Maintaining Vascular Access in Chronic Kidney Disease: Patient Perspectives

Abstract

Chronic kidney disease affects 16.8% of adults in the United States for which hemodialysis is most commonly used for renal replacement therapy. Although emphasis with the Fistula First Initiative has historically focused on the creation of autogenous arteriovenous access, higher rates of maturation failure and access dysfunction have prompted a reappraisal of this approach in the literature and clinical practice. Often, frail or medically complex patients with dysfunctional access will be subjected to a large number of surgical procedures to maintain or reestablish patency. The influence of arteriovenous fistula (AVF) dysfunction and repetitive reintervention on patient experience and quality of life remains largely unexplored in the contemporary literature. Using a provincial database of renal failure patients, we selected patients who had undergone five or more interventional procedures (open or endovascular) to maintain vascular access within a 20-year period from a single institution. Semistructured interviews were conducted with these patients, and the responses were analyzed qualitatively using the constant comparative approach. Sixteen patients who had met the inclusion criteria were recruited from across British Columbia. The cohort included patients from both genders (10 men; 6 women) aged 52 to 87 years. Four major thematic categories emerged from the interviews: impact of dialysis, treatment values, impact of repeated surgical intervention, and AVF satisfaction. For the impact of dialysis category, loss of independence (13 of 16) was a dominant theme, with the psychological impact secondary. Regarding treatment values, 11 of 16 patients stated survival was of primary importance, with a reduction in dialysis frequency secondary. The dominant theme in the impact of repeated surgical interventions was interruption to daily life (12 of 16), with travel interruptions and fatigue being minor. For AVF satisfaction, failure of the AVF was dominant (14 of 16), with pain associated with using the AVF considered the most common negative factor. Only 7 of 16 expressed satisfaction with their management pathway. Reduced independence and interruption to daily routine were the most cited difficulties regarding dialysis and surgical intervention. As expected, survival was a key treatment value. Recurrent access failure and reintervention were significant causes of impaired quality of life for patients requiring hemodialysis.