in the study by signing a written informed consent

Summary

Introduction

Chronic kidney disease (CKD) is a leading cause of mortality and morbidity globally [1]. Awareness of CKD is limited, among the general population but referring physicians too, thereby increasing the need for hospitalization and mortality [3]. Around 25%-40% of CKD patients need renal replacement therapy (RRT) in the form of dialysis or renal transplant, soon after referral to a nephrologist, which leads to higher morbidity, mortality, hospital admissions, and worse long-term survival [4]. The National Kidney FoundationKidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for vascular access suggest that an AVF or an AVG is preferred to a CVC in most incident and prevalent HD patients due to the lower infection risk [6]. AVF is associated with lower mortality and morbidity [7,8]

Methods

Results

Discussion

Conclusion